Aims. Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA. Methods. A retrospective analysis was conducted of 91 cementless THAs (57 male and 34 female) performed between 2008 and 2017 in patients who had history of hip infection during childhood. Clinical outcome was measured using Harris Hip Score (HHS) and Modified Merle d’Aubigne and Postel (MAP) score, and quality of life (QOL) using 12-Item Short Form Health Survey Questionnaire (SF-12) components: Physical Component Score (PCS) and Mental Component Score (MCS); limb length discrepancy (LLD) and radiological assessment of the prosthesis was performed at the latest follow-up. Reinfection and revision surgery after THA for any reason was documented. Results. There was significant improvement in HHS, Modified Merle d’Aubigne Postel hip score, and QOL index SF 12-PCS and MCS (p < 0.001) and there was no case of reinfection reported during the follow-up. The minimum follow-up for the study was three years with a mean of 6.5 (SD 2.3; 3 to 12). LLD decreased from a mean of 3.3 cm (SD 1) to 0.9 cm (SD 0.8) during follow-up. One patient required revision surgery for femoral component loosening. Kaplan-Meier survival analysis estimated revision-free survivorship of 100% at the end of five years and 96.9% (95% confidence interval 79.8 to 99.6) at the end of ten years. Conclusion. We found that cementless THA results in good to excellent functional outcomes in patients with a prior history of childhood infection. There is an exceedingly low rate of risk of reinfection in these patients, even though complications are not uncommon. Cite this article: Bone Jt Open 2022;3(4):314–320

High doses of intra-articular (IA) antibiotics has been shown to effectively achieve a minimal biofilm eradication concentration which could mitigate the need for removal of infected but well-ingrown cementless components of a total hip arthroplasty (THA). However, there are concerns that percutaneous catheters could lead to multi-resistance or multi-organism peri-prosthetic joint infections (PJI) following single stage THA revisions for PJI. Eighteen single-stage revision procedures were performed for acute (N=9) or chronic (N=9) PJI following a primary (N=12) or revision (N=6) cementless THA. Modular and loosened components were replaced. All well ingrown components were retained. Two Hickmann catheters were placed in the joint space. Along with intravenous antibiotics, IA antibiotics were injected twice a day for two weeks, followed by 3 months of oral antibiotics. Per-operative cultures demonstrated 4 multi-bacterial PJIs. None of the patients developed post-operatively an AB related renal or systemic dysfunction. At a mean follow-up of 38 months [range, 8–72] all patients had normal erythrocyte sedimentation rate and white blood cell count. Four had a slightly elevated C-reactive protein but were completely symptom free and did not show any sign of loosening at a mean of 27 months [range, 16–59]. Addition of high doses of IA antibiotics following single-stage revision for PJI in cementless THA, is an effective and safe treatment option that allows for retention of well-ingrown components. We found no evidence for residual implant infection or catheter induced multi-resistance. Total hip arthroplasty, revision surgery, Periprosthetic Joint Infection, Intra-articular antibiotics. Level 4 (Case series)

Aims. We present the clinical and radiological results at a minimum follow-up of 20 years using a second-generation uncemented total hip arthroplasty (THA). These results are compared to our previously published results using a first-generation hip arthroplasty followed for 20 years. Methods. A total of 62 uncemented THAs in 60 patients were performed between 1993 and 1994. The titanium femoral component used in all cases was a Taperloc with a reduced distal stem. The acetabular component was a fully porous coated threaded hemispheric titanium shell (T-Tap ST). The outcome of every femoral and acetabular component with regard to retention or revision was determined for all 62 THAs. Complete clinical follow-up at a minimum of 20 years was obtained on every living patient. Radiological follow-up was obtained on all but one. Results. Two femoral components (3.2%) required revision. One stem was revised secondary to a periprosthetic fracture one year postoperatively and one was revised for late sepsis. No femoral component was revised for aseptic loosening. Six acetabular components had required revision, five for aseptic loosening. One additional acetabular component was revised for sepsis. Radiologically, all femoral components remained well fixed. One acetabular was judged loose by radiological criteria. The mean Harris Hip Score improved from 46 points (30 to 67) preoperatively to 89 points (78 to 100) at final follow-up. With revision for aseptic loosening as the endpoint, survival of the acetabular component was 95% (95% confidence interval (CI) 90 to 98) at 25 years. Femoral component survival was 100%. Conclusion. The most significant finding of this report was the low prevalence of aseptic loosening and revision of the femoral component at a mean follow-up of 22 years. A second important finding was the survival of over 90% of the hemispheric threaded ring acetabular components. While these shells remain controversial, in this series they performed well. Cite this article: Bone Jt Open 2021;2(1):33–39

Periprosthetic femoral fractures (PFFs) remain a major concern following cementless total hip arthroplasty (THA). This study aimed to evaluate the association between different types of cementless tapered stems and the risk of postoperative PFF. A retrospective review of primary THAs performed at a single center from January 2011 to December 2018 included 3,315 hips (2,326 patients). Cementless stems were classified according to their design geometry using the system proposed by Radaelli et al. The incidence of PFF was compared between flat taper porous-coated stems (type A), rectangular taper grit-blasted stems (type B1), and quadrangular taper hydroxyapatite-coated stems (type B2). Multivariate regression analyses were performed to identify independent factors related to PFF. The mean follow-up duration was 61 months (range, 12‒139 months). Overall, 45 (1.4%) postoperative PFFs occurred. The incidence of PFF was significantly higher in type B1 stems than in type A and type B2 stems (1.8 vs. 0.7 vs. 0.7%; P=0.022). Additionally, more surgical treatments (1.7 vs. 0.5 vs. 0.7%; P=0.013) and femoral revisions (1.2 vs. 0.2 vs. 0%; P=0.004) were required for PFF in type B1 stems. After controlling for confounding variables, older age (P<0.001), diagnosis of hip fracture (P<0.001), and use of type B1 stems (P=0.001) were significant factors associated with PFF. Type B1 rectangular taper stems were found to have higher risks for postoperative PFF and PFF requiring surgical management than type A and type B2 stems in THA. Femoral stem geometry should be considered when planning for cementless THA in elderly patients with compromised bone quality

The purposes of this study were to review retrospectively the 25-year survival of cemented and cementless THA for hip dysplasia and to compare the effect of fixation methods on the long-term survival in patients with DDH. We retrospectively reviewed all patients with OA secondary to hip dysplasia treated with a cemented Bioceram hip system between 1981 and 1987, and a cementless cancellous metal Lübeck hip system between 1987 and 1991. The studied subjects were 76 hips of cemented THA (Group-C) and 57 hips of cementless THA (Group-UC). Both hip implants had a 28-mm alumina head on polyethylene articulation. The mean age at operation was 50.5 years (range, 36–60 years) in Group-C and 50.0 years (range, 29–60 years) in Group-UC. The survival at 25 years regarding any revision as the endpoint was 46% in Group-C and 76% in Group-UC. These difference was significant using Log-rank test (P=0.008). The cup survival at 25 years was 47% in Group-C and 83% in Group-UC (P= 0.0003). The stem survivals at 25 years were 95% in Group-C and 92% in Group-UC. (P= 0.416). Cementless THA in patients with DDH showed a higher survival rate at 25 years than cemented THA because of the excellent survival of the acetabular component without cement. We conclude that cementless THA with the cancellous metal Lübeck hip system led to better longevity at 25 years than cemented THA with the Bioceram in patients with OA secondary to DDH

Introduction. Long term results of Total Hip Arthroplasty (THA) are affected by wear of articulation. Ceramic on ceramic articulation have been used especially for young patients because of its low wear and bio-inert property. However, because of its hardness, it is concerned that ceramic fracture, chipping, or squeaking might happen with ceramic on ceramic articulation. Objective. The purpose of this study was to investigate over 10-years clinical and radiographic results of ceramic bearing cementless THA. Methods. Evaluation was performed in 60 patients (68 joints) who underwent primary cementless THA from May 2003 to April 2007. Mean age at surgery was 59 years. Mean follow up period was 11.2 years. Forty-nine patients were female. Mean BMI at surgery was 24.0 kg/m. 2. Fifty-one patients had osteoarthrosis, 6 patients had osteonecrosis, 2 patients had rheumatoid arthraitis, and 1 patient had PSS. A 28mm-size femoral head was used in all patients. Clinical evaluation was performed with Japanese Orthopaedic Association Hip Score (JOA score). Radiographic results were evaluated with standard bilateral hip radiograph in supine position. Results. Mean clinical score at surgery was 45 (pain: 13/40, ROM: 12/20, gait: 9/20, ADL: 12/20). Mean clinical score at final follow up was 92 (pain: 39/40, ROM: 17/20, gait: 17/20, ADL: 18/20). Pain score was dramatically improved from 13 to 39 (maximum pain score: 40). One stem was revised because of recurrent dislocation. Two other patients experienced one time dislocation during follow up. One stem showed 5mm of subsidence. ALL cups and stems showed bone ingrowth at final follow up. Cortical hypertrophy was seen in 17 joints. However, there was no patient complained thigh pain. Stress shielding was seen in 55 joints (81%). First, second and third degree of stress shielding were seen in 12, 40, and 3 joints, respectively. Most of the female patients who had surgery at the age over 60 years showed second and third degree of stress shielding. There was no measurable wear. No osteolysis was found around the implants. There were no ceramic fracture, chipping, and squeaking. Conclusion. This study demonstrated excellent clinical and radiographic results of ceramic bearing cementless THA. Excellent long term results will be expected with this system

Aims. Hip arthroplasty aims to accurately recreate joint biomechanics. Considerable attention has been paid to vertical and horizontal offset, but femoral head centre in the anteroposterior (AP) plane has received little attention. This study investigates the accuracy of restoration of joint centre of rotation in the AP plane. Methods. Postoperative CT scans of 40 patients who underwent unilateral uncemented total hip arthroplasty were analyzed. Anteroposterior offset (APO) and femoral anteversion were measured on both the operated and non-operated sides. Sagittal tilt of the femoral stem was also measured. APO measured on axial slices was defined as the perpendicular distance between a line drawn from the anterior most point of the proximal femur (anterior reference line) to the centre of the femoral head. The anterior reference line was made parallel to the posterior condylar axis of the knee to correct for rotation. Results. Overall, 26/40 hips had a centre of rotation displaced posteriorly compared to the contralateral hip, increasing to 33/40 once corrected for sagittal tilt, with a mean posterior displacement of 7 mm. Linear regression analysis indicated that stem anteversion needed to be increased by 10.8° to recreate the head centre in the AP plane. Merely matching the native version would result in a 12 mm posterior displacement. Conclusion. This study demonstrates the significant incidence of posterior displacement of the head centre in uncemented hip arthroplasty. Effects of such displacement include a reduction in impingement free range of motion, potential alterations in muscle force vectors and lever arms, and impaired proprioception due to muscle fibre reorientation. Cite this article: Bone Joint Res 2022;11(3):180–188

Introduction:. The outcome of previous cemented total hip arthroplasty has been reported to be inferior in renal transplant patients because of poor bone stock resulting from long-term steroid use. Moreover, as renal transplant patients remain on immunosuppressant therapy for life, higher levels of overall morbidity must be considered. We evaluated the mid-term results of cementless total hip arthroplasty in renal transplant recipients with osteonecrosis of the femoral head, and compared those with age and sex matched osteonecrosis patients that had not undergone organ transplantation or been treated with long-term steroid. Materials & Methods:. Between October 1997 and October 2008, 45 consecutive primary cementless total hip arthroplasties were performed in 30 patients with advanced osteonecrosis of the femoral head after renal transplantation. There were 18 males (27 hips) and 12 females (18 hips) of overall mean age 44 years (22 to 68). The clinical and radiographic results of cementless total hip arthroplasty in these 45 hips were compared with those of 96 sex and age-matched osteonecrotic hips of 72 patients that had not undergone organ transplantation or long-term steroid use. Patients were evaluated at surgery and at a mean of 7.2 years (range, 2–13 years) postoperatively. Results:. The mean Harris hip score of patients improved from 48 points preoperatively to 94 points at last follow-up (p < 0.05). Three hips in patient group had massive osteolysis with polyethylene wear requiring revision surgery. One hip in the patient group underwent revision surgery because of recurrent dislocation at 11 years postoperatively. No intergroup differences in overall rates of complications or revisions were observed. However, patients had a significantly higher rate of ectopic ossification. Conclusion:. Despite diffuse osteopenia and chronic immunosuppression in renal transplant patients with osteonecrotic hips, contemporary cementless total hip arthroplasty showed durable implant fixation to bone and did not increase complications

Introduction. The success of cementless total hip arthroplasty (THA) depends on the primary stability of the components. One of the biomechanical factors that comes into play is the mechanical quality of the bone. To our knowledge, there are no reported studies in the literature analyzing the impact of the preoperative bone mineral density on the outcomes of cementless THA. The goal of the study was to analyze the clinical results at 2 year follow-up according to the preoperative cancellous bone mineral density (BD). Our hypothesis was that the clinical outcomes were correlated to the BD. Material and methods. From January to June 2013, a prospective study included patients who underwent a cementless THA using a proximally shortly fixed anatomic stem. A 3D preoperative CTscan-based planning was performed according to the routine protocol using the Hip-Plan software in order to determine the hip reconstruction goals as well as the implants size and position. The Hounsfield bone density (BD) of the metaphyseal cancellous bone was computed in a volume (of 1 mm thick and of 1cm² surface) at the level of the calcar 10 mm above the top of the lesser trochanter and laterally to the medial cortical (Figure 1). Intra-and inter-observer repeatability measurements were performed. Patients were clinically assessed at 2 years follow-up using self-administered auto-questionnaires corresponding to the Harris and the Oxford scores. A Multivariate statistical analysis assessed correlations between clinical scores, age, gender, body mass index, and BD. Results. 50 patients were included consisting of 29 men and 21 women, with an average age of 62 ± 12 years and an average BMI of 25.8. The average preoperative BD was 69.4 ± 54 HU. At 2 years follow-up, the hip function scores were significantly correlated with the preoperative BD (0.42, p = 0.002) and the age (0.39, p = 0.005). However, there was no significant correlation between BD and BMI. Discussion Bone density appears to be an important parameter to consider when planning THA. This highlights also the importance of preoperative image calibration. Conclusion. The functional outcomes after cementless THA are correlated with preoperative cancellous bone density. Bone density needs to be integrated into THA 3D planning

The aim of our study was to determine the usefulness of preoperative digital templating of cementless total hip arthroplasty (THA). 60 consecutive cementless THA (synergy stem & reflection cup) were templated digitally by two senior hip arthroplasty fellows (GM, YG) independently. A metallic marker ball of known diameter was used in all images to help scale for magnification. A blinded observer then collated information on the actual implant sizes, size of head component, offset, and level of neck cut intraoperatively. This was used to statistically analyse the correlation (Interclass correlation coefficient) between the digitally templated implant sizes and actual implant sizes used and the reliability of digital templating. A high rate of coincidence between digitally templated estimates and actual implant sizes was noted for both groups of templates. A high intraclass correlation coefficient (ICC) for the acetabular cup, stem and head were noted (ICC of 0.825, 0.794, and 0.884 respectively). Moderate agreement was noted for neck cut (ICC of 0.567) and leg length (ICC of 0.612). In conclusion, digital templating can reliably estimate implant sizes in cementless total hip arthroplasty. Valuable information on neck cut and leg length can be obtained by preoperative templating

Total hip arthroplasty (THA) is frequently performed as a salvage procedure for the acetabular fracture when posttraumatic osteoarthritis, posttraumatic avascular necrosis, or fixation failure with subluxation develop. Special considerations for this situation include previous surgical exposure with dense scar tissue, the type and location of implants, the location and amount of heterotopic ossification, indolent infection, previous sciatic nerve palsy, and the pathoanatomy of existing acetabular defect. These factors can influence the choice of surgical exposure and the reconstructive method. The outcomes of THA after acetabular fracture are generally less favorable than those of the nontraumatic degenerative arthritis. Reason for this high failure is the low mean age and the high activity level of the patient. Other important reasons for failure include the problem of acetabular bone deficiency and compromised bone quality. We evaluated the results of cementless THA in patient who had previous acetabular fracture. We also compared this result with those of patients with posttraumatic avascular necrosis of the femoral head. Forty-five consecutive cementless THAs were performed for the treatment of post-traumatic osteoarthritis after acetabular fracture between December 1993 and December 2008. Of these patients, 15 patients were died or lost to follow-up monitoring before the end of the minimum one year follow-up period. This left 30 patients (30 hips) as the subjects of our retrospective review. We evaluated the clinical and radiographic results of these patients and compared with the results of THA in patients with post-traumatic AVN of the femoral head which had without acetabular damage. Two hips required revision of the cup secondary to early migration of the acetabular cup (1 hip) and postoperative deep infection (1 hip). There was no significant difference in clinical and radiographic results between two groups except implanted acetabular component size and required bone graft (p<0.05). The Kaplan-Meier ten-year survival rate, with revision as the end-point, was 90% and 96.7% with loosening of acetabular component as the end-point. Our series suggested that compared with cemented components, uncemented sockets may improve the results of arthroplasty after previous acetabular fracture. In conclusion, cementless THA following acetabular fracture presents unique challenge to the surgeon, careful preoperative assessment and secure component fixation with proper bone grafting is essential to minimize problems

Aims: Limb length discrepancy is a recognised complication of total hip arthroplasty (THA). Cementless THAs are increasingly being used, but in order to achieve rotational and axial stability larger implants may be required than originally templated for. This could potentially result in greater limb length discrepancy. Our objective was to determine if limb length discrepancy exists to a greater degree in cementless THA. Methods: 166 consecutive patients undergoing elective THA between June 2007 and May 2008 were included in this retrospective study. Post-operative, digital radiographs (PACS, Centricity. ®. ) were examined for each of these patients to determine limb length. Limb length discrepancy was calculated as the difference between the perpendicular distance between the inter-teardrop line and the most prominent points on the lesser trochanter of each limb. Magnification was determined from the measured radiographic diameter of the prosthetic heads and their actual diameters. Results: Of the 166 patients included in this study 128 had cementless THA and 38 had cemented. The average magnification was calculated as 30%. Limb length discrepancy was found post-operatively in 93% of cases. In 65% of patients the operated limb was longer (by 0 – 29 mm) and in 28% it was shorter (by 0 – 23 mm). The mean limb length discrepancy, corrected for magnification, was 6.21 mm for cemented THA and 6.22 mm for cementless THA. A student’s T-test demonstrated no significant difference in limb length discrepancy between these operations (p = 0.996). Conclusions: The incidence of limb length discrepancy after THA is high. However, no significant differences were demonstrated between cemented and cementless THAs in our series. Accurate and careful pre-operative templating is important in THA to minimise the risk of clinically significant limb length discrepancy

Although there are several reports of excellent long-term survival after cemented total hip arthroplasty (THA), cemented acetabular components are prone to become loose when compared with femoral components. On the other hand, the survival of cementless acetabular components has been reported to be equal or better than cemented ones and the use of cementless acetabular components is increasing. However, most of the reports on survival after THA are for patients with primary hip osteoarthritis (OA) and there is no report of 20-year survival of cementless THA for patients with hip dysplasia. It is supposed to be more difficult to fix cementless acetabular components for OA secondary to hip dysplasia than primary OA. The purposes of this study were to review retrospectively the 20-year survival of cemented and cementless THA for hip dysplasia and to compare the effect of fixation methods on the long-term survival for patients with hip dysplasia. We retrospectively reviewed all patients with OA secondary to hip dysplasia treated with a cemented Bioceram hip system between 1981 and 1987, and a cementless cancellous metal Lübeck hip system between 1987 and 1991. We excluded patients aged more than 60 years, males, and Crowe 4 hips. The studied subjects were 70 hips of cemented THA (Group-C) and 57 hips of cementless THA (Group-UC). Both hip implants had a 28-mm alumina head on polyethylene articulation. The mean age at operation was 50.5 years (range, 36–60 years) in Group-C and 50.0 years (range, 29–60 years) in Group-UC. The mean BMI was 23.2 kg/m. 2. in Group-C (range, 17.3–29.3 kg/m. 2. ) and 22.9 kg/m. 2. in Group-UC (range, 18.8–28.0 kg/m. 2. ). There were no significant differences in age and BMI between the two groups. The average follow-up period was 18.0 years in Group-C and 18.4 years in Group-UC. In Group-C, revision was performed in 33 hips due to aseptic cup loosening (30 hips), stem loosening (one hip), and loosening of both components (two hips). In Group-UC, revision was performed in 10 hips due to stem fracture secondary to distal fixation (4 hips), cup loosening (three hips), polyethylene breakage (two hips), and extensive osteolysis around the stem (one hip). The survival at 20 years regarding any revision as the endpoint was 51% in Group-C and 84% in Group-UC. This difference was significant using Log-rank test (P=0.006). The cup survival at 20 years was 54% in Group-C and 92% in Group-UC. This difference was also significant (P = 0.0003). The stem survival at 20 years was 95% in Group-C and 92% in Group-UC. This difference was not significant (P = 0.4826). Cementless THA showed a higher survival rate at 20 years for hip dysplasia than cemented THA because of the excellent survival of the acetabular component without cement. We conclude that cementless THA with the cancellous metal Lübeck hip system led to better longevity at 20 years than cemented THA with the Bioceram for patients with OA secondary to hip dysplasia

Introduction. Preoperative planning is an essential procedure for successful total hip arthroplasty. Many studies reported lower accuracy of two-dimensional analogue or digital templating for developmentally dysplastic hips (DDH). There have been few studies regarding the utility of three-dimensional (3D) templating for DDH. The aim of the present study is to assess the accuracy and reliability of 3D templating of cementless THA for hip dysplasia. Methods. We used 86 sets of 3D-CT data of 84 patients who underwent consecutive cementless THA using an anatomical stem and a rim-enlarged cup. There were six men and 78 women with the mean age of 58 years. The diagnosis was developmental dysplasia in 70 hips and osteonecrosis in 14 hips and primary osteoarthritis in 2 hips. There were 53 hips in Crowe group I, 11 hips in Crowe group II and 6 hips in Crowe group III. Each operator performed 3D templating prior surgery using a planning workstation of CT-based navigation system. Planned-versus-achieved accuracy was evaluated. The templating results were categorized as either exact size or +/− 1 size of implanted size. To assess the intra- and inter-planner reliabilities, 3D templating was performed by two authors blinded to surgery twice at an interval of one month. Kappa values were calculated. The accuracy and the intra- and inter-planner reliabilities were compared between the DDH group (70 hips) and the non DDH group (16 hips). Results. There was no significant difference in accuracy of component sizes between the DDH group and the non-DDH group. The accuracy of templating for cup sizes was 76 % for DDH and 75 % for non-DDH group (p=0.95). If accuracy was expanded to include all cups within one size of the implanted size, the accuracy was 97 % and 94 %, respectively (p=0.51). The accuracy of templating for stem sizes was 60 % for the DDH group and 75 % for the non-DDH group (p=0.27). The accuracy within 1 size was 99 % and 94 %, respectively (p=0.25). Regarding intra-planner reliability, mean kappa value for the cup size was 0.67 in the DDH group and 0.81 for the non-DDH group (p=0.18). Mean kappa value for the stem size was 0.64 in the DDH group and 0.79 for the non-DDH group (p=0.18). There were no significant differences in intra-planner reliability between the DDH and non-DDH group. Regarding inter-planner reliability for the cup size, mean kappa value was 0.33 in the DDH group and 0.37 in the non-DDH group (p=0.14). Mean kappa value for the stem size was 0.46 in the DDH group and 0.69 in the non-DDH group (p=0.07). There were no significant differences in inter-planner reliability between the DDH and non-DDH group. Conclusion. The 3D templating for cementless THA was accurate for hip dysplasia. Intra- and inter-planner reliabilities of the 3D templating were comparable with those of other primary diagnosis, while intra-planner reliability of cup sizes was fair regardless of diagnosis

Background. Nutrient arteries appear as radiolucent lines (Fig. 1) on account of their topography and may erroneously suggest fracture lines. Question/purpose. (1) How frequently the nutrient artery canals of the femur are seen after cementless THA and their distribution patterns are; (2) How to distinguish visible nutrient artery canal from fracture lines; and (3) Whether clinical significance of the nutrient artery canals of the femur in patients with primary cementless THA is evident or not. Methods. Between March 2010 and December 2013, 93 patients 102 hips were enrolled for this retrospective analysis. The number, location, direction of obliquity, length of the nutrient artery canals of the femur, the distance between the tip of the greater trochanter and the proximal end of the nutrient artery canal were measured. Results. The nutrient artery canal of the femur in the cortex on preoperative cross-table lateral hip radiograph (NACL) was seen in 32 of 102 hips (31.4%), the nutrient artery canal of the femur in the medullary cavity on preoperative anteroposterior hip radiograph (NAMA) was seen in 17 hips (16.6%), and the nutrient artery canal of the femur in the medullary cavity on preoperative cross-table lateral hip radiograph (NAML) was seen in 5 hips (4.9%). The nutrient artery canal of the femur in the cortex on anteroposterior hip radiograph was not seen at all. Entire visible NACLs coursed upward obliquely from postero-distal to antero-proximal direction. An average length of NACL was 32.6 ± 13.9 mm and an average distance between the tip of the greater trochanter and the proximal end of the NACL, NAMA and NAML was 130.1 ± 15.8 mm, 105.1 ± 13.4 mm and 102.5 ± 7.4 mm, respectively. NACL was seen postoperatively in 37 of 102 hips (36.3%), in 24 of which (23.5% overall) both ends of the nutrient artery canal were distal to the implant tip and in 13 of which (12.8% overall) one of the ends of the nutrient canal was at least proximal to the implant tip. NAMA was seen postoperatively in 8 of 102 hips (7.8%) and NAML was seen postoperatively in 6 hips (5.9%), in 5 of which (4.9% overall) femoral stems fully masked the nutrient artery canal and in 9 of which (8.8% overall) a nutrient artery canal was visible postoperatively, but its proximal end was not defined because of implant shadowing. The length of stems which fully masked the nutrient artery canals postoperatively were at least 150 mm or larger. Six (5.9%) intraoperative periprosthethic femoral fractures were detected (Fig. 2 and 3). One was type TL, one was type A1, three were type B2 and one was type B3. Type B2 fractures showed new or additional radiolucent lines on intraoperative and/or postoperative radiographs by comparison with the preoperative radiographs. Conclusions. The knowledge of radiographic features of the nutrient artery canals of the femur may be useful to distinguish them from intraoperative fractures after cementless THA

There are numerous studies in the current literature that have demonstrated altered levels of various biomarkers in the serum of patients with implant loosening. Despite increasing interest in the biology of implant incorporation there are no studies investigating the changes in biological marker (of either osteoblastic or osteoclastic activity) levels during the integration of the bone-implant interface. Such a study would provide data about the biological profile of normal integration and would be helpful for future monitoring of implant prosthetic performance (either normal or abnormal). We present data from a study performed on 100 osteoarthritic patients, who underwent cementless THA (Synergy, Reflexion Interfit, Smith & Nephew) and 100 non arthritic volunteers. Serial measurements of serum biochemical markers (bone formation and resorption), of cytokines and of other biological mediators and growth factors were evaluated at regular intervals over the course of six years. Curves of per cent changes from baseline and marker variability curves have been created for each marker which are indicative of the incorporation process. Evaluating markers of osteoblastic activity, a first response, with average values below baseline, was observed at the level of the seventh day (perhaps as a response to local trauma). A second osteo-productive response was observed between the third week and 9 months (peak average values at the level of the 6. th. month). At the 1st year time interval, average values reached baseline and remained at this level up to the 6th postoperative year. Evaluating markers of osteoclastic activity, a first response, with average values above baseline, was observed at the level of the seventh day (perhaps as a response to local trauma). A second osteoclastic response was observed between the third week and 3 months (perhaps a coupling response to enhanced osteoblastic activity). At 6 months, average values reached baseline and remained at this level up to the 6th postoperative year. It seems that bone implant interface in cementless total hip arthroplasty remains active up to the 9. th. postoperative month. Possible future deviation from such ‘individual normal’ curves will be indicative of the initiation of the osteolysis process and loss of fixation

Total hip arthroplasty (THA) is associated with high intraoperative and postoperative blood loss. Antifibrinolytic drugs have been used to minimize the potential risks of bleeding and blood transfusion. Studies on the effect of tranexamic acid on decreasing blood loss in THA have revealed interesting results, but most have focused on cemented THA. Yet its benefits in THA, especially in cementless THA, have not been proved. We conducted a prospective double-blind randomized controlled study on 64 patients who were candidates for cementless THA under epidural anesthesia between 2006 and 2008. Patients were randomly assigned into study and control groups. Patients in both groups were well matched regarding preoperative characteristics. Five minutes preoperatively 32 patients of the study and control groups received 15 mg/kg tranexamic acid or normal saline intravenously respectively. Our findings showed a significantly smaller decrease in 6- and 24-hour postoperative hemoglobin levels, less intraoperative and postoperative bleeding, and less need for allogenic blood transfusion in the tranexamic acid group. Our results also revealed a higher mean of 6- and 24-hour hematocrit level and shorter hospital stay in the tranexamic acid group compared to the control group, which were not statistically meaningful. In our study no thromboembolic event was seen; except 1 patient in the control group. Our study showed that administering tranexamic acid before the start of cementless THA under epidural anesthesia can reduce intraoperative and postoperative bleeding as well as need for blood transfusion

One of major problems in Total Hip Arthroplasty is thigh pain. We have examined the effect of femoral canal injection of Calcium Phosphate Paste (CPP) for cementless THA. CPP is a mixture of alpha Tri-Calcium Phosphate, Tetra-Calcium Phosphate, Calcium Hydrogen Phosphate and Hydroxyapatite. This paste harden in 10 minutes and its stiffness increases to 80Mpa in 3days. Cementless THA were performed in 45 osteoarthritic hips from 1999 to 2002. Eight of 40 patients were male and 32 were female, average age were 62.4 years old ranged 43 to 81. In 11 hips, CPP (10–12g) were filled as a femoral canal filler around the distal end of stem. In 34 hips, as a control, no CPP were filled in the canal. Proximal part of the stem was HA coated on rough metal surface. No thigh pain were observed in CPP group patients. In control group, five hips (14.7%) showed thigh pain (p< 0.05), but walking disability and pain were mild in the first year and improved by the next year. CPP filled in the canal were absorbed slowly on X-ray film, but prevention of thigh pain lasts for long time maximum 3 years. No infections and pulmonary embolism were observed in both series. Filling CPP into the gap between stem tip and femoral canal is useful technique to prevent thigh pain after cementless THA

Background. Although thigh pain is an annoying problem after total hip arthroplasty (THA), little information has been known about its natural course. Methods. To determine the frequency, time of onset, and duration of thigh pain after cementless THA, we evaluated 240 patients (240 hips) who underwent primary THA because of femoral head osteonecrosis with the use of a single tapered stem. Results. Twenty-seven patients (11.3%) experienced thigh pain during the follow-up of 3–11 years(mean, 84 months). The pain developed 2–78 months (median, 25 months) after THA. The 75% of pain developed within 36 months. In 25 patients, the pain disappeared postoperatively 1 month-64 months (mean, 17.4 months), and 2 patients (7.4%, 2/27) had persistent thigh pain. There were no differences in the latest Harris Hip Score between the thigh pain group and no thigh pain group. Conclusion. Our results provided basic information about the natural history of thigh pain after cementless THA with a tapered stem design

Metal-on-metal bearing was re-introduced with the aim of eliminating polyethylene wear and resulting complications of osteolysis and aseptic loosening in total hip arthroplasty (THA). However, authors of recent studies have reported periprosthetic osteolysis and aseptic failure following second-generation metal-on-metal THA. The purpose of this study is to report the results at a minimum of five years following cementless total hip arthroplasty with a contemporary metal-on-metal articulation. Our study included findings of histologic examination on periprosthetic tissues from revised hips and wear and roughness analysis of retrieved implants. A consecutive series of 158 cementless THAs that were performed in 154 patients using a contemporary metal-on-metal bearing were assessed at a mean of 6.5 years (5 to 8). Their mean age at surgery was 53 years (21 to 80). The patients were assessed clinically with use of the Harris hip score, and the hips were assessed radiographically. Histological analysis was performed on specimens retrieved from the revised hips, and wear and roughness measurements were made for the explanted prostheses. The average Harris hip score improved from 45 points preoperatively to 92 points at the final follow-up examination. There was no aseptic loosening of the femoral or acetabular components. One hip was revised because of recurrent dislocation and one was managed with two-stage re-implantation for deep infection. Thirteen hips (8%) had osteolysis; 11 had osteolysis localized within the greater trochanter and two had both femoral and ace-tabular osteolysis. Of these, five patients who had a persistent pain and osteolysis underwent revision operation for the consideration of bearing exchange to a ceramic-on-ceramic or ceramic-on-polyethylene combination. All these revised hips showed extensive synovial-like tissue hypertrophy and perivascular infiltration of lymphocytes on histological examinations. Annual volumetric wear rate measured on one retrieved femoral head was 1.04mm3/yr, and roughness measured on three retrieved femoral heads was consistently very low between 8nm and 117nm. After the revision surgery, all the patients noticed disappearance of pain as well as radiographic evidence of healing of the osteolytic lesion. Our mid-term follow-up of cementless THA using a contemporary metal-on-metal bearing revealed an unexpectedly high rate of periprosthetic osteolysis possibly in association with metal hypersensitivity. In patients with persistent hip pain and osteolysis after contemporary metal-on-metal THA, surgeons should consider an exchange of the articulation surface to a ceramic-on-ceramic or ceramic-on-polyethylene combination because they can be cured only after an elimination of the source of hypersensitivity reaction