Increased urinary crosslink levels in aseptic loosening of total hip arthroplasty

The diagnosis of aseptic loosening in total hip arthroplasty is predominantly based on clinical and radiographic evaluation. Loosening is usually associated with increased bone resorption at the interface. In this study we wanted to evaluate the diagnostic value of bone markers in aseptic loosening. We compared 50 patients with proven component loosening during surgery with 50 age-, sex-, and implant-matched patients without clinical or radiological signs of loosening. We measured serum markers of bone formation (bone-specific alkaline phosphatase, osteocalcin [OC], procollagen type I propeptides) and bone resorption (collagen n-telopeptide [NTX], deoxypyridinoline [DPYD], pyridinoline [PYD]). We found significantly increased levels of NTX, DPYD, PYD, and OC in the loosening group. The other markers showed no significant difference between both groups. We conclude that determination of urinary crosslinks may offer a new and valuable diagnostic method in the detection of aseptic loosening in total hip arthroplasty.     

Bone mineral density and biochemical markers of bone turnover in aseptic loosening after total hip arthroplasty.

The aims of this study were to determine whether subjects with aseptic loosening after total hip arthroplasty (THA) have regional differences in periprosthetic bone mineral density (BMD) and systemic biochemical markers of bone turnover compared to subjects with successful implants.Proximal femoral and pelvic BMD were measured by dual energy X-ray absorptiometry and bone turnover markers were assayed in 49 subjects 12.6+/-4.3 (mean+/-SD) years after cemented THA. Femoral BMD was lower in Gruen zones 2, 5, 6, and 7 in subjects with a loose femoral implant (n=17) compared to those (n=32) with fixed femoral implants (P<0.05 all comparisons). This BMD difference was greatest (-31%, P=0.02) in the proximal and medial region of the femur. Subjects with femoral loosening had higher levels of the bone resorption marker N-telopeptides of type-I collagen (P=0.02) than those with a fixed femoral implant. No differences in pelvic BMD or bone turnover markers were found between subjects with loose (n=18) versus fixed (n=31) pelvic implants.This study suggests that failure of femoral components after cemented THA is associated with region-specific decreases in BMD and an increase in urinary excretion of N-telopeptide cross-links of type-I collagen. These surrogate outcome markers may be of value in monitoring response to antiresorptive therapies used to treat periprosthetic osteolysis, although the diagnosis of aseptic loosening remains clinical and radiological.     

Effect of osteonecrosis on bone density and its management on the results of revision arthroplasty of the hip]

128 hips after revision arthroplasty in 115 patients which had been operated in our Ward in 1990-2001 were retrospectively evaluated. There were 99 women and 16 men with mean age: 68.9 years old. The mean time of follow-up was 28.6 months (form 3 to 120 months). In 98 hips there were aseptic loosening of the both elements of the prosthesis, in 13 hips there were aseptic loosening of the stem, in 17 hips there were aseptic loosening of the cup only. Cement total hip rearthroplasty was made in 112 cases and cementless total hip rearthroplasty was made in 16 hips. In presented material there were used the acetabular bone grafts in 114 cases, and the femoral bone grafts in 97 cases--all with allogenic frozen bone grafts. The additional implants were used in 31 cases (meshwork, wire, screw). The bone defects in acetabulum and femoral stem was based on Paprovsky classification. There were good and excellent results in 90% and poor or bad results in 10% according to clinical and radiological evaluation. Mean clinical result was 78.5 p. in Harris Hip Score. The radiological results were poor in 13 hips (according to criterion proposed by joined committee of The Hip Society, SICOT and AAOS). Osteointegration of bone allografts was radiologically confirmed in 81% of cases. Complication rates is 20%. There is no correlation between the type of acetabular or femoral bone defects and results of revision hip arthroplasty. Poor results are correlated with use of SKT or Weller stem. Wagner femoral osteotomy and the lack of bone allografts healing.     

Three-Year Follow Up Utilizing Tantal Cones in Revision Total Knee Arthroplasty

There still is no consensus on the treatment of choice in revision knee arthroplasty associated with severe femoral and/or tibial bone loss. A total of 44 patients underwent revision knee arthroplasty procedures using porous tantalum cones (TM cones) to reconstruct tibial and/or femoral bone defects. At latest follow up after 37 months (32–48), 38 patients remained in the study. Tibial and femoral bone loss was categorized according to the AORI-Classification. The average preoperative KSS improved from 34 (range, 6–90) to 63 points (range, 7–90 points). The VAS improved from 7.5 to 4.8. Two patients required a re-revision due to aseptic loosening. There was no correlation between the different types of knee prosthesis implanted. Our study shows favourable clinical and radiological outcomes using TM cones in managing significant bone loss in revision total knee surgery.     

Effect of risedronate on bone metabolism after total hip arthroplasty: a prospective randomised study

Aseptic loosening due to bone remodeling and osteolysis is the main reason for revision hip arthroplasty. At present, there is no established prophylaxis for this complication. On the other hand, it has been demonstrated that bisphosphonates prevent bone loss around total hip arthroplasties (THA). The aim of this study was to assess the efficacy of oral bisphosphonate risedronate for the prevention of deleterious changes in bone metabolism after hip replacement. Twenty-four patients who underwent THA were randomised to two treatment arms: 35 mg risedronate once weekly for 6 months (12 patients) and no treatment for controls (12 patients). Markers of bone turnover bone specific alkaline phosphatase, serum osteocalcin and urinary deoxypiridinoline were evaluated at baseline, third and sixth postoperative month. Dual energy X-ray absorptiometry of the nonsurgical hip was performed preoperatively and at 6 months postoperatively. There were no significant differences in clinical or radiographic findings between the two groups at either 3 or 6 months. In the two groups, all biochemical marker responses at the third postoperative month were suppressed compared with baseline. Values of bone resorption marker urinary deoxypiridinoline increased significantly at six months in the control group. For the 10 risedronate patients with bone densitometry bone mineral density reached 1.01% increase at 6 months. Administration of oral risedronate led to a significant reduction in bone metabolism at 6 months after hip replacement. This therapeutic strategy may improve the results and longevity of total hip arthroplasty. The beneficial effect of risedronate should be confirmed in further studies including larger number of patients and longer follow-up. The action of risedronate could prevent aseptic loosening of hip arthroplasty by preserving periprosthetic bone stock.     

Boneloc bone-cement: experience in hip arthroplasty during a 3-year period

Polymethyl methacrylate (PMMA) bone-cement was introduced in the 1960s for fixation of total hip arthroplasty replacement components. Long-term results of cement fixation for hip and knee arthroplasty have been extremely good. Although the use of PMMA bone-cement has enabled long-term survival of joint arthroplasty implants, there has been concern about aseptic loosening. This concern led to the introduction of Boneloc bone-cement (Biomet, Warsaw, IN) in the early 1990s. It was hoped that with the improved physical and chemical characteristics of Boneloc, there would be less aseptic loosening in the long-term. A clinical trial was conducted to evaluate Boneloc bone-cement in cementing the femoral component of the Bimetric total hip arthroplasty prosthesis in 33 hips in 32 patients. On follow-up, 7 stems (24%) developed definite loosening, and 3 stems (10%) were possibly loose. Of the 7 definite loose stems, 5 (17%) were revised because of increasing pain or progressive loosening. Despite the biologic advantages of Boneloc, this study suggests that the chemicals substituted in Boneloc bone-cement led to an alteration in its mechanical properties. These properties proved to be inferior to conventional PMMA bone-cement. There is possible time-dependent deterioration of mechanical properties leading to early aseptic loosening. The conventional PMMA bone-cement has stood the test of time. Research and experimental studies should continue to improve the mechanical properties of Boneloc before further human trials.     

Modulare Femurendoprothese, bestehend aus einer Kombination von Kopfteil und Marknagel, bei Knochendefektsituationen des Femurs

There is an increasing number of patients with bone defects of the femur requiring primary or revision arthroplasty of the hip. Especially problematic in this respect are trochanteric fractures, periprosthetic fractures and aseptic loosening. We report about certain technical aspects, the postoperative course as well as clinical and radiological results after implantation of a modular hip prosthesis for these indications. The modular hip prosthesis consists of a separate head and shaft component with a stem similar to a femoral nail. One hundred and nine patients were prospectively recorded. Hospital mortality was 4.2% and as major surgical complications there were 6 femoral fractures which occurred intraoperatively. Follow-up (mean 13,2 months) could be completed for 48 patients (25 patients had already died). Two patients showed aseptic loosening of modular hip prosthesis and revision with a cemented prosthesis was necessary. In 2 patients with a condition following a periprosthetic fracture radiological signs of loosening could be detected. Quality of life assessed by a modified Harris Hip Score was comparable to the situation prior the fracture or even better in the group following the implantation of modular hip prosthesis because of aseptic loosening. Depending on the fact that 2 individual components, each of which coming in different sizes, can be assembled, the device shows a high degree of variability for different indications. Radiological and clinical results are good, however, follow-up time is too short for final evaluation. Periprosthetic fractures have to be treated more frequently by additional bone grafting in order to improve osseointegration of modular hip prosthesis.     

The ScanHip ® total hip arthroplasty: Radiographic assessment of 72 hips after 10 years

We analyzed the radiographic and clinical outcome of the ScanHip total hip arthroplasty in 70 patients after 10 years. The Swedish National Hip Register, in which the end-point of the survival analysis is defined as revisions, reported a 10-year survival rate of 94% with the ScanHip, but in the present series 13% of the femoral stems and 29% of the sockets met the criteria for aseptic loosening. Focal osteolysis was found around 8 sockets (11%) and 23 stems (32%) and had occurred significantly oftener around loose sockets, but not around femoral stems. Linear polyethylene wear was significantly increased in loose sockets, but no relationship was noted between polyethylene wear and stem loosening or was there a correlation between clinical symptoms or patients' satisfaction and component loosening. Therefore precise serial long-term radiographic follow-up is the only satisfactory method for detecting aseptic loosening of total hip arthroplasty. It gives the surgeon more detailed information about each case than survival analysis alone.     

The ScanHip total hip arthroplasty: radiographic assessment of 72 hips after 10 years

We analyzed the radiographic and clinical outcome of the ScanHip total hip arthroplasty in 70 patients after 10 years. The Swedish National Hip Register, in which the end-point of the survival analysis is defined as revisions, reported a 10-year survival rate of 94% with the ScanHip, but in the present series 13% of the femoral stems and 29% of the sockets met the criteria for aseptic loosening. Focal osteolysis was found around 8 sockets (11%) and 23 stems (32%) and had occurred significantly oftener around loose sockets, but not around femoral stems. Linear polyethylene wear was significantly increased in loose sockets, but no relationship was noted between polyethylene wear and stem loosening or was there a correlation between clinical symptoms or patients' satisfaction and component loosening. Therefore precise serial long-term radiographic follow-up is the only satisfactory method for detecting aseptic loosening of total hip arthroplasty. It gives the surgeon more detailed information about each case than survival analysis alone.     

Biochemical markers of bone turnover in aseptic loosening in hip arthroplasty

The aim of this study was to determine the diagnostic value of systemic biochemical markers of bone turnover in aseptic loosening in hip arthroplasty, namely the urine levels of three bone resorption peptides – crosslinked n-telopeptides (NTX), c-telopeptides (CTX I) and deoxypyridinoline (DPD). We compared 52 patients with surgically proven component loosening with 52 patients without clinical or radiological signs of endoprosthetic loosening and 52 healthy individuals. All three markers were measured using commercially available enzyme-linked immunoassays. We found significantly increased levels of DPD in the loosening group (p < 0.05), but there was no significant difference between the loosening group and the two reference groups for the other two markers tested. Our data suggest that DPD can be used as an additional tool in the diagnosis of aseptic loosening in hip arthroplasty but CTX I and NTX have no predictive value in this context.

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Résumé  Le but de cette étude est de déterminer la valeur diagnostic de marqueurs bio-chimiques dans le descellement aseptique des prothèses totales de hanche, en mesurant un certain nombre peptides issus de la résorption osseuse (crosslinked n-telpeptides [NTX], c-telpepetides [CTX I] et deoxypyridinoline [DPD]. nous avons comparé les paramètres de 52 individus présentant un descellement aseptique à 52 individus sains. Tous les paramètres ont été mesurés par la méthode ELISA. nous avons trouvé une augmentation significative des DPD dans le groupe prothèses descellées (p < 0.05). Il n’y a pas de différence significative entre les deux groupes pour les autres marqueurs. nous suggérons que la DPD peut être utilisée comme un marqueur additionnel du diagnostic des descellements aseptiques des prothèses totales de hanche par contre, il n’y a pas de valeurs prédictives pour les marqueurs CTX1 et NTX.

     

Bone graft incorporation after revision hip arthroplasty in patients with rheumatoid arthritis, seventy eight revisions using bone allografts with or without metal reinforcements

Purpose

The aim of the study was to assess bone graft incorporation after revision hip arthroplasty in patients with rheumatoid arthritis (RA).

Methods

We report an acetabular reconstruction using impacted, morselized, frozen, radiation sterilized bone allografts in 71 patients suffering from RA. There were sixty-six women and five men at a mean age of 57.5 years. Reconstruction was performed in 78 revision total hip arthroplasties (THAs) for aseptic loosening of acetabular component. The mean follow-up was five years and four months. In 38 cases, a revision was done with use of reinforcement devices.

Results

In four revised hips (10 %) without reinforcement implants, resorption of the allografts was noticed. All Mueller rings and 50 % of unscrews cages (Link, Howmedica) were revised because of aseptic loosening and bone graft resorption. In all of 17 hips with the Burch-Schneider cage, no measurable migration or bone allografts resorption occurred. There were no major general complications.

Conclusions

Acetabular reconstruction with use of morselized, frozen, radiation sterilized bone allografts and the Burch-Schneider cage can be highly successful in managing massive deficiency of acetabular bone stock in revision hip arthroplasty in RA patients.     

假体周围组织冰冻切片对诊断髋关节假体无菌性松动的特异性分析

[目的]评价冰冻切片对诊断髋关节假体无菌性松动的作用.[方法]回顾分析了57例(63髋)因髋关节无菌性松动行髋关节翻修的病例,将冰冻切片和石蜡切片结果进行病理学分级,将至少5个高倍镜视野、每个高倍镜视野的中性粒细胞数≥5个视为切片结果阳性；以之前文献报道的无菌性松动的诊断标准为参照标准,计算冰冻切片的特异性、符合率.[结果]冰冻切片的特异性为96.8％,冰冻切片和石蜡切片诊断假体无菌性松动时符合率为96.8％.[结论]在全髋关节翻修术中利用组织冰冻切片进行诊断性检查来确定是否存在感染时要注意冰冻切片和石蜡切片的偏差.     

Uncemented acetabular components with bulk femoral head autograft for acetabular reconstruction in developmental dysplasia of the hip: results at five to twelve years.

BACKGROUND: Anterolateral acetabular bone deficiency is one of the technical problems associated with total hip arthroplasty in patients with developmental hip dysplasia. The purpose of this study was to evaluate the results of one method of acetabular reconstruction for hip dysplasia-placement of an uncemented socket in conjunction with a bulk femoral head autograft. METHODS: Forty-four hips in thirty-five patients (twenty-nine female and six male; average age, thirty-nine years) with developmental hip dysplasia were treated with primary total hip arthroplasty with use of an uncemented porous-coated titanium cup fixed with screws and an autogenous bulk femoral head graft. The patients were followed clinically in a prospective fashion for five to 12.3 years (mean, 7.5 years), and radiographs were analyzed retrospectively. RESULTS: Four acetabular components were revised: two, because of severe polyethylene wear and osteolysis; one, because of aseptic loosening; and one, because of fracture of the acetabular shell. The mean Harris hip score for the unrevised hips improved from 51 points preoperatively to 91 points postoperatively. No unrevised socket had definite radiographic evidence of loosening. Forty-three of the forty-four hips had no radiographic evidence of resorption of the graft or had radiographic evidence of resorption limited to the nonstressed area of the graft lateral to the edge of the cup. CONCLUSIONS: This method of reconstruction provided reliable acetabular fixation and appeared to restore acetabular bone stock in patients with developmental hip dysplasia. We use this technique for patients with moderate anterolateral acetabular bone deficiency requiring total hip arthroplasty.     

Treatment of femoral bony defects with a modular hip prosthesis and distal interlocking

Patients with bony defects of the proximal femur after trochanteric fracture, implant failure (cut-out), periprosthetic fracture or aseptic loosening of prosthesis are difficult to treat with primary or revision endoprosthesis. Modular femoral hip prosthesis (MHP) with stems of different length and the possibility of distal interlocking screws are an operative solution for those patients. In a prospective study from January 1996 to January 2002 all patients treated with a MHP because of proximal and / or distal femoral bony defect or fracture were included. Follow-up after 6 to 30 months was evaluated clinically and radiologically in hospital. Change of modified Harris Hip Score and radiological signs of loosening (radiolucent line, migration of MHP, breaking interlocking screw) were documented. 106 patients with a follow-up of 58.5 % were included in the study. At time of follow-up clinical and radiological outcome after trochanteric fracture was good. Harris Hip Score was comparable to the situation of patients before fracture, only one MHP was loose. However in patients after revision arthroplasty 25 % of MHP were loose and in many patients the interlocking screw was broken. Distal interlocking screw in MHP prevents stability after trochanteric fracture to achieve osseointegration. However in case of periprosthetic fracture or revision arthroplasty MHP shows insufficient stability in many cases.     

The fate of cementless jumbo cups in revision hip arthroplasty

We report 5-year minimum results of cementless over-sized cups used in revision hip arthroplasty, with significant associated bone defects. Forty-three porous-coated jumbo cups were used to treat acetabular defects in revision hip arthroplasty in 42 patients with a mean age of 63 (range, 25-86). Morsellized allograft only was used in 27 hips, and bulk allograft was used in 8 cases. Two patients were lost to follow-up, and 5 died after a mean 7 years' follow-up, with retention of their prostheses. In the remaining 36 cases, the mean follow-up was 10 years (range, 6-14 years). Two acetabular components were revised for aseptic loosening and graft resorption. Two cases were complicated by dislocation. A satisfactory 92% Kaplan Meier shell survival rate was seen at 14 years.     

人工髋关节置换术后假体无菌性松动的临床及影像学评估

人工髋关节置换术(THA)后假体无菌性松动问题始终是临床上存在并需要解决的问题。通过临床及放射学检查，观察分析假体松动的表现与过程，对于人工髋关节置换术后假体松动的及时临床处理及预防均有指导意义。本对人工髋关节置换术后假体无菌性松动的临床及影像学评估方法进行了回顾和分析，指出临床及各影像学评估方法的意义，提出正确的评估原则。     

Metal-on-Metal Hip Arthroplasty Does Equally Well in Osteonecrosis and Osteoarthritis

Many previous reports suggest total hip arthroplasty performs suboptimally in young patients with osteonecrosis. We retrospectively compared the performance of metal-on-metal articulation in a select group of 107 patients with 112 hips (98 uncemented and 14 cemented stems) 60 years of age or younger with either osteonecrosis (27 patients, 30 hips) or primary osteoarthritis (80 patients, 82 hips). We evaluated all patients with patient-generated Harris hip score forms and serial radiographs. Five mechanical complications were caused by impingement, two with pain, two dislocations, and one liner dissociation. At a minimum followup of 2.2 years (mean, 5.5 years; range, 2.2-11.7 years), we observed no osteolysis or aseptic loosening in the osteonecrosis group, whereas one osteoarthritic hip had cup revision for loosening (none showed evidence of osteolysis). None of the stems were loose. Patients with osteonecrosis or primary osteoarthritis were similar in clinical and radiographic performance. The patients with metal-on-metal hip arthroplasty for osteonecrosis had no revisions for aseptic loosening, but did have one liner change in a cup for painful impingement.     

Excellent long-term results of the Müller acetabular reinforcement ring in primary total hip arthroplasty

Background and purpose — The original Müller acetabular reinforcement ring (ARR) shows favorable medium-term results for acetabular reconstruction in total hip arthroplasty, where it is used when the acetabular bone stock is deficient. However, there are no data regarding long-term survival of the device. We therefore investigated long-term survival and analyzed radiological modes of failure.

Patients and methods — Between 1984 and 2002, 321 consecutive primary arthroplasties using an ARR were performed in 291 patients. The mean follow-up time was 11 (0–25) years, and 24 hips were lost to follow-up. For survival analysis, we investigated 321 hips and the end of the follow-up was the date of revision, date of death, or the last patient contact date with implant still in situ. Radiological assessment was performed for 160 hips with a minimum of 10 years of follow-up and with radiographs of sufficient quality. It included evaluation of osteolysis, migration, and loosening.

Results — 12 ARR THAs were revised: 1 isolated ARR revision for aseptic loosening, 4 revisions of the ARR and the stem for aseptic loosening, 6 for infection, and 1 for recurrent dislocation. The cumulative revision rate for all components, for any reason, at 20 years was 15% (95% CI: 10–22), while for the ARR only it was 7% (95% CI: 4–12) for any reason and 3.4% (95% CI: 1–9) for aseptic loosening. 21 (13%) of 160 ARR THAs examined had radiological changes: 7 had osteolysis but were not loose, and 14 were radiologically loose but were not painful and not revised.

Interpretation — Our data suggest that the long-term survival of the ARR is excellent.     

Endosteal femoral bone loss after hip rearthroplasty

The cortical bone area of the middle femur was investigated with computed tomography in 12 patients after hip rearthroplasty due to aseptic prosthetic loosening. The patients had undergone their original arthroplasty because of unilateral arthrosis 11 years before these measurements. Both legs were scanned, and the reoperated side was compared with the healthy side. A control group was chosen of 13 patients with unilateral hip arthroplasty because of unilateral arthrosis, but without subsequent rearthroplasty. In the patients who had undergone rearthroplasty, there was an 11% loss in endosteal bone area of the middle femur compared with the contralateral side. In the control group (non-reoperated patients), only a loss of 6% was found compared with the contralateral side. The periosteal bone area of the reoperated femur and the non-reoperated femur showed no significant change compared with the corresponding healthy side. The larger endosteal resorption noted among patients in the rearthroplasty group could be ascribed to the primary prosthetic failure and could also contribute to further aseptic prosthetic loosening.     

Does bone quality predict loosening of cemented total hip replacements?

We matched 78 patients with a loose cemented Charnley Elite Plus total hip replacement (THR) by age, gender, race, prosthesis and time from surgery with 49 patients with a well-fixed stable hip replacement, to determine if poor bone quality predisposes to loosening. Clinical, radiological, biomechanical and bone mineral density indicators of bone quality were assessed. Patients with loose replacements had more pain, were more likely to have presented with atrophic arthritis and to have a history of fragility fracture, narrower femoral cortices and lower peri-prosthetic or lumbar spine bone mineral density (all t-test, p < 0.01). They also tended to be smokers (chi-squared test, p = 0.08). Vitamin-D deficiency was common, but not significantly different between the two groups (t-test, p = 0.31) In this series of cemented hip replacements performed between 1994 and 1998, aseptic loosening was associated with poor bone quality. Patients with a THR should be screened for osteoporosis and have regular radiological surveillance.