Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head: a concise follow-up, at an average of seventeen years, of a previous report

We previously evaluated ninety-eight consecutive patients (148 hips) at mean of 9.3 years after total hip arthroplasty; the mean age at the time of the index surgical procedure was 47.3 years. Fifty patients (100 hips) had simultaneous bilateral arthroplasty with a cemented stem in one hip and a cementless stem in the contralateral hip. Forty-eight patients (forty-eight hips) had unilateral hip arthroplasty with a cementless stem. All patients had a cementless acetabular component. In our first report, we found no difference in clinical results, as measured with the Harris hip score and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), between the cementless and cemented stems. One hip (2%) in the hybrid group (a cementless cup and a cemented stem) had revision because of infection and two hips (2%) in the fully cementless group had revision of the femoral component because of a periprosthetic fracture. Between the time of follow-up in that study (at a mean of 9.3 years) and the time of follow-up in the present study (at a mean of 17.3 years), twenty-two revisions of acetabular components were performed, with eight in the hybrid group and fourteen in the fully cementless group. There was no difference in clinical results, as measured with the Harris hip score and the WOMAC, between the hybrid and fully cementless groups. At the time of the present review, forty (83%) of forty-eight acetabular components in the hybrid group and eighty (85%) of ninety-four acetabular components in the fully cementless group were intact. Most of the femoral components (98%) in both groups were intact. Wear and periacetabular osteolysis were the causes of failure in the hips requiring revision.     

Does Implant Selection Impact Postoperative Complications Following Hip Arthroplasty for Failed Intertrochanteric Fractures? A Retrospective Comparative Study

The purpose of this study is to compare postoperative complications among different acetabular and femoral components of hip arthroplasty for failed intertrochanteric fractures. A total of 79 patients were included and followed‐up for an average of 75.6 months (range, 24–244). Fifty‐five patients underwent total hip arthroplasty, and 24 had bipolar hemiarthroplasty. Cementless metaphyseal locking, cementless diaphyseal locking, and cemented standard stems were used in 41, 29, and 9 patients, respectively. Dislocation and wear rate were not different between the total hip arthroplasty and bipolar hemiarthroplasty groups. Stem subsidence or loosening was more frequently found in the cementless, metaphyseal locking stem groups. In conclusion, cemented standard stem and cementless diaphyseal locking stem might be better implant choices. With regard to dislocation rate, our results were insufficient to conclude a better implant choice of total hip arthroplasty or bipolar hemiarthroplasty than the other.     

Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head

BACKGROUND: The rate of failure of primary total hip arthroplasty in patients with osteonecrosis of the femoral head is higher than that in patients with osteoarthritis. The purpose of this prospective study was to document the clinical and radiographic results of arthroplasty with so-called third-generation cementing and the results of second-generation cementless total hip arthroplasty in ninety-eight consecutive patients with osteonecrosis of the femoral head. METHODS: Fifty patients who had had simultaneous bilateral total hip arthroplasty with a cemented stem in one hip and a cementless stem in the other and forty-eight patients who had had a unilateral total hip arthroplasty with a cementless stem were included in the study. A cementless acetabular component was used in all hips. The presumed cause of the osteonecrosis was ethanol abuse in fifty-seven patients, unknown in twenty-seven, fracture of the femoral neck in nine, and steroid use in five. There were eighty men and eighteen women. The mean age at the time of the arthroplasty was 47.3 years (range, twenty-six to fifty-eight years). Clinical and radiographic evaluations were performed preoperatively; at six weeks; at three, six, and twelve months; and yearly thereafter. The average duration of follow-up was 9.3 years. RESULTS: The average Harris hip scores in the group treated with unilateral arthroplasty (97 points) and the group treated with bilateral arthroplasty (94 points) were similar at the time of final follow-up. They were also similar between the group treated with cement (mean, 96 points) and that treated without cement (95 points). No component had aseptic loosening in either group. In one hip, a cemented femoral stem (2%) and a cementless cup were revised because of infection. Two cementless stems (2%) were revised because of fracture of the proximal part of the femur with loosening of the stem. Annual wear of the polyethylene liner averaged 0.22 mm in the group treated with cement (a zirconia head) and 0.14 mm in the group treated without cement (a cobalt-chromium head). The prevalence of osteolysis in zones 1 and 7 of the femur was 16% in the group treated with cement and 24% in the group treated without cement. CONCLUSIONS: Advancements in surgical technique and better designs have greatly improved the long-term survival of cemented and cementless implants in young patients with osteonecrosis of the femoral head. Although there was no aseptic loosening of the components, a high rate of linear wear of the polyethylene liner and a high rate of osteolysis in these high-risk young patients remain challenging problems.     

Bilateral cemented and cementless total hip arthroplasty

A subjective, clinical, and radiographic comparison was made between 140 primary cemented and cementless femoral components in 70 patients <50 years old who underwent bilateral simultaneous total hip arthroplasty. The average duration of follow-up was 7.8 years (range, 7-9 years). Hip scores were similar in both groups at the final follow-up. The prevalence of transitory thigh pain was 17% in the cementless group and 3% in the cemented group. No hip had subsidence or aseptic loosening of the acetabular or femoral components in either group. One cemented hip was revised for late infection, and 1 cementless hip was revised for recurrent dislocation. There was no difference in the incidence of osteolysis in the femur (9% in the cemented hip vs 13% in the cementless hip) and acetabulum (9% each) between the groups.     

Comparison of total hip arthroplasty performed with and without cement: a randomized trial. A concise follow-up, at twenty years, of previous reports

Total hip arthroplasty has been associated with excellent implant survival rates, but debate remains concerning the best fixation method for the components. A randomized controlled trial, which included 250 patients (mean age, sixty-four years) with osteoarthritis who were managed with total hip arthroplasty between October 1987 and January 1992, was conducted to compare the results of fixation with and without cement. Patients were followed for a mean of twenty years (range, seventeen to twenty-one years). Kaplan-Meier survivorship analysis at twenty years revealed significantly lower survival rates for cemented implants as compared with cementless implants. The cementless tapered stem had an extremely good survival rate of 99%. Radiographs showed evidence of mild stress-shielding around 95% of the cemented stems and 88% of the cementless stems; stress-shielding of grade 3 or greater was seen around the remaining 12% of the cementless stems.     

Results With the Cementless Spotorno Stem in Total Hip Arthroplasty

Increasingly young and active patients are undergoing total hip arthroplasty, making hip prosthesis survival rates an important issue. Cementless total hip arthroplasty provides better prosthesis longevity than does cemented hip arthroplasty, especially in younger patients. Because there is growing support in the literature for tapered geometry in cementless femoral components, we evaluated short-term results for total hip arthroplasty using Cementless Spotorno (CLS) titanium stems. We performed 100 consecutive primary cementless total hip arthroplasties in 87 patients during a 9-year period using CLS stems. Outcome was assessed in terms of survival rate and Harris Hip Score. The stem survival rate was 99%, and the average Harris Hip Score improved from 41 before surgery to 92 at a mean point of 5 years after surgery. Only 1 hip underwent stem revision for a periprosthetic shaft femur fracture caused by high-velocity trauma from a vehicle accident that occurred 6 months after the original surgery. The CLS stems have an excellent survival rate in the short term, especially in younger patients, but long-term studies are required to provide a fuller picture.     

Incidence of fat embolism syndrome after cemented or cementless bilateral simultaneous and unilateral total knee arthroplasty

This prospective study enrolled 100 patients undergoing unilateral total knee arthroplasty (TKA) and 100 patients undergoing bilateral simultaneous TKA. Bilateral simultaneous TKAs were done under 1 anesthesia with one side immediately following the other. To determine hemodynamic changes and to detect fat and bone marrow embolization, arterial and right atrial blood samples were obtained before insertion (baseline) and 1, 3, 5, and 10 minutes after insertion of the femoral alignment rod. Arterial and right atrial blood samples were obtained 1, 3, 5, and 10 minutes after insertion of the tibial component broach. Blood samples were obtained at 24 and 48 hours after the operation. Arterial blood pressure, heart rate, right atrial pressure, arterial oxygen tension, and carbon dioxide tension were monitored at corresponding times. The presence of fat was determined with oil red O fat stain, and the presence of cellular contents of bone marrow was determined with Wright-Giemsa stain. Fat embolism was found in 65 patients (65%) with a bilateral TKA and 46 patients (46%) with a unilateral TKA. Bone marrow cell embolism was found in 12 patients (12%) with a bilateral TKA and in 4 patients (4%) with a unilateral TKA. Six patients with positive bone marrow cells (2 patients with a unilateral TKA and 4 patients with a bilateral TKA) had neurologic manifestations.     

Simultaneous bilateral total hip arthroplasty with a cementless femoral stem

Simultaneous bilateral total hip arthroplasty (THA) is an increasingly common procedure. Although use of a cementless stem can eliminate cement complications, some surgeons limit application of cementless THA because of concerns about early implant loosening. In this article, we report on 30 cementless THA cases (15 patients) followed up for a minimum of 2 years (range, 26-50 months). Despite 73% of femoral bone being type B or type C, all stems showed stable bone ingrowth fixation and no evidence of subsidence. Polyethylene wear rates (left, 0.154 mm/y; right, 0.114 mm/y) did not differ significantly. The excellent clinical results obtained with simultaneous bilateral cementless THA are comparable with those obtained with unilateral THA.     

Fat embolism associated with cementing of femoral stems designed for press-fit application

The authors report four cases of fat embolism syndrome following total hip arthroplasty using cementless acetabular press-fit components and cemented press-fit femoral components. Factors implicated in the production of this syndrome following "hybrid" total hip arthroplasty include increased canal pressure during femoral reaming and prosthetic insertion, retained marrow elements and reaming debris, and the use of lumbar epidural anesthesia. This potentially fatal syndrome must be a recognized complication following the use of cemented press-fit femoral stems. Specific recommendations for decreasing the incidence of this complication are reviewed.     

Total hip arthroplasty after failed intertrochanteric valgus osteotomy for advanced osteoarthrosis.

Thirty hips that had undergone conversion total hip arthroplasty because of failed intertrochanteric valgus osteotomy for advanced osteoarthrosis were analyzed clinically and radiographically for more than 2 years. The average followup after total hip arthroplasty was 7 years (range, 2-18 years). The average age of the patients at the time of valgus osteotomy was 42 years (range, 30-63 years). The average age of the patients at the time of conversion total hip arthroplasty was 57 years (range, 43-76 years), and the average period between valgus osteotomy and conversion was 14 years (range, 3-24 years). Perioperative complications in conversion total hip arthroplasties were minimal, and intramedullary reaming was performed easily. Of the 30 conversion total hip arthroplasties, 12 cemented and 18 cementless components were used, respectively. Kaplan-Meier's survival analysis indicated that survivorship of cemented stems was significantly higher than that of conventional cementless stems. Cemented stems are preferable for conversion total hip arthroplasty after failed femoral valgus osteotomy.     

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.     

Fat embolism during total hip arthroplasty. Cementless versus cemented--a quantitative in vivo comparison in an animal model

Thrombembolic complications,which include the fat embolism syndrome, are well-known consequences of cementless and cemented femoral total hip replacement. Thrombembolic phenomena have been demonstrated in clinical and experimental situations with both these fixation techniques, but so far no exact quantification of the intravasated fat emboli has been performed. In a standardized animal model in 15 Merino sheep we investigated the intravasation of fat into the bloodstream during simultaneous bilateral prosthetic implantation (cemented versus cementless). After identical preparation of the intramedullary canal on both sides, a cement restrictor was additionally inserted on the cemented side and the canal was cleaned by 250 ml jet lavage. Catheters in the external iliac veins made it possible to collect the drained blood in two phases, after preparation of the intramedullary canal and during insertion of the prosthesis, and the fat content of these blood samples was measured. The amount of fat that passed into the venous draining system of the femur induced by cemented implantation (2.2749 g; S=+/-1.0079) was twice the amount seen with cementless implantation (1.1586 g; S=+/-0.4555) ( P=0.0002). An obvious effect of the canal preparation was recognizable with the cemented implantation, 8 of the 13 animals evaluated showing a peak in the fat intravasation caused by application of the cement restrictor. Our results emphasize the importance of a thorough preparation of the intramedullary canal, particularly when cemented fixation is performed. The jet lavage,which should be considered mandatory standard in cemented total hip arthroplasty, should be implemented before the insertion of the cement restrictor in order to further reduce the risk of fat embolism.     

Changes in tibial bone mass after primary cementless and revision cementless total hip arthroplasty in canine models

The purpose of this study was to examine right-left differences in tibial bone mass after unilateral (left) cementless total hip arthroplasty (THA). Of 39 dogs with THAs, 9 had primary cementless porous-coated femoral stems for 6 months and 15 had similar stems for 2 years. Five dogs had aseptically failed cemented hips, and 10 had aseptically failed cemented hips that were revised with cementless porous-coated femoral stems (5 without bone graft and 5 with autogenous bone graft). These animals were sacrificed 6 months after the revision surgery. The primary cementless dogs showed no right-left difference in tibial bone mineral content (BMC) or cortical bone cross-sectional geometry after 6 months, but after 2 years there was a distal right-left difference in BMC of 6% caused by expansion of the medullary canal in the tibia of the operated limb. Tibial BMC was more than 20% lower in the operated limb of the failed cemented dogs, approximately 15% lower in the nongrafted group, and 7% lower in the grafted group. The right-left tibial difference in BMC in the 2-year primary cementless group is most probably because of subclinical disuse of the operated limb. Among the dogs with failed cemented stems, the lower right-left difference in the two revised groups compared with the non-revised group suggests that improved limb function after cementless revision THA may cause gain of previously lost bone.     

Outcome of primary total hip arthroplasty in Charnley Class C patients with juvenile idiopathic arthritis: a case series

The outcome and complications of 37 primary total hip arthroplasties by one surgeon in 24 patients with Charnley Class C juvenile idiopathic arthritis with up to 19.6 years follow-up are reported. Twenty-six femoral components were cementless; all acetabular components were cementless with screws. Age at operation averaged 22.6 years. Two patients (3 hips) have died. Twelve hips in 9 patients have failed. Six cementless acetabular components with conventional polyethylene were revised because of osteolysis after 5.5 to 14.5 years. All 3 cementless C2 femoral stems with minimal porous coating failed. One of eight cemented AML Bantam stems loosened at 3.5 years; 2 of 23 cementless AML Bantam stems loosened at 9.5 and 19.6 years. Pain relief and functional improvement are dramatic after total hip arthroplasty in juvenile idiopathic arthritis; however, the long-term outcome is guarded.     

Comparison of cemented and cementless total hip arthroplasty in patients with bilateral hip arthroplasties

A consecutive series of 36 patients underwent primary cemented total hip arthroplasty followed by primary cementless total hip arthroplasty of the contralateral hip. Clinical pain scores between the cementless and cemented hips were not different. Subjectively, patients either had no preference or preferred the cementless side. Comparison of results in the same patient eliminates variability introduced by differences in sex, weight, comorbidities, bone quality, and activity level. Control of these factors permits more meaningful comparison of the type of fixation.     

The role of cemented stems in revision total hip arthroplasty

Cemented stems in revision total hip arthroplasty were reported to have unacceptably high rates of mechanical failure in early publications. This led to the development and current popularity of cementless revision stems, which have shown good results. However, there are still circumstances when cemented femoral revision can provide immediate, reliable fixation with comparatively good results, and this technique remains an important part of the arthroplasty surgeon's armamentarium. In this review, we will discuss the role of cemented stems in revision total hip arthroplasty, focusing on cement-in-cement revision, and impaction bone grafting of the femur.     

Fatal fat embolism during cemented total knee arthroplasty: a case report

Evidence is accumulating that embolization of bone marrow contents to the lungs can cause the hypotension, hypoxemia, cardiac arrest and death reported after total hip arthroplasty and that the embolism results from high intramedullary pressures exerted during implantation of the prosthesis. The authors describe such an occurrence in an 80-year-old man who had a cemented long-stem total knee prosthesis inserted. Autopsy revealed numerous pulmonary fat emboli that were distributed predominantly in arterioles and capillaries. The possibility of pulmonary fat microembolism occurring during cemented total knee arthroplasty should be recognized, particularly when prostheses with long intramedullary stems are used. Preventive or prophylactic measures that should be considered to avoid fat embolism during implantation include venting the intramedullary canal and meticulous lavage to clear away intramedullary debris. Increasing the inspired oxygen concentration as the prosthesis is inserted and monitoring of cardiopulmonary status to avoid simultaneous hypotension and hypoxemia may help to prevent the cardiopulmonary changes associated with pulmonary fat microembolism.     

Does Femoral Component Cementation Affect Costs or Clinical Outcomes After Hip Arthroplasty in Medicare Patients?

BackgroundBundled payment initiatives were introduced to reduce costs and improve quality of care. Cemented vs cementless femoral fixation is a modifiable variable that may influence the cost and quality of care. New bundled payment data from the Centers for Medicare and Medicaid Services allowed us to study the influence of femoral fixation strategy on (1) 90-day costs; (2) readmission rates; (3) reoperation rates; (4) length of stay (LOS); and (5) discharge disposition for Medicare patients undergoing total hip arthroplasty.MethodsWe retrospectively studied 1671 primary total hip arthroplasty Medicare cases, comparing 359 patients who received cemented femoral fixation to 1312 patients who received cementless fixation. Centers for Medicare and Medicaid Services cost data as well as clinical data were reviewed. Demographic differences were present between the 2 cohorts. Statistical analyses were performed, including multiple regression models to adjust for baseline differences.ResultsControlling for cohort differences, cemented patients were significantly more likely to be discharged home compared to cementless patients. Cemented patients also demonstrated trends toward lower costs, lower readmission rates, and shorter LOS compared to cementless patients. All reoperations within the early postoperative period occurred in patients managed with cementless femoral fixation.ConclusionAmong Medicare patients, cemented femoral fixation outperformed cementless fixation with respect to discharge disposition and also trended toward superiority with regards to LOS, readmission, cost of care, and reoperation. Cemented femoral fixation remains relevant and useful despite the rising popularity of cementless fixation.     

Results of 3,668 primary total hip replacements for primary osteoarthritis in patients under the age of 55 years

Background and purpose In a previous study based on the Finnish Arthroplasty Register, the survival of cementless stems was better than that of cemented stems in younger patients. However, the survival of cementless cups was poor due to osteolysis. In the present study, we analyzed population-based survival rates of the cemented and cementless total hip replacements in patients under the age of 55 years with primary osteoarthritis in Finland.

Patients and methods 3,668 implants fulfilled our inclusion criteria. The previous data included years 1980–2001, whereas the current study includes years 1987–2006. The implants were classified in 3 groups: (1) implants with a cementless, straight, proximally circumferentially porous-coated stem and a porous-coated press-fit cup (cementless group 1); (2) implants with a cementless, anatomic, proximally circumferentially porous-coated stem, with or without hydroxyapatite, and a porous-coated press-fit cup with or without hydroxyapatite (cementless group 2); and (3) a cemented stem combined with a cemented all-polyethylene cup (the cemented group). Analyses were performed separately for 2 time periods: those operated 1987–1996 and those operated 1997–2006.

Results The 15-year survival for any reason of cementless total hip replacement (THR) group 1 operated on 1987–1996 (62%; 95% CI: 57–67) and cementless group 2 (58%; CI: 52–66) operated on during the same time period was worse than that of cemented THRs (71%; CI: 62–80), although the difference was not statistically significant. The revision risk for aseptic loosening of cementless stem group 1 operated on 1987–1996 (0.49; CI: 0.32–0.74) was lower than that for aseptic loosening of cemented stems (p = 0.001).

Interpretation Excessive wear of the polyethylene liner resulted in numerous revisions of modular cementless cups. The outcomes of total hip arthroplasty appear to have been relatively unsatisfactory for younger patients in Finland.