Fifteen-Year Comparison of Wear and Osteolysis Analysis for Cross-Linked or Conventional Polyethylene in Cementless Total Hip Arthroplasty for Hip Dysplasia—A Retrospective Cohort Study

Background

Cross-linked polyethylene (XLPE) acetabular liners used in cementless total hip arthroplasty (THA) have demonstrated better wear resistance at 10 years compared with conventional polyethylene (CPE) liners. No clinical studies have compared XPLE to CPE liners beyond 10 years.

Computed Tomographic Osteolytic Analysis of a First-Generation Remelted Highly Cross-Linked Polyethylene in Total Hip Arthroplasty—At a Minimum of 15-Year Follow-Up

BackgroundLow polyethylene wear rate and low incidence of osteolysis have been reported after total hip arthroplasty (THA) using first-generation remelted highly cross-linked polyethylene (HXLPE). However, osteolysis has not been evaluated in long-term studies of these patients (15 years or more). The present study assessed computed tomography (CT) images to determine the incidence of osteolysis associated with HXLPE in THA during at least 15 years of follow-up.MethodsWe evaluated 105 primary THAs in 84 patients (77 women and 7 men). Mean follow-up was 15.9 years (range, 15-18 years). All THAs used a Longevity HXLPE liner and a 26-mm zirconia femoral head. Areas of osteolysis were identified from CT images using 3D and multiplanar reconstruction views.ResultsCT 3D multiplanar reconstruction images at 15-year follow-up showed no obvious osteolysis in the acetabulum or femur of any patient. No patients developed cup loosening or liner breakage.ConclusionOur study indicates that first-generation remelted HXLPE liners do not increase the risk of osteolysis during 15-year follow-up and suggests that the wear particles from first-generation remelted HXLPE are less biologically active than those generated by conventional polyethylene devices.     

Ten- to Sixteen-Year Follow-Up of Highly Cross-Linked Polyethylene in Total Hip Arthroplasty: What Factors Affect Wear?

BackgroundIncrease in acetabular cup abduction in total hip arthroplasty (THA) using conventional polyethylene is associated with greater linear wear. Whether this relationship holds true for highly crosslinked liners, particularly with long-term follow-up, is still controversial. The effect of liner thickness on wear of highly cross-linked liners also remains to be clarified.This study sought to determine (1) the long-term clinical and radiological performance of highly cross-linked polyethylene in THA and (2) the effect of acetabular component positioning, polyethylene thickness, and patient demographics on wear.MethodsNinety-three THAs using a 28-mm hip ball, single brand of highly cross-linked polyethylene liner, and cementless cup were performed in 87 patients. Clinical outcomes were evaluated using the Harris Hip Score and need for revision surgery. Linear and volumetric wear, presence of osteolysis, and cup abduction angle were assessed.ResultsThe mean age at operation was 51.4 years. The mean duration of follow-up was 12.7 years (10-16 years). Patients aged >50 years had higher rates of linear wear than those aged <50 years (P = .015). Positive correlation was found between cup abduction angle (P = .014) and cup version (P = .035) with a linear wear rate. Thinner liners (≤7 mm) had similar rates of linear and volumetric wear as thicker liners (≥8 mm) (P = .447).ConclusionThis is the only study to demonstrate a positive significant relationship between cup abduction angle and version with linear wear rate in THA with at least 10 years of follow-up. Liner thickness was not found to affect wear rates.     

No Differences Found in Bearing Related Hip Survivorship at 10–12 Years Follow-Up Between Patients With Ceramic on Highly Cross-Linked Polyethylene Bearings Compared to Patients With Ceramic on Ceramic Bearings

At a minimum follow-up of ten years we compared clinical and radiographic findings and survivorship in a cohort of 412 patients (447 hips) who received alumina on alumina CoC bearings to findings from a cohort of 216 patients (228 hips) with alumina on highly cross-linked polyethylene (HXLPE) bearings. All patients were operated for osteoarthritis. With bearing-related complications as endpoint, analysis showed no significant difference in survivorship between cohorts (99.8% for the CoC vs. 99.4% for HXLPE). In addition, there were no significant differences in clinical and radiographic findings between cohorts. We concluded that alumina on HXLPE bearings are a reasonable lower cost alternative to ceramic on ceramic bearing couples.     

CORR Insights®: High Survivorship and Few Complications With Cementless Total Wrist Arthroplasty at a Mean Followup of 9 Years

Clinical Orthopaedics and Related Research® -     

Long-Term Outcomes of Ultra-Short Metaphyseal-Fitting Anatomic Cementless Femoral Stem in Total Hip Arthroplasty With Ceramic-on-Ceramic Articulation for Young Patients

BackgroundThe aim of this study is to assess the long-term outcomes of this specific stem in patients younger than 50 years old, with regard to clinical and radiographic outcomes, survivorship, and complication rate.MethodsTwo hundred thirty-nine consecutive series of patients (324 hips) who were younger than 50 years old at the time of surgery were enrolled in the study. Osteonecrosis (50%) and dysplastic hip (34%) were most common diagnoses. Patients were informed to use crutches or walker for 4 weeks to protect the femoral component against rotational stress. The mean follow-up was 15.6 years (range 14-17).ResultsAt the latest follow-up, the mean Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index score, and University of California, Los Angeles activity score were 93 points, 13 points, and 7 points, respectively. Three patients (1.3%) had moderate thigh pain. All of the acetabular components and 321 (99%) femoral stems were solidly fixed at the time of the latest follow-up. Three stems (0.9%) were revised for aseptic loosening. Two hips (0.6%) had a dislocation and 2 hips (0.6%) had a periprosthetic fracture. Ceramic fracture or osteolysis was not found in any hip at the time of the final follow-up. Survival rate of the femoral component was 99.1% (95% confidence interval 94-100) and that of the acetabular component was 100% (95% confidence interval 94-100) at 15.6 years.ConclusionIn this series, THA using an ultra-short metaphyseal-fitting anatomic cementless femoral stem provided excellent long-term clinical and radiographic results in patients younger than 50 years old. Furthermore, our initial theoretical concerns about early aseptic loosening due to the absence of distal stem fixation were not justified.     

The Ideal Total Hip Replacement Bearing Surface in the Young Patient: A Prospective Randomized Trial Comparing Alumina Ceramic-On-Ceramic With Ceramic-On-Conventional Polyethylene: 15-Year Follow-Up

Background

The optimum bearing surface for total hip arthroplasty remains debatable. We have previously published our outcome at 10 years and this represents the 15-year follow-up.

Does Highly Cross-Linked Polyethylene Wear Less Than Conventional Polyethylene in Total Hip Arthroplasty? : A Double-Blind,Randomized, and Controlled Trial Using Roentgen Stereophotogrammetric Analysis

A prospective double-blind, randomized, and controlled trial was conducted using roentgen stereophotogrammetric analysis; 54 total hip arthroplasty patients were randomized to receive either highly cross-linked polyethylene (HXLPE) or standard ultra-high-molecular-weight polyethylene (UHMWPE) liners. The 3-dimensional penetration of the liner was determined over 2 years. For the first 3 months, both polyethylene types had a rapid penetration rate (HXLPE: 0.22 mm, SD = 0.17 mm; UHMWPE: 0.21 mm, SD = 0.15 mm; P = .78). After 3 months, the HXLPE penetration rate (0.06 mm/y, SD = 0.06 mm/y) was significantly lower than the UHMWPE penetration rate (0.10 mm/y, SD = 0.07 mm/y; P = .04). The penetration in the first 3 months was probably caused by creep or bedding in; from 3 months onward, much of the penetration was probably caused by wear. We conclude that HXLPE has a 40% lower wear rate as compared with UHMWPE, suggesting that it will perform better in the long term.     

Follow-Up Results of 10–12 Years After Total Hip Arthroplasty Using Cementless Tapered Stem — Frequency of Severe Stress Shielding With Synergy Stem in Japanese Patients

Synergy stems are tapered stems featuring a proximal porous coating, grid blasting below the proximal third to the distal end. This study included 41 patients (50 hips) who underwent total hip arthroplasty with follow-ups for 10 years or more. No stem reimplantations were performed. Spot welds were observed in the distal stem in Gruen zones 3 and 5 in 35 and 32 hips, respectively. First-degree stress shielding occurred in 8 hips; 2nd-degree, 20 hips; 3rd-degree, 13 hips; and 4th-degree, 9 hips. Because of bone fixation to the distal grit-blasted section of the stem, severe stress shielding was observed in nearly half of the cases. Multiple regression analysis of stress shielding determinants revealed a correlation between stem size and short patient height, showing the cause of stress shielding to be a mismatch in size between the stem and the femoral bone.     

Comparable Cumulative Incidence of Late Periprosthetic Femoral Fracture and Aseptic Stem Loosening in Uncemented Total Hip Arthroplasty—A Concise Follow-Up Report at a Minimum of 20 Years

Background

There is a lack of long-term studies into the third decade reporting on the incidence of periprosthetic femoral fracture (PPFF) and aseptic stem loosening (ASL) after cementless total hip arthroplasty (THA). The aim of the present retrospective, longitudinal cohort study was to compare the cumulative incidence of PPFF and ASL in a consecutive cohort of 326 patients with 354 primary uncemented THAs after 20-25 years and to identify risk factors being associated with PPFFs.

Long-Term Nonoperative Management is Associated With Lower Mean 9-Year Follow-Up Survival Compared to Total Knee Arthroplasty in Knee Osteoarthritis Patients—Survival Analysis of a Nationwide South Korean Cohort

BackgroundTotal knee arthroplasty (TKA) and medications are both considered as a treatment for knee osteoarthritis. However, the impact of the TKA on long-term survival remains controversial. This study aimed to compare 9-year follow-up survival between a TKA group with a nonoperative medication group.MethodsFrom 2007 to 2009, knee osteoarthritis patients were divided into TKA (N = 2,228) and nonoperative medication (N = 76,430) groups, and followed for up to 9 years. The hazard ratio (HR) and subdistribution HR (SHR) were derived from Cox proportional hazards regressions and Fine and Gray analyses, respectively.ResultsThe TKA group had a significantly lower adjusted mortality rate (adjusted HR , 0.78, 95% confidence interval [CI], 0.68–0.9) than the nonoperative medication group. Dose-response relationship between medication possession ratio and mortalities for overall (adjusted HR , 1.02; 95% CI, 1.01-1.04) and cardiovascular (CV) death (adjusted SHR, 1.03; 95% CI, 1.01-1.05) was also found. Also, there were significant interactions that indicate stronger protective survival effects of the TKA in several covariates: age >75 years (P = .04 for overall; P = .009 for CV), hypertension (P = .006 for overall), and ischemic heart disease (P = .009 for CV).ConclusionsThis study suggests that TKA patients had better mean 9-year follow-up survival than the nonoperative medication group after adjusting for baseline differences. For overall death, including CV death, adjusted mortality rates were higher in the medication group and showed a dose-response relationship. Specifically, the protective effect of the TKA for overall or CV deaths was found to be higher for age >75, hypertension, or ischemic heart disease patients.Level of EvidenceIII.     

Isolated Liner Exchange in Total Hip Arthroplasty at a Mean of 13 Years of Follow-up: Does Fixation Technique Matter?

BackgroundIsolated liner exchange is an option to address polyethylene wear after total hip arthroplasty (THA). The liner can be fixed with either the original locking mechanism or cemented into the acetabular cup. Whether the method used for liner fixation has any bearing on the outcomes in the first and second decade after surgery is still unclear.MethodsData for all patients who had undergone isolated liner exchange surgery in our institution between April 1995 and January 2015 were retrieved. Patients were classified according to the type of polyethylene liner (conventional or highly crosslinked polyethylene) and the locking mechanism used (original locking mechanism or cemented). Survivorship and revision rates were compared among different subgroups. A total of 118 isolated liner exchanges were performed and patients had a mean duration of follow-up of 13 years (range, 5 to 25).ResultsOverall estimated mean survivorship was 17 years. Use of highly crosslinked polyethylene (HXLPE) had a lower re-revision rate compared to conventional liners (10.5 versus 46.9%) (P < .001). The re-revision rate of exchanges using HXLPE was not affected by the type of fixation (original locking mechanism 11.1 versus cement 10.0%, P = .868). Conversely, using the original locking mechanism with a conventional liner had a higher re-revision rate compared to cemented conventional liners (58.3 versus 12.5%) (P = .024).ConclusionHXLPE liners should be used in insert exchange surgery whenever possible. Re-revision rate of exchanges using HXLPE was not affected by the fixation technique used. Cementing an insert into an acetabular component is associated with good survivorship at a mean of 13 years follow-up.     

Local Infiltration Analgesia With Liposomal Bupivacaine Improves Pain Scores and Reduces Opioid Use After Total Knee Arthroplasty: Results of a Randomized Controlled Trial

Background

Local infiltration analgesia (LIA) with liposomal bupivacaine (LB) in patients undergoing total knee arthroplasty (TKA) has yielded mixed results. The PILLAR study, which was designed to minimize limitations associated with previous studies, compared the effects of LIA with or without LB on pain scores, opioid consumption, including proportion of opioid-free patients, time to first opioid rescue, and safety after primary unilateral TKA.

Neuraxial Anesthesia Significantly Reduces 30-Day Venous Thromboembolism Rate and Length of Hospital Stay in Primary Total Hip Arthroplasty: A Stratified Propensity Score–Matched Cohort Analysis

BackgroundGeneral anesthesia (GA) has been the commonly used protocol for total hip arthroplasty (THA); however, neuraxial anesthesia (NA) has been increasingly performed. Our purpose was to compare NA and GA for 30-day postoperative outcomes in United States veterans undergoing primary THA.MethodsA large veteran’s database was utilized to identify patients undergoing primary THA between 1999 and 2019. A total of 56,244 patients had undergone THA and were included in our study. Of these, 44,780 (79.6%) had received GA, and 10,788 (19.2%) had received NA. Patients receiving NA or GA were compared for 30-day mortalities, cardiovascular, respiratory, and renal complications, and wound infections and hospital lengths of stay (LOS). Propensity score matching, multivariate regression analyses, and subgroup analyses by American Society of Anesthesiology classification were performed to control for selection bias and patient baseline characteristics.ResultsUpon propensity-adjusted multivariate analyses, NA was associated with decreased risks for deep venous thrombosis (odds ratio [OR] = 0.63; 95% CI = 0.4-0.9; P = .02), any respiratory complication (OR = 0.63; 95% CI = 0.5-0.9; P = .003), unplanned reintubation (OR = 0.51; 95% CI = 0.3-0.9; P = .009), and prolonged LOS (OR = 0.78; 95% CI = 0.72-0.84; P < .001). Subgroup analyses by American Society of Anesthesiology classes showed NA decreased 30-day venous thromboembolism rate in low-risk (class I/II) patients and decreased respiratory complications in high-risk (class III/IV) patients.ConclusionUsing a patient cohort obtained from a large national database, NA was associated with reduced risk of 30-day adverse events compared to GA in patients undergoing THA. Postoperative adverse events were decreased with NA administration with similar decreases observed across all patient preoperative risk levels. NA was also associated with a significant decrease in hospital LOS.     

Is Second Generation Metal-On-Metal Primary Total Hip Arthroplasty With a 28 mm Head a Worthy Option? : A 12- to 18-Year Follow-Up Study

To determine whether MoM THA with a small head is still worthy of use, we investigated survivorship, complications, and factors influencing failure. Of 149 consecutive patients (195 hips), 141 (180 hips) of mean age 43 (19–55) years were available for review at a mean of 14.4 years postoperatively. Survivorship for cup revision for any cause was 97.8% at 18.4 years postoperatively. Nine hips generated complaints of groin pain; six showed periacetabular osteolysis, one had pain without radiological change, and two were diagnosed as symptomatic pseudotumors. Four of six hips with periacetabular osteolysis or aseptic loosening were revised. Surgery- and patient-related factors had no effect in results. Our results are encouraging, however, further study will be necessary to determine the incidence and fates of pseudotumors after MoM THA with a small head.     

Does a Program Based on Cognitive Behavioral Therapy Affect Kinesiophobia in Patients Following Total Knee Arthroplasty? A Randomized,Controlled Trial With a 6-Month Follow-Up

Background

To evaluate the effects of a cognitive behavioral therapy (CBT) program on kinesiophobia, knee function, pain and pain catastrophizing in patients following total knee arthroplasty (TKA).

Incidence of Adverse Reactions to Metal Debris From 28-mm Metal-on-Metal Total Hip Arthroplasties With Minimum 10 Years of Follow-Up: Clinical,Laboratory, and Ultrasound Assessment of 44 Cases

Background

Total hip arthroplasty with metal-on-metal (MoM) bearings has been suspected to cause adverse reactions to metal debris (ARMD), with the incidence varying greatly by implant type and patient gender. The prevalence of ARMD from small-diameter MoM bearings in women is unknown, especially after 10 years of follow-up (FU).