Cementless total hip arthroplasty with ceramic-on-ceramic bearing in patients younger than 45 years with femoral-head osteonecrosis

Despite improvements in the quality of alumina ceramics, osteolysis has been reported anecdotally after total hip arthroplasty (THA) with use of a contemporary alumina-on-alumina ceramic bearing. The purpose of this study was to evaluate the clinical and radiographic outcomes of THA using alumina-on-alumina ceramic bearing and to determine osteolysis using radiographs and computed tomographic (CT) scans in young patients. Consecutive primary cementless THA using alumina-on-alumina ceramic bearing were performed in 64 patients (93 hips) who were younger than 45 years of age with femoral-head osteonecrosis. There were 55 men (84 hips) and nine women (nine hips). Average age was 38.2 (range 24–45) years. Average follow-up was 11.1 (range 10–13) years. Preoperative Harris Hip Score was 52.9 (range 22–58) points, which improved to 96 (range 85−100) points at the final follow-up examination. Two of 93 hips (2%) had clicking or squeaking sound. No hip had revision or aseptic loosening. Radiographs and CT scans demonstrated that no acetabular or femoral osteolysis was detected in any hip at the latest follow-up. Contemporary cementless acetabular and femoral components with alumina-on-alumina ceramic bearing couples function well with no osteolysis at a ten year minimum and average of 11.1-year follow-up in this series of young patients with femoral-head osteonecrosis.     

Total hip arthroplasty in patients with Down��s syndrome

Patients with Down’s syndrome (DS) have an increased incidence of coxarthrosis which may become symptomatic with prolonged life expectancy. We present seven consecutive patients (nine hips) with DS who had primary total hip arthroplasty (THA). Average clinical and radiological follow-up was 9.9 ± 6.4 years (range 2–22.25). Harris hip scores (HHS) improved significantly (p < 0.01) from 41.1 (range 18.5–65) to 80.2 (range 67.5–91) at latest follow-up. Two patients required revision arthroplasty for stem loosening at 16 (osteolysis) and six years (trauma) following THA, respectively. Six of the THAs required a constrained liner. No dislocations or deep infections were encountered. We contend that THA is a reliable surgical intervention in patients with DS and may be performed in symptomatic patients.     

Direction of hip arthroplasty dislocation in patients with femoral neck fractures

In order to prevent hip arthroplasty dislocations, information regarding the direction of the dislocation is important for accurate implant positioning and for optimising the postoperative regimens in relation to the surgical approach used. The aim of this study was to analyse the influence of the surgical approach on the direction of the dislocation in patients treated by a hemiarthroplasty (HA) or total hip arthroplasty (THA) after a femoral neck fracture. Fracture patients have a high risk for dislocations, and this issue has not been previously studied in a selected group of patients with a femoral neck fracture. We analysed the radiographs of the primary dislocation in 74 patients who had sustained a dislocation of their HA (n = 42) or THA (n = 32). In 42 patients an anterolateral (AL) surgical approach was used and in 32 a posterolateral (PL). The surgical approach significantly influenced the direction of dislocation in patients treated with HA (p < 0.001), while no such correlation was found after THA (p = 0.388). For THA patients there was a correlation between the mean angle of anteversion of the acetabular component and the direction of dislocation when comparing patients with anterior and posterior dislocations (p = 0.027). These results suggest that the surgical approach of a HA has an influence on the direction of dislocation, in contrast to THA where the position of the acetabular component seems to be of importance for the direction of dislocation in patients with femoral neck fractures.     

A cementless elastic monoblock socket in young patients: a ten to 18-year clinical and radiological follow-up

The survival of acetabular components depends on several factors: wear, osteolysis and septic or aseptic loosening. Osteolysis seems to be the main cause for concern in cementless arthroplasties. Acetabular osteolysis results from particle debris and segmental unloading of acetabular bone by rigid sockets. We investigated a cementless elastic monoblock socket with regard to acetabular osteolysis and aseptic loosening in a cohort of young patients. We evaluated 158 hip arthroplasties with a minimum follow-up of ten years (ten to 18) and a mean age of 42 years (18–50). The overall revision rate at 14 years was 80% with a 98% survival rate for aseptic loosening. The mean polyethylene wear rate was 0.11 mm/year. Progressive acetabular osteolysis was seen in 3% of patients evaluated. In conclusion, we found low pelvic osteolysis rates, acceptable overall wear rates, satisfactory overall survival and excellent survival rates for aseptic loosening of a cementless elastic monoblock socket in patients younger than 50 years. Ongoing tribology developments and knowledge about acetabular bone adaptations behind acetabular implants will further lower wear and osteolysis rates and optimise survival rates of cementless sockets.     

Relationship between the pelvic osteolytic volume on computed tomography and clinical outcome in patients with cementless acetabular components

The purpose of this study was to evaluate the relationship between the pelvic osteolytic volume on computed tomography (CT) and clinical outcome in patients with cementless acetabular components. We reviewed 87 patients (104 hips) who met the following inclusion criteria: (1) there was evidence of pelvic osteolysis on CT at a minium of five years postoperatively, (2) all cups and stems were radiographically stable at the time of CT, (3) the follow-up period after CT was a minimum of two years clinically. The mean pelvic osteolytic volume was 2.3 ± 6.9 cm³. The mean Harris hip score (HHS) at CT was 92.3 ± 7.9 points. Inversely moderate correlation (r = −0.569, P < 0.05) was found between the HHS at CT and pelvic osteolytic volume. In ten cases of hips with acetabular revisions, the mean pelvic osteolytic volume was 16.3 ± 26.9 cm³. The mean HHS at CT and HHS at reoperation was 87.6 ± 9.2 points and 73.4 ± 8.8 points, respectively, with significant difference (P < 0.05). The area under curve (ROC) analysis showed that the optimal cutoff value of the osteolytic volume was 4.8 cm³ with 100% each for sensitivity and specificity. We conclude that the amount of pelvic osteolytic volume on CT may be used to guide treatment decision-making in patients with well-fixed cementless acetabular components who show evidence of pelvic osteolysis.     

Eighteen-Year Follow-Up Study of 2 Alternative Bearing Surfaces Used in Total Hip Arthroplasty in the Same Young Patients

BackgroundThis study compares the long-term functional, radiographic, and computed tomography scan outcomes and implant survivorship of ceramic-on-ceramic total hip arthroplasty (C-O-C THA) and ceramic-on-highly cross-linked polyethylene total hip arthroplasty (C-O-HXLPE THA) in the same patients.MethodsIn this randomized, prospective trial conducted between January 1999 and April 2003, 133 patients (266 hips) younger than 55 years were enrolled. Each patient received C-O-C THA in 1 hip and a C-O-HXLPE THA in the other. The mean follow-up was 17.1 years (range, 15-18 years); there were 84 men and 49 women with a mean age of 53 ± 7 years (range, 25-55 years).ResultsAt the latest follow-up, mean Harris hip scores (94 vs 93 points; P = .861), pain scores (43 vs 42 points; P = .651), and patient satisfaction scores (7.8 vs 7.6 points; P = .379) were not different between the 2 groups. Eight hips (3%) in the C-O-C THA had an audible squeaking sound. The mean annual penetration rate of HXLPE was 0.0162 ± 0.032 mm per year. No osteolysis was recorded on radiographs or computed tomography scans in either group. At 17.1 years, the survival rate of the acetabular component was 97% in the C-O-C bearing group and 98% in the C-O-HXLPE bearing group (P = .923). The survival rate of the femoral component was 99% in both groups.ConclusionBoth C-O-C THA and C-O-HXLPE THA functioned well, with no osteolysis at mean of 17.1-year follow-up.     

Cementless total hip arthroplasty with a metal-on-metal bearing in patients younger than 50 years

Total hip arthroplasty (THA) longevity is the primary concern in young patients. Metal-on-metal articulations were reintroduced to reduce polyethylene particle-induced osteolysis and improve survivorship; to date, based on issued reports, this strategy appears to have been successful. In this study, the authors investigated metal-on-metal articulation survivorship and osteolysis incidence in young patients (19-50 years old at index operations) and retrospectively reviewed cementless metal-on-metal THAs in 70 patients (78 hips) with a mean follow-up of 12.4 years. Metasul articulation was used with the Wagner acetabular component in all. Survivorship with revision for any cause was 98.7% (95% confidence interval, 98%-100%), and survivorship due to the development of osteolysis for any lesion was 97.5% (95% confidence interval, 95%-99%). Mean Harris hip score improved from 51 to 95 points at final follow-up. The findings of this study indicate that outcomes of cementless THA with a metal-on-metal bearing in young patients are satisfactory. However, longer-term studies in larger cohorts are required to determine whether metal-on-metal articulations are really a favorable option in young patients.     

Retention of a well-fixed acetabular component in the setting of acetabular osteolysis

Purpose  

The treatment strategy for pelvic osteolysis with a well-fixed acetabular component after total hip arthroplasty (THA) involves replacing the acetabular cup liner and femoral head, débriding osteolytic lesions, and grafting.     

全髋关节置换术治疗髋臼骨折内固定术后继发创伤性髋关节炎的疗效观察

目的:探讨人工全髋关节置换术治疗髋臼骨折术后创伤性关节炎的临床疗效。方法:回顾性分析2010年6月至2014年6月收治的33例(33髋)髋臼骨折术后创伤性关节炎患者资料,男21例,女12例;年龄22~65岁,平均44.6岁。均采用生物型假体行全髋关节置换术治疗。采用Harris评分对患者术前后的髋关节功能进行评分,拍X线片对假体状态进行影像学评估。结果:所有患者获得随访,随访时间7~38个月,平均21.6个月。末次随访时髋关节Harris评分从术前平均(53.6±2.4)分提高至(94.0±3.0)分,差异有统计学意义(t=55.37,P0.05),髋关节功能明显改善。影像学评估显示假体位置良好,无假体松动、关节脱位及明显假体周围骨溶解等并发症。结论:全髋关节置换术是治疗髋臼骨折内固定术后继发创伤性髋关节炎的有效治疗手段,髋臼骨折内固定材料显露困难但不影响假体安放,行全髋置换术可不取出。     

Precoated femoral component in primary hybrid total hip arthroplasty: results at a mean 10-year follow-up

This is a mid-term report at 10 years' mean follow-up of a study of a precoated femoral component used in primary hybrid total hip arthroplasty (THA). Of an original cohort of 98 hips undergoing THA performed by one surgeon, 75 hips in 65 patients (mean age, 67 years) were prospectively followed up for 7 to 12 years (mean, 10 years). All hips had the same porous coated acetabular component and a precoated femoral component (with an oval cross-section) implanted using Simplex bone cement (Howmedica, Rutherford, NJ). There was no femoral component loosening or revision. Two acetabular components in patients with rheumatoid arthritis and protrusio acetabulae had radiographic loosening; however, only 1 was symptomatic and was revised. Acetabular osteolysis was seen in 4 hips (5.3%), and minor femoral osteolysis was seen in 3 hips (4%). Used in this manner in this patient population, precoating is not detrimental to successful fixation at 10 years' mean follow-up of primary hybrid THA.     

髋臼骨折内固定失败术后的全髋关节置换术

目的:探讨髋臼骨折内固定失败术后继发创伤性关节炎和(或)股骨头缺血性坏死行全髋关节置换术的特点及临床疗效。方法:2009年2月至2014年10月,采用全髋关节置换术对31例(31髋)髋臼骨折内固定失败继发创伤性关节炎和(或)股骨头缺血性坏死患者进行治疗,其中男26例,女5例;受伤时平均年龄(41±12)岁。患者因髋臼骨折内固定术后3~132个月,平均(20.6±26.9)个月内继发创伤性关节炎和(或)股骨头缺血性坏死而行全髋关节置换术,全髋关节置换术均采用后外侧入路。观察术后并发症和关节活动度,并比较术前和术后随访时髋关节VAS疼痛评分和Harris髋关节评分。结果:术后27例获得随访,随访时间12~80个月,平均(43.2±11.7)个月。其中出现关节感染1例,假体松动1例,脱位1例,无继发坐骨神经损伤病例发生。所有随访病例髋关节功能和步态有明显改善;至末次随访时,VAS由术前平均(7.6±1.2)分,降低到术后平均(1.2±0.9)分,Harris评分由术前平均(45.5±13.6)分,提高到术后平均(88.5±7.8)分,差异均有统计学意义(P0.01)。髋关节除后伸外,前屈、外展、内收、内旋及外旋活动范围较术前显著增加,差异有统计学意义(P0.05)。X线片复查示:髋臼假体无不稳定发生,1例股骨柄假体下沉3 mm,2例发生异位骨化。结论:正确处理内固定物,提防潜在感染,合理重建髋臼骨缺损,是髋臼骨折内固定失败术后全髋关节置换成功的关键。     

Open reduction and internal fixation alone versus open reduction and internal fixation plus total hip arthroplasty for displaced acetabular fractures in patients older than 60 years: A prospective clinical trial

IntroductionThe optimal treatment of elderly patients with an acetabular fracture is unknown. We conducted a prospective clinical trial to compare functional outcomes and reoperation rates in patients older than 60 years with acetabular fracture treated with open reduction and internal fixation (ORIF) alone versus ORIF plus concomitant total hip arthroplasty (ORIF + THA). Our hypothesis was that patients who had ORIF + THA would have better patient reported outcomes and lower reoperation rates postoperatively.MethodsInclusion criteria were patients older than 60 years with acetabular fracture plus at least one of three fracture characteristics: dome impaction, femoral head fracture, or posterior wall component. Eligible patients were operative candidates based on fracture displacement, ambulatory status, and physiological appropriateness. Patients received either ORIF alone or ORIF + THA (accomplished at same surgery through same incision). Outcome measurements included Western Ontario and McMaster Universities Osteoarthritis Index hip score, Short Form 36, Harris Hip Score, and Patient Satisfaction Questionnaire Short Form scores. Additionally, patients were monitored for any unplanned reoperation within 2 years.ResultsForty-seven of 165 eligible patients with an average age of 70.7 years were included. The mean Harris Hip Score difference favored ORIF + THA (mean difference, 12.3, [95% confidence interval (CI), -0.3 to 24.9, p = 0.07]). No clinically important differences were detected in any other validated outcome score or patient satisfaction score 1 year after surgery. ORIF + THA decreased the absolute risk of reoperation by 28% (95% CI, 13% to 44%, p < 0.01). No postoperative hip dislocation occurred in either group.ConclusionsIn patients older than 60 years with an operative displaced acetabular fracture with specific fracture features (dome impaction, femoral head fracture, or posterior wall component), treatment with ORIF + THA resulted in fewer reoperations than treatment with ORIF alone. No differences in patient satisfaction and other validated outcome measures were detected.     

Multicentre use of a porous tantalum monoblock acetabular component

The purpose of this study was to evaluate the minimum five-year prospective results from the multicentre use of a porous tantalum monoblock acetabular component for primary total hip arthroplasty (THA). A multicentre study was performed in 253 consecutive primary THAs in three separate surgical centres. All patients underwent identical postoperative protocols including radiological and clinical evaluation. The average preoperative total HHS score was 44.0 ± 13.8 and increased at one-year follow-up to 95.2 ± 4.8 (p  <0.05), remaining constant through the five-year follow-up at 97.0 ± 6.2 (p < 0.05). There was no radiographic evidence of gross polyethylene wear, progressive radiolucencies, osteolytic lesions, acetabular fracture, or component subsidence. From these results, we can recommend the continued use of this material for acetabular components in primary THA and that further review of the current multicentre population is warranted to determine the long-term durability of the acetabular composite.

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Résumé  Le propos de cette étude est d'évaluer, à cinq ans de suivi, les résultats d'une étude prospective multicentrique sur l'utilisation de composants acétabulaires ou monobloc en tantalum lors de prothèses totales de hanche. Matériel et méthode: cette étude multicentrique concernait 253 prothèses de hanche consécutives dans trois centres différents. Tous les patients ont bénéficié du même protocole postopératoire incluant une étude radiologique et une évaluation clinique. Résultats: le score HHS postopératoire a été de 44.0 ± 13.8 et s'est amélioré à un an postopératoire à 95.2 ± 4.8 (p < 0,05). Ce score demeure constant à 5 années de suivi 97.0 ± 6.2 (p < 0,05). Il n'y a pas de signe sur les radiographies d'usure grossière du polyéthylène, ni de liserés, ni de lésions ostéolytiques, ni de fractures de l'accetabulum ou de migrations des composants. En conclusion, à partir de ces résultats, nous pouvons recommander l'utilisation de ce matériel pour les composants acétabulaires de prothèses totales de hanche. Néanmoins, il sera nécessaire de faire d'autres études afin d'évaluer cette évolution sur un plus long terme.

     

An unusual mode of failure of a tripolar constrained acetabular liner: a case report

Dislocation after primary total hip arthroplasty (THA) is the most commonly encountered complication and is unpleasant for both the patient and the surgeon. Constrained acetabular components can be used to treat or prevent instability after primary total hip arthroplasty. We present the case of a 42-year-old female with a BMI of 41. At 18 months post-primary THA the patient underwent further revision hip surgery after numerous (more than 20) dislocations. She had a tripolar Trident acetabular cup (Stryker-Howmedica-Osteonics, Rutherford, New Jersey) inserted. Shortly afterwards the unusual mode of failure of the constrained acetabular liner was noted from radiographs in that the inner liner had dissociated from the outer. The reinforcing ring remained intact and in place. We believe that the patient’s weight, combined with poor abductor musculature caused excessive demand on the device leading to failure at this interface when the patient flexed forward. Constrained acetabular components are useful implants to treat instability but have been shown to have up to 42% long-term failure rates with problems such as dissociated inserts, dissociated constraining rings and dissociated femoral rings being sited. Sometimes they may be the only option left in difficult cases such as illustrated here, but still unfortunately have the capacity to fail in unusual ways.     

Age-related appearance of muscle trauma in primary total hip arthroplasty and the benefit of a minimally invasive approach for patients older than 70?years

Old age is frequently associated with a poorer functional outcome after THA. This might be based upon muscular damage resulting from surgical trauma. Minimally invasive approaches have been widely promoted on the basis of the muscle sparing effect. The aim of the study was to evaluate of the functional outcome and the grade of fatty muscle atrophy of the gluteus medius muscle by magnetic-resonance-imaging (MRI) in patients undergoing minimally invasive or traditional THA. Forty patients (21 female, 19 male) underwent THA either via a modified direct lateral (mDL) or a minimally invasive anterolateral (ALMI) approach. Patients were evaluated clinically and by MRI in terms of age (< or ≥70 y) preoperatively and at three and 12 months postoperatively. The Harris hip score and Trendelenburg’s sign were recorded and a survey of a pain (using a numeric rating scale of 0–10) and satisfaction score (using a numeric rating scale of 1–6) was performed. Fatty atrophy (FA) of gluteus medius muscle was rated by means of a five-point rating scale (0 indicates no fat and 4 implies more fat than muscle). Younger patients reached a significantly higher Harris hip score, lower pain score and lower rate of positive Trendelenburg’s sign accompanied by a significantly lower rate of postoperative FA (P = 0.03; young: FA (MW) = (preop. / 3 / 12 months), 0.15 / 0.7 / 0.7; old: FA (MW) = 0.18 / 1.3 / 1.36). Older patients with an mDL-approach had the significantly lowest clinical scores, the highest rate of positive Trendelenburg’s sign and also the highest rate of fatty atrophy (P = 0.03; FA (old) mDL: 1.8; ALMI: 0.7). Interestingly, no influence of the approach could be detected within the younger group. Patients older than 70 years had a poorer functional outcome and a higher postoperative extent of FA when compared to younger patients, which must be based upon a higher vulnerability and a reduced regenerative capacity of their skeletal muscle. Through a minimally invasive approach the muscle trauma in older patients can be effectively reduced and thus the functional outcome significantly improved. Incision and detachment of tendons and muscles should be strictly avoided.     

Catastrophic Periprosthetic Osteolysis in Total Hip Arthroplasty at 20 Years: A Case Report and Literature Review

BackgroundPeriprosthetic osteolysis is a serious complication following total hip arthroplasty (THA). However, most orthopedic surgeons only focus on bone loss and hip reconstruction. Thus, it was required to understand the treatment algorithm for periprosthetic osteolysis integrally.Case PresentationA 52‐year‐old Asian male presented with chronic hip pain. A mass appeared on the medial side of the proximal left thigh at more than 20 years after bilateral THA. Radiographs revealed catastrophic periprosthetic osteolysis, especially on the acetabular side. Large amounts of necrotic tissue and bloody fluids were thoroughly debrided during revision THA. A modular hemipelvic prosthesis was used for revision of the left hip. Four years later, the patient presented with right hip pain, where a mass appeared on the medial side of the proximal right thigh. A primary acetabular implant with augment was used for revision of the right hip. Laboratory evaluation of bloody fluid retrieved from surgery revealed elevated levels of inflammatory markers.ConclusionInflammatory responses to polyethylene wear debris can lead to severe bone resorption and aseptic loosening in the long‐term following THA. Therefore, in spite of revision THA, interrupting the cascade inflammatory might be the treatment principle for periprosthetic osteolysis.