Comparison of the results of cemented,porous-ingrowth,and threaded acetabular cup fixation: A meta-analysis of the orthopaedic literature

A meta-analysis of the orthopaedic literature was performed to evaluate the clinical performance of cementless, threaded acetabular cups. The hypothesis for the study was that the clinical performance of the cementless, threaded acetabular cup is equivalent to that of the cemented and porous-ingrowth acetabular cups. Ninety-five articles were included in the study. There were 1,269 cases in the threaded cup group, 1,979 in the porous control group, and 10,230 in the cemented control group. The primary outcome variable tested was the rate of aseptic loosening of the acetabular components as measured by the revision rates following the index total hip arthroplasty procedure. Other measures of acetabular component loosening that were analyzed included clinical rating scores, pain scores, frequency of radiolucencies according to location and size, frequency of radiolucencies as a separately defined outcome variable, progressive radiolucencies, and component migration. The threaded cup group was found to have a significantly higher rate of revision, clinical and pain score failures, progressive radiolucencies and migrations when compared with the cemented and porous control groups (P < .05). Despite the many limitations of meta-analyses and the poor state of the orthopaedic literature database, this study provides a reasonable comparison of the clinical performance of threaded acetabular cups with that of cemented and porous-ingrowth acetabular cups.     

A preliminary report of the use of a cementless acetabular component with a cemented femoral component

A clinical and roentgenographic study was done on 52 primary total hip arthroplasties (THAs) in which all patients were treated with hip reconstruction with a combination of a cementless, porous-coated acetabular component and a cemented femoral component. The operations were performed between November 1982 and May 1984, and the patients were followed for an average of 31 months (range, 24-40 months). The average age of the patients (55 years) was younger than in many THA series. At the last follow-up assessment, 50 hips were classified as good or excellent, one as fair, and one as a poor result. No total hip component required revision. No acetabular components had migrated as judged by conventional roentgenographic examination, and only one hip had progressive radiolucencies around the acetabular component. No femoral component was rated definitely loose or probably loose, and only one was rated possibly loose. If long-term follow-up study confirms these preliminary results, the combination of a cemented femoral component with a cementless socket may prove to be of value for selected patients requiring THA.     

Failures after revision hip arthroplasties with threaded cups and structural bone allografts: Loosening of 13/18 cases after 1-4 years

Uncemented threaded, smooth cup acetabular components and structural deep-frozen bone allografts harvested from femoral heads during arthroplasties were used for reconstruction of the acetabulum in 18 revision hip arthroplasties. Autogenous bone grafts were also used in every case. The mean follow-up time was 2.5 (1-4) years. Loosening of the prosthetic component occurred in 13 cases. In 8 cases revision of the acetabular component has already been performed, and 5 cases remain to be reoperated. The use of uncemented, threaded cups in combination with reconstruction of bone defects with structural allografts cannot be recommended in acetabular revisions.     

Use of structural bone graft with cementless acetabular cups in total hip arthroplasty

We retrospectively studied 15 primary and 13 revision total hip arthroplasties in which structural acetabular bone grafts were used in conjunction with cementless acetabular cups (for 11 type I segmental acetabular defects and 17 type III combined segmental/cavitary acetabular defects). Mean follow-up was 7.7 years in the primary and 6.8 years in the revision group. Radiographic analysis was performed to assess graft incorporation, component migration, bone-implant radiolucencies, and polyethylene wear. Two acetabular components (7.1%) were radiographically loose and demonstrated component migration. One of the two patients with these components also showed evidence of eccentric polyethylene wear. Three patients (10.7%) exhibited eccentric polyethylene wear. All grafts were well-incorporated radiographically without evidence of resorption. Modified Harris hip scores for all patients improved postoperatively.     

Cementless total hip arthroplasty using a threaded cup and a rectangular tapered stem. Follow-up for ten to 17 years

We carried out a clinical and radiological review of 103 cementless primary hip arthroplasties with a tapered rectangular grit-blasted titanium press-fit femoral component and a threaded conical titanium acetabular component at a mean follow-up of 14.4 years (10.2 to 17.1). The mean Harris hip score at the last follow-up was 89.2 (32 to 100). No early loosening and no fracture of the implant were found. One patient needed revision surgery because of a late deep infection. In 11 hips (10.7%), the reason for revision was progressive wear of the polyethylene liner. Exchange of the acetabular component because of aseptic loosening without detectable liner wear was carried out in three hips (2.9%). After 15 years the survivorship with aseptic loosening as the definition for failure was 95.6% for the acetabular component and 100% for the femoral component.     

Polyethylene liner dissociation in Harris-Galante acetabular components: a report of 7 cases.

Harris-Galante modular acetabular components (Zimmer, Warsaw, IN) have been used widely for primary and revision total hip arthroplasties. The survivorship of this implant has been well documented in the literature. Failure of the liner locking mechanism and subsequent dissociation of the polyethylene liner from the metal-backed shell is a potential cause of failure, however. We report 7 cases of liner dissociation and propose the mode of failure. The result in all cases was a well-fixed metal acetabular shell with a failed locking mechanism, which usually is managed by revision of the entire component. This procedure may be accompanied by the potential loss of acetabular bone stock, which should be replenished.     

Acetabular supporting ring in total hip replacement

A series of 14 total hip arthroplasties with a Müller acetabular supporting ring including 3 primary and 11 revision arthroplasties is reviewed. This device was used in cases of acetabular bone deficiency, and bone raft was added in 11 cases. The mean length of follow-up was 39.9 months. Twelve patients had good or satisfactory results, while two operations failed. These results indicate that the acetabular supporting ring is a useful implant in cases with acetabular bone stock deficiency.     

Results of revision for mechanical failure after cemented total hip replacement, 1979 to 1982. A two to five-year follow-up

From January 1979 to February 1982, 143 patients (seventy-nine women and sixty-four men) with 146 uninfected cemented total hip arthroplasties had revision cemented hip arthroplasty at The Hospital for Special Surgery for what was considered to be mechanical failure. The average age of the patients at primary arthroplasty was 56.1 years and at revision, 62.1 years. Loosening of the femoral component before revision correlated with varus positioning in 50 per cent of the hips, inadequate cement in 34 per cent, and a relatively young age in 16 per cent. The average age of the patients (fifteen hips) with a loose femoral component that had been placed in a neutral or valgus position with good cementing technique was 48.2 years at the time of primary arthroplasty. Loosening of the acetabular component was attributed to high placement of the cup in 41 per cent, inadequate bone in 18 per cent, a vertical orientation of the opening of the cup in 7 per cent, and poor cementing technique in 3 per cent. Complications associated with revision included perforation of the femoral cortex in 13 per cent, postoperative deep infection in 3.4 per cent, postoperative dislocation in 8.2 per cent, trochanteric complications in 6.2 per cent, and sciatic palsy in 0.7 per cent. Of the 139 hips that were followed for an average of 3.6 years (range, two to five years) after revision, the results were excellent in 59 per cent, good in 7 per cent, fair in 16 per cent, and poor in 18 per cent. After revision of the 139 hips, 29 per cent showed progressive radiolucencies; 18 per cent, femoral subsidence; and 9 per cent, acetabular migration. Definite mechanical failure after revision was identified in 15.8 per cent of the hips. These failures were due to loosening in 12.2 per cent of the hips, femoral fracture in 2.2 per cent, and disabling dislocation in 1.4 per cent. At the time of follow-up, twelve hips (8.6 per cent) had been revised a second time: six (4.3 per cent) for loosening of one or both components, three (2.2 per cent) for femoral fracture, and three (2.2 per cent) for infection. Mechanical failure and progressive radiolucencies were associated with poor quality of bone (p less than 0.001) and inadequate anatomical reconstruction (p less than 0.03).     

Cementless jumbo cups for revision of failed Furlong prosthesis. A case series

BackgroundRevision of failed total hip arthroplasty (THA) presents great challenge to any orthopaedic surgeon especially in the presence of acetabular defects where the main goal is to achieve durable fixation of prosthetic components to bone which is the key to successful revision surgery.MethodsSeventeen patients (17 hips) with mean age of 52 (40–61) years had revision surgery for aseptic failure of Furlong hydroxyapatite-ceramic-coated (HAC) prosthesis using cementless jumbo cups. Patients were reviewed clinically and radiographically with mean follow-up of 3.5 years (2–6). No patient was lost to follow up.ResultsAll revised acetabular components showed polyethylene wear, severe metallosis, with acetabular defects IIB (4/17), and IIIA (13/17) according to Paprosky classification. The femoral component was well fixed in all cases but one patient had stem revision for femoral fracture mal-union. There was one early post-operative infection; there was no postoperative dislocation, sciatic nerve injury, periprosthetic fracture or deep venous thrombosis. At last follow-up, no progressive radiolucencies or acetabular migration was identified. The mean Harris hip score improved from 42 (24–59) pre-operatively to 85 (72–92).ConclusionGood clinical results and radiographic stability were obtained at short term follow up after acetabular revision using cementless jumbo cups, which justify its use in revision surgery even in the face of major acetabular defects. Furlong HAC femoral component gives excellent long-term survival in young and active patients with a survival rate of 94% at 18.6 years.     

Simultaneous primary total hip arthroplasty and contralateral revision hip arthroplasty: role for use of femoral head autograft

We report the outcome of revision hip arthroplasty for patients with acetabular bone loss in whom the femoral head retrieved from arthritic contralateral hip during the same anesthesia was used as autograft for acetabular reconstruction. Thirty-two hips in 16 patients with a mean age of 63.8 years (range, 43-79 years) were followed for an average of 3.5 years. All primary arthroplasties were successful. Evidence of autograft incorporation was found in all except 2 patients. The acetabular component failed and required revision in the latter 2 patients. The use of femoral head autograft in a select group of patients with symptomatic arthritis of hip and a failed prosthetic hip with severe bone loss in the contralateral side is a viable option. However, this technique should not be applied to acetabular reconstructions in which protected weight-bearing in the postoperative period may be necessary.     

Revision arthroplasty using an anti-protrusio cage for massive acetabular bone deficiency.

Revision hip arthroplasty in patients with massive acetabular bone deficiency has generally given poor long-term results. We report the use of an 'anti-protrusio cage', secured to the ischium and ilium, which bridges areas of acetabular bone loss, provides support for the acetabular socket, and allows pelvic bone grafting in an environment protected from excessive stress. Forty-two failed hip arthroplasties with massive acetabular bone loss were revised with the Burch-Schneider anti-protrusio cage and evaluated after two to 11 years (mean five years). There was failure due to sepsis in five hips (12%) and aseptic loosening in five (12%); the remaining 32 hips (76%) showed no evidence of acetabular component failure or loosening.     

Results of total hip reconstruction using acetabular mesh in patients with central acetabular deficiency

Fifty-three patients (54 hips) treated with cemented total hip reconstruction with the aid of an acetabular mesh made of Vitallium (Howmedica Inc., Rutherford, New Jersey), a cobalt-chrome molybdenum alloy, to reinforce the medial cement for deficient bone stock in the central acetabular region, were evaluated at an average follow-up period of 6.8 years (range, five to ten years). Thirty of these patients (30 hips) were treated with revision operations for either failed cup arthroplasty (ten hips), failed endoprosthesis (six hips), or failed total hip arthroplasty (14 hips) and presented difficult problems for acetabular reconstructions. Although none of the hips required reoperations for acetabular loosening, three patients showed roentgenographic evidence of acetabular component migration, and three others showed signs of impending failure of fixation of the acetabular component. The overall mean Harris hip rating improved from a mean of 43 points preoperatively to 87 points at follow-up evaluations. The extent of bone loss in the central acetabular region had the greatest influence on the results of acetabular fixation at the follow-up evaluation. None of the hips with intact medial acetabular cortex had roentgenographic evidence of failure of fixation, while 14% of the hips with medial cortical defects measuring less than 1 cm, and 75% of the hips with larger defects developed acetabular component loosening. The results of total hip reconstruction using acetabular mesh were unsatisfactory in patients with moderate or severe central acetabular bone loss and defects through the medial wall.(ABSTRACT TRUNCATED AT 250 WORDS)     

The fate of revised uncemented acetabular components in patients with rheumatoid arthritis

The results of patients with rheumatoid arthritis who had revision hip arthroplasty have been studied infrequently. The purpose of this study was to review the authors' clinical and radiographic experiences and outcomes with revision hip arthroplasty. Revision total hip arthroplasties were done on 28 patients (30 hips). All hips had morselized bone grafting and four hips had bulk allografts for segmental defects. The mean age of the patients at the time of surgery was 50 years (range, 20-74 years). Patients were followed up for 4 to 15 years (mean, 7 years). At the latest followup, 14 hips (13 patients) of the 30 hips (47%) had good and excellent Harris hip score ratings. Mechanical failures included six hips (five patients) that had revision arthroplasty and two hips (two patients) that had resection arthroplasty. Six other hips (five patients) had poor Harris hip score ratings. The Kaplan-Meier survivorship curve for failure of the acetabular component revealed an 89% chance of survivorship curve for failure of the acetabular component revealed an 89% chance of survival at 60 months and a 44% chance of survival at 108 months. Based on the results of this study, revision hip arthroplasty for acetabular loosening with a cementless acetabular prosthesis has a low rate of success in patients with rheumatoid arthritis.     

Long-term results of primary hip total prosthesis with acetabulum reinforcement ring

The Müller acetabular reinforcement ring has proven very useful, especially in total hip revision when the bone of the acetabulum is of poor quality or deficient. However, the acetabular reinforcement ring may also be indicated in primary total hip replacement, especially in the case of poor quality bone in the acetabular bone stock, e.g. in chronic polyarthritis or protrusio acetabuli, or of deficient morphology of the acetabulum, e.g. in hip dysplasia. We analysed the results recorded in 145 patients operated on between 1977 and April 1983. Each of these patients had received a total hip prosthesis for the first time, with the polyethylene cup supplemented by an acetabular reinforcement ring. This patient group cannot be compared with the usual patient populations reported on in connection with primary hip replacement, since most of our 145 patients had several risk factors and had undergone previous surgery on up to seven occasions on the hip ultimately replaced by a prosthesis. Radiological analysis did not show a significant correlation between malposition of the acetabular reinforcement ring and signs of loosening, except when the acetabular component had been implanted in a most atypical manner. The infection rate was 4.8%, but it must be borne in mind that from 1977 to 1983 there was no routine prophylaxis with antibiotics. The incidence of aseptic loosening of the acetabular reinforcement ring necessitating revision was 0.7% after a mean follow-up of 7.7 years (range 5.5-11 years).(ABSTRACT TRUNCATED AT 250 WORDS)     

Cementless acetabular revision for aseptic failure of cemented hip arthroplasty

This study is a 5- to 11-year retrospective followup of 40 hips in 33 patients with cementless acetabular revision for aseptic failure of a cemented total hip arthroplasty. A porous coated, Harris-Galante acetabular component was used in all revisions. Thirty-eight of the 40 hips received acetabular bone grafting at revision. The mean Harris Hip Score improved from 51 points just before the index cementless revision to 87 points at the most recent followup. Twenty-nine of 40 (73%) hips were classified as having a good or excellent result. Radiolucencies were observed in seven of the 40 (18%) hips at the most recent followup, but none of these radiolucencies were complete or progressive. Five of the 40 (13%) hips were rated as failures and required repeat revision. Two (5%) of these failures were caused by aseptic loosening, with both hips having severe acetabular bone damage at the time of the index revision. This failure rate for aseptic loosening was less than that reported for cemented acetabular revision, thereby confirming the efficacy of cementless acetabular components in revision hip surgery in the intermediate term.     

Are abductor muscle quality and previous revision surgery predictors of constrained liner failure in hip arthroplasty?

Dislocation is one of the most common complications of total hip arthroplasty. The use of constrained liners is an option for the management of chronic hip instability, typically used after other methods have failed. The purposes of this study were to evaluate the overall clinical outcomes and failure rates of a tripolar constrained liner design, to assess the radiographic outcomes of its use, and to examine whether various factors such as abductor mechanism quality and history of previous revision surgeries were associated with an increased risk of failure. Forty-three hips in 39 patients who had a mean follow-up of 51 months (range, 24–110 months) were reviewed. Ninety-one percent of the hips (39 of 43 hips) did not need any revisions over the study period. A new liner was implanted in all four failed hips with concurrent revision of the acetabular cup in three cases. No further dislocations occurred in this group. The mean hip score for surviving hips was 82 points (range, 38–100 points) at final follow-up. Radiographic evaluation revealed stable, well-fixed acetabular components in all surviving hips without progressive radiolucencies. No association was found between abductor muscle quality and the incidence of failure, but patients who experienced a constrained liner failure were more likely to have undergone at least one previous hip revision operation. Tripolar constrained acetabular liners can provide successful outcomes in patients with hip instability, although it is important not to rely on the use of a constrained liner alone in an attempt to compensate for other correctable factors such as component positioning.     

Revision of a cemented acetabular component to a cementless acetabular component. A ten to fourteen-year follow-up study.

BACKGROUND: Although cementless acetabular components are routinely used in revision hip surgery, few investigators have evaluated the retention and efficacy of these components in the long term. In the current study, the clinical and radiographic outcomes of a series of arthroplasties performed by one surgeon with a cementless acetabular component were assessed at a minimum of ten years. METHODS: From 1986 through 1988, sixty-one consecutive revision total hip arthroplasties were performed in fifty-five patients because of aseptic failure of one or both components of a prosthesis in which both components had been cemented. Twenty-eight patients (thirty-two hips) were alive at a mean of 12.9 years (range, 11.5 to 14.3 years) after the operation. In all of the patients, the acetabular component was revised to a porous-coated Harris-Galante component inserted without cement, and the femoral component was revised to an Iowa component affixed with contemporary cementing techniques. The hips were evaluated clinically and radiographically at a minimum of ten years subsequent to the index revision. No hips were lost to follow-up. RESULTS: None of the acetabular components required revision because of aseptic loosening. Two hips (3%) demonstrated radiographic evidence of aseptic loosening of the acetabular component. The polyethylene liner was exchanged during the follow-up period in eight hips. CONCLUSION: After a minimum of ten years of follow-up, cementless acetabular fixation in revision hip arthroplasty had produced durable results that were markedly better than those reported for acetabular fixation with cement.     

Allogeneic cancellous bone graft and a Burch-Schneider ring for acetabular reconstruction in revision hip arthroplasty.

BACKGROUND: There is an ever-increasing number of failed hip arthroplasties associated with massive deficiency of acetabular bone stock consisting of a segmental or cavitary defect. This study was undertaken to evaluate the long-term results after use of morselized cryopreserved allogeneic bone graft and an antiprotrusio cage to treat such a deficiency. METHODS: From January 1, 1988, to January 1, 1994, forty-one patients (forty-one hips) with an acetabular defect classified as type IIl or IV according to the American Academy of Orthopaedic Surgeons system were operated on with use of a Burch-Schneider ring and morselized cryopreserved allogeneic cancellous bone graft. Thirty-eight patients (thirty-eight hips) were available for clinical and radiographic follow-up examinations at an average of 7.3 years (range, 4.2 to 9.4 years) after surgery. RESULTS: All measured clinical parameters had improved significantly by the time of the follow-up examination (p < 0.0001). Radiographs confirmed that none of the thirty-eight hips had any measurable migration or displacement of the acetabular component and that osseous consolidation occurred only within the grafted area in all patients. CONCLUSION: Acetabular reconstruction with use of morselized cryopreserved allogeneic cancellous bone graft and the Burch-Schneider ring can be highly successful in managing massive acetabular deficiencies in revision hip arthroplasty.     

Bilobed oblong porous coated acetabular components in revision total hip arthroplasty

Thirty-eight oblong bilobed noncustom uncemented, porous-coated titanium acetabular components were used to reconstruct failed hip arthroplasties with large superior segmental acetabular bone deficiencies. No structural bone grafts were used. All patients were followed up for 2 to 5 years (mean, 3 years) after the operation. One patient (whose socket rested primarily on a structural bone graft from a previous procedure) had revision surgery for acetabular loosening. No other patients have had revision surgery or had another ipsilateral hip operation. At latest followup, 35 patients had no or mild pain and two patients had moderate pain. Two implants migrated more than 2 mm in the first year, then stabilized. On the latest radiographs, two implants had bead shedding, but there was no measurable migration or change in position. For selected patients with large superolateral acetabular bone deficiencies, this implant facilitated a complex reconstruction, provided good clinical results, and showed satisfactory stability at early to midterm followup in most patients.     

Limits in cementless hip revision total hip arthroplasty. Midterm experience with an oblong revision cup

Revision of an acetabular component in a patient who has severe periacetabular bone loss is a complex problem, particularly when there is not enough bone stock to allow placement of an acetabular component near the normal anatomical hip center. To fill the defect, a valuable option for revision arthroplasty is the cementless oblong revision cup (LOR). METHODS: 50 consecutive revisions of the acetabular component were performed in 48 patients. The mean age at the time of revision was sixty-one years (range, thirty-three to seventy-eight years). Forty-eight hips were available for follow-up, at a mean of thirty-two months (range, eighteen to sixty-one months). The acetabular defect classified according to Paprosky, the migration and the radiolucencies were followed radiologically. RESULTS: 8 hips (16 %) were revised again: two because of infection (4 %) and six because of instability (12 %). The revised hips are not associated to the preoperative degree of acetabular defect (34 % defect type III) (P > 0.05). The mean Harris Hip score was corrected from 36.5 (range, 7.5 to 92.5) to 78.2 points (range, 47.6 to 97.6) (P < 0.01). The mean d'Aubigné Score was corrected from 8.3 (range, 4 to 6) to 15 points (range, 10 to 18) (P < 0.01). Neither pre- nor postoperative results were associated to the degree of acetabular defect (P > 0.05). However, patients with multiple revisions had a significantly reduced clinical outcome than patients with the first revision (P < 0.05). The hip center of rotation, cranially placed to the contralateral side (0.92 cm) was corrected by the revision to a more normal anatomic rotation center (0.27 cm). Partial zonal radiolucencies, always smaller than 1.5 mm were seen in 30 % of the patients. The mean migration of the acetabular component was not significant (P > 0.05). CONCLUSION: The authors support the use of the cementless oblong revision cup if contact can be made with host bone to more than 50 %. If this is not possible, acetabular bone reconstruction combined with a roof ring and a cemented cup is the component of choice.