The effects of surface roughness and polymethylmethacrylate precoating on the radiographic and clinical results of the Iowa hip prosthesis. A study of patients less than fifty years old

BACKGROUND: The purpose of the present study was to compare the results associated with two different surface finishes (bead-blasted and grit-blasted) for Iowa femoral components used in total hip arthroplasties performed between January 1979 and June 1991 in patients who were less than fifty years old. METHODS: Between January 1979 and December 1985, thirty-six primary total hip replacements were performed in twenty-five patients with insertion of a bead-blasted Iowa femoral component (average surface roughness, 0.8 micrometer) with cement and insertion of a titanium-backed acetabular component (thirty-five hips) or non-metal-backed acetabular component (one hip) with cement. Between January 1986 and June 1991, forty-five primary total hip replacements were performed in thirty-seven patients with use of a precoated grit-blasted Iowa femoral component (average surface roughness, 2.1 micrometers) and a Harris-Galante-I porous ingrowth acetabular component (forty-one hips) or an Osteonics component (four hips). The only change in the design of the femoral component (other than the surface finish) between the two consecutive series was the addition of polymethylmethacrylate precoating to the proximal third of all forty-five grit-blasted stems and modularity of the femoral head of the last eight grit-blasted stems. RESULTS: No hip was lost to follow-up. The duration of radiographic follow-up of the hips treated with the bead-blasted component averaged 11.3 years (range, ten to sixteen years) postoperatively, whereas that of the hips treated with the precoated grit-blasted component averaged 8.2 years (range, five to eleven years). Two (6 percent) of the bead-blasted femoral components were revised because of aseptic loosening compared with eight (18 percent) of the precoated grit-blasted components. Four bead-blasted components (11 percent) were either radiographically loose or were revised because of loosening compared with eleven precoated grit-blasted components (24 percent). Kaplan-Meier survivorship curves evaluated with log-rank analysis revealed that the bead-blasted Iowa femoral components were revised because of aseptic loosening (p = 0.0184) and were radiographically loose (p = 0.0068) less often than the precoated grit-blasted Iowa femoral components. CONCLUSIONS: The findings of the present study have led the senior ones of us to resume using femoral components with a polished surface and fixed with cement.     

Comparison of clinical outcomes in total hip arthroplasty using rough and polished cemented stems with essentially the same geometry

BACKGROUND: Aseptic loosening of the cemented stem is the most common cause of revision of total hip arthroplasties. The loosening is often associated with substantial lysis of the surrounding bone. The surface finish of femoral components is suspected as a contributing factor to this bone lysis. The purpose of this study was to compare the results associated with a rough surface and those associated with a polished surface in a consecutive series of cemented stems with essentially the same geometry. METHODS: The study included 244 consecutive total hip arthroplasties with a cemented femoral component performed by one surgeon. There was no difference in patient selection criteria or surgical techniques between the group treated with a polished stem and that treated with a grit-blasted stem. All arthroplasties were hybrid, with an uncemented acetabular component. Generally, patients were over the age of sixty years (mean age, 70.6 years). The stems inserted in the initial 122 hips had a grit-blasted surface with a roughness of 2.1 microm. The stem surface in the second 122 hips was polished (roughness, 0.1 microm). The results of clinical and radiographic assessments performed immediately after surgery were compared with those performed at the most recent visit. The average duration of clinical follow-up for the patients treated with the grit-blasted and polished stems was 5.98 years and 5.32 years, respectively. RESULTS: Four hips treated with the grit-blasted stem had aseptic loosening with substantial surrounding lysis and required revision. An additional two hips in this group had radiographic evidence of substantial lysis and were judged to have an impending need for revision. In contrast, no hip treated with the polished stem required revision, and only one had minimal lysis. This difference regarding failures and impending failures was significant (p = 0.05). The clinical results were comparable, with an Iowa hip rating of 98 points at the time of follow-up in both groups. CONCLUSIONS: There was a significant difference between grit-blasted and polished stems with respect to the prevalence of revisions and impending revisions, all of which were identified in a relatively short follow-up period. The results in this series favor the use of a polished stem when cement is employed for fixation of the femoral component.     

Hybrid total hip arthroplasty in patients under the age of fifty: A five- to ten-year follow-up

In 37 patients, 45 total hip replacements were performed using contemporary cementing techniques, an uncemented Harris-Galante I acetabular component and a cemented precoated Iowa femoral component in patients under the age of 50 at the time of their surgery; 36 patients with 43 hybrid hips were living, 1 patient with 2 hybrid hips was decreased. No patients were lost to follow-up. At 5- to 10-year follow-up, eight hips were revised for aseptic loosening. No acetabular components, and eight femoral components (18%) were revised for aseptic loosening. When looking at radiographic results, including revision as well as those components that were probably or definitely loose on radiographs, 0 acetabular components and 11 femoral components (24%) were radiographically loose. These results demonstrate the excellent durability of the uncemented Harris-Galante acetabular component in the younger patient. However, the Iowa grit-blasted methyl methacrylate precoated femoral component had a magnitude increase in the prevalence of revision for aseptic femoral loosening when compared to the senior author's long-term Charnley results in this age group. The authors attribute the failure to the rough surface finish applied to the femoral component. However, the polymethyl methacrylate proximal precoating and the femoral component design may also contribute to the femoral failures.     

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%).     

Ten-year survivorship of rough-surfaced femoral stem with geometry similar to Charnley femoral stem

The aim of this study is to review the 10-year results of 269 cemented total hip arthroplasties performed using the Harvard femoral stem with matte surface finish and Charnley stem-like geometry. This is a retrospective cross-sectional survivorship study. We retrospectively reviewed the results of 269 cemented total hip arthroplasties performed using the Harvard femoral stem in 257 patients (men/women 93:164, mean age 71.2 years) between 1990 and 1994. The median duration of follow-up for the surviving implants was 118 (range 60-129) months. Radiographs were reviewed to evaluate the type of osteoarthritis, cement mantle thickness, alignment of the components, presence of aseptic loosening, and radiolucent lines. Kaplan-Meier survival analysis and Cox proportional hazards analysis were performed to evaluate 10-year survival and the impact of various radiological parameters on the prosthesis survival respectively. Of the 248 eligible patients (260 hips), 6 patients (7 hips) were lost to follow-up, and 67 patients had died at the time of the study; 36 hips (35 patients) underwent revision surgery for aseptic failure (median duration 60 months, range 12-125 months), and 11 hips were revised for septic failure (median duration 24 months, range 10-53 months from the index procedure). The femoral component was revised in all patients, whereas the acetabular component was revised in 27 patients. Ten-year survival for the femoral and acetabular components using aseptic loosening (with and without revision surgery) as an end point was 77.5% (71.5%-83.5%) and 91.1% (87.2%-95%), respectively. Cox regression analysis did not reveal a statistically significant (P > 0.05) effect of various radiological parameters on survival rate. Our results demonstrate that the matte surface finish femoral component (with geometry similar to Charnley femoral component) has less satisfactory long-term survival rate.     

High placement of noncemented acetabular components in revision total hip arthroplasty. A concise follow-up, at a minimum of fifteen years, of a previous report

We previously reported the average ten-year results associated with the use of porous-coated noncemented acetabular shells that were placed at a high hip center at the time of revision total hip arthroplasty in thirty-four patients (thirty-six hips) with severe acetabular bone loss. We now report the average 16.8-year results for twenty-one patients (twenty-three hips). Of the original cohort of forty-four patients (forty-six hips), thirty-nine patients (forty-one hips; 89%) retained the shell. Two shells (4.3%) were revised because of aseptic loosening, and three (6.5%) were revised because of infection. Six femoral components were revised because of femoral osteolysis, and seven were revised because of aseptic loosening without osteolysis. On the basis of our results after an average duration of follow-up of 16.8 years, we believe that the placement of an uncemented acetabular component at a high hip center continues to be an excellent technique for revision total hip arthroplasty in selected patients with severe acetabular bone loss.     

Results of Charnley total hip arthroplasty at a minimum of thirty years. A concise follow-up of a previous report

The purpose of the current study was to update the results of a prospective, single-surgeon series of primary Charnley total hip arthroplasties performed with cement. This investigation is one of the first studies in which hips treated with total hip arthroplasty with cement were followed for a minimum of thirty years. Twenty-seven patients (thirty-four [10.3%] of the hips in the initial study group) were alive at a minimum of thirty years postoperatively. These patients served as the focus of the present study. Revision because of aseptic loosening of the acetabular component was performed in 7.3% (twenty-three) of the hips from the original study group (excluding those revised because of infection or dislocation) and 26% (eight) of the hips in the living cohort. Revision because of aseptic loosening of the femoral component was performed in 3.2% (ten) of the hips from the original study group (excluding those revised because of infection or dislocation) and 10% (three) of the hips in the living patients. Since the twenty-five-year review, three hips were revised (one because of acetabular loosening, one because of femoral loosening, and one because of instability). This end-result study demonstrated the remarkable durability of cemented Charnley total hip replacements over a span of three decades, with 88% of the original prostheses intact at the time of the final follow-up or at the patient's death.     

Total hip replacement with a cementless acetabular component and a cemented femoral component in patients younger than fifty years of age

BACKGROUND: We have been using hybrid total hip arthroplasty (a cementless acetabular component and a cemented stem) in young patients. The purpose of this study was to determine the prevalence of aseptic loosening, polyethylene wear, and osteolysis after the use of this technique. METHODS: We studied a prospective consecutive series of sixty-four primary hybrid total hip replacements in fifty-five patients younger than fifty years old. There were forty-three men and twelve women; the average age at the time of the index operation was 43.4 years. The average duration of follow-up was 9.4 years. We used a cementless acetabular component without screw-holes and a cemented femoral component with a 22-mm head in all hips. Clinical follow-up with use of Harris hip ratings and radiographic follow-up were performed at six weeks; at three, six, and twelve months; and yearly thereafter. The sequential annual linear and volumetric wear rates were measured, and bone-remodeling and osteolysis were assessed. RESULTS: The mean preoperative Harris hip score was 44 points, which increased to 95 points at the time of final follow-up. No hip had aseptic loosening. One hip (2%) was revised because of late infection. The average linear wear (and standard deviation) was 0.96 +/- 0.066 mm, with an average annual rate of 0.096 +/- 0.013 mm. The average volumetric wear was 364.7 +/- 25.2 mm (3), with an average annual rate of 43.4 +/- 3.5 mm (3). Six hips (9%) had an osteolytic lesion of <1 cm in diameter in the calcar femorale (zone 7). CONCLUSIONS: Our results show that a hybrid arthroplasty with a cementless acetabular component and a smooth cemented femoral component (Ra, 0.6 mm) is effective for primary total hip replacement in young patients. Although there was no aseptic loosening and a low prevalence of osteolysis at the latest follow-up evaluation, the high rates of linear and volumetric wear of the polyethylene liner in these young patients remain a concern.     

20-year experience with cemented primary and conversion total hip arthroplasty using so-called second-generation cementing techniques in patients aged 50 years or younger

We present the 20-year experience of 47 hips in 40 patients aged 50 years or younger with cemented primary total hip arthroplasty using second-generation femoral cementing techniques. Average follow-up duration in the 23 patients living at least 17 years was 18.2 years. Overall, 18 hips (38%) had components revised or removed for any reason, at an average duration of 12.6 years. Every revision or reoperation involved removing the acetabular component. Of these 18 acetabular components, 15 (32%) were revised for aseptic loosening. Eleven additional acetabular components were loose by radiographic criteria at final follow-up, yielding prevalence of aseptic acetabular loosening (55%). Four femoral components (8%) were revised for osteolysis without loosening, and 3 (6%) were revised for aseptic loosening. Femoral osteolysis, with or without component loosening, led to revision in 5 ( 11%) hips compared with 6% for aseptic loosening alone. Osteolysis was the primary problem leading to acetabular and femoral component revision in this series of people < or = 50 years old over the first 20 years after the index operation.     

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.     

Staged bilateral total hip arthroplasty using rough and smooth surface femoral stems with similar design: 10-year survivorship of 48 cases

BACKGROUND: Various studies have reported good long-term results using femoral stems with either smooth or rough surfaces. In this retrospective cross-sectional survivorship study, we reviewed the 10-year results of 51 bilateral staged cemented total hip arthroplasties using the Harvard or the Charnley femoral stems-which have almost similar geometry but a different surface finish. METHODS: 51 patients were reviewed at median interval of 10 (Harvard group) and 11 years (Charnley group) after the primary operation. We evaluated cement mantle thickness, alignment of the components, presence of radiolucent lines, and aseptic loosening. Kaplan-Meier analysis was performed to calculate the survival rate using various endpoints. RESULTS: 8 hips in the Harvard group were revised for aseptic loosening of the femoral component at a median interval of 6.3 years after the primary procedure. 3 hips in the Charnley group were revised for aseptic loosening of the femoral and acetabular components between 10 and 11 years after the primary procedure. The 10-year survival rate for the femoral component using revision surgery for aseptic loosening as an endpoint was 80% (95% CI: 31-42) and 95% (95% CI: 44-47) in the Harvard and the Charnley group, respectively. Cox regression analysis did not reveal any statistically significant effect of various radiographical parameters on the survival rate (p < 0.05). INTERPRETATION: Our results demonstrate that in the group of patients studied, the femoral stem component with the matt surface finish had less satisfactory 10-year survival than the femoral stem of similar design which had a smooth surface finish.     

Total hip arthroplasty with a modified cementing technique using hydroxyapatite granules

Results of total hip arthroplasties with a modified cementing technique using hydroxyapatite were evaluated. Femoral and acetabular components were inserted with cement after hydroxyapatite granules (phi = 100-300 microm). The study group comprised 268 hips in 232 patients. The diagnosis was osteoarthritis in 197 patients. After a mean follow-up of 10.3 years, 5 patients died and 30 patients were lost to follow-up, leaving 218 hips (197 patients; mean age, 58.2 years) for evaluation. Three hips were revised because aseptic (1) and septic (2) loosening of acetabular components. Six other sockets were defined as radiologically loose, and no femoral component was loose. Osteolysis was identified in 2 femora and 0 acetabula. The overall loosening rate was 3.2% for acetabular components and 0% for femoral components. These results show that the loosening rate of cemented total hip arthroplasty components, especially the acetabulum, is reduced markedly with this modified cementing technique.     

Hybrid revision total hip arthroplasty: a 7-year follow-up study

The hybrid method for fixation of total hip arthroplasty (THA) has shown excellent results during the first decade in primary operations. To investigate its role in revision surgery, data on 48 revision THAs in 45 patients that met the inclusion criteria were gathered prospectively, using HGP cementless acetabular components and precoated cemented femoral components inserted with so-called second generation femoral cementing technique in each case. For the 48 hips during an average follow-up period of 7.4 years, no acetabular components was loose or had pelvic lysis. One acetabular component was revised for recurrent dislocation; 1 of 48 femoral components was revised for aseptic loosening and 1 for periprosthetic fracture. Three additional femoral stems (6%) were loose. In this small series, the hybrid concept for revision of failed nonseptic THAs has shown excellent results.     

Staged bilateral total hip arthroplasty using rough and smooth surface femoral stems with similar design: 10-year survivorship of 48 cases

Background?Various studies have reported good long-term results using femoral stems with either smooth or rough surfaces. In this retrospective cross-sectional survivorship study, we reviewed the 10-year results of 51 bilateral staged cemented total hip arthroplasties using the Harvard or the Charnley femoral stems—which have almost similar geometry but a different surface finish.

Methods?51 patients were reviewed at median interval of 10 (Harvard group) and 11 years (Charnley group) after the primary operation. We evaluated cement mantle thickness, alignment of the components, presence of radiolucent lines, and aseptic loosening. Kaplan-Meier analysis was performed to calculate the survival rate using various endpoints.

Results?8 hips in the Harvard group were revised for aseptic loosening of thefemoral component at a median interval of 6.3 years after the primary procedure. 3 hips in the Charnley group were revised for aseptic loosening of the femoral and acetabular components between 10 and 11 years after the primary procedure. The 10-year survival rate for the femoral component using revision surgery for aseptic loosening as an endpoint was 80% (95% CI: 31–42) and 95% (95% CI: 44–47) in the Harvard and the Charnley group, respectively. Cox regression analysis did not reveal any statistically significant effect of various radiographical parameters on the survival rate (p < 0.05).

Interpretation?Our results demonstrate that in the group of patients studied, the femoral stem component with the matt surface finish had less satisfactory 10-year survival than the femoral stem of similar design which had a smooth surface finish.

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Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. A 12-year radiographic review.

To assess the effect of improved methods of femoral cementing on the loosening rates in young patients, we reviewed 50 'second-generation' cemented hip arthroplasties in 44 patients aged 50 years or less. The femoral stems were all collared and rectangular in cross-section with rounded corners. The cement was delivered by a gun into a medullary canal occluded distally with a cement plug. A clinical and radiographic review was undertaken at an average of 12 years (10 to 14.8) and no patient was lost to follow-up. No femoral component was revised for aseptic loosening, and only one stem was definitely loose by radiographic criteria. By contrast, 11 patients had undergone revision for symptomatic aseptic loosening of the acetabular component and 11 more had radiographic signs of acetabular loosening.     

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.     

Primary hybrid total hip replacement, performed with insertion of the acetabular component without cement and a precoat femoral component with cement. An average ten-year follow-up study

One hundred and twenty-one primary hybrid total hip replacements were performed in 107 patients. A titanium, porous-coated, hemispherical acetabular component was fixed with screws, and a collared, chromium-cobalt femoral stem, with a roughened surface and a thin layer of methylmethacrylate on the proximal third, was inserted with contemporary cementing techniques (that is, use of a femoral medullary plug, a cement gun, and centrifugation and pressurization of the cement). Fifteen patients (fifteen hips) died before a minimum duration of follow-up of seven years, four patients (four hips) were too ill for a detailed follow-up examination at the time of the study, and two patients (two hips) refused to be evaluated at the time of the latest follow-up. None of these twenty-one hips had had a revision or a reoperation at the time of the latest follow-up. Eighty-six patients (100 hips) were available for clinical follow-up at an average of 120 months (range, eighty-four to 153 months) and for radiographic follow-up at an average of 118 months (range, eighty-four to 153 months). The average age of the patients at the time of the index arthroplasty was sixty-five years (range, forty-five to eighty-seven years). Three acetabular components were revised because of dissociation of the liner in association with a fracture of a locking tine. One well fixed acetabular component was revised because of pelvic osteolysis, and the femoral stem in the same patient was revised because of aseptic loosening. None of the ninety-six remaining acetabular components migrated, was classified as radiographically loose, or was revised because of aseptic loosening. Osteolytic lesions were identified adjacent to five acetabular components, and one of them was treated with bone-grafting around the well fixed acetabular shell. Two hips had a continuous radiolucent line at the interface between the acetabular implant and the bone. Three femoral stems had evidence of radiographic debonding (a radiolucent line that was one millimeter wide or less between the cement and the prosthesis), and they were classified as radiographically loose despite excellent clinical results. Seven hips had osteolytic areas located in the proximal aspect of the most proximal zones of Gruen et al., and five had small osteolytic regions in more distal areas. The Harris hip score for the eighty-two patients (ninety-six hips) who did not have a revision improved from 48 points (range, 22 to 70 points) preoperatively to 92 points (range, 53 to 100 points) at the most recent follow-up examination. Eighty-one patients had no, slight, or mild pain in the hip, and they were satisfied with the clinical result. In the present study, the hybrid total hip replacement with use of the Harris-Galante acetabular component and the Precoat femoral stem continued to provide an excellent result for most patients at an average of approximately ten years after the operation.     

Use of constrained acetabular components for hip instability: an average 10-year follow-up study

The short-term efficacy of using constrained acetabular components for hip instability in the total hip arthroplasty construct has been documented. However, long-term concerns including late dislocation, loosening of components, and osteolysis have not been addressed. The authors evaluated, at an average 10.3-year follow-up, 101 tripolar constrained components (Stryker Howmedica Osteonics) used in the total hip arthroplasty construct. At final follow-up, 6 hips had dislocated or had failure of the constrained component, 5 of which were revised. In addition, 4 hips were revised for aseptic loosening of the acetabular component, 4 hips were revised for aseptic femoral loosening, and 1 hip was revised for acetabular osteolysis. Considering the complexity of the cases, this component has provided durable fixation and hip stability at this intermediate-term follow-up.