Fate of cementless acetabular components retained during revision total hip arthroplasty

BACKGROUND: Removal of a well-fixed cementless acetabular component can result in increased operative time and postoperative morbidity. The objectives of this retrospective study were to determine whether retention of a well-fixed acetabular component at the time of isolated femoral revision was compatible with long-term socket survival. METHODS: The records of eighty-three consecutive patients (ninety hips) in whom a well-fixed cementless socket had been retained during revision of a femoral component were reviewed. The mean age of the patients was 48.7 years at the time of the primary arthroplasty and 54.1 years at the time of femoral revision. The radiographic analysis was based on anteroposterior radiographs and was performed by a single independent reviewer. The intraoperative criterion for stability of the socket was the absence of movement at the bone-implant interface during the application of direct pressure to the edges of the socket in four quadrants with use of a metallic pusher. RESULTS: At the time of the isolated femoral revision, no socket demonstrated a radiolucent line measuring >1 mm in any two zones and forty of the ninety hips had periacetabular osteolysis. The mean size of the osteolytic lesions was 5.71 cm(2) (range, 0.4 to 24.2 cm(2)), and twenty-eight of the forty hips underwent bone-grafting. The mean duration of follow-up was 9.7 years after the isolated femoral revision and 14.9 years after the primary arthroplasty. Five acetabular sockets were revised at a mean of 6.8 years after the femoral revision. Only one of these sockets had failed because of aseptic loosening. With revision of the acetabular component for any reason as the end point, the survival rate was 98.7% at five years and 93.5% at ten years after the femoral revision and 100% at ten years and 93.9% at fifteen years after the primary arthroplasty. No hip showed recurrence or expansion of periacetabular osteolysis. The prevalence of dislocation was 16% (fourteen of ninety). CONCLUSIONS: Revision of a stable, cementless acetabular component solely on the basis of its duration in vivo or the presence of periacetabular osteolysis does not appear to be warranted. Retention of the socket with grafting of larger periacetabular osteolytic lesions appears to be consistent with satisfactory socket longevity.     

Cementless bulk alumina socket: preliminary results at 6 years.

To avoid polyethylene wear observed in total hip replacement, an alumina-alumina combination has been used since 1977. The aim of this study is to report the results of a hybrid alumina-alumina total hip arthroplasty with a cementless press-fit bulk alumina socket and a cemented titanium alloy stem in 55 patients (62 hips) operated on between 1982 and 1990. The bearing surfaces were a 32-mm alumina head articulating within the alumina socket. Four failures occurred: 3 aseptic loosenings of the socket and 1 femoral head fracture. Considering aseptic loosening as the endpoint, the survival rate was 93.2% after 6 years. At a mean of 72.1 months' follow-up, 92.4% of the surviving hips were graded as very good or good using the Merle d'Aubigné-Postel hip score. Radiolucent lines were observed on the acetabular side in 68.1 of the hips. The future of this interface, which is probably fibrous, remains questionable. With the exception of 1 femoral head fracture, all revisions were related to failure of the bony fixation of the socket, and no problem was encountered related to the alumina-alumina friction coupling. Alumina sockets with other types of cementless fixation have therefore been designed and are presently under clinical investigation.     

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

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

Results of Isolated Femoral Component Revision With Well-Fixed Acetabular Implant Retention

The present study was undertaken to evaluate the clinical and radiological results of isolated femoral revisions conducted while retaining well-fixed cementless acetabular sockets. Thirty-nine patients that underwent isolated femoral stem revisions were reviewed. Mean age at time of surgery was 60.5 years, and mean follow-up duration was 4.2 years. Decisions to retain acetabular sockets were based on clinical and radiographic findings and intraoperative stabilities. During revisions, polyethylene liners were exchanged for metal-inlay polyethylene liners to have a metal-on-metal bearing surface in 23 cases. Mean Harris hip score improved from 58 points preoperatively to 85 points at final follow-up (P < .001). With the exception of one patient, no increases in acetabular radiolucent line numbers or thicknesses were observed during follow-up visits. Isolated femoral stem revisions with acetabular socket retention were found to provide excellent clinical and radiographic results.     

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.     

A second-generation cementless total hip arthroplasty mean 9-year results

Two hundred fifty-eight primary total hip arthroplasties in 231 patients were implanted using a circumferentially, proximally porous-coated, collared femoral component and a cementless, hemispherical, porous-coated acetabular component and followed up for a mean of 9 years (5-14 years). Four femoral components were revised (2 stems for infection and 2 stems for aseptic loosening). One additional femoral component was radiographically loose at last follow-up. Nine hips underwent acetabular revision (4 for instability, 2 for infection, 2 for loosening, and 1 for osteolysis). Ten-year survivorship with revision or loosening of any component as the end point was 92%; with femoral component aseptic loosening as end point, survivorship was 98%; with acetabular aseptic loosening as the end point, survivorship was 99%. Osteolysis was identified in 26 hips (13%).     

Factors influencing the longer-term survival of uncemented acetabular components used in total hip revisions

BACKGROUND: There are few longer-term follow-up reports of the results and complications of the use of cementless acetabular components in revision hip arthroplasty. In this study, we analyzed the clinical and radiographic results to determine the factors that affect longer-term survival of titanium-fiber-metal-coated acetabular components. METHODS: During a fourteen-year period, one surgeon performed 211 consecutive unselected cementless acetabular revisions in 194 patients with a mean age of sixty-two years. The same technique was used for all revisions: the component was impacted and was fixed with multiple screws, and bone deficiencies were augmented with supplemental bone graft. Both the acetabular and the femoral components were revised in 142 hips, whereas an isolated acetabular revision was performed in sixty-nine hips. All 211 revisions were included in a survivorship analysis to twelve years. Prospectively determined clinical results in 135 hips and radiographic results in 131 hips were available at a minimum of five years postoperatively. RESULTS: Seven acetabular components were removed: three, because of infection; one, because of recurrent dislocation; and three, because of mechanical loosening. There was asymptomatic radiographic loosening of one additional acetabular component, for a total rate of aseptic loosening of 2%. The twelve-year prosthetic survival rate was 95% (95% confidence interval, 91% to 99%), with failure defined as component removal for any reason. There was no significant difference in the rate of survival of the cup or femoral component between the sixty-nine hips treated with isolated acetabular revision and the 142 hips in which both components were revised. There was a significant difference in the rate of dislocation between the hips treated with isolated acetabular revision (dislocation in fourteen hips, 20%) and those in which both components had been revised (dislocation in eleven hips, 8%; p = 0.03), but there was no difference in component survival if a dislocation occurred. There was a significant association between a patient weight of >82 kg and acetabular failure (p = 0.04). CONCLUSIONS: This titanium-fiber-metal-coated hemispheric component fixed with multiple screws had a twelve-year survival rate of 95% when used in an unselected, consecutive series of acetabular revisions. The rate of dislocation was significantly higher in the patients treated with isolated acetabular revision, and routine postoperative bracing is now recommended for that group.     

Minimum 20-Year Follow-Up Results of Revision Total Hip Arthroplasty With Improved Cementing Technique

A consecutive, non-selective cohort of 83 (77 patients) cemented total hip arthroplasty revisions using contemporary cementing techniques was analyzed at a minimum of 20 years following the index procedure. No patients were lost to follow-up. The average age at revision was 62.4 years (23 to 89). Twenty-two hips (26.5%) had had a reoperation, eighteen (21.7%) for aseptic loosening, 3 (3.6%) for femoral prosthesis fracture and 1 (1.2%) for dislocation. The incidence of re-revision for aseptic femoral loosening was 7.5% and for aseptic acetabular loosening was 21.7%. These results confirm that cemented femoral revision using improved cementing techniques is a durable option in revision hip surgery. In contrast to this, THA revisions using a cemented acetabular component have been less durable at this length of follow-up.     

Press-fit metal-backed alumina sockets: a minimum 5-year followup study

Two hundred thirty-four consecutive alumina-on-alumina hip replacements using a press-fit metal-backed socket, performed on 214 patients (98 women, 116 men) have been reviewed. These included 201 primary procedures and 33 revision procedures. The median age of the patients at the time of surgery was 62 years (range, 21-83 years). Fourteen patients (16 hips) died from unrelated causes. Eleven patients (11 hips) underwent a total hip arthroplasty revision for recurrent dislocation (one hip), deep infection (two hips), fracture of alumina femoral head (one hip), persistent hip pain (one hip) and aseptic loosening (six hips). The survival rate after 9 years was 93.4% when revision of the prosthesis was considered the end point, and 97.4% if revision of the prosthesis for aseptic loosening was considered the end point. Results were assessed in the surviving patients with a minimal 5-year followup (170 patients, 184 hips). At the median followup of 7.8 years, the average Merle d'Aubigné and Postel score had improved from 11.9- to 17.7. Results were graded as excellent in 148 hips (80.5%), very good in 31 hips (17%), good in two hips (1%), and fair in three hips (1.5%). Radiologic data were documented for 134 patients (143 hips). Three sockets (2%) had a complete and nonprogressive radiolucent line less than 1-mm thick, one stem (0.7%) had lucencies involving five zones, and two stems (1.4%) had isolated femoral osteolysis. Neither component migration nor acetabular osteolysis were detected. A press-fit metal-backed socket may offer a good solution for alumina socket fixation when combined with a careful surgical technique of implantation.     

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.     

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.     

Results of isolated acetabular revisions: The fate of the unrevised femoral component

Controversy exists over whether to remove a well-fixed femoral component at the time of revision of a failed acetabular component, and it has been suggested that the femoral component be removed and recemented. The hypothesis presented in this article is that only the acetabular component should be revised in these situations. Thirty-eight isolated, uncemented acetabular revisions were performed by 1 surgeon and prospectively followed for a mean of 4 years (range, 2–10 years). The femoral component was well fixed at the time of revision and left in situ. There were 30 cemented and 8 uncemented femoral components, which had been in place for a mean of 10.7 years. The hips were evaluated clinically using the Harris hip score rating system. Radiographic evaluation of both components was performed using well-established criteria. Morselized cancellous allograft was used to fill acetabular defects in 30 hips, and a bulk allograft was used in 1 hip. There was a good or excellent clinical result in 32 hips (84%). Two cemented femoral components required revision for aseptic loosening at 2.5 and 4 years. No acetabular component migrated or was revised, and no revisions of either component are pending. Thirty-six (95%) of the unrevised femoral components remain well fixed at the most recent follow-up examination. Compared with a similar population of hips in which both the acetabular and femoral components were revised, the mean blood loss for these revisions was 52% less and the mean surgical time was 35% shorter. Revision of only the acetabular component is recommended for isolated acetabular aseptic loosening. Because the femoral component is not removed, surgical time and blood loss are decreased and serious potential complications related to removing a well-fixed femoral component can be avoided.     

Hybrid alumina total hip arthroplasty using a press-fit metal-backed socket in patients younger than 55 years. A six- to 11-year evaluation

Between 1990 and 1992, we implanted 71 hybrid alumina-on-alumina hip arthroplasties in 62 consecutive patients under the age of 55 years, with a mean age of 46 years at surgery. There were 56 primary and 15 secondary procedures. The prostheses involved a cemented titanium alloy stem, a 32 mm alumina head, and a press-fit metal-backed socket with an alumina insert. Three patients (four hips) died from unrelated causes. Four hips had revision surgery for either deep infection, unexplained persistent pain, fracture of the alumina head, or aseptic loosening of the socket. The nine-year survival rate was 93.7% with revision for any cause as the end-point and 98.4% with revision for aseptic loosening as the end-point. The outcome in the surviving patients (50 patients, 57 hips) with a minimum five-year follow-up (mean eight years) was excellent in 47 hips (82.5%), very good in eight (14%), good in one and fair in one. A thin, partial, lucent line, mainly in zone III was present in 38% of the sockets and one socket had a complete lucency less than 1 mm thick. One stem had isolated femoral osteolysis. There was no detectable component migration nor acetabular osteolysis. This hybrid arthroplasty gave satisfactory medium-term results in active patients. The press-fit metal-backed socket appeared to have reliable fixation in alumina-on-alumina hip arthroplasty. The excellent results using cemented fixation of the stem may be related to the low production of wear debris.     

Prevention and treatment of dislocation after total hip replacement using large diameter balls

The purpose of this study was to review safety and efficacy of total hip arthroplasty using large-diameter femoral heads in treatment and prevention of dislocation. One hundred forty hips in 135 patients were replaced using femoral heads at least 36 mm in diameter. The average age of the patients was 61.6 years. The patients were grouped into three categories depending on their diagnoses: recurrent dislocations from previous total hip replacements (Group 1; 29 hips); revision surgeries not including revisions for dislocations (Group 2; 54 hips); and primary surgeries (Group 3; 57 hips). The average followup was 5.5 years (range, 1-17 years). A total of 16 hips were revised: six for instability, four for fracture or disassociation of a conventional polyethylene liner, three for aseptic loosening of the socket, and three for sepsis. One hip from Group 1 dislocated at 12.5 years postoperatively, was treated with closed reduction, and since has been nonrecurring. UCLA hip scores all improved significantly. The prevalence of dislocation varied among the three groups, with 13.7% for Group 1, 1.8% for Group 2, and 3.5% for Group 3. The failure in the six cases that required revision for instability was attributable to poor socket orientation. All the hips became stable after revision without the use of a constrained acetabular liner. Large-diameter femoral heads provide additional stability not only for patients with recurrent dislocations, but also for patients having revision. The new, more wear-resistant bearings now enable the surgeon to extend the use of big femoral heads to primary total hip arthroplasty. Metal-on-metal seems to be the material of choice for a bone-conserving reconstruction with large femoral heads.     

Alumina-on-alumina total hip prostheses in patients 40 years of age or younger

To avoid the consequences of polyethylene wear in a high-risk population, 128 alumina-on-alumina total hip arthroplasties have been done in 104 consecutive patients. The maximum age of patients was 40 years. The main preoperative diagnoses were osteonecrosis and sequellae of congenital hip dislocation (71% of the hips). The same titanium alloy cemented stem was implanted in all of the hips. Four types of alumina acetabular component fixations were used: a cemented plain alumina socket (41 hips), a screw-in ring with an alumina insert (22 hips), a press-fit plain alumina socket (32 hips), and a press-fit titanium metal back with an alumina insert (33 hips). Eight patients (11 hips) died during the followup period. Sixteen revisions have been documented, 12 for acetabular aseptic loosening, three for bipolar loosening (two of which were septic), and one for unexplained pain. Eighty-eight hips in 74 patients have been followed up radiologically for 2 to 22 years. Wear was unmeasurable. Four additional sockets showed definite migration. The respective survival rates after 7 years were 94.1% for the cemented cup, 88.8% for the screw-in ring, 95.1% for cementless press-fit plain alumina socket and 94.3% for the metal-back press-fit component. The 10-year survival rate was 90.4% for the cemented socket and 88.8% for the screw-in ring. The 15-year survival rate was 78.9% for the cemented socket. Grafting was the only prognostic factor, with a survival rate of 62.6% after 10 years for the hips with a bone graft and of 90.1% for hips without a graft. The alumina-on-alumina bearing surfaces seem to be a valuable alternative to the standard metal-on-polyethylene system for young patients. However, an improvement in socket fixation is required to lengthen the life span of the prosthesis to match the life expectancy of this demanding population.     

Acetabular revision without cement

We reviewed the clinical and radiologic results of 47 cementless acetabular revisions performed by a single surgeon. The mean follow-up period was 58 months. The American Academy of Orthopaedic Surgeons (AAOS) acetabular defect classification was type I in 4 hips, type II in 9 hips, and type III in 32 hips. All patients received AML (Depuy, Warsaw, IN) Duraloc cup implants. Morcellized allograft was used in 23 hips (49%), and screw augmentation in 22 hips (47%). The Harris Hip score improved from 72 to 90 points. No revisions were performed for aseptic loosening. Nonprogressive thin radiolucent lines were found in a single zone in 10 hips (21%) and in all 3 zones in 5 hips (11%). No migration was found in any cups with radiolucent lines, and the presence of a radiolucent line was considered clinically unimportant. Progressive loosening with migration of the cup was found in 1 hip (2%). Kaplan-Meier survivorship using revision for aseptic loosening or radiologic loosening as end points was 92% at 72 months. No statistically significant difference was found in the survival of the cups fixed with or without screws. These encouraging midterm results confirm the role of cementless acetabular revision.     

Long-term survivorship of cemented all-polyethylene acetabular components in patients > 75 years of age

Between 1974 and 1982, 132 consecutive hips in 112 patients >75 years of age were treated with primary total hip arthroplasty for osteoarthritis using a cemented all-polyethylene T28 socket and cemented T28 or TR28 stem with a 28-mm head size. At the time of review, 94 patients (110 hips [83%]) had died and 18 patients (22 hips [17%]) were still living (mean age at follow-up, 93 years). Five hips (5 patients) were lost to follow-up. Clinical follow-up averaged 8.9 years for the entire group and 14.6 years for patients still living. Only 2 acetabular components have been revised (1 for recurrent dislocation, 1 for infection). No acetabular component has required revision for aseptic loosening. Survivorship free of acetabular revision for aseptic loosening at 10 years was 100%; free of symptomatic acetabular loosening, 97.4% (95% confidence interval, 91.8-100%); and free of acetabular loosening, 95.9% (95% confidence interval, 89.7-100%). The commonest complication was postoperative hip dislocation, which occurred in 11 hips (8.7%) and which required reoperation in 2 hips. Cemented acetabular components implanted in patients >75 years of age with a diagnosis of osteoarthritis showed a high rate of survivorship free of revision and free of symptomatic aseptic loosening.     

人工髋关节置换术后翻修病例分析

目的分析人工髋关节置换术后翻修的原因,评价全髋翻修术的临床效果。方法本组33例34髋。初次关节置换类型:全髋置换21例,双杯髋关节置换1例,人工股骨头置换11例。翻修原因:无菌性松动23例24髋,髋臼位置不良1例1髋,股骨头置换后髋臼磨损5例5髋,感染4例4髋。翻修距初次手术时间:1年以内5髋,1～2年1髋,5～10年18髋,10～13年10髋。翻修假体类型:非骨水泥型假体20髋,混合型假体7髋,骨水泥型假体7髋。结果平均随访3.5年。1例术后半年发生股骨柄松动进行再翻修,其余病例假体保留,优良率为82.4%。结论翻修的最常见原因为无菌性松动,人工股骨头置换时髋臼磨损也是翻修原因之一,对较年轻的股骨颈骨折患者,如行假体置换,最好采用全髋关节置换。翻修术采用非骨水泥型假体较好。     

The fate of stable femoral components retained during isolated acetabular revision: a six-to-twelve-year follow-up study

BACKGROUND: The decision as to whether to revise a well-fixed femoral component in hips requiring isolated acetabular revision is challenging. The purpose of the present study was to determine the long-term results of, and the complications associated with, retention of a stable and well-fixed femoral component during isolated acetabular revision. METHODS: We retrospectively reviewed the clinical and radiographic results for thirty-one patients (thirty-two hips) who underwent isolated revision acetabuloplasty without removal of a well-fixed femoral component. The reason for acetabular revision was aseptic loosening in thirty-one hips and malposition in one hip. Of the thirty-two femoral components, twenty-one were cemented and eleven were cementless. The average duration of follow-up from the time of the index revision was 8.1 years (range, 6.4 to 12.5 years), and the average duration of total service of the femoral component was seventeen years (range, seven to twenty-five years) from time of the initial implantation. The average age of the patients at the time of the index revision was sixty-six years (range, twenty-nine to eighty-seven years). RESULTS: Thirty-one (97%) of the primary femoral components were judged to be stable and well fixed at the latest follow-up evaluation. One femoral component (3%) was revised because of aseptic loosening, eight years after the index acetabular revision and seventeen years after the initial total hip arthroplasty. Radiographic evaluation of the thirty-one femoral components that were not revised demonstrated no evidence of loosening or subsidence. There were no dislocations, nerve palsies, or intraoperative fractures associated with retention of the femoral component. Twenty-seven (84%) of the acetabular components were judged to be stable at the latest follow-up evaluation. CONCLUSION: In hips treated with isolated acetabular revision, a well-fixed femoral component can be retained successfully without adversely affecting the acetabular exposure; the placement, position, or stability of the acetabular component; or the ability to restore bone stock. The data from the present study support the decision to retain a well-fixed femoral component when the acetabular component needs to be revised.