Ceramic endoprosthesis in total hip arthroplasty

Aluminia-on-aluminia hip prosthesis with titanium alloy stem was used in 255 cases, for 143 patients with cemented acetabular cup and 112 with an uncemented screw cup. The average age of the patients was 62 years. Of the patients, 35 were treated bilaterally. The indication for surgery was osteoarthritis in 186 cases, fractures and nonunions of the hip joint in 34 cases, and congenital dislocations of the hip joint in 16 cases. Previous surgery of the hip joint was recorded for 43 cases. All procedures were primary arthroplasties. Only personal clinical examinations together with radiographic studies were accepted as clinical data. Three patients failed to show up for routine follow-up evaluation and these were excluded from the series. Revision operation was classified as failure. The indications for revision were aseptic loosening, late infection, and fracture of the acrylic cement resulting in loosening of the acetabular or femoral component. The acetabular component was cemented in 143 patients and the mean follow-up period for these patients was 6.7 years (range, 1-12 years). In this series, a revision operation was undertaken for 16 patients (11%). In 12 cases, broken acrylic cement resulted in acetabular aseptic loosening. In the series of 112 patients with uncemented titanium screw cup, the mean follow-up period was 3.6 years (range, 1-7 years) and a revision operation was undertaken in seven cases (7%). In two, the indication was late infection; in one, technical failure; and in two, progression of Pigmented villonodular synovitis. Acetabular aseptic loosening resulted in revision in only two cases. With cementless acetabular component bone transplantation is indicated.(ABSTRACT TRUNCATED AT 250 WORDS)     

Survivorship analysis of cemented total hip arthroplasty acetabular components implanted with second-generation techniques

The clinical and radiographic results of primary cemented total hip arthroplasty performed by a single surgeon, with particular emphasis on the performance of acetabular components implanted with so-called second-generation cement techniques, were studied. Seventy hips with 48 metal-backed and 22 polyethylene acetabular components were followed for a mean of 9 years (range, 5-11.5 years). The clinical results were evaluated using a recognized hip score. The fixation status of the cemented acetabular component was evaluated using two methods of measuring radiolucent lines at 5 years and at the last evaluation. Acetabular component loosening was defined as a circumferential radiolucent line, component migration, or revision for loosening. This study was unable to confirm the findings of others that demonstrated higher failure rates with cemented metal-backed components when compared with all-polyethylene components. The survival of cemented acetabular components with 28-mm head femoral prostheses was worse than the survival of cemented acetabular components with 22-mm femoral heads in other published reports, despite advances in cement techniques. Because of the high rate of loosening of cemented 28-mm-inner-diameter acetabular components at 5 and 10 years, the authors no longer use these cemented components for acetabular reconstruction.     

Isolated revision acetabuloplasty using a porous-coated cementless acetabular component without removal of a well-fixed femoral component. A 3- to 9-year follow-up study

The results of isolated acetabular revision performed in 31 patients (32 hips) were monitored for between 3 and 9 years. All femoral components were well fixed and not removed or revised at the time of index surgery. There were 4 hips with little or no acetabular bony defect, 2 hips with pure segmental defects (type I), 10 hips with cavitary defects (type II), 15 with combined segmental cavitary defects (type III), and I with pelvic discontinuity (type IV). All revision acetabular implants were cementless, using a porous-coated hemispheric cup with or without bone-graft. There were four grade I reconstructions, 16 grade II reconstructions, and 12 grade III reconstructions. At final follow-up evaluation 94% of the cups were judged to be stable. Two hips required a second revision acetabuloplasty because of loss of fixation of the cup. The 2 repeat revisions were also done without removal of the femoral component. One acetabular component had evidence of rotational migration, which stabilized and remained nonprogressive. There were no cases of femoral component radiographic or clinical failure. The mean pre and postoperative hip scores were 44 and 83, respectively. The pre- and postoperative pain scores were 12 and 42, respectively. The findings of this study suggest that isolated acetabular revision, using a cementless porous-coated hemispheric cup, can be successfully performed without removing or revising a well-fixed femoral stem and not compromise the final outcome.     

Porous-coated acetabular components with screw fixation. Five to ten-year results

The results of 136 consecutive primary total hip arthroplasties performed by one surgeon with the Harris-Galante-I porous-coated acetabular component were reviewed at a mean of seven years (range, five to ten years). In all hips, the outer diameter of the acetabular component was the same as the diameter of the final reamer used in the preparation of the acetabulum. However, this reamer was used only briefly at the rim of the acetabulum, and therefore the components had so-called press-fit stability. A mean of four screws (range, three to six screws) were used for additional fixation of the component. The clinical evaluation was performed with use of the Harris hip score. Standardized anteroposterior radiographs of the pelvis were assessed for migration of the component, radiolucent and radiodense lines, linear wear of the polyethylene, and osteolysis. No acetabular component had been revised for loosening and none were radiographically loose at the time of the most recent follow-up evaluation. There were no complications related to the use of the screws, and no screw had bent or broken. A non-progressive radiolucent line was seen in one acetabular zone in thirty-four hips (25 per cent) and in two acetabular zones in six hips (4 per cent). No hip had a radiolucent line in all three acetabular zones. The mean rate of linear wear of the polyethylene was 0.1 millimeter per year. There was no dissociation of the acetabular liner from the metal shell. Two hips (1 per cent) had asymptomatic osteolysis in the ischium and adjacent to the rim of the acetabular component; this was treated with grafting at the site of the lesion and exchange of the femoral head and the worn polyethylene liner. Five femoral components inserted without cement and one inserted with cement were revised because of loosening. The data suggest that, at a mean of seven years, fixation of this porous-coated component was uniformly excellent. The low prevalence of radiolucent lines and the absence of loosening are probably related, in part, to the technique of implantation. The low prevalence of polyethylene wear and pelvic osteolysis is a notable improvement compared with the results of arthroplasty with other porous-coated acetabular components. Although the results of the present study are encouraging, longer follow-up is necessary to determine the prevalence of late loosening and osteolysis.     

Effect of nitric oxide, prostacyclin, and thromboxane on the vasospastic action of hydrogen peroxide on human umbilical artery

During the years 1991-1994, the Norwegian Arthroplasty Register recorded 1,324 primary hip arthroplasties implanted with the Boneloc cement. We have compared the survival until revision due to aseptic loosening for charnley (n 955) and Exeter (n 172) prostheses. The Boneloc cemented hips were also compared with high viscosity cemented hips implanted during the same period. In the Boneloc cemented group, the estimated probability of survival at 4.5 years of a Charnley femoral component was 74% and for an Exeter femoral component 97% (p < 0.0001). Using a Cox regression model with adjustment for age, gender, type of cement, systemic antibiotic and stratified for diagnosis, an 8 times higher risk of revision was found in Boneloc cemented Charnley femoral components than in Exeter femoral components (p < 0.0001). For the acetabular components, the difference between the Charnley and Exeter components with Boneloc cement was not statistically significant. In both the Charnley and the Exeter prostheses, the high viscosity cemented components had significantly better survival than the Boneloc cemented components. The Cox regression model showed that a Boneloc cemented Charnley femoral component had a 14 times higher risk of revision than a high viscosity cemented component (p < 0.0001), and for Exeter femoral components a 7 times higher revision risk was found in the Boneloc cemented components (p = 0.003). Our results confirm the previously reported inferior results of Charnley prostheses implanted with Boneloc cement and inferior results of Boneloc cemented Exeter prostheses as well, but less pronounced than for Charnley prostheses.     

Charnley total hip arthroplasty in patients less than fifty years old. A twenty to twenty-five-year follow-up note

We evaluated the results twenty to twenty-five years after ninety-three consecutive, nonselected Charnley total hip arthroplasties performed with cement by the senior one of us in sixty-nine patients who were less than fifty years old at the time of the procedure. Seventy of the seventy-two hips in the living patients were followed radiographically for at least twenty years. Twenty-seven hips (29 per cent) had a revision or a resection of the prosthesis during the follow-up period. The revision or the resection was performed because of aseptic loosening in twenty-one hips (23 per cent), infection in four (4 per cent), dislocation in one (1 per cent), and fracture of the femur in one. Eighteen acetabular components (19 per cent) and five femoral components (5 per cent) were revised because of aseptic loosening, and an additional fourteen acetabular components (15 per cent) and seven femoral components (8 per cent) demonstrated definite or probable radiographic loosening. The present study demonstrates the long-term durability of total hip arthroplasty performed with cement in an active population of patients. The fixation of the femoral component was found to perform better than that of the acetabular component at twenty to twenty-five years after the procedure.     

Spatial differences in gap junction gating in the lens are a consequence of connexin cleavage

Thirty patients had 32 cementless total hip arthroplasty revisions and were evaluated postoperatively for clinical function (Harris Hip Score) and radiographic evidence of implant stability. Of the 26 femoral components revised, 16 were revised with anatomic long-stem femoral prostheses, and 10 were revised with straight mid-stem-length components. All components were collared and had circumferential proximal fiber-mesh porous coating. Seven of 16 patients had radiographic subsidence after revision with long-stem components (2 to 30 mm); 6 of 10 patients had subsidence after revision with mid-stem femoral components (2 to 25 mm). Of the 13 patients with femoral subsidence, 8 had calcar reconstruction with allograft bone; of the 13 patients without radiographic subsidence, 8 did not require calcar reconstruction. One of 27 fiber-mesh, porous-coated acetabular components migrated (30 mm). No components have been removed or revised. Even with circumferential proximal porous coating, femoral implant stability remains unpredictable in total hip arthroplasty revision.     

Acetabular and femoral fixation 15 years after cemented total hip surgery

Total hip arthroplasty in patients younger than 51 years of age remains controversial. The authors report results in 47 hips in 40 patients at an average followup of 15 years. Second generation femoral cementing techniques were used. Special attention was given to studying the differences between the outcome of acetabular versus femoral fixation. The patient group included 11 in whom custom components were used and 13 who had structural autografts for severe acetabular dysplasia. One femoral component and 10 acetabular components were revised for aseptic loosening. After 15 years, improved cementing techniques produced a marked reduction in the rate of femoral aseptic loosening. Loss of fixation of cemented acetabular components was common.     

Effect of improved cementing techniques on the longevity of fixation in revision cemented femoral arthroplasties. Average 8.8-year follow-up period

Forty-six revision cemented femoral arthroplasties in which second-generation cementing techniques were used have been reviewed. After an average follow-up period of 8.8 years, 91% of the femoral components remained in place and 87% remained well fixed. Only 7% were rerevised for aseptic loosening. These results demonstrate a marked improvement over those of first-generation cementing techniques.     

Radiotherapy for elderly patients

Fifty-seven revision total hip arthroplasties in fifty-six patients were performed with a Harris-Galante porous-coated acetabular component by one surgeon, and the patients were followed prospectively for a mean of seven years (range, five to twelve years). A trochanteric osteotomy was performed in forty hips, and a posterior approach with an extended anterior capsulectomy was used in the other seventeen. The acetabular defect was classified as segmental in seven hips, cavitary in twenty-three, and combined in twenty-one; six hips had no notable defect. A bulk allograft was used in eleven hips, and morseled cancellous-bone allograft or autogenous graft was used in thirty-four hips; twelve hips did not have bone-grafting. Both the femoral and the acetabular component were revised in forty-five hips, and only the acetabular component was revised in twelve. Thirty-nine hips (68 per cent) had a good or excellent clinical result according to the Harris hip score. The acetabular component was well fixed in the fourteen hips that had a fair result and the four hips that had a poor result. The acetabular component was considered to have migrated if there was a change in the angle of the cup of 5 degrees or more or a change in the horizontal or vertical position of the cup of more than three millimeters. Despite varying degrees of bone loss, no acetabular component had radiographic evidence of loosening at the latest follow-up examination. No component was revised and no revisions were scheduled. One hip was debrided for a late metastatic infection, but the component was well fixed and was not revised. There were no complications related to the use of screws for fixation. These mid-term results confirm the early success of acetabular revisions performed with fixation of a titanium fiber-metal-coated hemispherical component with multiple screws and no cement.     

Failure of the Mecring screw-ring acetabular component in total hip arthroplasty. A three to seven-year follow-up study

We prospectively studied the results of 411 consecutive total hip arthroplasties with a Mecring screw-ring acetabular component inserted without cement combined with a Stanmore femoral stem inserted with cement. The duration of follow-up ranged from three to seven years (mean, four years and six months). Three hundred and thirty-one patients (378 hips) were available for physical examination and had a complete set of radiographs. The clinical result was good or excellent for 82 per cent (309) of the 378 hips. However, the rate of radiographic loosening of the acetabular component, as evidenced by migration at the most recent follow-up examination, was alarmingly high: 25 per cent (ninety-five) of the 378 hips. In general, these patients did not have serious clinical symptoms. The cups in women migrated significantly more often (p = 0.003) than those in men. Migration was also more frequent in patients who were less than fifty-one years old and in patients in whom the index procedure was a revision arthroplasty, but these differences were not significant. Twenty-one (6 per cent) of the acetabular cups were revised for aseptic loosening. The high rate of radiographic loosening has led us to abandon the use of the Mecring screw-ring acetabular component.     

Total hip arthroplasty with use of second-generation cementing techniques. An eighteen-year-average follow-up study

In this report, we present the results of a further follow-up of a series of 140 consecutive patients (161 hips) who had had a primary total hip arthroplasty with insertion of a bead-blasted monoblock femoral component with use of so-called second-generation cementing techniques. The average age of the patients at the time of the arthroplasty was sixty-one years (range, twenty-one to eighty-five years). Sixty-seven patients (seventy-seven hips) died less than seventeen years after the index operation. The remaining seventy-three patients (eighty-four hips) were followed for an average of eighteen years (range, seventeen to twenty years). No patient was lost to follow-up. In the entire group of 161 hips, over the twenty-year span of the study, eight femoral components (5 percent) and twenty-eight acetabular components (17 percent) had been revised because of aseptic loosening. Of the seventy-seven hips in the sixty-seven patients who died, four had been revised because of aseptic loosening of the acetabular component only; one, because of aseptic loosening of the femoral component only; and one, because of aseptic loosening of both components. Of the eighty-four hips in the seventy-three patients who were alive at least seventeen years after the index arthroplasty, twenty-four hips (29 percent) in twenty-one patients had had revision of one or both components for any reason. Twenty-three acetabular components (27 percent) and six femoral components (7 percent) had been revised because of aseptic loosening. An additional two hips (2 percent) in two patients were loose according to radiographic criteria but had not been revised. Of the sixty-five all-polyethylene acetabular components that had been inserted with cement and were in patients who were alive at least seventeen years postoperatively, fifteen (23 percent) had been revised because of aseptic loosening. An additional seventeen cups (26 percent) were loose according to radiographic criteria. Thus, a total of thirty-two cups (49 percent) had been revised because of loosening or were loose but had not been revised at the time of the latest follow-up. The femoral components that had been inserted with use of second-generation cementing techniques fared better than did the acetabular components that had been inserted with these techniques during the same time-period. We found that assessment of all postoperative radiographs rather than only those that had been made immediately postoperatively increased the accuracy of the grading of the cement around the femoral component. Subsequent radiographs frequently had been made at different projections, which revealed new findings, consisting primarily of previously undetected voids, areas of thin cement, and defects in the cement mantle. Thus, we now use all available radiographs to determine the grade of the cement.     

Cement versus cementless fixation in total knee arthroplasty

A prospectively studied group of 55 uncemented Press Fit Condylar total knee arthroplasties was compared retrospectively with a matched group of 51 cemented Press Fit Condylar total knee arthroplasties at a mean of 10 years after operation. For the cemented group, the pain and function scores improved from 32 and 45 preoperatively to 95 and 77, respectively. For the uncemented group the scores improved from 33 and 50 preoperatively to 93 and 60, respectively. There were 10 revisions in the uncemented group for femoral or tibial aseptic loosening or osteolysis compared with two revisions in the cemented group. Exclusive of problems related to patellar metal backing, survival to revision for aseptic failure or radiographic loosening was 72% in the uncemented group and 94% in the cemented group at 10 years. A significantly higher revision rate was found in the uncemented compared with cemented total knee arthroplasty of the Press Fit Condylar design.     

Membrane electrical properties associated with insulin receptor downregulation in human erythrocytes

We reviewed 29 consecutive patients after cemented femoral revision of cemented hip arthroplasties for osteolysis. After an average follow-up of 8.5 years, osteolysis had recurred in only two cases (6.9%) and 25 femoral components (86%) remained well fixed.     

Long-term results of total hip replacement in young patients who had ankylosing spondylitis. Eighteen to thirty-year results with survivorship analysis

We determined the long-term results of total hip replacement in a series of young patients who had ankylosing spondylitis. Between 1966 and 1978, forty-three Charnley low-friction arthroplasties were performed in twenty-four patients who had an average age of 28.8 years (range, nineteen to thirty-nine years) at the time of the operation. There were seventeen men and seven women. The average duration of follow-up for the series was 22.7 years (range, one month [a perioperative death] to 30.3 years). Four patients (seven hips) had died an average of 12.6 years (range, one month to 18.7 years) after the operation. The twenty surviving patients had clinical and radiographic follow-up until the time of writing or until both of the original components had been revised. All patients had substantial relief of pain and improvement of function and the range of motion of the joint. Twenty-one patients (88 per cent; thirty-nine hips) were completely free of pain (6 points, according to the scale of Merle d'Aubigne and Postel), and the remainder had only slight discomfort (5 points). Ten acetabular components and one femoral component were revised because of aseptic loosening, and one patient had a revision of both components because of late deep infection. Three additional femoral components were revised during a revision operation for a loose acetabular component. Although the femoral components were not loose, they had been in place for more than ten years and it was thought likely that the bearing surface was damaged. The average time to revision was 13.3 years (range, 4.0 to 20.3 years). At an average of 22.7 years, thirty-eight (88 per cent) of the original femoral components and thirty-two (74 per cent) of the original acetabular components remained in situ. The average annual rate of acetabular wear was 0.12 millimeter for the entire series. Only six hips (14 per cent) had minor heterotopic ossification, and none of the hips had clinically important ossification (class III or IV according to the system of Brooker et al.). To our knowledge, the present report describes the largest series of total hip arthroplasties, with the longest duration of follow-up, in young patients who had ankylosing spondylitis. Survivorship analysis with use of the Kaplan-Meier method revealed that the probability of survival of the femoral component (with 95 per cent confidence intervals) was 91 per cent (83 to 99 per cent) at twenty years and 83 per cent (72 to 94 per cent) at thirty years. The probability of survival of the acetabular components was 73 per cent (61 to 84 per cent) at twenty years and 70 per cent (57 to 83 per cent) at thirty years. The probability that both components would survive was 91 per cent (82 to 100 per cent) at ten years, 73 per cent (61 to 84 per cent) at twenty years, and 70 per cent (57 to 83 per cent) at thirty years. The Charnley low-friction arthroplasty provided consistently good long-term results, with a low rate of complications and revisions, in this group of young patients.     

The Ranawat Award. Histology of nine structural bone grafts used in total knee arthroplasty

The cross section radiographs and histology of nine bone grafts were examined to determine whether grafts are durable enough to support a total knee implant when the load is shared by host bone, graft bone, and a stemmed component. All cases had cemented total knee arthroplasties with stemmed components adjacent to bulk grafts. The cases included autografts and allografts, which had been in situ for an average of 41 months (range, 20-62 months). Seven of the grafts were retrieved postmortem from three patients (four knees), and two were retrieved at revision surgery from one patient. The allografts all were intact, but had not revascularized. The autografts were viable bone. New bone was being laid down on the dead graft bone at the periphery of the allografts. No change in the bone to cement interface, no graft collapse, no development of radiolucent lines, and no component loosening occurred in these cases. The promising clinical results of bone grafts in total knee arthroplasties were confirmed by the examination of these grafts at the cellular level. Using stemmed components in bone grafted knee reconstructions may have increased graft durability and protected the grafts from fatigue failure.     

The Rotaglide total knee arthroplasty. Prosthesis design and early results

The Rotaglide knee (Cozim Medical, UK) is a three-part knee containing a mobile polyethylene meniscal platform, imparting reduced loosening forces to the tibia. The femoral component design provides a high degree of congruency throughout the range of motion from 0 degree to 110 degrees, and both femoral and tibial components ensure minimal bone removal. The system is versatile, including a large number of component options, and it may be used in both primary and revision arthroplasties. The first results in 170 cemented knees (161 patients) with 2- to 5-year follow-up periods (average, 3.1 years) were very encouraging (excellent or good in 95% of knees, based on the British Orthopaedic Association knee assessment system). Poor results were seen only in revision cases. There have been no mechanical implant failures and no platform bearing dislocations, and the platforms continue to move as documented by postoperative roentgenograms, which show the metal markers of the platforms moving anteriorly in flexion and posteriorly in extension.     

Results after cemented total knee arthroplasty: a follow-up study over 5-to-14 years

Eighty-five cemented total knee arthroplasties were followed for five to fourteen years (mean 7.8 years). The clinical evaluation was excellent or good in 85% of this series. However, a complication developed in 15 knees (17.6%), and two thirds of these complications were found in the patello-femoral joint. One further case developed an infection (1.2%), and four others (4.7%) developed an aseptic loosening. Over all, 8 cases (9.4%) required revision surgery. Asymptomatic wear was seen to progress in some implants involving thin polyethylene, although their clinical results were rated as excellent. The outcome of the cemented knee arthroplasties was considered as acceptable at present, but improved surgical techniques and measures against polyethylene wear are required for future improvement in this surgery.     

Total hip arthroplasty with cement in patients who have rheumatoid arthritis. A minimum ten-year follow-up study

One hundred and six consecutive total hip arthroplasties with cement were performed by one surgeon, at least ten years before the time of the present clinical and radiographic review, in seventy-five patients who had adult-onset rheumatoid arthritis. Two patients (three hips) were lost to follow-up. Seven (7 per cent) of the remaining 103 hips were revised. The revisions were performed because of infection (three hips), dislocation (two hips), or aseptic loosening (two hips). Of the ninety-eight hips that were not lost to follow-up or revised because of infection or dislocation, eight (8 per cent) had radiographic loosening of the acetabular component and two (2 per cent) had radiographic loosening of the femoral component. Although the prevalence of radiographic loosening of the acetabular component was four times greater than the prevalence of radiographic loosening of the femoral component, the prevalence of revision because of aseptic loosening of the acetabular component was identical to that for the femoral component (one component each). These results compared favorably with those of total hip arthroplasty with cement, performed by the same surgeon, for the treatment of other diagnoses. Loosening of the acetabular component was significantly associated with a younger age at the time of the index operation (p = 0.03) and with acetabular osteolysis (p = 0.0006). Of forty-eight hips in thirty-two patients who survived for at least ten years, 96 per cent (forty-six hips) were considered by the patients to have a satisfactory result. At the time of the latest follow-up, twenty-four (75 per cent) of the patients had no pain in the hip. Although eighteen patients (56 per cent) could walk without support at a minimum of ten years after the operation, we found that the functional results for patients who had rheumatoid arthritis were inferior to those observed for patients who had had a total hip arthroplasty with cement, performed by the same surgeon, for the treatment of other diagnoses.     

Results of total hip arthroplasty for Crowe Type III developmental hip dysplasia

From 1969 through 1980, 90 hips in 82 patients had cemented total hip arthroplasty for Type III developmental hip dysplasia. Seventy hips were reviewed at an average of 16.6 years (range, 5-23 years) after operation. Aseptic loosening developed in 53% of acetabular cups and 40% of femoral stems. Despite attempts to place acetabular components in the anatomic center, 18 cups (25.7%) were placed outside that area. Using a measurement method to determine the true acetabular region and approximate femoral head center, final acetabular loosening strongly correlated with initial cup placement. Loosening occurred in 15 of 18 cups (83.3%) initially positioned outside of the true acetabular region compared with loosening in 22 of 52 cups (42.3%) initially positioned within the true acetabular region. Acetabular loosening also correlated with initial lateral displacement or initial superior displacement of the hip center from the approximate femoral head center. Initial cup placement medial to the approximate femoral head center was predictive of successful long term acetabular component fixation. The method of acetabular reconstruction did not affect eventual cup loosening. Placement of the hip arthroplasty center of rotation in or near the true acetabular region is recommended.