Total hip arthroplasty performed without cement in patients with femoral head osteonecrosis who are less than 50 years old

Seventy-two cementless total hip arthroplasties were performed by a single surgeon in 58 patients with the diagnosis of femoral head osteonecrosis. All patients were less than 50 years old (mean, 37 years). The mean follow-up was 84 months with a minimum of 48 months. Good-to-excellent results were maintained at final follow-up in 94% of the hips. Revision rate was 1.5% each for the cups and the stems. Mechanical failure rate was 7.6% for the cups, and 6% for the stems. If the results were analyzed excluding the data from the group of patients who received the Mittelmeier prostheses, the mechanical failure rates for the cups was 0% and for the stems was 4.2%. The probability of survival for the entire series using revision as the endpoint was 96.9% at 11 years. Survival probability decreased to 88.5% if radiographic failures were included. Excluding the Mittelmeier prostheses, survival probability was estimated to be 100% for the cups using both revision and radiographic failures as endpoints; for the stems, the survival probability was 98.0% using revision as the endpoint and 95.8% including radiographic failures. Femoral osteolysis was observed in 1.5% of the hips. No hip had acetabular osteolysis. No measurements of polyethylene wear were attempted in this study. These results appeared superior to total hip arthroplasties done with early cementing techniques in this population of young patients with femoral head osteonecrosis.     

Rheumatoid arthritis and hydroxyapatite-coated hip prostheses: five-year results. International ABG Study Group

Medium- and long-term results from cemented total hip arthroplasty (THA) in patients with rheumatoid arthritis (RA) show a higher incidence of infection and aseptic loosening when compared to other diagnoses. Early results using uncemented prostheses are variable. Hydroxyapatite (HA) coatings are thought to improve early osseointegration in uncemented THA. In a prospective, international, multicenter clinical study, 32 RA patients who received 33 uncemented HA-coated prostheses were followed up for a minimum of 5 years. Medium-term clinical results are excellent. No infection or aseptic loosening has been recorded. Excellent osseointegration was observed radiographically. Bone remodeling was consistent with mainly proximal to midstem stress transfer. We conclude that uncemented, proximally HA-coated prostheses are a promising alternative to cemented prostheses for RA patients.     

A femoral component inserted without cement in total hip arthroplasty. A study of the Tri-Lock component with an average ten-year duration of follow-up

Seventy-four total hip arthroplasties in sixty-six patients were performed, between 1983 and 1986, with use of a Tri-Lock femoral component inserted without cement. This tapered cobalt-chromium component has a fixed head and a circumferential proximal porous coating. Follow-up was conducted with use of a questionnaire, physical examination, and radiographic analysis. At the time of the latest follow-up, fifteen patients (eighteen hips) had died, three patients (four hips) had been lost to follow-up, and one patient (one hip) had refused to participate in the follow-up study; however, the status of fifteen hips at the time of death could be verified. Thus, clinical follow-up data were available for sixty-six of the original seventy-four hips. The average age at the time of the operation was sixty-two years (range, seventeen to eighty-four years), and the average interval between the operation and the latest follow-up evaluation was 10.0 years (range, 8.3 to 11.6 years). The Harris hip score was determined for forty-three hips (forty-one patients) in which the prosthesis was in situ at the time of the latest follow-up. The score was good for thirteen hips and excellent for twenty-eight, so the rate of clinical success was 95 per cent. Two patients had a fair result. One of them had persistent pain and the other had limited motion, but neither had radiographic evidence of loosening of the femoral or acetabular component. All forty-one patients were satisfied with the result. The probability (with standard error) of survival of the femoral component at ten years, with revision as the end point, was 0.95 +/- 0.03. The rate of revision of the femoral component because of aseptic loosening was one (2 per cent) of sixty-six. The overall rate of aseptic loosening of the femoral component in the hips that were followed radiographically was two (4 per cent) of forty-seven. Only one (2 per cent) of the forty-seven acetabular cups had evidence of aseptic loosening. There was no radiographic evidence of distal osteolysis around the prostheses that were well fixed. Proximal osteolysis was present in five (11 per cent) of forty-seven hips, but none of the lesions compromised the stability of the prosthesis or the bone and there were no associated fractures. At an average of ten years postoperatively, the Tri-Lock femoral component functioned well overall and patient satisfaction was high.     

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.     

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)     

Microalbuminuria and cardiovascular risk

As a part of long-term follow up (I) of 544 cemented Müller-curved stem total hip replacements (THR), implanted 1977 to 1983, 207 THR in 163 patients with rheumatoid arthritis (RA) were evaluated 9 to 15 years (11 on an average) postoperatively. The feed back rate was 96.9% so the results are very reliable. 18 cups were loosened (13 already changed), but no stem had to be changed for aseptic loosening. 2 THR (1.0%) had to be revised because of deep infection. Survival rate of Kaplan and Meier for aseptic loosening was 94.6% after 10 years, 83.5% after 15 years. The ARO multi-center-study 1995 (II) includes 3113 THR implanted 1987 and 1988. Within a follow-up period of 7 to 9 years the over all rate of aseptic changing for cemented cups (1.4%) was significantly lower than for uncemented cups (2.9%)--in RA even 1% versus 5.7%. The corresponding rates for stems was 1.0% (cemented) versus 1.8% (uncemented). We contributed 110 THR in 94 patients with RA with feed back of 100%. Because of deep infection one THR had to be changed and two were explanted. But no change of cup or stem because of aseptic loosening was observed. Also in the literature survival rates up to 97% after 10 years or 77% after 25 years even in younger patients with RA can be stated. CONCLUSIONS: Cemented THR shows good long-term-results in RA which with uncemented designs have also to be proved. As a consequence of analysing the (few) failures the cemented THR of Wessinghage with optimized bone-cement-implant-compound was introduced. We demand a high feed back rate in long-term follow-ups also with respect to quality management and comparing data.     

Transforming growth factor-beta 1 and 2 in the synovial-like interface membrane between implant and bone in loosening of total hip arthroplasty

OBJECTIVE: Development of a synovial-like membrane in the implant-bone or cement-bone interface has been linked to aseptic loosening of total hip arthroplasties (THA). This tissue consists of a fibrous stroma containing blood vessels and macrophages, but with relatively few lymphocytes, compared to "autoimmune" rheumatoid synovitis. Our aim was to examine transforming growth factor-beta (TGF-beta) in the synovial-like membrane of the interface and pseudocapsular tissue of loose THA and compare it to control knee synovial membrane. METHODS: Twenty samples obtained from 10 patients with loose THA at revisions performed for aseptic loosening and 10 samples of knee synovial membrane as controls were analyzed for TGF-beta expression using rabbit antihuman TGF-beta 1 and TGF-beta 2 IgG in immunohistochemical staining. Results were quantitated by a semi-automatic VIDAS image analysis system. RESULTS: Immunoperoxidase staining disclosed TGF-beta in macrophages and fibroblasts and also in some vascular endothelial cells and in occasional lymphocytes. Image analysis showed an increased number of positive cells/mm2 of both TGF-beta 1 (2327 +/- 212 vs 946 +/- 136; p < 0.01) and TGF-beta 2 (2292 +/- 594 vs 311 +/- 113; p < 0.01) compared to the control tissue. Increased expression of both TGF-beta 1 and TGF-beta 2 was also shown in the pseudocapsule (3210 +/- 585 and 1796 +/- 214). Use of cement or type of alloy did not seem to have any great effect on local expression of TGF-beta. CONCLUSION: Profibrotic and immunosuppressive TGF-beta are increased in the synovial-like membrane in periprosthetic tissues around loose hip prostheses. They may play a role in the formation, maintenance, and growth of the interface tissue, and thus in the aseptic loosening of THA.     

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.     

Purification and characterization of a cysteine protease produced by pathogenic luminous Vibrio harveyi

A histologic and biochemical comparison of interface membranes around femoral components of bipolar endoprostheses (n = 17) and total hip prostheses (n = 17) inserted without cement was conducted. The patients' profiles were similar in both groups with respect to age, sex, primary diagnosis, weight, and the interval between primary and revision arthroplasty. Macroscopically, marked circumferential abrasion of the polyethylene insert in the retrieved bipolar cups was noted. Histologic analysis revealed significantly larger amounts of polyethylene debris in the bipolar group. The membranes from the bipolar group also produced significantly greater amounts of prostaglandin E2 (P < .05). The inflammatory membranes associated with large amounts of polyethylene debris may have contributed to aseptic loosening and osteolysis in patients with a bipolar hip prosthesis.     

Proteasomal regulation of nuclear receptor corepressor-mediated repression

We analyzed the clinical results of 195 Harris Design-2 total hip replacements performed with so-called second-generation cementing techniques in 166 consecutive patients who had osteoarthrosis. The mean age of the patients at the time of the replacement was sixty-seven years and nine months (range, thirty-one to eighty-nine years). Forty-eight patients (fifty-four hips) died before the time of the latest follow-up, but the implants were apparently functioning well at the time of death. Three patients (four hips) were lost to follow-up. Five patients (five hips; 3 percent) had a revision because of aseptic loosening of the acetabular or femoral component, or both, that was related to wear-induced osteolysis. The mean Harris hip score for the 131 hips that were available at the latest follow-up examination at a mean of twelve years (range, ten to fifteen years) after the operation was 89 +/- 10 points. On the basis of the Harris hip score, seventy-six hips had an excellent result, thirty-four had a good result, fifteen had a fair result, and six had a poor result at the latest follow-up examination. Radiographically, twelve (9 percent) of the 131 acetabular components and three (2 percent) of the 131 femoral components were probably or definitely loose. At a mean of twelve years, 186 (97 percent) of 191 Harris Design-2 implants were in situ or had been in situ at the time of the patient's death.     

The Bürch-Schneider anti-protrusio cage in revision total hip arthroplasty: indications, principles and long-term results

Patients who had a revision total hip arthroplasty using the Bürch-Schneider anti-protrusio cage (APC) by a single surgeon have been reviewed after a minimum of five years. There were 63 operations in 58 patients with an average age of 63 years (41 to 83) at the time of revision. At an average follow-up of 8.5 years (5 to 18), 15 patients (25.9%) rated their results as excellent, 38 (65.5%) as good, and five (8.6%) as fair. Five further revisions of the acetabular prosthesis were required, three due to aseptic loosening, one for recurrent dislocation and one due to sepsis. Of the remainder, one was definitely loose, two probably loose, and 12 possibly so. Impressive augmentation of bone stock can be achieved with the anti-protrusio cage, while enabling the hip to be centred in its anatomical position.     

Replacement of total hip prosthesis--what does the patient expect? Analysis of 248 aseptic hip revisions

Aseptic loosening of prosthesis with consequential revision operations continues to be a major problem for both the patients concerned and the medical team. In the center of interest stands the magnitude of bone destruction caused by loosening effects. A concept designed to avoid uncontrolled progressive loss of bone stock is presented. Based on the experience of 248 cases of hip revision operations, advice to patients can be given. 2 septic (0.8%) and 6 aseptic (2.4%) cases with loosening and re-revision were documented. Statistical analysis of 5-year survivorship rate according to Kaplan-Meier shows 94.5%, and according to Armitage 92.5%. Clinical and radiologic 5-10-year findings in the first 72 consecutive cases are presented. Routine controls in patients with hip prostheses for early detection of bone destruction may help to perform simple and prognostically favourable revision operations.     

Activation of periprosthetic connective tissue in aseptic loosening of total hip replacements

In aseptic loosening of initially well inserted total hip prostheses, implant wear debris and cyclic mechanical loading lead to a foreign body type of chronic inflammatory reaction, then to osteolysis, and finally to loosening of the implant. In the present work the reactive and adaptive changes of the periprosthetic tissues and pseudojoint were characterized by analysis of the local cell proliferation. Immunohistochemical demonstration of proliferating cells was performed by application of affinity purified rabbit antihuman Ki-67 antibodies to periprosthetic tissues obtained from revision operations for loose total hip prostheses. The fibrous areas and, in particular, the cell rich, vascular areas of the interface tissue (between implant and bone) and the pseudocapsule around aseptically loosened implants contained higher numbers of proliferating cells than the tissues around well fixed implants. In addition, the pseudosynovial lining occasionally contained some Ki-67 positive proliferating cells. Somewhat surprisingly, proliferating vascular endothelial cells were relatively rare. These findings suggest that reactive (interface tissues) and adaptive (pseudojoint and capsule formed around the artificial joint) tissue changes in loosening total hip prostheses comprise proliferation of local fibroblastlike cells. It is concluded that periprosthetic tissues of the loosened total hip prosthesis represent activated mesenchymal tissue.     

Primary hybrid total hip arthroplasty: an interim followup

The senior authors' initial experience with primary hybrid hip replacement in patients with osteoarthritis was studied to evaluate the efficacy of the procedure. Hybrid total hip arthroplasty (uncemented Harris-Galante acetabular component and cemented Iowa precoated femoral component) was performed in 131 consecutive, nonselected hips in 118 patients with the diagnosis of primary osteoarthritis. Followup was performed at 8 to 9 years after the procedure. The average age at the time of the procedure was 68 years (range, 45-87 years). There were 50 men (55 hips) and 68 women (76 hips). At final followup 19 patients (22 hips) had died. The femoral component had been revised for aseptic loosening in 8 hips (6.1%). One additional hip showed definite radiographic loosening. Hence, the prevalence of radiographic femoral failure was 6.9% (9 hips). No acetabular component had been revised for aseptic loosening and no acetabular component had migrated. The senior author continues to perform hybrid total hip arthroplasty in all patients with primary osteoarthritis. However, design modifications have been made in the femoral component that is used.     

Autocrine regulation of keratinocytes: the emerging role of heparin-binding, epidermal growth factor-related growth factors

Two hundred and ninety-seven consecutive Charnley total hip replacements that had been followed for at least twenty years or until revision or death were analyzed to determine the effect of early debonding of the smooth-surfaced femoral component on its subsequent survival. Radiographically evident debonding was not found to have a significant effect, with the numbers available, on the long-term survival of the femoral component when the maximum thickness of the radiolucent line between the superolateral border of the prosthesis and the cement had been less than 2.0 millimeters during the first one to five years after the operation. The radiographic finding of debonding also was not found to be associated with pain in the hip. These data show that most components with early debonding functioned well during a long period of follow-up and suggest that debonding of a smooth femoral component of a Charnley total hip replacement should not be considered to be analogous to loosening. In contrast, when the maximum thickness of the radiolucent line between the superolateral border of the prosthesis and the cement was 2.0 millimeters or more, an early appearance of debonding was associated with a significantly poorer (p < 0.0001) probability of survival of the Charnley femoral component without revision because of aseptic loosening. Thus, pronounced early subsidence of the component within the cement mantle had a strong negative impact on the long-term performance of the implant. The results of the present study should not be extrapolated to prostheses with substantially different design characteristics, as it appears that different types of femoral components behave differently when debonding occurs.     

Acute cocaine results in rapid rises in intracellular free calcium concentration in canine cerebral vascular smooth muscle cells: possible relation to etiology of stroke

We report the outcome of 177 consecutive primary Charnley total hip arthroplasties inserted with Boneloc cement between November 1991 and November 1993. There were 107 women and 70 men. The mean age at the time of the operation was 71 years. 11 patients (13 hips) died during the follow-up period and 3 patients were too weak to attend a follow-up examination. Of the 161 remaining hips, 4 had been revised because of deep infection. The mean follow-up time for the remaining 157 hips was 2 (0.5-3) years. 24 hips had been revised and 6 are waiting for revision because of stem loosening. Of the remaining 127 hips, 72 showed radiographic signs of stem loosening and 2 hips were probably loose. Osteolysis was seen around the femoral component in 56 hips.     

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.     

How outcome studies have changed total hip arthroplasty practices in Sweden

The Swedish Hip Registry has defined the epidemiology of total hip replacement in Sweden. Most hip implants are fully cemented. Serious complications and rates of revision associated with total hip replacement have declined significantly despite an increasing number of patients at risk. During the past 5 years only 9% to 10% of hip replacement procedures are revision procedures. Aseptic loosening with or without osteolysis is the major problem and constitutes 73% of the revisions, but the incidence has decreased four times during the past 15 years to less than 3% at 10 years. Even septic complications can be prevented effectively. Demographics are important because male gender and young age increase the risk for revision because of aseptic loosening. Young female patients with rheumatoid arthritis and male patients with a previous hip fracture have five times higher revision rates than elderly patients. The quality of the surgical technique is the most important factor for reducing the risk for revision because of aseptic loosening, but choice of implant is also important. The variations among hospitals in type of surgical technique used is big enough to cause a 100% difference in revision rate for aseptic loosening. Total hip replacement practice in Sweden has improved based on information from this Registry about individualized patient risks, implant safety, and the efficacy of improving surgical and cementing techniques.