The Exeter Universal stem: a minimum ten-year review from an independent centre

We reviewed 142 consecutive primary total hip replacements implanted into 123 patients between 1988 and 1993 using the Exeter Universal femoral stem. A total of 74 patients (88 hips) had survived for ten years or more and were reviewed at a mean of 12.7 years (10 to 17). There was no loss to follow-up. The rate of revision of the femoral component for aseptic loosening and osteolysis was 1.1% (1 stem), that for revision for any cause was 2.2% (2 stems), and for re-operation for any cause was 21.6% (19 hips). Re-operation was because of failure of the acetabular component in all but two hips. All but one femoral component subsided within the cement mantle to a mean of 1.52 mm (0 to 8.3) at the final follow-up. One further stem had subsided excessively (8 mm) and had lucent lines at the cement-stem and cement-bone interfaces. This was classified as a radiological failure and is awaiting revision. One stem was revised for deep infection and one for excessive peri-articular osteolysis. Defects of the cement mantle (Barrack grade C and D) were found in 28% of stems (25 hips), associated with increased subsidence (p = 0.01), but were not associated with endosteal lysis or failure. Peri-articular osteolysis was significantly related to the degree of polyethylene wear (p < 0.001), which was in turn associated with a younger age (p = 0.01) and male gender (p < 0.001). The use of the Exeter metal-backed acetabular component was a notable failure with 12 of 32 hips (37.5%) revised for loosening. The Harris-Galante components failed with excessive wear, osteolysis and dislocation with 15% revised (5 of 33 hips). Only one of 23 hips with a cemented Elite component (4%) was revised for loosening and osteolysis. Our findings show that the Exeter Universal stem implanted outside the originating centre has excellent medium-term results.     

Long-Term Durability of the CLS Femoral Prosthesis in Patients with Osteonecrosis of the Femoral Head

Ninety-five hips with cementless wedge-shaped tapered CLS stem were evaluated with a mean duration of 12.7 years (range, 10.7–17.3 years). All patients were young and diagnosed with osteonecrosis of the femoral head. The Harris hip score was 92 at the latest follow-up. A subsidence greater than 3 mm was found in 3 hips (3.2%). Focal femoral osteolysis was found in 12 hips (12.6%). Endosteal bone formation and bony pedestal were observed in 94 hips (98.9%) and in 26 hips (27.4%), respectively. With revision for stem loosening as the end point, the survivorship showed 98.9% (95% CI, range 96.9%–100%) at 13 years. Stem alignment and proximal femur morphology did not influence loosening of the stem (p > 0.05).     

The Cementless Anatomic Benoist Girard (ABG) II Total Hip Arthroplasty : A Minimum 8-Year Follow-Up Study

We have evaluated 90 consecutive primary cementless ABG II total hip replacements. The bearings combined metal-on-polyethylene in 64 hips, and alumina-on-alumina in 26 hips. At the minimum 8-year follow-up, ten patients had died, seven had been lost to follow-up, two had undergone revision of either or both components, and 68 were still alive and had not been revised. With revision for any reason as the endpoint, the cumulative survival rate at 10 years was 97.5% ± 1.7%, and 98.7% ± 1.3% for the metal-back cup and the femoral component, respectively. No hip showed peri-acetabular osteolysis. The ABG II total hip arthroplasty has demonstrated favourable clinical and radiological outcomes as well as survival in the current series. Further follow-up is needed to confirm these mid-term results.     

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.     

High survival in young patients using a second generation uncemented total hip replacement

Purpose

Whilst excellent long-term results with contemporary uncemented stems have been reported for total hip arthroplasty in young patients, the survival rates for the whole reconstruction are often compromised by high failure rates on the acetabular site due to peri-acetabular osteolysis and accelerated wear.

Methods

In patients 60 years old or younger, we retrospectively reviewed the results at a minimum of ten years of 89 consecutive uncemented total hip replacements in 88 patients using the press-fit Fitmore acetabular component in combination with the CLS Spotorno stem and a 28-mm Metasul metal-on-metal articulation or a 28-mm alumina ceramic on conventional polyethylene bearing. The mean age at the time of surgery was 49 years (range, 25–60). The mean clinical and radiological follow-up was 12 years (range, 10–15).

Results

Six patients (six hips) died and two patients (two hips) were lost to follow-up. Five hips were revised: one for deep infection, one for peri-prosthetic femoral fracture, and one for aseptic stem loosening. In two hips an isolated revision of the acetabular liner was performed (one for recurrent dislocation and one for unexplained pain). No revision was performed for accelerated wear, osteolysis or aseptic loosening of the acetabular shell. We could not detect peri-acetabular osteolysis visible on plain radiographs in those hips evaluated radiographically. The Kaplan-Meier survival with revision for any reason as the endpoint was 94% (95% confidence interval, 86–97) at 12 years.

Conclusions

The survival rates and the radiological outcomes with this implant combination in this young and active patient group are encouraging when compared to the results reported for other uncemented cups in this age group.     

Cementless Total Hip Arthroplasty in Patients with Osteonecrosis After Kidney Transplantation

This study was to determine the mid- to long-term survivorship of cementless metal-on-metal THA in 52 patients (74 hips) who underwent THA for osteonecrosis of the femoral head with a cementless THA. The mean follow-up was 10.2 years. The mean age at operation was 42.1 years (range, 25–62 years). The survivorship analysis with revision as the end point estimated a 96.6% chance of THA survival during 16.4 years. The average Harris hip score at last follow-up was 89.2 points (range, 74–100). Two patients (two hips) required revision surgery for extensive acetabular osteolysis at 9 years and acetabular liner dissociation at 2 years. The survival rates of cementless THA in these patients are encouraging. However, the possibility of metallic wear related complications are raising concern.     

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

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

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

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

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

Failure Analysis of Alumina on Alumina Total Hip Arthroplasty With a Layered Acetabular Component : Minimum Ten-Year Follow-Up Study

This prospective study reports the outcome of total hip arthroplasty (THA) performed in a consecutive series of patients using an alumina ceramic on a ceramic-layered component (Alumina-Bearing-Surface system). The cohort consisted of 270 hips in 229 patients. The study evaluated the clinical and radiological results over a mean follow-up of 11.4 years. Revision THA was performed on 58 hips, including alumina alternative failure in 50 hips, loosening in 4 hips, recurrent dislocation in 2 hips, stem neck fracture in 1 hip and hematoma in 1 hip. The survival rate was 68% with revision for any reason as the end point. The risk factors of implant failure are the preoperative range of motion of the hip joint and postoperative dislocation.     

The Charnley versus the Spectron hip prosthesis: clinical evaluation of a randomized, prospective study of 2 different hip implants.

Prospective, randomized studies must be performed when new surgical techniques or implants are evaluated. In this study, a new implant system was compared with the Charnley prosthesis, which over the years has been the most used hip implant in Sweden. Between 1985 and 1989, 410 hips were randomized to treatment with a Charnley or a Spectron total hip arthroplasty: 206 Charnley and 204 Spectron prostheses were implanted. The patients were operated on by a standardized procedure using a contemporary cementing technique. The patients were followed prospectively by an independent observer after 1, 3, 5 to 6, and 10 years. Harris Hip Score and patient satisfaction were recorded in the outcome evaluation. A total of 144 patients with 164 hips were deceased, and 15 patients (8 Charnley and 7 Spectron) have required a revision. Nine hips were revised because of aseptic loosening (5 Charnley stems and 4 Spectron metal-backed cups). The Charnley stem as well as the metal-backed Spectron cup had a higher risk for revision because of aseptic loosening. The Charnley ogee cup and the Spectron stem have performed remarkably well with no revision of these components. Seven Charnley prostheses dislocated, but no dislocation was recorded in the Spectron group. Survivorship calculations with a mean follow-up of 10 years revealed an overall 11-year survivorship of 94.5% +/- 3.4% (Charnley, 93.2% +/- 5.8%; Spectron, 95.9% +/- 3.0%). The clinical outcome did not differ between the 2 systems. The overall results in this old population, using a contemporary surgical technique, illustrate that cemented hip arthroplasty is an excellent treatment alternative for elderly patients.     

The Charnley versus the Spectron hip prosthesis: radiographic evaluation of a randomized, prospective study of 2 different hip implants.

A total of 410 hips were randomized to treatment with either a Charnley (206 hips) or a Spectron (204 hips) total hip arthroplasty. The patients were operated on by a standardized procedure using a contemporary cementing technique and were followed after 1, 3, 5 to 6, and 10 years. The postoperative radiographs showed a significantly increased rate of malalignment and consequently low grade of cement mantle quality of the Charnley stem compared to the Spectron. No differences concerning cement mantle quality or positioning were found between the Charnley ogee cup and the metal-backed Spectron. Evaluation of the follow-up radiographs revealed 10 loose Charnley stems and 1 loose Spectron stem and 4 loose Charnley ogee cups and 23 loose Spectron metal-backed cups. The differences of revision rate for the femoral and acetabular components of the 2 prostheses were significant (P = .03, Charnley femoral component more frequent; P = .03, Spectron acetabular component more frequent). The radiographic evaluation strengthened this disparity. Poor wear characteristics of the metal-backed Spectron cup are perhaps the main reason for the highly significant difference in mechanical failure rate between the 2 cups. We therefore propose that metal-backing of cemented cups should be avoided, at least when combined with larger femoral heads. The difficulty in positioning the Charnley stem with an adequate cement mantle, especially in the absence of trochanteric osteotomy, might explain the inferior Charnley stem longevity in this study.     

A Modified Modular Stem in Primary Total Hip Arthroplasty for Developmental Dysplasia of the Hip: Average 11-year Follow-Up in Cases With Previously Reported 3-year Clinical Results

BackgroundModular stems require careful follow-up, especially after any design modification. This study investigated the mid- to long-term outcomes of total hip arthroplasty in patients with developmental dysplasia of the hip using the S-ROM-A stem, a modified S-ROM stem for Asians.MethodsWe previously reported short-term outcomes for all 220 dysplastic hips that underwent primary total hip arthroplasty with the S-ROM-A stem. Here, we followed the clinical and radiological outcomes of 201 of the 220 hips (91%) for a mean 11.4 years postoperatively. We also performed multivariate analysis to determine whether large anteversion angle adjustment was associated with increased osteolysis.ResultsThe cumulative survival rate of the stem at 168 months postoperatively was 97.4%. Two hips underwent revision surgery, including 1 due to neck trunnionosis. Characteristic distal stem fracture occurred in 3 hips (1.5%). Most partial radiolucent lines observed around the sleeve early postoperatively disappeared by 7 years, postoperatively. Mild osteolysis occurred relatively frequently (20%), but a multivariate model adjusted for polyethylene type showed no significant association between the occurrence of osteolysis and anteversion adjustment of the modular stem (stem anteversion decreased ≤?20°, P = .829; stem anteversion increased ≥+20°, P = .619).ConclusionPartial radiolucent lines early postoperatively do not affect long-term outcomes. The clinical benefits of actively adjusting the stem anteversion angle outweigh the mechanical risks. Mild osteolysis, stem fracture, and trunnionosis were relatively frequent complications. Analysis with longer follow-up and more cases are necessary to clearly determine if these complications are associated with the design modification.     

Long-term survivorship of the Charnley Elite Plus femoral component in young patients

We studied prospectively the long-term results of the Charnley Elite-Plus femoral stem in 184 consecutive young patients (194 hips). There were 130 men and 54 women with a mean age of 49.1 years (21 to 60). The predominant diagnosis was osteonecrosis of the femoral head (63.6%, 117 patients). Clinical and radiological evaluation was undertaken at each follow-up. The mean follow-up was 11.2 years (10 to 12). The mean pre-operative Harris hip score was 43.4 (12 to 49) which improved to 91 (59 to 100) at the final follow-up. The survival of the femoral stem at 12 years was 99% with revision as the end-point. The mean annual linear wear of the polyethylene liner was 0.17 mm (0.13 to 0.22). The prevalence of acetabular osteolysis was 10.8% (21 hips) and osteolysis of the calcar femorale 12.9% (25 hips). A third-generation cementing technique, accurate alignment of the stem and the use of a 22 mm zirconia head were important factors in the prevention of aseptic loosening of the Elite Plus femoral stem in these high-risk young patients.     

The 27 to 29-Year Outcomes of the PCA Total Hip Arthroplasty in Patients Younger Than 50 Years Old

We previously reported our six and 19.4-year results of arthroplasty with the PCA total hip prosthesis. We now report on the performance of this prosthesis at 27–29 years. Eighty-eight consecutive primary THAs using a PCA total hip system were performed in 70 patients (mean age, 45.6 ± 11.1 years). The mean follow-up was 28.4 years (27–29). The mean Harris hip score was 89 points at final follow-up. Thigh pain was reported in 22 hips (25%). The mean annual polyethylene wear was 0.182 ± 0.03 mm. There were 75 acetabular (85%) and 40 femoral (45%) osteolysis. The rate of survival after 28.4 years as the end point of revision was 66% for the acetabular component and 90% for the femoral component.     

Long-Term Survival of the Cemented Exeter Universal Stem in Patients 50 Years and Younger: An Update on 130 Hips

BackgroundThere is variable evidence regarding survivorship beyond 20 years of total hip arthroplasties in young patients. We report the long-term results of the Exeter cemented hip system in patients ≤50 years at minimum of 20 years.MethodsClinical and radiological outcomes of 130 consecutive total hip arthroplasties in 107 patients aged 50 years or younger at primary operation were reviewed; 77% had a diagnosis other than osteoarthritis. All patients were followed at 5-year intervals, no patients were lost to follow-up, and the status of every implant is known.ResultsMean age at surgery was 41.8 (17-50) years. Mean follow-up was 22.0 (20.0-26.1) years. There were 79 hips surviving, 14 hips (11 patients) deceased, and 37 hips revised. Reasons for revision: 29 hips for aseptic cup loosening (26 stems revised using cement-in-cement, three left in-situ); three stems for femoral osteolysis, two related to acetabular polyethylene wear (14.1 and 17.0 years), one with Gaucher’s disease (21.1 years); one broken stem (12.9 years); one cup for instability (4.3 years–stem revised using cement-in-cement); and two hips with infection (8.5 and 23.8 years). There were no cases of aseptic loosening of the Exeter stem. There were no radiologically loose stems although eight patients had radiological evidence of loosening of the cemented cup. Survivorship at 22 years was 74.9% for revision for all causes and 96.3% for revision of the stem for aseptic loosening or lysis.ConclusionThe Exeter cemented stem has excellent survivorship at minimum 20 years in young patients. Acetabular component survivorship was less favorable, but the advent of highly cross-linked polyethylene may improve this in the long term.     

Cementless Modular Total Hip Arthroplasty in Patients Younger than Fifty with Femoral Head Osteonecrosis: Minimum Fifteen-Year Follow-Up

This study aimed to report the outcome of total hip arthroplasty (THA) with a modular femoral component in patients younger than fifty years with osteonecrosis of femoral head. Sixty-four osteonecrotic hips in fifty-five patients were available for clinical and radiographic analyses at minimum follow-up of fifteen-years. The mean Harris hip score improved from 36 points preoperatively to 92.7 points at final follow-up. Sixty-two (95.3%) hips demonstrated stable bone ingrowth. No hips showed loosening or required revision for aseptic loosening. Survivorship with an end point of stem revision for any reason was 93.8% and for aseptic loosening was 100% at 16.8 years. We believe that cementless THA with a modular stem is a promising procedure for young and active patients with osteonecrosis of the femoral head.     

Minimum 15-Year Results of a Dual-Offset Uncemented Femoral Stem in Total Hip Arthroplasty

BackgroundThe aim of the present study is to assess the long-term clinical and radiological outcomes of a proximal porous-coated, dual-offset, tapered titanium alloy uncemented stem at a minimum of 15 years of follow-up.MethodsWe reviewed 210 total hip arthroplasties (in 193 patients) performed between 1996 and 1999 and followed prospectively in our database who received the Synergy stem. We report a Kaplan-Meier survival analysis as well as the Harris Hip Score, the Western Ontario and McMaster University Arthritis Index, and the Short Form Health Survey-12 scores. Radiographs were evaluated for evidence of subsidence, osteolysis, osteointegration, or loosening.ResultsThe average follow-up was 16 years (range, 15-17.7 years). Kaplan-Meier survival analysis with revision of stem for aseptic mechanical loosening (1 stem) as the end point revealed a cumulative survival rate of 99.5% at 16 years. The Harris Hip Score, the Western Ontario and McMaster University Arthritis Index, and the Short Form Health Survey-12 physical scores were all significantly improved (P < .001) from the preoperative period to latest follow-up. Minor osteolysis was observed proximally in 14 hips (6.6%) with no osteolysis distal to the porous coating.ConclusionTo our knowledge, this study represents the largest series reporting the longest clinical follow-up of this third-generation, dual-offset, proximal ingrowth, tapered cementless stem. The Synergy stem design has achieved excellent clinical outcomes, predictable osteointegration, and outstanding survivorship of 99.5% at a minimum of 15 years follow-up, representing the standard for femoral stems at our institution.     

Isolated Acetabular Revision With Ceramic-on-Ceramic Bearings Using a Ceramic Head With a Metal Sleeve

The purpose of this study is to evaluate results of isolated acetabular revision with ceramic-on-ceramic bearings using a ceramic head with a metal sleeve. A retrospective review of fifty-three hips was performed. The mean patient age was 49.9 years and the mean follow-up period was 5.7 years. The mean modified Harris hip score improved from 47.5, pre-operatively, to 84.7 at the time of last follow-up (P < 0.001). Two patients reported squeaking of the hip. Three patients experienced loosening cup, necessitating re-revision surgery. There was a significant difference of acetabular bone defect between loose cup group and stable cup group (P = 0.018). There were no ceramic fractures and no osteolysis. The survival rate of the acetabular cup at the mid-term follow-up was 94.3%. In conclusion, ceramic head with a metal sleeve can be a reliable option for isolated acetabular revision.     

Isolated Acetabular Revision Hip Arthroplasty with the Use of Uncemented Cup

We evaluated the clinical and radiological results of isolated acetabular revision hip arthroplasty. Forty-three hips underwent isolated acetabular revision with uncemented cup and were followed up for an average of 76 months. The monoblock femoral stems were used in 20 hips and modular femoral stems in 23 hips. The average Harris Hip Score improved to 87 at last follow-up from 57 preoperatively. All femoral stems maintained stable fixation with bone ingrowth and no subsidence at last follow-up. Five hips with the monoblock stem underwent rerevision due to loosening of cup with osteolysis. The isolated acetabular revision is encouraging, but in reflection of the results of the monoblock head, the visual inspection of the femoral head is not enough for evaluation of its surface status.     

Revision of Ceramic Head Fracture After Third Generation Ceramic-on-Ceramic Total Hip Arthroplasty

We performed 24 revisions of fractures of third generation ceramic heads. The stem was not changed in 20 revisions; a new ceramic-on-ceramic bearing was used in four and a metal-on-polyethylene bearing in 16. The stem was changed in four revisions; a new ceramic-on-ceramic bearing was used in three and a metal-on-polyethylene bearing in one. During the follow-up of 57.5 months, complications occurred in five hips among the 20 stem retained revisions: a fracture of the new ceramic head in two, metallosis with pseudocyst in two, and femoral osteolysis with stem loosening in one. However, there were no complications in the four revisions where the stem was changed. Revision surgery after ceramic head fracture shows high rates of early complications. We recommend stem revision in cases of THA failure due to fracture of a modern ceramic head.     

Clinical and radiological results of the collarless polished tapered stem at 15 years follow-up

We prospectively followed 191 consecutive collarless polished tapered (CPT) femoral stems, implanted in 175 patients who had a mean age at operation of 64.5 years (21 to 85). At a mean follow-up of 15.9 years (14 to 17.5), 86 patients (95 hips) were still alive. The fate of all original stems is known. The 16-year survivorship with re-operation for any reason was 80.7% (95% confidence interval 72 to 89.4). There was no loss to follow-up, with clinical data available on all 95 hips and radiological assessment performed on 90 hips (95%). At latest follow-up, the mean Harris hip score was 78 (28 to 100) and the mean Oxford hip score was 36 (15 to 48). Stems subsided within the cement mantle, with a mean subsidence of 2.1 mm (0.4 to 19.2). Among the original cohort, only one stem (0.5%) has been revised due to aseptic loosening. In total seven stems were revised for any cause, of which four revisions were required for infection following revision of the acetabular component. A total of 21?patients (11%) required some sort of revision procedure; all except three of these resulted from failure of the acetabular component. Cemented acetabular components had a significantly lower revision burden (three hips, 2.7%) than Harris Galante uncemented components (17 hips, 21.8%) (p < 0.001). The CPT stem continues to provide excellent radiological and clinical outcomes at 15?years following implantation. Its results are consistent with other polished tapered stem designs.