Introduction

Upper femoral fractures include intra and extra-capsular fracture (ECF). For intra-capsular fracture (ICF), hemi-arthroplasty (HA) is the most commonly used treatment. Interest in total hip arthroplasty (THA) is growing because THA yields less revision (4% versus 7%) associated to better functional results despite higher dislocation rate (9% versus 3%). Regarding ECF, internal fixation is the reference treatment. THA could represent a relevant alternative. This study evaluates the efficiency of THA using dual mobility cup (THA-DMC) as treatment of these fractures specially in elderly patients.

BACKGROUND PURPOSES

dislocation is a classical complication in total hip arthroplasty (THA) revision. Cup fixation is the second concern. Since 1998 we routinely use cementless Dual mobility cup (DMC) in revision surgery. In order to know outcomes at 2 years, we followed a prospective series of 78 patients treated in our institution. Purpose is to demonstrate that DMC used in revision THA is safe as regards dislocation risk and bone fixation.

Mid and long-term follow-up of Charnley total hip arthroplasty (THA) demonstrated good functional results with 85% survivorship at 25-year follow-up. However dislocation still remains an unsolved problem. Dislocation may occur all along the patient and implant life. The aim of this study is to answer the question: does Dual Mobility Cup (DMC) decrease the dislocation risk? Method: We report comparative results at ten years of follow-up of 2 groups of primary cemented Charnley-type THA, one with a standard polyethylene cup (group 1, n=215) and the other one with a DMC (group 2, n=105). Results: In group 1, twenty-six dislocations (12.9%) occurred. In group 2 only one dislocation (0.9%) occurred. This dislocation was successfully reduced by close reduction, without any recurrence. This difference was statistically significant (p=0.0018). In group 1, reason for revision was recurrent dislocation in twenty one cases. Five patients have been revised for other reasons. The global revision rate was 12.9%. In group 2, two patients needed revision surgery for aseptic loosening. The global revision rate was 2.1%. This difference was statistically significant (p=0.0054). The goal was reached for the patients of group 2 who had more risks factors of dislocation (age, aetiology, ASA and Devane scores) than those of group 1. When using a DMC, we observed a low rate of dislocation in primary THA (0.9%). This surgical choice seems to be a secure and effective technique in Charnley-type THA, especially in a high risk population.

Introduction

Polyethylene (PE) wear is clearly linked to total hip arthroplasty (THA) failure, leading to osteolysis and decreasing survivorship rates. Dual mobility cups (DMC) are widely used to prevent or treat THA instability. However some studies have pointed PE wear risk as a “dual wear” risk. Hip wear simulation is usually used to understand factors influencing wear and to differentiate design, PE types and materials performances. To date, few works have been published studying dual mobility insert wear.

Purpose of the study: Loss of acetabular bone stock is a very common finding at revision total hip arthroplasty (rTHA). The acetabular bone defect can be filled with an autograft or with cyropreserved or lyophilized and radiated allografts. The permanent availability lypophylized radiated allografts is a certain advantage. For more than ten years (1994), we have used Phoenix® (TBF) lyophylized radiated bone grafts.

Material and methods: We conducted a retrospective study of all patients who underwent rTHA for aseptic loosening between 1994 and 1999 with replacment of the acetabular implant requiring use of a lyophyilized radiated allograft (TBF, Phoenix®) fashioned from femoral heads and cut to fit. Grafts were impacted followed by acetabulra replacement with a cemented polyethylene (PE) cup or a Kerboull retaining ring, or an ace-tabular grid as needed. This procedure was used for 18 hips (16 patients). The Postel-Merle-d’Aubigné (PMA) clinical score and radiographic assessment were noted at five years with the Paprovsky classification. In addition, the status of the allograft (homogeneous aspect) and the presence of a lucent line between the host bone and the allograft were noted.

Results: One patient was lost to follow-up. The analysis thus included 17 of 18 hips. Mean age was 63 years at rTHA surgery and 55 years at primary surgery. The reason for revision was cup loosening (n=13), isolated PE wear (n=4) with acetabular bone defects. The mean preoperative PMA score was 10.4 (range 5–18). At three months, the PMA score was 15.2 (range 12–18), at one year 16.2 (range 15–18), and at five years 17.2 (range 16–18). Implant migration was not observed on the five-year x-rays. Allografts were incorporated for seven hips which presented a homogeneous graft image. Five hips presented a partial lucent line and five a complete lucent line but with no evidence of implant instability. None of the patients required surgical revision to change the implant or for a new bone graft.

Discussion: Acetabular revisions are often associated with bone defects which can be filled with allografts. This study demonstrated the good incorporation of lyophilized radiated allografts. This incorporation is progressive with good implant stability at more than five years. Use of this graft material for filling acetabular defects can correct for the bone deficiency.

Conclusion: Use of lyophilized grafts gives satisfactory results with reliable outcome at five years comparable with other bone replacement methods, particularly cyropreserved femoral grafts used before 1994.

Purpose of the study: Long-term outcome of Charn-ley total hip arthroplasty (THA) (more than 30 years follow-up) has demonstrated that the longevity of these prostheses is inversely proportional to polyethylene wear and head penetration into the cup. In order to limit wear phenomena, we have used since 1997 a Charnley THA with a 22.225 mm zirconia (Zr) head (Prozyr®, Saint-Gobain Desmarquet). The goal was to reduce wear and improve implant longevity.

Material and methods: We reviewed at minimum five years follow-up 62 patients with 69 THA with a standard Zr/PE bearing. These patients had undergone surgery in 1997–1999, the cup or the high-density PE insert were furnished by Centerpulse Zimmer. The measurement method correlated the Livermore technique with determination of the center of the head using the Chevrot and Kerboull method and interobserver radiological measurements made on digitalized images after magnification.

Results: At mean six years follow-up, the Postel-Merle-d’Aubigné score was 17.6 and overall anteroposterior wear at mast follow-up was 0.76 mm (0.73 mm with the Acoplot PE cup and 0.78 mm with the hybrid THA with an isofit cup). Mean wear for this series of implants was thus 0.12 mm/year. There were no fractures of the Zr heads. The rate of osteolysis was 10% with very minimal osteolysis defects, general in the Merckel spine. Wear on the same implant in a previous series operated on in 1997 was 0.40 mm at three years, i.e. also 0.12 mm/year.

Discussion: Wear was not greater with the Zr/PE bearing than usually observed with a 22.225 metal-backed PE bearing. This is in contradiction with observations by J. Allain and D. Goutallier in 1999 and with the publication by P. Piriou (SOFCOT 2003). Furthermore, we did not observe, like Hamadouche (SOFCOT 2001) major osteolytic lesions. On the other hand, we did not observe, as was shown by Wroblewsk, any decrease in the rate of penetration of the head into the PE insert. Using the same 22.225 Prozyr bearing with conventional PE and a cemented head, Wbroblewski showed in 2004 that at mean 4.3 years follow-up (range 0–8 years) mean penetration was 0.03 mm/yr.

Conclusion: Today, at five years follow-up, we have found that with a Charnley THA wear is the same with the Zr/PE as with the metal/PE bearing.

Purpose of the study: Thromboembolism is a serious complication after hip surgery. The residual rate of venous thrombosis has varied according to the type of screening used with rates reported from 3.54% to 54.2% without prophylaxis. These discordant figures led us to conduct a prospective study devoted to thromboembolic complications.

Material and methods: This prospective study was conducted from April 1995 to April 1996 in 61 consecutive patients who underwent total hip arthroplasty under general anesthesia. Duplex Doppler was performed systematically on day 8 to 10 to search for thromboembolic complications. Results of this study were compared with those of a study we conducted in 2960 total hip arthroplasties implanted from 1950 to 1999 where search for thromboembolic complications was guided by the clinical presentation.

Results: Clinical screening for thromboembolic complications in the series of 2960 total hip arthroplasties revealed a rate of 3.54% [pulmonary embolism (n=46), phlebitis (n=95), heparin induced thrombopenia (n=14)]; the rate of anticoagulant accidents was 2.5%. Associating these anticoagulant accidents with the cases of heparin induced thrombopenia, the rate of these complications was 2.97%, almost the same as that of thromboembolic complications. Duplex Doppler screening on day 8–10 detected venous thrombosis in 36.8% of patients.

Discussion: Thromboembolic complications with clinically detected phlebitis confirmed by duplex Doppler were observed in 3.54% of our series of 2960 operated patients, but systematic screening with duplex Doppler found a ten-fold higher rate, 36.8%. Should duplex Doppler be performed systematically in the postoperative period? What would be the cost, and the cost-effectiveness? It is known that when phlebitis is detected, anticoagulant treatment must be continued for at least three months postoperatively. In addition, the cases of phlebitis detected by duplex Doppler are generally distal, with no clinical expression; so what would be the benefit for these patients of long-term treatment? Considering the expenditures involved in 1000 total hip arthroplasties treated preventively with low-molecular-weight heparin, the cost of systematic duplex Doppler screening would lead to a supplementary cost of 456000 euros, without counting the cost of treatment for complications due to the anticoagulant treatment.

Conclusion: In our opinion, systematic duplex Doppler screening is not warranted. We believe that clinical screening is a valid procedure, in line with evidence provided by duplex Doppler performed in symptomatic patients. Anticoagulant treatment should be continued for six weeks after the arthroplasy as a preventive measure and should be initiated 12 to 24 hours after the operation. Systematic ultrasound screening is only useful in high-risk patients or when thrombosis prophylaxis cannot be instituted.

Purpose: Prosthetic hip surgery (150,000 total hip arthroplasties in France including 10–12% revision procedures) have required the development of bone banks to have graft material readily available. Safety and tracability requirements have led to the disappearance of local banks and the creation of validated tissue banks. The French tissue bank (TBF), which received its official authorization from the AFSSAPS in January 2001, began operating in 1992, collecting femoral heads (FH) procured during hip arthroplasties.

Material and methods: Material collection has increased steadily over the last five years. In 2002, 5004 FH were collected in 126 public or private centres. The number of FH which were rejected for regulatory, health (clinical and biological selection) and harvesting quality remained relatively stable around 20% from 1997 to 2000. Rejection for socioclincal reasons, which varied from 3 to 5%, included, in decreasing order, cancer, transfusion history, systemic disease and/or history of neurodegenerative disease, long-term corticosteroid treatment, and notion of infectious risk (mainly viral). Secondary rejection because regulatory tests could not be performed varied from 3 to 6% and included haemolysis, insufficient quantity for assay or preservation in the serum bank, ALAT assay impossible, serology suggestive of recent or former viral infection: HCV, HBV, HIV, HTLV. The FH underwent chemical treatment (viral and prion inactivation), mechanical treatment (production of bone shreads, cancellous blocks, wedges, whole heads, heads without neck), radiosterilisation and lyophylisation.

Results: Sixty percent of the grafts were used for hip arthroplasty, mainly during revision procedures (80%) (1.4 grafts on average, whole heads and blocks and more recently shredded bone); 8.5% were used for knee arthroplasty and 11.5% (blocks) for spinal surgery, 11% for fractures (in decreasing order femur, distal tibia, tibial plateau, ankle, foot, shoulder, arm, other), 4% for nonunions, 5% for osteotomies (blocks or wedges).

Conclusion: More and more grafts are used for osteotomy and spinal fusion procedures. Use of shredded bone is increasing. We are currently working on a cancellous bone paste combined with bone substitute.

Purpose: From 1985 to 2001, nearly 400,000 Zircone heads were implanted for total hip arthroplasty. In France, following an abnormally high rate of ruptures in two lots of heat-treated heads, production of Zircone heads was interrupted in 2001. Following work by Allain et al., another controversy developed concerning abnormal secondary wear of Zircone heads. According to certain authors, head roughness was increased by pitting phase transformation. This hypothesis was corroborated by Haraguchi (2001) who reported three explanted heads. We wanted to check the hypothesis.

Material and methods: In 2002, we explanted three Prozyr 22.2 Zircone heads for recurrent dislocation. We compared the explanted heads with a new Zircone head, a 28-mm alumina head explanted after prosthesis loosening and a new alumina head, using the same protocol as Haraguchi.

Results: On the explanted heads, the percentage of monoclinic Zircone was always less than 10% (3–10%). Roughness was also very minimal (Ra=0.01μm) for Zircone and ceramic heads, whether new or explanted, with no pitting and no notable structural change. The mean size of femoral head grains remained within the ISO 13 356 standard (1997).

Discussion: In 2003, Clark who studied three Zircone heads removed 2.8 to 10 years after implantation selected among 23 explanted heads, was unable to demonstrate any phase transformation or surface alterations. On one head explanted at eight years, Clark found significant monoclinic phase transformation. In our study, the three explanted heads did not exhibit significant monoclinic phase transformation since it remained less than 10% without pitting nor increased roughness. The behaviour of 22.2 Zircone heads may be different from 28 Zircone heads in terms of fracture (since no fractures have been observed after high-temperature furnace treatment of 22.2 heads) and in terms of monoclinic phase transformation.

Conclusion: This point is crucial for patients with a Zircone head total hip arthroplasty. Surveillance must be continued. At the present time and for mid term, we can conclude that the rate of monoclinic phase transformation of explanted Zircone heads is minimal and that production quality is good, particularly for 22.225 mm heads.

Purpose: Between 1979 and 2000, we performed 115 total hip arthroplasties with a bone block, mainly for degenerative hips secondary to congenital dislocation. Up to 1992, we used the classical bone block fixed with a screw and a cemented all-polyethylene Charnley cup inserted in the paleoacetabulum. The drawback of this technique was the two-month delay required for bone healing before weight bearing could be attempted. Since 1992, we have modified this technique, using an embedded bone block impacted into the dihedral angle between the capsule – neoacetabulum and the non-cemented press-fit cup with a screw in the paleoacetabulum. This method allowed immediate postoperative weight bearing, just like after first-intention total hip arthroplasty.

Material: Between 1992 and 2002, we operated 56 patients (63 hips) using this technique, 50 (56 hips) were reviewed at a mean five years (range 1 – 9.5). Three patients had died (three hips) and three (four hips) were lost to follow-up. The purpose of this work was to check integration of the bone block and absence of acetabular complications related to early weight bearing. Mean age at surgery was 58.5 years (range 17 – 88). There had been one earlier intervention for 17 hips, two for 13 and three for four.

Methods: Physical examination and standard x-rays (AP, lateral, Lequesne oblique views) were available at last follow-up. In addition to the radiographic assessment of the bone block, the Postel Merle d’Aubigné (PMA) objective clinical score and subjective patient satisfaction were recorded.

Results: The mean PMA score was 11.7 preoperatively and 17.6 at last follow-up. Ninety-four percent of the patients were very satisfied or satisfied, 6% were dis-satisfied (three postoperative dislocations). Radiographically, we noted block lysis (n=1), non-integrated block (n=8), perfect osteointegration (n=47). The cup showed no radiographic sign of ascension. There were two lucent lines in zone 1 (14.8%) and three in zone 3 (16.8%). There was no relation between bone block integration and presence of acetabular lucent lines. Four complications were recorded: one loosening at eight months, one sudden loosening treated by changing the cup, and three dislocations including one treated four years after implantation by anti-dislocation crescent. There was no relationship between complications and block behaviour.

Discussion: The advantage of the embedded block technique with a hybrid prosthesis using a metal-backed polyethylene cup (22.225) is that the postoperative rehabilitation is the same as after a standard prosthesis in good position. Immediate weight bearing on the press-fit cup without cement did not lead to deleterious complications whether clinically or for bone block behaviour.

Conclusion: This technique is a reliable method allowing early weight bearing and a shorter recovery time with satisfactory cup stability.

Purpose: Since 1962, when Sir John Charnley implanted the first total arthroplasty, long-term studies have demonstrated the excellent survival of these implants with greater than 85% survival at 25 years (John Older, Mike Wroblewski, ACORA group in 1995). Polyethylene wear is the main obstacle to long-term survival of the Charnley total hip arthroplasty. New friction surfaces have been proposed to reduce wear, notable the ceramic/ceramic junction proposed by Pierre Boutin since 1970 with the ceramic/polyethylene derivative. The alumine ceramic head cannot be greater than 22.225 cm due to the risk of fracture, leading to the zircone head. D. Goutallier and his school recently demonstrated (1999) that the use of zircone can increase wear with early development of osteolysis and acetabular loosening. For this reason, we compared wear between two series of prostheses using the 22.2 zircone/polyethylene combination versus the metal/polyethylene combination.

Material and methods: Two series of 37 patients were compared for wear. The first series included 41 hips with a zircone/polyethelene combination using a 22.2 cm head. The second series of 38 hips used a metal/polyethylene combination and 22.2 cm heads. The femoral components were the same in the two series with an 8/10 Morse cone. Mean follow-up in the two series was 38 months. All patients underwent surgery in 1997 for the zircone/polyethylene implants and in 1995 for the metal/polyethylene implants. Mean age in the zircone/polyethylene series was 58 years and in the metal/polyethylene series 66. The Postel Merle d’Aubigné (PMA) score at review was 16.6 for the zircone/polyethylene series and 17.7 for the metal/polyethylene series. Manual measurements of wear were made using the Livermore method with determination of the centre of the head according to Cherrot and Kerboull, doubled with computer-assisted interobserver radiological measurements.

Results: At three years, 31.5% of the metal/polyethylene implants were devoid of any signs of wear compared with 29.2% in the zircone/polyethylene implants. Mean wear was 0.19 per year for the metal/polyethylene implants versus 0.12 per year for the zircone/polyethylene implants. Overall wear on the AP view at last follow-up was 0.62 mm for the metal/polyethylene implants and 0.40 mm for the zircone/polyethylene implants at three years. This difference was significant p < à.005).

Discussion: We did not find any greater wear with the zircone/polyethylene combination compared with metal/polyethylene as was also demonstrated by D. Goutallier. M. Wroblewski (2000) demonstrated in a study with 10 years follow-up that wear was twice as great the first two years with a 22.225 diameter head using the alumine ceramic/polyethylene combination (0.1 mm per year), then stabilised. This was probably due to a stabilisation period. We are probably currently in this stabilisation period with the zircone/polyethylene implants.