Objectives. Our primary aim was to describe migration of the Exeter stem with a 32 mm head on highly crosslinked polyethylene and whether this is influenced by age. Our secondary aims were to assess functional outcome, satisfaction, activity, and bone mineral density (BMD) according to age. Patients and Methods. A prospective cohort study was conducted. Patients were recruited into three age groups: less than 65 years (n = 65), 65 to 74 years (n = 68), and 75 years and older (n = 67). There were 200 patients enrolled in the study, of whom 115 were female and 85 were male, with a mean age of 69.9 years (sd 9.5, 42 to 92). They were assessed preoperatively, and at three, 12 and, 24 months postoperatively. Stem migration was assessed using Einzel-Bild-Röntgen-Analyse (EBRA). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), EuroQol-5 domains questionnaire (EQ-5D), short form-36 questionnaire (SF-36,) and patient satisfaction were used to assess outcome. The Lower Extremity Activity Scale (LEAS), Timed Up and Go (TUG) test, and activPAL monitor (energy expelled, time lying/standing/walking and step count) were used to assess activity. The BMD was assessed in Gruen and Charnley zones. Results. Mean varus/valgus tilt was -0.77⁰ and axial subsidence was -1.20 mm. No significant difference was observed between age groups (p ⩾ 0.07). There was no difference according to age group for postoperative WOMAC (p ⩾ 0.11), HHS (p ⩾ 0.06), HOOS (p ⩾ 0.46), EQ-5D (p ⩾ 0.38), patient satisfaction (p ⩾ 0.05), or activPAL (p ⩾ 0.06). Patients 75 years and older had a worse SF-36 physical function (p = 0.01) and physical role (p = 0.03), LEAS score (p < 0.001), a shorter TUG (p = 0.01), and a lower BMD in Charnley zone 1 (p = 0.02). Conclusion. Exeter stem migration is within normal limits and is not influenced by age group. Functional outcome, patient satisfaction, activity level, and periprosthetic BMD are similar across all age groups. Cite this article: N. D. Clement, M. Bardgett, K. Merrie, S. Furtado, R. Bowman, D. J. Langton, D. J. Deehan, J. Holland.
There is continued debate as to whether cemented or cementless implants should be utilized in particular cases based upon chronological age. This debate has been rekindled in the UK and other countries by directives mandating certain forms of acetabular and femoral component fixation based exclusively on the chronological age of the patient. This editorial focuses on the literature-based arguments to support the use of cementless total hip arthroplasty (THA), while addressing potential concerns surrounding safety and cost-effectiveness. Cite this article:
We report the outcome of 320 primary Total Hip Arthroplasties (THA) with minimum 10-year follow-up (range 10–17 years, mean 12.6 years), performed by a single surgeon in Tauranga New Zealand, with the Exeter Contemporary Flanged all-polyethylene cup and Exeter femoral stem via a posterior approach. The aim of the study is to compare the results with the published results from the design centre and create a baseline cohort for further outcomes research in this centre. All patients were prospectively followed at 6 weeks, 1 year, 5 years, 10 years, (and 15 years when available). Of 333 cases that matched the inclusion criteria, 13 procedures in 12 patents were excluded because of concomitant bone grafting and/or supplementary cage fixation, leaving 320 primary THA procedures in 280 patients, including 26 bilateral procedures in 13 patients. Mean follow-up of the surviving cases was 12.6 (range 5.0-17.1) years. There were 12 revisions – 2 for fracture, 5 for instability, 1 for impingement pain and 4 for infection. There were no revisions for aseptic cup loosening. Kaplan-Meier survivorship with revision for aseptic loosening as the endpoint was 100% at 15.0 years (with minimum 40 cases remaining at risk). All-cause acetabular revision in 12 cases result in a Kaplan-Meier survival of 95.9% (95% CI: 93.5 to 98.3%).
Abstract.
Our objective was to examine revision rates and patient reported outcome scores (PROMS) for cemented and uncemented primary total knee joint replacement (TKJR) at six months, one year and five years post-operatively. Patients and Methods: This matched cohort study involved secondary analyses of data collected as part of a large prospective observational study monitoring outcomes following knee replacement in Christchurch, New Zealand.
Aims. Total hip arthroplasty (THA) is a very successful and cost-effective operation, yet debate continues about the optimum fixation philosophy in different age groups. The concept of the 'cementless paradox' and the UK 'Getting it Right First Time' initiative encourage increased use of cemented fixation due to purported lower revision rates, especially in elderly patients, and decreased cost. Methods. In a high-volume, tertiary referral centre, we identified 10,112 THAs from a prospectively collected database, including 1,699 cemented THAs, 5,782 hybrid THAs, and 2,631 cementless THAs. The endpoint was revision for any reason. Secondary analysis included examination of implant survivorship in patients aged over 70 years, over 75 years, and over 80 years at primary THA. Results.
Aims. Uncemented mobile bearing designs in medial unicompartmental knee arthroplasty (UKA) have seen an increase over the last decade. However, there are a lack of large-scale studies comparing survivorship of these specific designs to commonly used cemented mobile and fixed bearing designs. The aim of this study was to evaluate the survivorship of these designs. Methods. A total of 21,610 medial UKAs from 2007 to 2018 were selected from the Dutch Arthroplasty Register. Multivariate Cox regression analyses were used to compare uncemented mobile bearings with cemented mobile and fixed bearings. Adjustments were made for patient and surgical factors, with their interactions being considered. Reasons and type of revision in the first two years after surgery were assessed. Results. In hospitals performing less than 100 cases per year, cemented mobile bearings reported comparable adjusted risks of revision as uncemented mobile bearings. However, in hospitals performing more than 100 cases per year, the adjusted risk of revision was higher for cemented mobile bearings compared to uncemented mobile bearings (hazard ratio 1.78 (95% confidence interval 1.34 to 2.35)). The adjusted risk of revision between cemented fixed bearing and uncemented mobile bearing was comparable, independent of annual hospital volume. In addition, 12.3% of uncemented mobile bearing, 20.3% of cemented mobile bearing, and 41.5% of uncemented fixed bearing revisions were for tibial component loosening. The figures for instability were 23.6%, 14.5% and 11.7%, respectively, and for periprosthetic fractures were 10.0%, 2.8%, and 3.5%. Bearing exchange was the type of revision in 40% of uncemented mobile bearing, 24.3% of cemented mobile bearing, and 5.3% cemented fixed bearing revisions. Conclusion. The findings of this study demonstrated improved survival with use of uncemented compared to cemented mobile bearings in medial UKA, only in those hospitals performing more than 100 cases per year.
Source of the study: University of Auckland, Auckland, New Zealand. Unicompartmental knee arthroplasty (UKA) is effective for patients with isolated compartment osteoarthritis, however the procedure has higher revision rates. Long-term survivorship and accurate characterisation of revision reasons are limited by a lack of long-term data and standardised revision definitions. We aimed to identify survivorship, risk factors and revision reasons in a large UKA cohort with up to 20 years follow-up. Patient, implant and revision details were recorded through clinical and radiological review for 2,137 consecutive patients undergoing primary medial UKA across Auckland, Canterbury, Counties Manukau and Waitematā DHB between 2000 and 2017. Revision reasons were determined from review of clinical, laboratory, and radiological records for each patient using a standardised protocol. To ensure complete follow-up data was cross-referenced with the New Zealand Joint Registry to identify patients undergoing subsequent revision outside the hospitals. Implant survival, revision risk and revision reasons were analysed using Cox proportional-hazards and competing risk analyses. Implant survivorship at 15 years was comparable for cemented fixed-bearing (cemFB; 91%) and uncemented mobile-bearing (uncemMB; 91%), but lower for cemented mobile-bearing (cemMB; 80%) implants. There was higher incidence of aseptic loosening with cemented implants (3–4% vs. 0.4% uncemented, p<0.01), osteoarthritis (OA) progression with cemMB implants (9% vs. 3% cemFB/uncemMB; p<0.05) and bearing dislocations with uncemMB implants (3% vs. 2% cemMB, p=0.02). Compared with the oldest patients (≥75 years), there was a nearly two-fold increase in risk for those aged 55–64 (hazard ratio 1.9; confidence interval 1.1-3.3, p=0.03). No association was found with gender, BMI or ASA.
The initial success of modern total hip arthroplasty can in large part be attributed to the reliable fixation of the femoral component with the use of acrylic bone cement. Early success with cement led to a common pathway of development in North America and the European countries. Much of the early to mid-term research concentrated on refinement of variables related to the methodology and technique of cement fixation. Scandinavian registries were subsequently able to report on improved survivorship with better cementing technique. The net effect has been standardisation towards a small number of cemented implants with good long-term outcomes representing the majority of stems implanted in Sweden, for example. In North America, during the mid-term development of THA in the late 1980's, the term “cement disease” was coined and the cemented THA saw a precipitous decline in use, now to the point where many American orthopaedic residents are completing training never having seen a cemented THA. Modern uncemented femoral components can now claim good long-term survivorship, perhaps now comparable to cemented fixation. However, this has come at a cost with respect to the premium expense applied to the implant itself as well as lineage of failed uncemented constructs. The last several years have seen a proliferation of uncemented implants, usually at a premium cost, with no demonstrated improvement in survivorship. Osteolysis has not been solved with uncemented implants and cement disease has largely been recognised as a misnomer. Long-term outcomes of cemented femoral fixation have consistently demonstrated excellent survivorship, even in the younger age group.
Although data on uncemented short stems are available, studies on cemented short-stemmed THAs are limited. These cemented short stems may have inferior long-term outcomes and higher femoral component fracture rates. Hence, we examined the long-term follow-up of cemented short Exeter stems used in primary THA. Within the Exeter stem range, 7 stems have a stem length of 125 mm or less. These stems are often used in small patients, in young patients with a narrow femoral canal or patients with anatomical abnormalities. Based on our local database, we included 394 consecutive cemented stems used in primary THA (n=333 patients) with a stem length ≤125 mm implanted in our tertiary referral center between 1993 and December 2021. We used the Dutch Arthroplasty Registry (LROI) to complete and cross-check the data. Kaplan-Meier survival analyses were performed to determine 20-year survival rates with stem revision for any reason, for septic loosening, for aseptic loosening and for femoral component fracture as endpoints. The proportion of male patients was 21% (n=83). Median age at surgery was 42 years (interquartile range: 30–55). The main indication for primary THA was childhood hip diseases (51%). The 20-year stem survival rate of the short stem was 85.4% (95% CI: 73.9–92.0) for revision for any reason and 96.2% (95%CI: 90.5–98.5) for revision for septic loosening. No stems were revised for aseptic femoral loosening. However, there were 4 stem fractures at 6.6, 11.6, 16.5 and 18.2 years of follow-up. The stem survival with femoral component fracture as endpoint was 92.7% (CI: 78.5–97.6) at 20 years.
The initial success of modern total hip arthroplasty can in large part be attributed to the reliable fixation of the femoral component with the use of acrylic bone cement. Early success with cement led to a common pathway of development in North America and the European countries. Much of the early- to mid-term research concentrated on refinement of variables related to the methodology and technique of cement fixation. Scandinavian registries were subsequently able to report on improved survivorship with better cementing technique. The net effect has been standardisation towards a small number of cemented implants with good long-term outcomes representing the majority of stems implanted in Sweden, for example. In North America, during the mid-term development of THA in the late 1980's, the term “cement disease” was coined and the cemented THA saw a precipitous decline in use, now to the point where many American orthopaedic residents are completing training never having seen a cemented THA. Modern uncemented femoral components can now claim good long-term survivorship, perhaps now comparable to cemented fixation. However, this has come at a cost with respect to the premium expense applied to the implant itself as well as lineage of failed uncemented constructs. The last several years have seen a proliferation of uncemented implants, usually at a premium cost, with no demonstrated improvement in survivorship. Osteolysis has not been solved with uncemented implants and cement disease has largely been recognised as a misnomer. Long-term outcomes of cemented femoral fixation have consistently demonstrated excellent survivorship, even in the younger age group.
Stems may improve fixation and stability of components
during revision total knee replacement. However, the choice between
cemented and cementless stems is not a clear one.
Introduction. Revision total knee arthroplasty (TKA) is becoming increasingly common in the United States as the population ages and larger numbers of primary TKA are performed in younger individuals.
Aims. To evaluate the outcomes of cemented total hip arthroplasty (THA)
following a fracture of the acetabulum, with evaluation of risk
factors and comparison with a patient group with no history of fracture. . Patients and Methods. Between 1992 and 2016, 49 patients (33 male) with mean age of
57 years (25 to 87) underwent cemented THA at a mean of 6.5 years
(0.1 to 25) following acetabular fracture. A total of 38 had undergone
surgical fixation and 11 had been treated non-operatively; 13 patients
died at a mean of 10.2 years after THA (0.6 to 19). Patients were
assessed pre-operatively, at one year and at final follow-up (mean
9.1 years, 0.5 to 23) using the Oxford Hip Score (OHS). Implant
survivorship was assessed. An age and gender-matched cohort of THAs
performed for non-traumatic osteoarthritis (OA) or avascular necrosis
(AVN) (n = 98) were used to compare complications and patient-reported outcome
measures (PROMs). Results. The mean time from fracture to THA was significantly shorter
for patients with AVN
(2.2 years) or protrusio (2.2 years) than those with post-traumatic
OA (9.4 years) or infection (8.0 years) (p = 0.03). Nine contained
and four uncontained defects were managed with autograft (n = 11),
bulk allograft (n = 1), or trabecular metal augment (n = 1). Initial
fracture management (open reduction and internal fixation or non-operative),
timing of THA
(>
/<
one year), and age (>
/<
55 years) had no significant
effect on OHS or ten-year survival. Six THAs were revised at mean
of 12 years (5 to 23) with ten-year all-cause survival of 92% (95%
confidence interval 80.8 to 100). THA complication rates (all complications,
heterotopic ossification, leg length discrepancy >
10 mm) were significantly higher
following acetabular fracture compared with atraumatic OA/AVN and
OHSs were inferior: one-year OHS
(35.7 versus 40.2, p = 0.026); and final follow-up
OHS (33.6 versus 40.9, p = 0.008). . Conclusion .
Durable humeral component fixation in shoulder arthroplasty is necessary to prevent painful aseptic loosening and resultant humeral bone loss. Causes of humeral component loosening include stem design and material, stem length and geometry, ingrowth vs. ongrowth surfaces, quality of bone available for fixation, glenoid polyethylene debris osteolysis, exclusion of articular particulate debris, joint stability, rotator cuff function, and patient activity levels. Fixation of the humeral component may be achieved by cement fixation either partial or complete and press-fit fixation. During the past two decades, uncemented humeral fixation has become more popular, especially with short stems and stemless press fit designs.
Introduction. Cemented total knee arthroplasty (TKA) remains the gold standard with survivorship above 90% at greater than 10 years postoperatively. However, with younger, heavier, more active patients undergoing TKA at an increasing rate, cementless implants have the appeal of potential for improved implant fixation longevity and decreased rates of aseptic loosening. The cementless implants are more expensive than their cemented counterparts such that implant costs may create a barrier to utilization. However, such comparisons fail to consider the unavoidable additional costs of cementing, including the cost of operating room time, cement and cementing accessories. The purpose of this study is to compare the actual cost of cemented and cementless TKA. Methods. The TKA cost calculation included the cost of operative time, implants, cement and cementing accessories. The difference in operative time between cemented and cementless TKA was determined from a previously published study of 100 TKAs performed using a cemented (55) or press fit (45) implant of the same design performed at a single institution by four fellowship trained arthroplasty surgeons. The decision to use cemented or cementless design in these patients was made based on patient bone quality intraoperatively. Operative time was compared between groups using a Student's two-tailed T-test. The cost of operating room time was based on estimates in the recent literature. The cost of cement and cementing accessories was estimated based on publically available market data. The cost of implants was estimated from institutional data for multiple companies. Results. The cost comparison between cemented and cementless total knee arthroplasty is summarized in Table 1. Mean operative time for cemented TKA was 14.3 minutes longer than for cementless TKA (94.7 + 15.2 vs. 80.4 + 15.7, p<0.01). The estimated cost of one minute of operating room time in the literature ranges from $30 to $60. For our analysis, we used an estimate of $36 per minute obtained from a recently published multi-center study. This resulted in an average operating room time cost $3406 for cemented and $2894 for cementless TKA. Antibiotic cement costs an average of $250 per bag and antibiotic-free cement costs an average of $75 per bag. Cement mixing techniques vary across surgeons. Approximately 95% use a vacuum system and 5% use a mixing bowl. The cost of vacuum systems ranges from $80 for an enclosed bowl to $125 for a vacuum system that can be directly connected to a cement gun. The cost of a plastic mixing bowl and spatula is $20. The cost of the disposables from a cement injection kit is $25. The average cost of a primary TKA implant, including femoral, tibial and polyethylene liner components, is $3530 for cemented and $4659 for cementless designs. Patellar resurfacing is not routinely used at our institution and therefore was not included in implant cost. Based on our calculations, the average cost of a cementless TKA is $7553. Using the cheapest cementing technique with 2 bags of plain cement and a manual mixing bowl with spatula, the cost of a cemented TKA $7114. Using the most expensive cementing technique with 2 bags of antibiotic cement and a cement gun compatible vacuum mixer, the cost of a cemented TKA is $7564. Conclusion.
Background. The acknowledged benefit of the direct anterior (DA) approach is early functional return. Most surgeons in the U.S. use cementless femoral replacement given the negative track record of some cemented designs. However, delayed osseointegration of a femoral stem typically seen in older patients with poor bone quality will delay recovery, diminishing the benefits of the DA approach. Registry studies have shown a higher revision rate and complications in this patient population leading to a renewed interest in cemented fixation. Questions posed. To achieve the functional benefits of the DA approach and the fixation benefits of cemented replacement, this study combined the 2 techniques posing the following questions:1) Does the limited access of the DA approach adversely affect the cement technique? 2) Does such a cementing technique reduce the incidence of cementless complications?. Methods. A consecutive series of 341 patients (360 hips) receiving the DA approach between 2016–2018 were reviewed. There were 203 cementless stems and 157 cemented stems. Mean age was 75 in the cementless group and 76 in the cemented group, 70% females. Femoral complications were compared between the 2 groups using the T-test. Results. The cementless group had a higher rate of femoral complications (8 versus 0, P=0.011). There were 2 loose stems and 6 fractures, all requiring revision. Fractures occurred about 14.5 days and loosening about 10 months postoperatively. Conclusion. A higher rate of complications occurred with cementless stems.
Conventional cemented acetabular components are
reported to have a high rate of failure when implanted into previously
irradiated bone. We recommend the use of a cemented reconstruction
with the addition of an acetabular reinforcement cross to improve
fixation. We reviewed a cohort of 45 patients (49 hips) who had undergone
irradiation of the pelvis and a cemented total hip arthroplasty
(THA) with an acetabular reinforcement cross. All hips had received
a minimum dose of 30 Gray (Gy) to treat a primary nearby tumour
or metastasis. The median dose of radiation was 50 Gy (Q1 to Q3:
45 to 60; mean: 49.57, 32 to 72). . The mean follow-up after THA was 51 months (17 to 137). The cumulative
probability of revision of the acetabular component for a mechanical
reason was 0% (0 to 0%) at 24 months, 2.9% (0.2 to 13.3%) at 60
months and 2.9% (0.2% to 13.3%) at 120 months, respectively. One
hip was revised for mechanical failure and three for infection.
Dislocation remains a leading cause of failure following revision total hip arthroplasty (THA). While dual-mobility (DM) bearings have been shown to mitigate this risk, options are limited when retaining or implanting an uncemented shell without modular DM options. In these circumstances, a monoblock DM cup, designed for cementing, can be cemented into an uncemented acetabular shell. The goal of this study was to describe the implant survival, complications, and radiological outcomes of this construct. We identified 64 patients (65 hips) who had a single-design cemented DM cup cemented into an uncemented acetabular shell during revision THA between 2018 and 2020 at our institution. Cups were cemented into either uncemented cups designed for liner cementing (n = 48; 74%) or retained (n = 17; 26%) acetabular components. Median outer head diameter was 42 mm. Mean age was 69 years (SD 11), mean BMI was 32 kg/m2 (SD 8), and 52% (n = 34) were female. Survival was assessed using Kaplan-Meier methods. Mean follow-up was two years (SD 0.97).Aims
Methods
Total knee replacement (TKA) is one of the most successful procedures in orthopaedic surgery. Although originally limited to more elderly and less active individuals, the inclusion criteria for TKA have changed, with ever younger, more active and heavier patients receiving TKA. This broadening of indications coincided with the widespread adoption of modular cemented and cementless TKA systems in the 1980's, and soon thereafter wear debris related osteolysis and associated prosthetic loosening became major modes of failure for TKA implants of all designs. Initially, tibial components were cemented all polyethylene monoblock constructs. Subsequent long-term follow-up studies of some of these implant designs have demonstrated excellent durability in survivorship studies out to twenty years. While aseptic loosening of these all polyethylene tibial components was a leading cause of failure in these implants, major polyethylene wear-related osteolysis around well-fixed implants was rarely (if ever) observed.
Introduction.
Polished taper-slip (PTS) cemented stems have an excellent clinical track record and are the most common stem type used in primary total hip arthroplasty (THA) in the UK. Due to low rates of aseptic loosening, they have largely replaced more traditional composite beam (CB) cemented stems. However, there is now emerging evidence from multiple joint registries that PTS stems are associated with higher rates of postoperative periprosthetic femoral fracture (PFF) compared to their CB stem counterparts. The risk of both intraoperative and postoperative PFF remains greater with uncemented stems compared to either of these cemented stem subtypes. PFF continues to be a devastating complication following primary THA and is associated with high complication and mortality rates. Recent efforts have focused on identifying implant-related risk factors for PFF in order to guide preventative strategies, and therefore the purpose of this article is to present the current evidence on the effect of cemented femoral stem design on the risk of PFF. Cite this article:
Periprosthetic fractures (PPFs) following hip arthroplasty are complex injuries. This study evaluates patient demographic characteristics, management, outcomes, and risk factors associated with PPF subtypes over a decade. Using a multicentre collaborative study design, independent of registry data, we identified adults from 29 centres with PPFs around the hip between January 2010 and December 2019. Radiographs were assessed for the Unified Classification System (UCS) grade. Patient and injury characteristics, management, and outcomes were compared between UCS grades. A multinomial logistic regression was performed to estimate relative risk ratios (RRR) of variables on UCS grade.Aims
Methods
Femoral revision in cemented THA might include some technical difficulties, based on loss of bone stock and cement removal, which might lead to further loss of bone stock, inadequate fixation, cortical perforation or consequent fractures.
We performed 88 primary ball-and-socket arthroplasties of the trapeziometacarpal joint in 84 patients (69 women and 15 men) with a mean age of 61 years (37 to 81).
The aim of this retrospective study was to assess the incidence of early periprosthetic femoral fracture (PFF) associated with Charnley-Kerboull (CK) femoral components cemented according to the ‘French paradox’ principles through the Hueter anterior approach (HAA) in patients older than 70 years. From a prospectively collected database, all short CK femoral components implanted consecutively from January 2018 to May 2022 through the HAA in patients older than 70 years were included. Exclusion criteria were age below 70 years, use of cementless femoral component, and approaches other than the HAA. A total of 416 short CK prostheses used by 25 surgeons with various levels of experience were included. All patients had a minimum of one-year follow-up, with a mean of 2.6 years (SD 1.1). The mean age was 77.4 years (70 to 95) and the mean BMI was 25.3 kg/m2 (18.4 to 43). Femoral anatomy was classified according to Dorr. The measured parameters included canal flare index, morphological cortical index, canal-calcar ratio, ilium-ischial ratio, and anterior superior iliac spine to greater trochanter (GT) distance.Aims
Methods
The aim of this study was to report the three-year follow-up for a series of 400 patients with a displaced intracapsular fracture of the hip, who were randomized to be treated with either a cemented polished tapered hemiarthroplasty or an uncemented hydroxyapatite-coated hemiarthroplasty. The mean age of the patients was 85 years (58 to 102) and 273 (68%) were female. Follow-up was undertaken by a nurse who was blinded to the hemiarthroplasty that was used, at intervals for up to three years from surgery. The short-term follow-up of these patients at a mean of one year has previously been reported.Aims
Methods
Restoration of an anatomical hip centre frequently requires limb lengthening, which increases the risk of nerve injury in the treatment of Crowe 4 DDH. The objective was to perform a prospective evaluation of SDTSO with
Cementless total knee arthroplasty (TKA) offers a number of conceptual benefits including osteointegration, bone preservation and reduced aseptic loosening from third body wear. Evidence of equivalence to cemented fixation exists, but the cam-post interaction of posterior-stabilised (PS)-TKA on implant osteointegration remains uncertain. This study aims to assess the survivorship of a single prosthesis PS-TKA. All patients undergoing a PS-TKA using the Triathlon Total Knee System (Stryker Orthopaedics, USA) between 01/01/2010 and 08/04/2019, with exposure to at least 2 years’ risk of revision were identified from the hospital database.Abstract
Introduction
Methodology
Introduction: The best method of management of displaced intracapsular femoral neck fractures in elderly patients remains undecided. Most are treated by hemiarthroplasty. Aim: To clarify the issue of whether or not to use cement in hemiarthroplasty for displaced, intracapsular, femoral neck fractures in the elderly. Methods: Consecutive patients with displaced, intracapsular, femoral neck fractures treated by hemiarthroplasty between January 1997 and May 1998, in two hospitals within one region were reviewed. The same monoblock prosthesis was used; in Hospital A they were uncemented (121 patients), and in Hospital B they were cemented (123 patients). All surviving patients (50 and 56 respectively) were interviewed for assessments of pre-fracture and current pain, walking ability, use of walking aids and activities of daily living (ADL), using validated scoring systems. The average follow-up was 36 months. Results: The patients’ demographical data were similar (the mean age was 82 and 84 years respectively). There was no greater incidence of intra-operative fall in diastolic blood pressure or oxygen saturation in the cemented group.
The use of a cemented implant instead of a spacer has been proposed due to the improved function in comparison with a spacer. Unfortunately the removal of a conventional cemented stem can be challenging. The use of a short cemented stem can overcome this problem. Between July 2011 and May 2013, 10 infected hips were treated with a short cemented stem as a spacer. The infected implants were cemented in 6 cases and cementless in 4 cases. Mean time from index operation was 3 years (range 0 to 8 years). It was the first treatment for infection in all cases. Antibiotic loaded cement and an all-poly cup was used in all cases. The bugs were staph aureus and staph epidermidis in most cases. A Friendly short cemented stem with specific cement restrictor and standard cementing tecnique was used in all cases. This stem has been successfully tested in over 200 patients and approved by TUV to be released on the marked. In all cases, the infection was successfully cured with antibiotics for a period ranging from 3 to 5 months. 2 patients were revised after the infection was cured for recurrent dislocation. No recurrent infection was found at the latest follow up. One stage revision is gaining in popularity for the decreased morbidity and better quality of life of the patients. Weak points of one-stage revision are slightly inferior results in terms of eradication of the infection and the fact that it can be done only with cemented implants.
Total knee replacement (TKR) is one of the most successful procedures in orthopaedic surgery. Although originally limited to more elderly and less active individuals, the inclusion criteria for TKR have changed, with ever younger, more active and heavier patients receiving TKR. Currently, wear debris related osteolysis and associated prosthetic loosening are major modes of failure for TKR implants of all designs. Initially, tibial components were cemented all polyethylene monoblock constructs. Subsequent long-term follow-up studies of these implants have demonstrated excellent durability in survivorship studies out to twenty years. Aseptic loosening of the tibial component was one of the main causes of failure in these implants.
The alumina on alumina articulation in THA has induced less macrophage reaction and cytokine section than polyethylene bearings. Thus THA using alumina on almina articulation has induced little periprosthetic osteolysis. However alumina fracture is still a concern. We had underwent 100 THAs that it was a cemented polyethylene backed acetabular component with an alumina inlay(ABS Cup; Kyocera, Kyoto, Japan), PHS stem(Kyocera) and 28mm alumina femoral head. This system was formerly used in only Japan, over 10 years results have not reported yet. We retrospectively reviewed 94 patients(100 hips) with cemented alumina on alumina THAs to identify factors relating to alumina failure, and to evaluate mid-term(>10years) results. 16 patients died from unrelated causes within 10 years of the operation and 14 patients was lost to follow up. The remaining 70 patients(79 Hips) were evaluated after a mean follow-up of 10 years. We performed clinical evaluation using the JOA score, and radiological evaluation was performed that inclination and anteversion angle of cup measurement with 2D template system at anteroposterior radiograph. On the radiographs at the final examination, radiolucency and osteolysis were evaluated around the acetabular component, and around the femoral component. These evaluations were scheduled for 3,6,9, and 12 months and yearly thereafter. All the operations were performed by same surgeon, at same center. Cumulative survival rates were calculated using the Kaplan-Meier method with failure defined as the end point of revision for alumina failure or for any reason. To compare groups with and without alumina failures in age, BMI, gender, activity, function, abduction angle, size of component, or existence of radiolucent lines, we used the nonparametric Mann-Whitney U-test. The mean age of the patients at surgery was 63.0 years. The mean follow up term was 13.8 years. Inclination and anteversion mean angle of cup were 45.6°and 14.2°.ã��Revision surgery was performed because of alumina inlay failure in 4hips(2 fractures and 2 dissociation;5.1%), loosening in 2 hips(2 cup loosenings; 2.5%) recurrent dislocation in 1 hip, and femoral fracture in 1 hip, no deep infection and DVT. The 10-year survival rate was 92.4% with revision for any reason and 95.9% with revision for alumina failure as the end point. We detected 3 ceramic failures at a mean of 8.9 years(4.1ï¼ï¿½12.5) after the index operation. There were no differences in BMI, function, cup angles(inclination and anteversion), and cup loosening among the 4hips with alumina failure. But there were differences in age, gender, and activity with alumina failure. This alumina on alumina THA yielded passably mid-term results, but it was occurred a high rate of catastrophic alumina inlay failure. In July 2000, we discontinued use of this type of THA to avoid alumina failure. This ABS cup was banned in 2002, because of numerous alumina failures. We suggest all patients with this type of acetabular component be followed carefully.
Introduction: Restoration of an anatomical hip centre frequently requires limb lengthening, which increases the risk of nerve injury in the treatment of Crowe 4 DDH. Objective: Prospective evaluation of SDTSO with
The best management of displaced intracapsular femoral neck fractures in the elderly remains undecided. Most are treated by hemiarthroplasty. The aim of this study was to establish whether the advantages of cement outweigh the disadvantages. All patients with displaced intracapsular femoral neck fractures treated with herniarthroplasty between January 1997 and May 1998, in 2 hospitals within the same Deanery, were reviewed. The same prosthesis was used, but in hospital A they were uncemented, and in B cemented. There were 122 patients in hospital A and 123 in B. We conducted a detailed retrospective analysis of hospital notes. All surviving patients (50 and 56 respectively) were interviewed to obtain pre-fracture and current scores of pain, walking ability, use of walking aids, activities of daily living (ADL) and accommodation status, using validated scoring systems. The relative deterioration over the follow-up period (32–36 months) was determined and the groups compared. Patient demographics confirmed comparability of groups. There was no greater incidence of intra-operative fall in diastolic blood pressure, or oxygen saturation in the cemented group.
The purposes of this study were to report the accuracy of stem anteversion for Exeter cemented stems with the Mako hip enhanced mode and to compare it to Accolade cementless stems. We reviewed the data of 25 hips in 20 patients who underwent THA through the posterior approach with Exeter stems and 25 hips in 19 patients with Accolade stems were matched for age, gender, height, weight, disease, and approaches. There was no difference in the target stem anteversion (20°–30°) between the groups. Two weeks after surgery, CT images were taken to measure stem anteversion. The difference in stem anteversion between the plan and the postoperative CT measurements was 1.2° ± 3.8° (SD) on average with cemented stems and 4.2° ± 4.2° with cementless stems, respectively (P <0.05). The difference in stem anteversion between the intraoperative measurements and the postoperative CT measurements was 0.75° ± 1.8° with Exeter stems and 2.2° ± 2.3° with Accolade stems, respectively (P <0.05). This study demonstrated a high precision of anteversion for Exeter cemented stems with the Mako enhanced mode and its clinical accuracy was better with the cemented stems than that with the cementless stems. Although intraoperative stem anteversion measurements with the Mako system were more accurate with the cemented stems than that with the cementless stem, the difference was about 1° and the accuracy of intra-operative anteversion measurements was quite high even with the cementless stems. The smaller difference in stem anteversion between the plan and postoperative measurements with the cemented stems suggested that stem anteversion control was easier with cemented stems under the Mako enhanced mode than that with cementless stems. Intraoperative stem anteversion measurement with Mako total hip enhanced mode was accurate and it was useful in controlling cemented stem anteversion to the target angle.
Introduction and Aims:
Introduction: The information in the literature about the relative merits of cemented and cementless unicompartmental knee replacement (UKR) is contradictory, with some favouring cementless fixation while others favouring cemented fixation.
Joint registries suggest a downward trend in the use of uncemented Total Knee Replacements (TKR) since 2003, largely related to reports of early failures of uncemented tibial and patella components. Advancements in uncemented design such as trabecular metal may improve outcomes, but there is a scarcity of high-quality data from randomised trials. 319 patients <75 years of age were randomised to either cemented or uncemented TKR implanted using computer navigation. Patellae were resurfaced in all patients. Patient outcome scores, re-operations and radiographic analysis of radiolucent lines were compared. Two year follow up was available for 287 patients (144 cemented vs 143 uncemented). There was no difference in operative time between groups, 73.7 v 71.1 mins (p= 0.08). There were no statistical differences in outcome scores at 2 years, Oxford knee score 42.5 vs 41.8 (p=0.35), International Knee Society 84.6 vs 84.0 (p=0.76), Forgotten Joint Score 66.7 vs 66.4 (p=0.91). There were two revisions, both for infection one in each group (0.33%). 13 cemented and 8 uncemented knees underwent re-operation, the majority of these being manipulation under anaesthetic (85.7%), with no difference (8.3% vs 5.3%, 95% CI -2.81% to 8.89%, p = 0.31). No difference was found in radiographic analysis at 2 years, 1 lucent line was seen in the cemented group and 3 in the uncemented group (0.67% v 2.09%, 95%CI -4.1% to 1.24%, p = 0.29). We found no difference in clinical or radiographic outcomes between cemented and uncemented TKR including routine patella resurfacing at two years. Early results suggest there is no difference between cemented and uncemented TKR at 2 years with reference to survivorship, patient outcomes and radiological parameters.
Periprosthetic femoral fracture (PFF) following primary total hip arthroplasty (THA) is of raising concern with the aging of the population. The aim of this retrospective study was to assess the incidence of early PFF associated with Charnley- Kerboull (CK) stems cemented line-to-line according to the “French paradox” principles through the anterior approach (AA) in patients older than 70 years old. This monocentric study involved 25 surgeons with various level of experience. From a prospectively collected database, all CK stems (AmisK®, Medacta, Castel San Pietro, Switzerland) done consecutively from January 2018 to May 2022 through the AA in patients older than 70 years were included. The measured parameters included canal flare index (CFI), morphological cortical index (MCI), canal-calcar ratio (CCR), ilium-ischial ratio (IIR), ilium overhang, and anterior superior iliac spine (ASIS) to greater trochanter distance. Dorr classification was also recorded. A total of 416 CK stems performed by 25 surgeons were included. All patients had a minimal 3-month follow-up. The mean age was 77.4 years, and the mean BMI was 25.3 kg/m2. According to the Dorr classification 240 hips were of Dorr type A, 144 Dorr type B, and 2 Dorr type C. Mean CFI, MCI, CCR, IIR and ASIS-GT were 3.8, 0.5, 2.8, 2.5, and 101mm, respectively. Amongst the 416 THAs, one (0.24%; 95% CI 0.20 – 0.28%) early PFF Vancouver type B2 fracture that occurred 24 days postoperatively was observed. This study demonstrated that CK stems cemented according to the “French Paradox” were associated with an extremely low rate of early PFF in patients over 70 years. The observed results are better than those reported with uncemented or taper slip cemented stems. Longer follow-up is warranted to evaluate further rate of fracture that may occur during the bone remodeling process around the femoral component.
Introduction. Humeral radiolucent lines after anatomic TSA (aTSA) have been well described; however, little clinical consequences have been attributed to them. The recent emergence of shorter humeral stems has demonstrated higher incidences of humeral radiolucencies than has been reported historically with standard length components. This large scale database analysis quantifies and compares the clinical outcomes of aTSAs with and without radiolucent humeral lines using one specific prosthesis to determine their impact on clinical outcomes. Methodology. This is a multicenter, retrospective, case controlled radiographic and clinical review. Preoperative and postoperative data was analyzed from 671 aTSA patients with a minimum of 2 years followup. 538 of these 671 aTSA patients had full radiographic followup (80.2%) and were included in this study; these patients had an average followup of 45.3 months). 459 patients had noncemented humeral stems; whereas, 79 patients had cemented humeral stems. Radiographs were reviewed at latest follow up for humeral radiolucent lines based on the technique described by Gruen et al. Patients were evaluated and scored pre-operatively and at latest follow-up using the SST, UCLA, ASES, Constant, and SPADI scoring metrics; ROM was also recorded. A Student's two-tailed, unpaired t-test was used to identify differences in pre-operative, post-operative, and improvement in results, where p<0.05 denoted a significant difference. Results. All patients demonstrated significant improvements in pain and function following treatment with the primary shoulder arthroplasty. 14 patients (8 female, avg: 65.6 yrs; 6 male, avg: 61.7 yrs) were observed to have radiolucent lines around the humeral component (2.6%). The rate of humeral radiolucent lines was observed to be significantly higher in patients with cemented (7.6%) vs. noncemented (1.7%) humeral stems (p = 0.0025). Pre-operatively, no difference was noted in any clinical metric score between patients with or without radiolucent humeral lines. (Figure 1) However post-operatively, patients with radiolucent humeral lines had significantly worse ASES (p=0.0087), UCLA (p=0.0371), SST (p=0.0341), and SPADI (p=0.0051) scores (Figure 2) and significantly lower improvements in outcomes according to ASES (p=0.0120) and SPADI (p=0.0247) scores (Figure 3), relative to patients without radiolucent humeral lines. Additionally, radiolucent lines had a more profound effect on cemented stems (as compared to noncemented stems), where cemented stems with radiolucent humeral liners were associated with significantly lower post-operative outcomes and significantly lower improvements in outcomes. Finally, patients with humeral radiolucent lines had a significantly higher complication rate (21.4% vs 4.6%, p = 0.004) as compared to the complication rate of patients without radiolucent humeral lines. Conclusions. The study demonstrated a relatively low incidence of humeral radiolucent lines with anatomic TSA.
Introduction:
The optimal method of fixation for primary total hip replacements (THR), particularly fixation with or without the use of cement is still controversial. In a systematic review and meta-analysis of all randomized controlled trials (RCT) comparing cemented versus uncemented THRS available in the published literature, we found that there is no significant difference between cemented and uncemented THRs in terms implant survival as measured by the revision rate. Better short-term clinical outcome, particularly an improved pain score can be obtained with cemented fixation. However, the results are unclear for the long-term clinical and functional outcome between the two groups. No difference was evident in the mortality and the post operative complication rate. On the other hand, the Radiographic findings were variable and do not seem to correlate with clinical findings as differences in the surgical technique and prosthesis design might be associated with the incidence of osteolysis. We concluded in our review that
Aim: To clarify the issue of whether or not to cement the hemiarthroplasty in the treatment of displaced intra-capsular femoral neck fractures in the elderly. Method: All patients with displaced intracapsular femoral neck fractures treated with hemiarthroplasty between January 1997 and May 1998, in 2 hospitals within the same Deanery, were reviewed. The same prosthesis was used; in hospital A they were uncemented, and in B cemented. There were 121 patients in hospital A and 123 in hospital B; all patients alive at follow-up (50 and 56 respectively) were interviewed for pre-fracture and current assessments of pain and functional ability using validated scoring systems. Follow-up was 32–36 months. Results: Patient demographics were similar.
Stemmed tibial components are frequently used in revision total knee arthroplasty (TKA). The purpose of this study was to evaluate patient satisfaction, overall pain, and diaphyseal tibial pain in patients who underwent revision TKA with cemented or uncemented stemmed tibial components. This is a retrospective cohort study involving 110 patients with revision TKA with cemented versus uncemented stemmed tibial components. Patients who underwent revision TKA with stemmed tibial components over a 15-year period at a single institution with at least two-year follow-up were assessed. Pain was evaluated through postal surveys. There were 63 patients with cemented tibial stems and 47 with uncemented stems. Radiographs and Knee Society Scores were used to evaluate for objective findings associated with pain or patient dissatisfaction. Postal surveys were analyzed using Fisher’s exact test and the independent-samples Aims
Methods
Introduction. Severe osteolysis of the femur secondary to aseptic loosening in hip arthroplasty, remains a difficult revision scenario. Multiple techniques have been developed to aid the surgeon, including restoration of bone stock with impaction bone grafting or strut allografts, various distal fixation prostheses and mega-prostheses. Cemented femoral components, with integration of the cement into the cavitations, has largely fallen out of favour. We examined the long-term outcomes with this technique. Patients/Materials & Methods. Between 1977 and 1990, 109 patients had a cemented stem revision (without bone grafting) for severe femoral osteolysis in the absence of infection. Severe osteolysis was defined as cavitation in a minimum of 4 Gruen zones. Follow-up included functional scoring, radiological assessment and any complications. Further revision and survivorship analysis for stem failure or aseptic loosening of the femoral component were recorded. Results. 109 patients (117 hips) were reviewed with an average age of 65.4years (range 31–82). 39 patients had five zone involvement, 25 had six zone involvement and in 13 patients all seven zones were affected. 17 patients had an isolated stem revision, 100 patients had both components revised. Post-operative complications during the entire follow-up period were 7 dislocations, 10 trochanteric non-unions, 2 periprosthetic fractures and no infections. Only 9 patients had further revision of the femoral stem, 8 for aseptic loosening and 1 for stem fracture. In addition, re-revision procedures were performed for aseptic loosening of the cup (8 procedures) and dislocation (2 procedures). Analysis for stem revision demonstrated 91.17% survival at 12 years (minimum 40 hips at risk). Conclusion.
ZrN-multilayer coating is clinically well established in total knee arthroplasty [1-3] and has demonstrated significant reduction in polyethylene wear and metal ion release [4,5]. The goal of our study was to analyze the biotribological behaviour of the ZrN-multilayer coating on a polished cobalt-chromium cemented hip stem. CoCr28Mo6 alloy hip stems with ZrN-multilayer coating (CoreHip®AS) were tested versus an un-coated version. In a worst-case-scenario the stems with ceramic heads have been tested in bovine serum in a severe cement interface debonding condition under a cyclic load of 3,875 N for 15 million cycles. After 1, 3, 5, 10 & 15 million cycles the surface texture was analysed by scanning-electron-microscopy (SEM) and energy-dispersive x-ray (EDX). Metal ion concentration of Co,Cr,Mo was measured by inductively coupled plasma mass spectroscopy (ICP-MS) after each test interval. Based on SEM/EDX analysis, it has been demonstrated that the ZrN-multilayer coating keeps his integrity over 15 million cycles of severe stem cemented interface debonding without any exposure of the CoCr28Mo6 substrate. The ZrN-multilayer coated polished cobalt-chromium cemented hip stem has shown a reduction of Co & Cr metal ion release by two orders of a magnitude, even under severe stem debonding and high interface micro-motion conditions. ZrN-multilayer coating on polished cobalt-chromium cemented hip stems might be a suitable option for further minimisation of Co & Cr metal ion release in total hip arthroplasty. Clinical evidence has to be proven during the next years.
Aim of this study was to identify reoperation rates in patients with short oblique and transverse fractures around a well fixed cemented polished taper slip stem and to determine any associations with treatment failure. Retrospective cohort study of 31 patients with AO transverse or short oblique Vancouver B1 PFFs around THA (total hip arthroplasty) cemented taper slip stems: 12 male (39%); mean age 74±11.9 (range 44–91); mean BMI 28.5±1.4 (range 16–48); and median ASA 3. Patient journeys were assessed, re-interventions reviewed. The primary outcome measure was reoperation. Time from primary THA to fracture was 11.3±7.8yrs (0.5–26yrs). Primary surgical management was fixation in 27/31 and rTHA (revision total hip arthroplasty) in 4/31. 10 of 31 (32%) patients required reoperation, 9 within 2 years of fracture: 1 following rTHA and 8 following ORIF. The commonest mode of failure was non-union (n=6). No significant associations with reoperation requirement were identified. Kaplan-Meier free from reoperation was 67.4% (49.8–85.0 95% CI) at 2 years and this was unaffected by initial management with ORIF or rTHA (Log rank 0.898). Of those reoperated, 6/10 required multiple reoperations to obtain either bony union or a stable revision construct and 13% ultimately required proximal femoral endoprostheses. The relative risk of 1 year mortality was 1.6 (0.25 to 10.1 95%CI) among patients who required reoperation compared to those who did not. These are difficult fractures to manage, should not be underestimated and patients should be counselled that there is a 30% risk of reoperation and 20% of requiring multiple reoperations.
Studies have shown that 10–30% patients do not achieve optimal function outcomes after total hip replacement (THR). High quality randomised controlled trials (RCTs) evaluating the clinical and cost-effectiveness of techniques to improve functional outcomes after THR are lacking. We performed this study to evaluate the feasibility of a RCT comparing patient-reported functional outcomes after hybrid or fully cemented THR (ISRCTN11097021). Patients were recruited from two centres and randomised to receive either a fully cemented or hybrid THR. Data collection included Patient Reported Outcome Measures (PROMs), non-serious adverse events of special interest (AESI), serious adverse device effects (SADE) and NHS resource use. Qualitative interviews were undertaken to understand a) patient experiences of study processes and their reasons for taking part or not, and b) to understand surgeons’ perceptions of the study, factors affecting willingness to participate, and barriers to implementation of the future RCT findings. The target of 40 patients were successfully recruited for the feasibility RCT; the ratio of successful recruitment to eligible patients was 0.61 across both sites. Treatment crossovers occurred in four patients, all related to bone quality. Four patients were withdrawn due to not undergoing surgery within the study window because of the pandemic. Follow-up was 100% and PROMs were completed by all patients at all time points. The feasibility of conducting a within-trial cost-utility analysis was demonstrated. Interviews were conducted with 27 patients and 16 surgeons. Patients and surgeons generally found the study procedures acceptable and workable. Some declined participation because they did not want treatment allocated at random, or because blinding was off-putting. Surgeons’ perceptions of equipoise varied, and implementation of findings from the future RCT would need to recognise the ‘craft’ nature of surgery and the issue of training. We conclude that a full RCT with economic analysis will be both feasible and practicable, although mechanisms to safely implement potential changes to practice because of RCT findings may need consideration by the wider arthroplasty community.
Recent registry data from around the world has strongly suggested that using cemented hip hemiarthroplasty has lower revision rates compared to cementless hip hemiarthroplasty for acute femoral neck hip fractures. The adoption of using cemented hemiarthroplasty for hip fracture has been slow as many surgeons continue to use uncemented stems. One of the reasons is that surgeons feel more comfortable with uncemented hemiarthroplasty as they have used it routinely. The purpose of this study is to compare the difference in revision rates of cemented and cementless hemiarthroplasty and stratify the risk by surgeon experience. By using a surgeons annual volume of Total Hip Replacements performed as an indicator for surgeon experience. The Canadian Joint Replacement Registry Database was used to collect and compare the outcomes to report on the revision rates based on surgeon volume. This is a large Canadian Registry Study where 68447 patients were identified for having a hip hemiarthroplasty from 2012-2020. This is a retrospective cohort study, identifying patients that had cementless or cemented hip hemiarthroplasty. The surgeons who performed the procedures were linked to the procedure Total Hip Replacement. Individuals were categorized as experienced hip surgeons or not based on whether they performed 50 hip replacements a year. Identifying high volume surgeon (>50 cases/year) and low volume (<50 cases/year) surgeons. Hazard ratios adjusted for age and sex were performed for risk of revision over this 8-year span. A p-value <0.05 was deemed significant. For high volume surgeons, cementless fixation had a higher revision risk than cemented fixation, HR 1.29 (1.05-1.56), p=0.017. This pattern was similar for low volume surgeons, with cementless fixation having a higher revision risk than cemented fixation, HR 1.37 (1.11-1.70) p=0.004 We could not detect a difference in revision risk for cemented fixation between low volume and high volume surgeons; at 0-1.5 years the HR was 0.96 (0.72-1.28) p=0.786, and at 1.5+ years the HR was 1.61 (0.83-3.11) p=0.159. Similarly, we could not detect a difference in revision risk for cementless fixation between low volume and high volume surgeons, HR 1.11 (0.96-1.29) p=0.161 Using large registry data, cemented hip hemiarthroplasty has a significant lower revision rate than the use of cementless stems even when surgeons are stratified to high and low volume. Low volume surgeons who use uncemented prostheses have the highest rate of revision. The low volume hip surgeon who cements has a lower revision rate than the high volume cementless surgeon. The results of this study should help to guide surgeons that no matter the level of experience, using a cemented hip hemiarthroplasty for acute femoral neck fracture is the safest option. That high volume surgeons who perform cementless hemiarthroplasty are not immune to having revisions due to their technique. Increased training and education should be offered to surgeons to improve comfort when using this technique.
Recent registry data from around the world has strongly suggested that using cemented hip hemiarthroplasty has lower revision rates compared to cementless hip hemiarthroplasty for acute femoral neck hip fractures. The adoption of using cemented hemiarthroplasty for hip fracture has been slow as many surgeons continue to use uncemented stems. One of the reasons is that surgeons feel more comfortable with uncemented hemiarthroplasty as they have used it routinely. The purpose of this study is to compare the difference in revision rates of cemented and cementless hemiarthroplasty and stratify the risk by surgeon experience. By using a surgeons annual volume of Total Hip Replacements performed as an indicator for surgeon experience. The Canadian Joint Replacement Registry Database was used to collect and compare the outcomes to report on the revision rates based on surgeon volume. This is a large Canadian Registry Study where 68447 patients were identified for having a hip hemiarthroplasty from 2012-2020. This is a retrospective cohort study, identifying patients that had cementless or cemented hip hemiarthroplasty. The surgeons who performed the procedures were linked to the procedure Total Hip Replacement. Individuals were categorized as experienced hip surgeons or not based on whether they performed 50 hip replacements a year. Identifying high volume surgeon (>50 cases/year) and low volume (<50 cases/year) surgeons. Hazard ratios adjusted for age and sex were performed for risk of revision over this 8-year span. A p-value <0.05 was deemed significant. For high volume surgeons, cementless fixation had a higher revision risk than cemented fixation, HR 1.29 (1.05-1.56), p=0.017. This pattern was similar for low volume surgeons, with cementless fixation having a higher revision risk than cemented fixation, HR 1.37 (1.11-1.70) p=0.004 We could not detect a difference in revision risk for cemented fixation between low volume and high volume surgeons; at 0-1.5 years the HR was 0.96 (0.72-1.28) p=0.786, and at 1.5+ years the HR was 1.61 (0.83-3.11) p=0.159. Similarly, we could not detect a difference in revision risk for cementless fixation between low volume and high volume surgeons, HR 1.11 (0.96-1.29) p=0.161 Using large registry data, cemented hip hemiarthroplasty has a significant lower revision rate than the use of cementless stems even when surgeons are stratified to high and low volume. Low volume surgeons who use uncemented prostheses have the highest rate of revision. The low volume hip surgeon who cements has a lower revision rate than the high volume cementless surgeon. The results of this study should help to guide surgeons that no matter the level of experience, using a cemented hip hemiarthroplasty for acute femoral neck fracture is the safest option. That high volume surgeons who perform cementless hemiarthroplasty are not immune to having revisions due to their technique. Increased training and education should be offered to surgeons to improve comfort when using this technique.
“Get It Right First Time” (GIRFT) and NHS England’s Best Practice Tariff (BPT) have published directives advising that patients over the ages of 65 (GIRFT) and 69 years (BPT) receiving total hip arthroplasty (THA) should receive cemented implants and have brought in financial penalties if this policy is not observed. Despite this, worldwide, uncemented component use has increased, a situation described as a ‘paradox’. GIRFT and BPT do, however, acknowledge more data are required to support this edict with current policies based on the National Joint Registry survivorship and implant costs. This study compares THA outcomes for over 1,000 uncemented Corail/Pinnacle constructs used in all age groups/patient frailty, under one surgeon, with identical pre- and postoperative pathways over a nine-year period with mean follow-up of five years and two months (range: nine months to nine years and nine months). Implant information, survivorship, and regular postoperative Oxford Hip Scores (OHS) were collected and two comparisons undertaken: a comparison of those aged over 65 years with those 65 and under and a second comparison of those aged 70 years and over with those aged under 70.Aims
Methods
Micromotion of the polyethylene (PE) inlay may contribute to backside PE wear in addition to articulate wear of total knee arthroplasty (TKA). Using radiostereometric analysis (RSA) with tantalum beads in the PE inlay, we evaluated PE micromotion and its relationship to PE wear. A total of 23 patients with a mean age of 83 years (77 to 91), were available from a RSA study on cemented TKA with Maxim tibial components (Zimmer Biomet). PE inlay migration, PE wear, tibial component migration, and the anatomical knee axis were evaluated on weightbearing stereoradiographs. PE inlay wear was measured as the deepest penetration of the femoral component into the PE inlay.Aims
Methods
To achieve the functional benefits of the direct anterior (DA) approach and the fixation benefits of cemented replacement, this study combined the two techniques posing the following questions: does the limited access of the DA approach adversely affect the cement technique?; and does such a cementing technique reduce the incidence of cementless complications? A consecutive series of 341 patients (360 hips) receiving the DA approach between 2016 and 2018 were reviewed. There were 203 cementless stems and 157 cemented stems. Mean age was 75 years (70 to 86) in the cementless group and 76 years (52 to 94) in the cemented group, with 239 (70%) females in the whole series. Femoral complications were compared between the two groups. Mean follow-up was 1.5 years (0.1 to 4.4) for patients in the cementless group and 1.3 years (0.0 to 3.9) for patients in the cemented group.Aims
Methods
To compare long-term survival of all-cemented and hybrid total hip arthroplasty (THA) using the Exeter Universal stem. Details of 1,086 THAs performed between 1999 and 2005 using the Exeter stem and either a cemented (632) or uncemented acetabular component (454) were collected from local records and the New Zealand Joint Registry. A competing risks regression survival analysis was performed with death as the competing risk with adjustments made for age, sex, approach, and bearing.Aims
Methods
The aim of the study was to report the survival of open reduction and internal fixation (ORIF) of Vancouver B fractures associated with the Exeter Stem (ES) at a minimum of 5 years. This retrospective cohort study assessed 129 consecutive patients with Vancouver B type fractures treated with ORIF from 2008-2016 at a minimum of 5 years. Patient records were examined, and the following recorded: details of primary prosthesis, details of injury, Vancouver classification, details of operative management, complications, and requirement for reoperation. Data was analysed using SPSS. Survival analysis was undertaken using the endpoint ‘reoperation for any reason’. Mean age at fracture was 78.2 (SD10.6, 46-96) and 54 (43%) were female. Vancouver subclassifications were: 24% B1, 70.5% B2 and 5.5% B3. For all Vancouver B fractures, Kaplan Meier analysis demonstrated a 5 year survival free from reoperation of 88.8% (82.0-94.7 95%CI). Fourteen patients required reoperation, most commonly within the first year for non-union and plate fracture (5.4%). Five-year survival for any reoperation differed significantly according to fracture type (p=0.016) and was worst in B1s: B1 76.6% (61.3-91.9); B2 92.6% 986.9-98.3); and 100% of B3. Univariate analysis identified B1 type (p=0.008) and a transverse fracture pattern (p=0.003) to be significantly associated with the need for reoperation. Adopting a strategy of fixation of all Vancouver B fractures involving the ES where the fracture was anatomically reducible and the bone cement interface was well-fixed was associated with a 5 year survival, free from reoperation of 88.8%.
The demand for revision total knee arthroplasty (TKA) has grown significantly in recent years. The two major fixation methods for stems in revision TKA include cemented and ‘hybrid’ fixation. We explore the optimal fixation method using data from recent, well-designed comparative studies. We performed a systematic review of comparative studies published within the last 10 years with a minimum follow-up of 24 months. To allow for missing data, a random-effects meta-analysis of all available cases was performed. The odds ratio (OR) for the relevant outcome was calculated with 95% confidence intervals. The effects of small studies were analyzed using a funnel plot, and asymmetry was assessed using Egger's test. The primary outcome measure was all-cause failure. Secondary outcome measures included all-cause revision, aseptic revision and radiographic failure. There was a significantly lower failure rate for hybrid stems when compared to cemented stems (p = 0.006) (OR 0.61, 95% CI 0.42-0.87). Heterogeneity was 4.3% and insignificant (p = 0.39). There was a trend toward superior hybrid performance for all other outcome measures including all-cause re-revision, aseptic re-revision and radiographic failure. Recent evidence suggests a significantly lower failure rate for hybrid stems in revision TKA. There is also a trend favoring the use of hybrid stems for all outcome variables assessed in this study. This is the first time a significant difference in outcome has been demonstrated through systematic review of these two modes of stem fixation. We therefore recommend the use, where possible, of hybrid stems in revision TKA.
Purpose: The purpose of this retrospective study was to evaluate at minimal 5 years follow-up outcome in a consecutive series of total hip arthroplasties implanted for fracture of the acetabulum. Material and methods: The series included 53 arthroplasties implanted between January 1980 and December 1995 in 53 patients, 16 women and 37 men, mean age 53.1 years (24–84). The initial fracture involved the acetabular wall in 18 patients, one column in seven and two columns in six. It was a complex fracture in eleven cases and classification was unknown in the eleven other hips. Orthopaedic treatment was used for 23 patients and surgery for 30. Mean time between fracture and arthroplasty was 16.4±10.8 years.
Introduction: The purpose of this study was to review the results of revision total hip replacement, using cement, done by a single surgeon in a tertiary referral centre. 164 patients underwent revision hip surgery for aseptic loosening, infection or recurrent dislocation. Methods: 95 patients had a one stage revision, 25 patients had two stage revisions and the remainder had either the stem or socket revised. 10 patients had application of a PLAD for recurrent dislocation. Structural and morselized bone grafting was carried out in patients with extensive bone loss. 46 patients had morselized impaction bone grafting to the acetabulum. The first hundred patients with revision of both components and minimum follow up of twelve months were reviewed. Patients were routinely followed up in the clinic and assessed using the Oxford Hip Score and Merle D’Abigne scores for pain, function and range of movements. Radiographs were assessed for any demarcation or loosening. Results: The mean age at surgery was 69.99 years (36ys to 95yrs). The mean follow up was 25 months (12 to 60 months). There were 5 dislocations, 2 wound dehiscence, 3 DVT’s and 2 deep infections in the whole group. There were 2 dislocations, 2 DVT, 1 wound dehiscence and 1 infection in the study group. The preoperative scores were available for 83 patients and the average scores for pain, function and range of movements were 3.2, 2.8 and 1.6 respectively. The average scores at the latest follow up were 5.08, 4.2 and 4.0. The mean Oxford Hip scores were 26.65. X-rays showed no demarcation in the acetabulum in 88 patients and in the femur in 92 patients. The trochanter was united in 72 patients. In 13 patients the trochanter had migrated more than 1 cm. Conclusion: Revision total hip replacement using cement has shown good results in the short term.
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. Fixation remains a challenge in Revision TKR. Irregular and cavitary bone loss may precludeproper metaphyseal cementation and pressurization. Metaphyseal sleeves have been proposed to improve theinherent rotational stability of the implant bone interface. The goal of this study was to assess the effect of the use of metaphyseal sleeves on the quality of the cement fixation achieved. Methods. Fifty consecutive revision TKRs for AORI type 2 and 3 bone loss between January 2005 through January 2008 with average 2 years follow up were assessed retrospectively. Twelve patients were excluded for inadequate follow up. Nineteen patients with 26 cemented metaphyseal sleeves (15 tibiae and 11 femora) formed group 1 and 19 patients with 36 revision components (without metaphyseal sleeves) served as control (group 2). Patients were assessed clinically with knee society scores (KSS) and radiographically by quality of metaphyseal cement mantle and radiolucent lines(RLL). Groups were matched for pre-op bone loss and length of follow-up. Results. The presence of uniform cement mantle was 100% in group 1as opposed to only 70% (25 out of 36) in group 2. Incidence of metaphyseal RLL was 3.8% (1 out of 26 components) in group 1; as opposed to 16.7% (6 out of 36 components) in group 2. The average postoperative knee society and function score in group 1 was 90 and 80 and in group 2 was 88 and 81 respectively at final follow-up. Conclusion.
Paget's disease of bone (PDB) is characterised by increased bone resorption and development of an erratic bone structure that is highly fragile and susceptible to fracture. In addition, altered joint biomechanics lead to arthritis, more often in the hip and pelvis, resulting in disability and a Total hip Arthroplasty (THA) may be required. THA in PDB is associated with more complications compared to normal population. There is no consensus on the type of arthroplasty that performs better in people with PDB. To our knowledge, there is no meta-analysis in literature on this rare problem. We undertook a systematic review and meta-analysis to compare the effectiveness of cemented versus cementless THA in patients with PDB. PRISMA guidelines were followed. Search strings were generated based on Boolean operators for identification of the reference articles. 31 studies were included overall. Revision rate was lower in the cementless group compared to the cemented group (chi square=4.36, p=0.04), aseptic loosening was lesser in the cementless group compared to the cemented group (chi square=4.13, p=0.04). The type of the arthroplasty did not affect the infection rate (chi square=2.51, p=0.11), pre and post op Harris Hip Score showed statistically significant difference, but there was no difference between types of arthroplasty We conclude that THA with uncemented components is better and provided lower revision and aseptic loosening when compared to cemented groups in patients with PDB.
This study aims to implement and assess the inter and intra-reliability of a modernised radiolucency assessment system; the Radiolucency In cemented Stemmed Knee (RISK) arthroplasty classification. Furthermore, we assessed the distribution of regions affected by radiolucency in patients undergoing stemmed cemented knee arthroplasty. Stemmed knee arthroplasty cases over 7-year period at a single institution were retrospectively identified and reviewed. The RISK classification system identifies five zones in the femur and five zones in the tibia in both the anteroposterior (AP) and lateral planes. Post-operative and follow-up radiographs were scored for radiolucency by four blinded reviewers at two distinct time points four weeks apart. Reliability was assessed using the kappa statistic. A heat map was generated to demonstrate the reported regions of radiolucency. 29 cases (63 radiographs) of stemmed knee arthroplasty were examined radiographically using the RISK system. Intra-reliability (0.83) and Inter-reliability (0.80) scores were both consistent with a strong level of agreement using the kappa scoring system. Radiolucency was more commonly associated with the tibial component (76.6%) compared to the femoral component (23.3%), and the tibial anterior-posterior (AP) region 1 (medial plateau) was the most affected (14.9%). The RISK classification system is a reliable assessment tool for evaluating radiolucency around stemmed knee arthroplasty using defined zones on both AP and lateral radiographs. Zones of radiolucency identified in this study may be relevant to implant survival and corresponded well with zones of fixation, which may help inform future research.
The Oxford Unicompartmental Knee Replacement's (OUKR's) fully-congruent design minimises polyethylene wear. Consequently, wear is a rare failure mechanism. Phase-3 OUKR linear wear at 5 years was higher than previous OUKR phases, but very low compared to fixed-bearing UKRs. This study aimed to measure OUKR bearing wear at 10 years and investigate factors that may affect wear. Bearing thickness for 39 OUKRs from a randomised study was calculated using radiostereometric analysis at regular intervals up to 10 years. Data for 39 and 29 OUKRs was available at 5 and 10 years, respectively. As creep occurs early, wear rate was calculated using linear regression between 6 months and 10 years. Relationships between wear and patient factors, fixation method, Oxford Knee Score (OKS), bearing position, and component position were analysed.Abstract
Introduction
Methodology
In this RCT the primary aim was to assess whether a short (125mm) Exeter V40 stem offered an equivalent hip specific function compared to the standard (150mm) stem when used for cemented total hip arthroplasty (THA). Secondary aims were to evaluate health-related quality of life (HRQoL), patient satisfaction, stem height and alignment, radiographic loosening, and complications between the two stems. A prospective multicentre double-blind randomised control trial was conducted. During a 15-month period, 220 patients undergoing THA were randomised to either a standard (n=110) or short (n=110) stem Exeter. There were no significant (p≥0.065) differences in preoperative variables between the groups. Functional outcomes and radiographic assessment were undertaken at 1- and 2-years. There were no differences (p=0.428) in hip specific function according to the Oxford hip score at 1-year (primary endpoint) or at 2-years (p=0.767) between the groups. The short stem group had greater varus angulation (0.9 degrees, p=0.003) when compared to the standard group and were more likely (odds ratio 2.42, p=0.002) to have varus stem alignment beyond one standard deviation from the mean. There were no significant (p≥0.083) differences in the Forgotten joint scores, EuroQol-5-Dimension, EuroQol-VAS, Short form 12, patient satisfaction, complications, stem height or radiolucent zones at 1 or 2-years between the groups. The Exeter short stem offers equivalent hip specific function, HRQoL, patient satisfaction, and limb length when compared to the standard stem at 2-years post-operation. However, the short stem was associated with a greater rate of varus malalignment which may influence future implant survival.
Aims: The purpose of the study was to obtain long-term results after total hip arthroplasty (THA) with cemented titanium stems typ Mueller-Geradschaft. Methods: 91 patients with a total of 110 THA were clinically and radiologically examined after an average follow-up of 9,5 years (9 to 11). The recruitment was 84%. The Harris score was determined clinically. Radiologically the directly postoperative radiographs were compared to the control radiographs according to the recommendations of Gruen et al. and Johnston et al. Results: In 1 cases (1%) a septical complication appeared after two years which was treated in two-stage surgery. Revisions after aseptic loosening have been carried out in 4 cases (4%). No other cases showed evident signs of loosening and applied revision surgery. Clinically, in all of those 4 cases of aseptic loosening the Harris score remained above 75 points. Altogether in 36 cases more than one RLL was ascertained which were only be observed in zones 1, 7, 8, 14. The body weight was significantly higher (82 kg; d=2.4) in the 4 revisions than in cases without RLL, especially the ratio body weight to surface of the stem was clearly different (1.5 kg/cm2 versus 1 kg/cm2; p<
0.005) in the two patients groups. This did not apply to sex, activity, size or kind of stem, Harris-score, ectopic ossification or body-weight index. Conclusions:
Aim: To evaluate the possible increase to surgical/operating room capacity by increasing the percentage of uncemented total hip replacement. Introduction: Globally there is growing demand for increased efficiency and productivity from medical care. In hip arthroplasty there has been increased interest in the use of uncemented components with several studies and registry data showing them to perform well clinically . 1. , . 2. One concern with their increased use has been increased costs . 3. We have examined the issue of operative timing and discuss the possible role these components may have in increasing theatre utilisation times and so offsetting their cost. Methods: This was a prospective, cohort study of every hip replacement performed in a dedicated arthroplasty unit within a district general hospital over one year. All care of patients was standardised using pathways, including all surgeons using a posterior approach with posterior repair. This allowed us to determine the relative effect of prosthesis type on quality, safety and efficiency. Demographic, anaesthetic, operative and timing details on all cases performed were collected prospectively and independently of the surgical team. Patients were reviewed at six weeks and one year post op. All readmissions to any hospital were noted and any further surgery recorded. Results: There were 1248 cases performed in one year. Of these 194 were uncemented (both components) and 286 cemented total hip replacements. Patient demographics were similar (mean age 70.9 years, range 28–92). Both hip types showed no difference in quality or safety factors as assessed by hip scores, patient mobilisation times, complication rates or revision rates. The only difference was in the surgical times. These were (in minutes):. – Mean Standard Deviation Minimum Maximum. – Uncemented 49 * 14 25 122. –
Introduction: There are more than 60 different hip prostheses currently available for total hip replacement (THR).
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.
Background. Surgeons always must take into account that a primary total hip arthroplasty (THA) in a young patient will be revised in the future, this because of the long life expectancy of young THA patients and the limited durability of prosthetic implants in these patients. Therefore we would like to accentuate the revisability of a primary THA in this specific and high demanding patient population. Methods. 343 consecutive THA in 267 patients under the age of 50 years were evaluated. We also assessed the results of the revised THA (n=53) within the same population. Clinical, radiographical and survival of primary and revision THA were evaluated. Results. With no patient lost during follow-up, 53 primary hips were revised after a mean follow-up of 8.9 (range 2.0–19.3) years. Survival with endpoint revision for any reason of either component was 86% after 10 years for primary THA. The average follow-up of the revisions of this population was 4.2 (range 0.1–14.8) years and 3 hips needed a repeat revision. Survival was 91% after 5 years for the revision THA. As well after primary as revision THA showed good clinical outcome. Conclusions.
An attempt to analyse whether impaction allografting without cement is more or less satisfactory than the technique with the addition of cement is compromised by conflicting reports of where the migration actually occurs. In some cemented series distal migration of the prosthesis within the cement mantle has been recorded as well as migration of the whole cement/prosthesis construct into the graft. Two prospective consecutive series of revision hip arthroplasties by a single surgeon:- Group 1; Uncemented impaction grafting revision hip replacement in a series of 30 patients (33 hips). Group 2;
Periprosthetic femoral fractures are increasingly seen in recent years, adding considerable burden to the National Health Service. These require complex revision or fixation and prolonged post-operative care, with significant morbidity with associated costs. The purpose of this study was to assess whether the size of femoral cement mantle is associated with periprosthetic femoral fractures (PPF). This retrospective study was carried out on a cohort of 49 patients (Fracture Group - FG) who previously had a revision procedure following a proximal PPF between 2010 and 2021. Inclusion criteria – all primary cemented total hip replacements (THR). Exclusion criteria – complex primary THR, any implant malposition that required early revision surgery or any pre-fracture stem loosening. The antero-posterior (AP) radiographs from this cohort of patients were assessed and compared to an age, sex, time since THR-matched control group of 49 patients without PPF (Control Group - CG). Distal cement mantle area (DCMA) was calculated on an AP radiograph of hip; the position of the femoral stem tip prior to fracture was also recorded: valgus, varus or central. Limitations: AP radiographs only. Statistical analyses were performed using Microsoft® Excel. Chi-square test demonstrated statistically significant difference in DCMA between FG and CG. DCMA of 700 to 900 mm² appeared to be protective when compared to DCMA of 0 to 300 mm². Also, a valgus position observed in 23% in FG Vs 4 % in CG increased the risk, with a smaller area of DCMA. This study demonstrates and recommends that a size of 700 – 900 mm² of the DCMA is protective against periprosthetic fractures, which are further influenced by the positioning of the distal stem tip. This could be due to the gradual decrease in the stiffness gradient from proximal to distal around the stem tip than steep changes, thereby decreasing possibility of a stress riser just distal to the cement mantle or restrictor. Further biomechanical research specific to this finding may be helpful to validate the observation, progressing to suggest a safe standardised surgical technique.
Instability and aseptic loosening are the two main complications after revision total hip arthroplasty (rTHA). Dual-mobility (DM) cups were shown to counteract implant instability during rTHA. To our knowledge, no study evaluated the 10-year outcomes of rTHA using DM cups, cemented into a metal reinforcement ring, in cases of severe acetabular bone loss. We hypothesized that using a DM cup cemented into a metal ring is a reliable technique for rTHA at 10 years, with few revisions for acetabular loosening and/or instability. This is a retrospective study of 77 rTHA cases with severe acetabular bone loss (Paprosky ≥ 2C) treated exclusively with a DM cup (NOVAE STICK; SERF, DÉCINES-CHARPIEU, FRANCE) cemented into a cage (Kerboull cross, Burch-Schneider, or ARM rings). Clinical scores and radiological assessments were performed preoperatively and at the last follow-up. The main endpoints were revision surgery for aseptic loosening or recurring dislocation. With a mean follow-up of 10.7 years [2.1-16.2], 3 patients were reoperated because of aseptic acetabular loosening (3.9%) at 9.6 years [7-12]. Seven patients (9.45%) dislocated their hip implant, only 1 suffered from chronic instability (1.3%). Cup survivorship was 96.1% at 10 years. No sign of progressive radiolucent lines were found and bone graft integration was satisfactory for 91% of the patients. The use of a DM cup cemented into a metal ring during rTHA with complex acetabular bone loss was associated with low revision rates for either acetabular loosening or chronic instability at 10 years. That's why we also recommend DM cup for all high risk of dislocation situations.
Introduction: There has been a renewed interest in metal-on-metal articulation in hip joint Arthroplasty. The reason for having metal-on-metal articulation is to reduce the volume of wear particles that are produced with THR. The outcome of reduced particle formation will hopefully be reduced osteolysis. Methods: We reviewed the results of 139 primary hip arthroplasties (130 patients) performed using Metasul articulation and cemented Weber cup. Six patients were lost to follow-up leaving 133 hips (124 patients) for review with at least 5-year follow-up. The acetabular socket was the cemented Weber cup and Bone grafting of the acetabulum and application of a reinforcement ring was done where necessary.
Introduction: The new anatomical adapted stem system OptanTM (Zimmer) is presented, showing the first mid-term-results for cemented and cementless fixation. Its cross-section in the proximal area corresponds with its antetorsion, anteversion and helitorsion, to the 3D-morphology of the proximal femur. Material and Methods: 313 Optan stems (175 cemented, 148 cementless) were implanted in 306 patients (mean age 62.1 y. (20–74 y.), m/f-ratio 0,8). The clinical and radiological parameters for calculation of Harris Hip Score (HHS), Merle d’Aubigné (MD), WOMAC and periprosthetic bone reaction (Gruen et al.) were recorded. An implant migration analysis using two different biplanar radiographic digital measurement systems (DMA, UMA) was done also. Results: The clinical results for latest follow up examination (5 and more y.p.o.) for cementless (cemented) Optan are: HHS mean (m) 97.6, standard deviation (SD) 7.32 (m 95.1, SD 9.85), MD m 17.6, SD 1.04 (m 17.1, SD 1.48), WOMAC m 1.44, SD 1.56 (m 1.75, SD 1.62).
Purpose: The purpose of this retrospective study was to assess clinical and radiological outcome at ten years follow-up at least in a continuous series of total hip arthroplasties performed in patients with aseptic necrosis of the femoral head. Material and methods: The series included 122 arthroplasties performed between January 1980 and December 1996 in 96 patients (26 women and 70 men), aged 50.8±13.3 years (range 21–85 years). The underlying cause was essential necrosis in 40.6%, cortocosteroid threapy in 19.8%, chronic alcoholism for 17%, trauma for 12%, and another medical cause for 10%. The Ficat and Arlet classification was grade IV 80 hips, grade III 42 hips. All arthroplasties were performed via the transtrochanteric approach.
The main aims were to identify risk factors predictive of a radiolucent line (RLL) around the acetabular component with an interface bioactive bone cement (IBBC) technique in the first year after THA, and evaluate whether these risk factors influence the development of RLLs at five and ten years after THA. A retrospective review was undertaken of 980 primary cemented THAs in 876 patients using cemented acetabular components with the IBBC technique. The outcome variable was any RLLs that could be observed around the acetabular component at the first year after THA. Univariate analyses with univariate logistic regression and multivariate analyses with exact logistic regression were performed to identify risk factors for any RLLs based on radiological classification of hip osteoarthritis.Aims
Methods
We conducted a systematic review and meta-analysis to compare the mortality, morbidity, and functional outcomes of cemented versus uncemented hemiarthroplasty in the treatment of intracapsular hip fractures, analyzing contemporary and non-contemporary implants separately. PubMed, Medline, EMBASE, CINAHL, and Cochrane Library were searched to 2 February 2020 for randomized controlled trials (RCTs) comparing the primary outcome, mortality, and secondary outcomes of function, quality of life, reoperation, postoperative complications, perioperative outcomes, pain, and length of hospital stay. Relative risks (RRs) and mean differences (with 95% confidence intervals (CIs)) were used as summary association measures.Aims
Methods
Purpose: To compare the torsional stability provided by five implant stems with different cross-sectional geometries under cyclic loading. Methods:
Multiple joint registries have reported better implant survival for patients aged >75 years undergoing total hip arthroplasty (THA) with cemented implant combinations when compared to hybrid or uncemented implant combinations. However, there is considerable variation within these broad implant categories, and it has therefore been suggested that specific implant combinations should be compared. We analysed the most common contemporary uncemented (Corail/Pinnacle), hybrid (Exeter V40/Trident) and cemented (Exeter V40/Exeter X3) implant combinations in the New Zealand Joint Registry (NZJR) for patients aged >75 years. All THAs performed using the selected implants in the NZJR for patients aged >75 years between 1999 and 2018 were included. Demographic data, implant type, and outcome data including implant survival, reason for revision, and post-operative Oxford Hip Scores were obtained from the NZJR, and detailed survival analyses were performed. Primary outcome was revision for any reason. Reason for revision, including femoral or acetabular failure, and time to revision were recorded. 5427 THAs were included. There were 1105 implantations in the uncemented implant combination group, 3040 in the hybrid implant combination group and 1282 in the cemented implant combination group. Patient reported outcomes were comparable across all groups. Revision rates were comparable between the cemented implant combination (0.31 revisions/100 component years) and the hybrid implant combination (0.40 revisions/100 component years) but were statistically significantly higher in the uncemented implant combination (0.80/100 component years). Femoral-sided revisions were significantly greater in the uncemented implant combination group. The cemented implant and hybrid implant combinations provide equivalent survival and functional outcomes in patients aged over 75 years. Caution is advised if considering use of the uncemented implant combination in this age group, predominantly due to a higher risk of femoral sided revisions. The authors recommend comparison of individual implants rather than broad categories of implants.
We prospectively reviewed 2440
To determine if primary cemented acetabular component geometry (long posterior wall (LPW), hooded, or offset reorientating) influences the risk of revision total hip arthroplasty (THA) for instability or loosening. The National Joint Registry (NJR) dataset was analyzed for primary THAs performed between 2003 and 2017. A cohort of 224,874 cemented acetabular components were included. The effect of acetabular component geometry on the risk of revision for instability or for loosening was investigated using log-binomial regression adjusting for age, sex, American Society of Anesthesiologists grade, indication, side, institution type, operating surgeon grade, surgical approach, polyethylene crosslinking, and prosthetic head size. A competing risk survival analysis was performed with the competing risks being revision for other indications or death.Aims
Methods
Purpose: To compare the survivorship, at 15 years, of cemented versus cementless fixation of press-fit condylar primary total knee replacements. Methods: A prospective randomised consecutive series of 501 primary knee replacements received either cemented (219 patients, 277 implants) or cementless (177 patients, 224 implants) fixation. All operations were performed either by, or under the direct supervision of, a single surgeon (PJG). Patients were followed up to establish the rate of implant survival. No patients were lost to follow up. Revision was defined as further surgery, irrespective of indication, that involved replacement of any of the three original components. Life table analysis was used to assess survival. Cox’s proportional hazards regression analysis was used to compare the cumulative survival rates for the two groups. Results: Altogether 44 patients underwent revision surgery (24 cemented vs. 20 cementless). 11 cases were revised secondary to infection, 26 were revised due to aseptic loosening and 7 cases were revised for other reasons (instability, anterior knee pain, polyethylene wear, patellar malallignment). At time of analysis a further 7 had revision planned. For cemented knees 15-year survival=80.7% (95%CI, 71.5–87.4), 10-year survival=91.7 (95%CI, 87.1–94.8). For cementless knees 15-year survival=75.3% (95% CI, 63.5–84.3), 10-year survival=93.3% (95%CI, 88.4–96.2). There was no difference between these two groups. When comparing the covariates (operation, sex, age, diagnosis, side), there was no significant difference between operation type (Hazard ratio=0.83 (95%CI, 0.45–1.52) p=0.545), side of operation (HR=0.58 (95%CI, 0.32–1.05) p=0.072), age (HR=0.97 (95%CI, 0.93–1.01) p=0.097), diagnosis (OA vs. non OA, (HR=1.25 (95%CI,0.38–4.12) p=0.718). However, there was a significant gender difference (Males vs. Females (HR=2.48 (95%CI, 1.34–4.61) p=0.004). The worst case scenario was calculated to include those patients that have also been listed for revision.
Aims: Thrombembolic complications, which include the fat embolism syndrome, are well known consequences of cementless and cemented total hip replacement. Embolic phenomena could be demonstrated clinically and experimentally with both fixation techniques. Methods: We investigated in a standardized animal model in 15 Merino sheep the fat intravasation into the blood stream during bilateral simultaneous prosthetic implantation (cemented versus cementless). After identical preparation of the intramedullary canal a cement restrictor was additionally inserted on the cemented side and the canal was cleaned with 250ml jet-lavage. By catheters in the external iliacal veins the drained blood was collected in two phases, one after preparation of the intramedullary canal and another during insertion of the prosthesis, and the fatty contents of these blood samples were measured. Results:
Early implant migration measured with radiostereometric analysis (RSA) has been proposed as a useful predictor of long-term fixation of tibial components in total knee arthroplasty. Evaluation of actual long-term fixation is of interest for cemented components, as well as for cementless fixation, which may offer long-term advantages once osseointegration has occurred. The objective of this study was to compare the long-term migration with one- and two-year migration to evaluate the predictive ability of short-term migration data and to compare migration and inducible displacement between cemented and cementless (porous metal monoblock) components at least ten years postoperatively. Patients who had participated in RSA migration studies with two-year follow-up were recruited to return for a long-term follow-up, at least ten years from surgery. Two cemented tibial designs from two manufacturers and one porous metal monoblock cementless tibial design were studied. At the long-term follow-up, patients had supine RSA examinations to determine migration and loaded examinations (single leg stance) to determine inducible displacement. In total, 79 patients (54 female) returned, with mean time since surgery of 12 years (10 to 14). There were 58 cemented and 21 cementless tibial components.Aims
Patients and Methods
Total knee arthroplasty is an established treatment for knee osteoarthritis with excellent long-term results, but there remains controversy about the role of uncemented prostheses. We present the long-term results of a randomized trial comparing an uncemented tantalum metal tibial component with a conventional cemented component of the same implant design. Patients under the age of 70 years with symptomatic osteoarthritis of the knee were randomized to receive either an uncemented tantalum metal tibial monoblock component or a standard cemented modular component. The mean age at time of recruitment to the study was 63 years (50 to 70), 46 (51.1%) knees were in male patients, and the mean body mass index was 30.4 kg/m2 (21 to 36). The same cruciate retaining total knee system was used in both groups. All patients received an uncemented femoral component and no patients had their patella resurfaced. Patient outcomes were assessed preoperatively and postoperatively using the modified Oxford Knee Score, Knee Society Score, and 12-Item Short-Form Health Survey questionnaire (SF-12) score. Radiographs were analyzed using the American Knee Society Radiograph Evaluation score. Operative complications, reoperations, or revision surgery were recorded. A total of 90 knees were randomized and at last review 77 knees were assessed. In all, 11 patients had died and two were lost to follow-up.Aims
Methods
Cementless fixation of Oxford Unicompartmental Knee Replacements (UKRs) is an alternative to cemented fixation, however, it is unknown whether cementless fixation is as good long-term. This study aimed to compare primary and long-term fixation of cemented and cementless Oxford UKRs using radiostereometric analysis (RSA). Twenty-nine patients were randomised to receive cemented or cementless Oxford UKRs and followed for ten years. Differences in primary fixation and long-term fixation of the tibial components (inferred from 0/3/6-month and 6-month/1-year/2-year/5-year/10-year migration, respectively) were analysed using RSA and radiolucencies were assessed on radiographs. Migration rates were determined by linear regression and clinical outcomes measured using the Oxford Knee Score (OKS).Abstract
Introduction
Methodology
Introduction: 3–5 year follow up results of the new anatomical adapted stem system OptanTM (Zimmer) are presented. Its cross-section in the proximal area corresponds with its antetorsion, anteversion and helitorsion, to the 3D-morphology of the proximal femur. Philosophy and aim of the cementless Optan-stem is a proximal fixation and force transmission in the femoral bone. Material and Methods: Between July 1999 and Dec. 2001 242 Optan stems (122 cemented, 120 cementless) were implanted in 221 patients (mean age 62.1 y. (20–74 y.), m/ f-ratio 0,8). The clinical and radiological parameters for calculation of Harris Hip Score (HHS), Merle d’Aubigné (MD), WOMAC, periprosthetic bone reaction (Gruen et al.) and periarticular heterotopic bone formation (Brooker et al.) were recorded. An implant migration analysis using two different biplanar radiographic digital measurement systems (DMA, UMA) was done also. Results: The clinical results for latest follow up examination (3–5 y.p.o.) for cementless (cemented) Optan are: HHS mean (m) 97.6, standard deviation (SD) 7.32 (m 95.1, SD 9.85), MD m 17.6, SD 1.04 (m 17.1, SD 1.48), WOMAC m 1.44, SD 1.56 (m 1.75 ,SD 1.62). Radiographic results of cementless stem show a low rate (29,1%) of secondary endostal reactive line formation in the distal part of the stem (Z3,4,5) beginning 6–12 month postoperative, especially when drilling of femoral bone canal was done. When the distal part of the stem (Z3,5) was fixed directly to cortical bone little hypertrophy of the cortical bone gets relevant 4–5 years p.o. in a few cases.
Introduction: The original Müller straight stem (MSS, Zimmer. ®. ; Winterthur, Switzerland) is made out of CoNiCr and showed excellent 20 year results but later modifications of the stem proved to be inferior. Aim of this study was to analyse the effect of shape, material and surface roughness on aseptic loosening of cemented Müller type straight stems. Materials and patients: Between 1984 and 1996 a total of 926 THR were operated with four different versions of cemented Müller type straight stems and followed prospectively in the in-house register at our institution. Two different shapes of cemented Müller type straight stems (MSS and SL), both made out of two different alloys (CoNiCr and TiAl), were included in this study. All four versions differed in surface roughness (MSS CoNiCr Ra 1.0μm (satin); SL CoNiCr Ra 1.2μm (satin); MSS TiAl Ra 2.0μm (rough); SL TiAl Ra >
2.0μm (rough)). Survival analysis was done using Kaplan-Meier curves with aseptic loosening as endpoint, risk factors were tested with regression analysis. Results: The 4 groups did not differ in age, gender and diagnosis, the mean follow up was 11.4 (0.1 to 23.0) years. Survival with aseptic loosening as endpoint was 97.7% (MSS CoNiCr), 96.4% (SL CoNiCr), 82.5% (MSS TiAl) and 67.4% (SL TiAl), respectively, at ten years. At final follow up all four groups differed significantly (p=0.044 Log rank test). Increasing roughness increased the risk for aseptic loosening and the harder CoCr had better survival than TiAl. results were significantly worse for the combination of the soft TiAl with a rough surface (SL TiAL, Ra >
2.0μm). For both stem designs the MSS shape had better survival than the SL shape (p=0.001). Discussion: Wear modalities (abrasion vs. fretting) in the cement-stem interface are directly correlated with surface roughness, the amount of the released particles correlates with loosening. All examined stems had a roughness exceeding the limit of Ra =0.4 μm, producing abrasive wear with a higher volume of wear particles as compared to established polished stems which show fretting wear. Stem roughness and hardness are more important for long-term survival than some modifications in the shape. Conclusion:
Background:
Revision hip surgery is reportedly rising inexorably yet not all units report this phenomenon. The outcome of 1143 consecutive Corin TaperFit primary hip arthroplasties (957 patients) performed between 1995 and 2010 is presented. The implants were cemented under pressurisation and combined the TaperFit stem with Ogee flanged cups. Data was gathered from local arthroplasty database and case note review of revised joints. 13 hips have been revised (1.1%). Cumulative prosthesis survival is 0.99 +/− 0.0. Two femoral stems were revised (0.2%); one at 6 months for sepsis, one at 14 days after dislodgment during reduction of dislocation. No revisions were undertaken for aseptic loosening of the stem or cup, nor for thigh pain. 32 patients (32 hips) ≥15 year follow up, 13 survive today and none have been revised (0%). Of the 471 with ≥10 year follow up, 38 were aged ≤50 at time of surgery and 1/38 has been revised to date (PLAD for dislocation). The strong population stability in this region, supported by independent investigation by Scottish Arthroplasty Project, endorses the accuracy of the data quoted. The low incidence of revision in this cohort, and absence of revision for aseptic loosening (mean follow up 8.03 years +/− SD 3.94; range 18 months to 16yrs 2 months), substantially supports the longevity and use of cemented, double-taper, polished, collarless femoral stems in combination with cemented polyethylene cups in primary hip arthroplasty in all patient age groups.
To date, there is insufficient evidence available to compare
the outcome of cemented and uncemented fixation of the humeral stem
in reverse shoulder arthroplasty (RSA). A systemic review comprising 41 clinical studies was performed
to compare the functional outcome and rate of complications of cemented
and uncemented stems in RSA. These included 1455 cemented and 329
uncemented shoulders. The clinical characteristics of the two groups
were similar. Variables were compared using pooled frequency-weighted means
and relative risk ratios (RR).Aims
Methods