Total hip arthroplasty (THA) is one of the preferable solutions for regaining ambulatory activity for patients with end-stage osteoarthritis, and the procedure is well developed technically and large numbers of patients benefit from THA worldwide. However, despite the improvements in implant designs and surgical techniques, revision rates remain high, and the number of revisions is expected to increase in the future as a result of the increase in the volume of primary THA and the increase in the proportion of younger, more active patients who are likely to survive longer than their prosthetic implants. In revision THA, associated loss of bone stock in the acetabulum presents one of the major challenges. The aim of the present study was to analyze the clinical and radiographic outcomes and Kaplan-Meier survivorship of patients underwent revision surgeries of the acetabular cup sustaining aseptic loosening. We reviewed consecutive 101 patients (120 hips; 10 men 11 hips; 91 women 109 hips; age at surgery, 66 years, range, 45–85) who underwent acetabular component revision surgery, at a follow-up period of 14.6 years (range, 10–30). For the evaluation of the state of the acebtabulum, acetabular bony defects were classified according to the classification of the AAOS based on the intraoperative findings as follows; type I [segmental deficiencies] in 24 hips, type II [cavity deficiency] in 48 hips, type III [combined deficiency] in 46, and type IV [pelvic discontinuity] in 2. Basically, we used the implant for acetabular revision surgery that cement or cementless cups were for the AAOS type I acetabular defects, cementless cup, or cemented cup with reinforcement device were for type II, cemented cup with reinforcement device were for type III. Follow-up examination revealed that Harris Hip score improved from 42.5±7.8 points before surgery to 76±16.2 points (p<0.05). The survival rates of the acetabular revision surgery with cemented cups, cementless cups, and cemented cups with reinforcement devices were 65.1%, 72.8%, and 79.8%, respectively, however, there was no significant differences between the groups. There were nine cases, which failed in the early stage in the groups of cementless cups and cemented cups with reinforcement devices, because of the instability of the cementless cups or breakage of reinforcement plates caused by inadequate bone grafting. We conclude that the usage of the cementless cups for type I and II acetabular bony defects, and the cemented cups with reinforcement devices for type III bony defects will demonstrate durable long-term fixation in case of adequate contact between acetabular components and host-bone with restoration of bone stock by impaction bone grafting.

Introduction

Reconstructing acetabular defects in revision hip arthroplasty can be challenging. Small, contained defects can be successfully reconstructed with porous-coated cups without bone grafts. With larger uncontained defects, a cementless cup even with screws, will not engage with sufficient host bone to provide enough stability.

Porous titanium augments were originally designed to be used with cementless porous titanium cups, and there is a scarcity of literature on their usage in cemented cups with bone grafting.

The increasing need for total hip replacement (THR) in an ageing population will inevitably generate a larger number of revision procedures. The difficulties encountered in dealing with the bone deficient acetabulum are amongst the greatest challenges in hip surgery. The failed acetabular component requires reconstruction to restore the hip centre and improve joint biomechanics. Impaction bone grafting is successful in achieving acetabular reconstruction using both cemented and cementless techniques. Bone graft incorporation restores bone stock whilst providing good component stability. We provide a summary of the evidence and current literature regarding impaction bone grafting using both cemented and cementless techniques in revision THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:98–102.

Background: Cemented and cementless fixations of acetabular components in total hip arthroplasty are routine practice with inherent advantages and disadvantages. The aim of our prospective randomized study was to compare the clinical and radiographic results of cementless porous-coated cobalt chromium acetabular component with cemented all-polyethylene acetabular component in total hip arthroplasty.

Methods: Three hundred patients were randomized to receive a cementless hemispherical cobalt chromium porous-coated no-hole acetabular component (group 1) or cemented all-polyethylene acetabular component (group 2) with an identical cemented femoral stem and 28mm cobalt-chromium head. Patients were evaluated clinically with Harris Hip Scores (HHS) and radiographically. Analysis of both intention-to-treat groups was performed.

Results: Group 1 had 128 patients (55 male, 73 female) with average age of 70.3 years. Group 2 had 147 patients (63 male, 84 female) with average age of 71.2 years. Average follow-up was 9.5 years (1.03–13.23). The median follow-up was 10 years. 25 patients were excluded from analysis for reasons including unfit for surgery (2), operation cancelled (2), missing data (8) and non-study device (10). Average preoperative HHS improved from 34.4 and 34.5 to 80 and 82.5 postoperatively in group 1 and 2 respectively. There was no statistically significant difference between the average HHS of the two groups (p=0.449) at last follow-up. There were 7 revisions in group 1 [infection (2), cup migration (2), aseptic loosening (1), slipped cup (1) and fractured liner (1)]. 11 patients had revision in group 2 [aseptic loosening (8) and recurrent dislocations (3)]. Revision rate between the two groups was not statistically significant (p=0.465). 10-year survivorship was 93.8%; and 86.6%; for group 1 and 2 respectively. No statistically significant difference was noted for prognostic factors like gender (p=0.006), body mass index (p=0.433), age (p=0.657) and surgical approach (p=0.004) for the two groups. Prognostic factors like gender (male, p=0.006) and surgical approach (posterior, p=0.004) were noted to be significant but body mass index (p=0.433) and age (p=0.657) had no statistical significance. Bootstrapping analysis for the two groups (p-value calculations N=3000) showed a significant p-value for 19 and not significant p-value for 2981 calculations. 4 porous coated cups and 29 all-polyethylene cups had radiolucencies. None of the porous-coated cups had expansile osteolysis.

Conclusions: The results from our study indicate that patients with a cemented all-polyethylene cup and cementless porous coated cup have similar long term outcomes. In patients over 75 years cemented cups have excellent results (100% survivorship at 10 years).

Introduction: Highly cross-linked polyethylene acetabular cups and Oxinium femoral heads were developed to reduce wear debris induced osteolysis. Laboratory tests have shown less wear with these new materials. This RSA-study was performed to compare these new materials in vivo with conventional bearing materials used in total hip arthroplasty.

Methods:150 patients were randomized to 5 groups. The patients received either a cemented Charnley mono-block stainless steel femoral stem with a 22.2 mm head or a cemented Spectron EF femoral stem with a 28 mm head. The Charnley stem articulated with a cemented Charnley Ogee acetabular cup. The Spectron EF stem was used with either cemented Reflection All-Poly EtO-sterilized ultra-high molecular weight polyethylene (UHMWPE) acetabular cups or cemented Reflection highly cross-linked polyethylene (XLPE) acetabular cups, combined with either Cobalt Chrome or Oxinium 28 mm femoral heads. Patients were followed up with repeated radiostereometric analysis (RSA) for two years to assess the rate of penetration of the femoral head into the cup (MTPM).

Results: At 2 years follow-up the mean MTPM (95 % CI) for Charnley Ogee (n=25) was 0.20 mm (0.11–0.29). For the Spectron EF femoral stem used with Reflection All-Poly UHMWPE acetabular cups the mean MTPM (CI) at 2 years was 0.40 mm (0.23–0.57) when combined with Cobalt Chrome femoral head (n=23) and 0.50 mm (0.29–0.71) when combined with Oxinium femoral head (n=16). When using the Spectron EF femoral stem with Reflection XLPE combined with Cobalt Chrome (n=27) or Oxinium (n=24) femoral head the mean MTPM (CI) at 2 years was 0.19 mm (0.10–0.28) and 0.18 mm (0.07–0.29), respectively. There were no differences in penetration between the Charnley/Ogee, XLPE/CoCr and XLPE/Oxinium groups (student t-test, p=0.5–0.8). There was no statistically significant difference between the two Reflection All-Poly UHMWPE groups (p=0.09). The groups with Reflection All-Poly cups had a statistically significant higher penetration than the three groups mentioned above (p< 0.001).

Discussion: The use of Reflection XLPE cups instead of Reflection All-Poly cups reduced femoral head penetration at 2 years. We used the Charnley Ogee cup as a reference due to a long clinical record. This cup was superior to Reflection All-Poly, but not Reflection XLPE, regarding femoral head penetration. Because the femoral head of Charnley Ogee is smaller than the Oxinium/Cobalt Chrome head it might be more clinical relevant to measure volumetric wear. The groups with Oxinium heads did not have less wear than the groups with Cobalt Chrome heads after 2 years follow-up. Further follow-up is needed to evaluate the benefits, if any, of Oxinium femoral heads in the clinical setting.

Background: RSA cannot discern whether a single prosthesis is fixed or migrating below the detection level. Samples of patients usually show migration values that appear to be continuously distributed. Is there a dichotomy between stable and migrating prostheses?

Methods: We analysed the migration of 147 cemented acetabular cups of 7 different designs, by use of a new set of algoritms for frequency distribution analysis called Rmix. The migration vector lengths were assumed to be a compound of log-normal distributions. The algoritm then calculated if the observed frequency distribution is best explained by one or more log-normal distributions.

Results: After 2 years there was a significant dichotomy (p=0.006) between 2 lognormal subgroups within the sample. Neither cup design, sex or operating department could explain the dichotomy into two groups, which appears to reflect the existence of two different types of behaviour. The migration along the 3 axes in space, showed a similar dichotomy. During the second year, around 80 % of the patients belonged to a distinct, normally distributed subgroup with a mean not different from 0 mm and a small variation, corresponding to the measuring error. The remainder differed significantly from this subgroup and showed migration.

Interpretation: The majority of the cups belonged to a subpopulation that appeared completely stableduring the second year. For a single type of prosthesis, the relative size of the stable subgroup might be a good index of the expected performance.

Acetabular bone stock loss represents one of the main challenges in revision hip surgery.

We present 149 consecutive aseptic acetabular reconstructions with impacted bone allograft technique and a cemented cup followed clinically and radiographically for an average of 52 months (range 24–156 months). Patients requiering reinforcement rings were not included in this series. Seven reconstructions in six patients were lost to follow-up.

The average postoperative Merle DAubigne and Postel score was 5.7 points for pain, 4.5 points for mobility and 5.2 points for gait. Radiographic analysis evidenced incorporation of the grafts in all but in four cups with more than 5 mm migration, demonstrating radiographic failure. All of these patients presented clinical failure as well. Non progressive radiolucent lines were observed in 29 non symptomatic patients. mainly in Zone 1 according to De Lee and Charnley. Six patients were reoperated (4.5%), 3 of them because of deep infection and 3 patients for aseptic failure related to massive segmental and cavitary defects. Overall survival rate of the acetabular reconstruction was 95.8% (CI 95%:92.3–99.1). When infected cases were excluded, this rate was 98%.

Providing precise indications, acetabular reconstruction with impacted morsellized bone allografts and cemented cups is an excellent biologic reconstructive technique in patients with bone stock deficiency

The aim of this study was to measure polyethylene wear in uncemented metal-backed cups and compare it with cemented ultra-high molecular weight (UHMW) polyethylene cups in a controlled double-blind study.

The study group was made up of 91 patients aged 50 to 70 years undergoing THR for unilateral OA of the hip between February 1995 and July 2002. The male to female ratio was 40:60. In all patients, a cemented stem and 28-mm ceramic head was inserted, using a third-generation cementing technique and UHMW polyethylene. Patients were randomly allocated to receive either a cemented or uncemented acetabular cup. Eight patients were lost to follow-up.

Cemented cups were used in 28 patients (mean age 64 years). The mean thickness of the polyethylene was 9.6 mm (7.5 to 12.5). The mean liner thickness in the metal-backed cups was 8.9 mm (7 to 12.2). In measuring wear, baseline 3-month postoperative radiographs were compared with the most recent follow-up radiographs and Martell software was used.

The polyethylene in metal-backed cups had a mean wear rate of 0.49 mm at 4.7 years, with a mean annual wear rate of 0.12 mm. The cemented polyethylene cups had a mean wear rate of 0.45 mm at 5.3 years, with a mean annual wear rate of 0.11 mm.

The study is ongoing. Currently we conclude that there is no significant difference in the annual wear rate of polyethylene in uncemented metal-backed cups and cemented cups.

Introduction and Aims: To determine whether polyethylene wear is different comparing cemented polyethylene cups with metal-backed cups and a polyethylene insert.

Method: A sample of patients who had hip replacements between February 1995 and July 2002 have been studied. They were randomly allocated to either a cemented polyethylene cup or a metal-backed press-fit cup and polyethylene insert. All patients had a cemented stem and a 28mm ceramic head inserted. Ninety-one patients were treated, and 83 are available for analysis. The pre-operative diagnosis in all was unilateral osteoarthritis. The trial is a prospective randomised one and patients have been assessed clinically and radiologically annually. Twenty-eight patients with cemented polyethylene cups and 55 patients with uncemented metal-backed cups have been analysed. The polyethylene thickness of the cemented cups is 9.6mm on average, and the metal-backed cups had an average liner thickness of 8.9mm. Wear measurements were done using the Martell computer system.

Results: Based on measurements done on acetabular cups with the longest follow-up, the metal-backed cups have an average wear of 0.65mm, with an annual wear rate of 0.14mm. The cemented cups have an average wear of 0.64mm, with an annual average of 0.12mm. The study is ongoing and data will be updated.

Conclusion: Wear measurements were done using the three-month post-operative x-ray as the baseline and the most recent follow-up x-ray. Based on measurements done on cups with the longest follow-up, there is very little difference between the two groups. The study is ongoing and data will be updated.

Aims: The mid- and long-term results of uncemented cups are uncertain. The aim of this study was to assess their results and to compare them with the most common cemented cup, the Charnley. Material and methods: In the study we included only patients under the age of 60 that had been operated with one of the 10 most common uncemented cup brands or the Charnley cup. Only brands that had been in use for at least 6 years were included. There were only minor differences among the brands concerning age, gender and diagnosis. Survival percentages were calculated with the Kaplan-Meier method. Results: With all cup revisions (change of cup or polyethylene liner) as end-point, the overall 5 year survival probability was 97% (95% CI: 96.3 97.3) which decreased to 86% (95% CI: 84.4 Ð 87.5) at 10 years. The 10 years survival varied from 74% for the Atoll cup to 88% for the Optiþx and the Harris-Galante cup, whereas for the cemented Charnley cup the 10 years survival probability was 94%. For the uncemented cups the increase in revision risk after 6 years was mainly due to wear and osteolysis. For the HA-coated cups also aseptic loosening increased after 6 years of follow-up. Conclusion: Uncemented cups in young patients had good short-term results. At 10 years of follow-up for the investigated uncemented cup brands, the results were inferior to the Charnley cup.