Introduction

The purpose of this study was to evaluate the in vivo migration patterns of a polished femoral component cemented line-to-line using EBRA –FCA.

Introduction: The aim of this study was to evaluate the in vivo migration patterns using EBRA-FCA of a consecutive series of polished femoral components cemented line-toline.

Materials and Methods: Between January 1988 and December 1989, 164 primary total hip arthroplasties were performed in 155 patients. The mean age at the time of the index arthroplasty was 63.8 ± 11.6 years. A single design prosthesis was used combining an all-polyethylene socket and a 22.2 mm femoral head. The mono-block double tapered (5.2°) femoral component made of 316-L stainless steel had a highly polished surface (Ra = 0.04 μm) and a quadrangular section(Kerboull^® MKIII, Stryker). The femoral preparation included removal of diaphyseal cancellous bone to obtain primary rotational stability of the stem prior to the line-to-line cementation. For each patients, all available AP radiographs of the pelvis were digitized (Vidar Sierra Plus, Vidar System Corporation, Herdon, Virginia) and linked to an IMB-compatible computer. The EBRAFCA software is a validated method designed to assess migration of a femoral component through comparable pairs of radiographs.

Results: At the minimum 15-year follow-up, 73 patients (77 hips) were still alive and had not been revised at a mean of 17.3 ± 0.8 years (15–18 years), 8 patients (8 hips) had been revised for high polyethylene wear associated with periacetabular osteolysis, 66 patients (69 hips) were deceased, and 8 patients (10 hips) were lost to follow-up. Among the 8 revision procedures, the femoral component was loose in 3 hips. A total of 1689 radiographs (mean 10.3 per hip) were digitized. At the last follow-up, the mean subsidence of the entire series was 0.63 ± 0.49 mm (median of 0.61 mm; range 0 to 1.94 mm). When using a 1.5 mm threshold (accuracy of the EBRAFCA method) for subsidence, 4 of the 142 stems with adequate EBRA-FCA data were considered to have migrated. Using a threshold of 2 mm for subsidence, none of the 142 stems were considered to have migrated. The patterns of migration were calculated every 2 years giving 9 intervals. The evolution of mean subsidence during the whole follow-up period remained below 1.5 mm.

Discussion: Mean subsidence of this quadrangular highly polished femoral component remained below the accuracy of the method (± 1.5 mm) throughout the entire follow-up period. Of the 142 hips analyzed, only four (2.8%) had subsided of more than 1.5 mm and none more than 2 mm. This study demonstrates that contrary to other cemented femoral components that have provided excellent survival in the long term frequently associated with stem subsidence, a highly polished cemented double tapered femoral component with a quadrangular cross-section cemented line to line does not subside up to 18-year follow-up.

Introduction: The purpose of this study was to report on the minimal 10-year followup results of a prospective randomized and a historical series of low friction cemented hip arthroplasties according to the surface finish of the femoral implant.

Patients and Methods: The prospective randomized series included 284 patients (310 hips) with a mean age of 64.1 years. Among these 310 hips, the femoral component had a highly polished surface (Ra = 0.04 micron, MKIII, Stryker) in 165 hips, and a matte surface finish (Ra = 1.7 microns, CMK3, Vector Orthopedique) in the remaining 145 hips. The historical series that was operated by the sames surgeons according to the same surgical technique included 111 patients (123 hips) with a satin finish femoral component (Ra = 0.9 micron, CMK2, Sanortho). Clinical results were rated according to the Merle d’Aubigne hip score. Radiologic analysis was performed according to the criteria of Barrack et al. for the definition of loosening. Moreover, a survival analysis according to the actuarial method was conducted.

Results: At the minimum 10-year follow-up evaluation, 43 patients (48 hips) were lost to follow-up (0.3 to 8.7 years), 80 patients (83 hips) were deceased (0.1 to 13.6 years), 26 patients had revision of either or both components (0.9 to 15.9 years), and 246 patients (276 hips) were alive and had not been revised after a mean 12.3 ± 1.9 years (10 to 16 years). Radiologic loosening of the femoral component, including revision, occured in one, four, and 15 hips for the polished, stain, and matte groups, respectively. The survival rate at 13 years of the femoral component, using loosening as the end point, was 97.3 ± 2.6% (95% CI, 92.2 to 100%), 97.1 ± 2.1% (95% CI, 93 to 100%), and 78.9 ± 5.8% (95% CI, 67.6 to 90.3%) for polished, satin, and matte stems, respectively.

Discussion: This study demonstrated that cement fixation of a femoral component was more reliable in the long term with a polished or satin surface finish. Based upon our results and the review of the literature, we recommend abondoning the use of cemented stems with a surface roughness greater than 1 micron.

We have evaluated the in vivo migration patterns of 164 primary consecutive Charnley-Kerboull total hip replacements which were undertaken in 155 patients. The femoral preparation included removal of diaphyseal cancellous bone to obtain primary rotational stability of the stem before line-to-line cementing. We used the Ein Bild Roentgen Analyse femoral component method to assess the subsidence of the femoral component.

At a mean of 17.3 years (15.1 to 18.3) 73 patients were still alive and had not been revised, eight had been revised, 66 had died and eight had been lost to follow-up. The mean subsidence of the entire series was 0.63 mm (0.0 to 1.94). When using a 1.5 mm threshold, only four stems were considered to have subsided. Our study showed that, in most cases, a highly polished double-tapered stem cemented line-to-line does not subside at least up to 18 years after implantation.

We describe 129 consecutive revision total hip replacements using a Charnley-Kerboull femoral component of standard length with impaction allografting. The mean follow-up was 8.2 years (2 to 16). Additionally, extramedullary reinforcement was performed using struts of cortical allograft in 49 hips and cerclage wires in 30.

There was one intra-operative fracture of the femur but none later. Two femoral components subsided by 5 mm and 8 mm respectively, and were considered to be radiological failures. No further revision of a femoral component was required. The rate of survival of the femoral component at nine years, using radiological failure as the endpoint, was 98%. Our study showed that impaction grafting in association with a Charnley-Kerboull femoral component has a low rate of subsidence. Reconstruction of deficiencies of distal bone with struts of cortical allograft appeared to be an efficient way of preventing postoperative femoral fracture for up to 16 years.

Purpose: The purpose of this retrospective study was to evaluate the clinical and radiological results of Charnley-Keroboull total hip arthroplasty performed in patients aged less than 50 years. We searched for factors which might affect wear and sustained fixation.

Material and methods: Among the 2,804 arthroplasties performed in patients aged less than 50 years between 1975 and 1995, we selected randomly 287 (10% of the annual operations). These prostheses were implanted in 222 patients (144 women and 78 men), mean age 40.1±8 years (15–50). All of the arthroplasties were inserted via a transtrochanteric approach. Charnley-Kerboull implants were cemented in all patients using a metal polyethylene bearing. Functional outcome was assessed with the Postel-Merle-d’Aubigné score. Cup wear was measured with the Chevrot technique. The actuarial method was used to calculate prosthesis survival.

Results: At last follow-up, 155 patients (210 hips) were living and had not had a revision procedure at mean 16.1±4.6 years, 23 patients (25 hips) required revision of the acetabular or femoral element, ten patients (10 hips) had died, and 34 patients (42 hips) were lost to follow-up. The mean preoperative functional score was 9.6±2.5 (9–15) versus 17.2±0.8 (9–18) at last follow-up (Wilcoxon rank test p< 0.001). For the acetabular element, there was certain loosening in 15 hips and possible loosening in 24. For the femoral element, loosening was certain for 12 implants and possible for four. Twentyfive hips required revision, including 17 for aseptic loosening. Mean wear was 0.12±0.21 mm (0–2.23). Among the 287 hips, 196 had wear measured at less than 0.1 mm/yr (mean 0.02 mm/yr). Mean overall implant survival, defining revision as failure, was 85.4±5.0% at twenty years (95%CI 78.4–92.4). Among the factors tested, only abnormally rapid wear (> 0.1 mm/yr) was predictive of failure.

Discussion: The results of this series allow us to conclude that total hip arthroplasty using a Charnley-Kerboull implant remains the best solution for young patients in terms of implant survival.

Purpose: Certain authors have indicated that the primum movens of loosening of cemented femoral stems is related to the decohesion of the cement implant interface. Under such conditions, improvement in this interface was attempted with the development of a rough surface for the femoral piece. The purpose of this retrospective analysis was to evaluate results a minimum ten years follow-up in a consecutive series of total hip arthroplasties comparing types of femoral implant surfaces.

Material and methods: Between January 1988 and December 1989, 311 THA were implanted in 286 patients aged 63.6±11.8 years (26–91). All implantations were performed via the transtrochanteric approach by two senior surgeons. Two types of femoral implant were used: 166 non-polished pieces with a round section Ra = 3 mm (CMK3, Vector Orthopédique) and 145 polished pieces with a quadrangular section Ra = 0.4 mm (MKIII, Stryker Howmedica). The preoperative data were comparable for the two groups. Functional results were assessed with the Postel Merle d’Aubigné score (PMA). Actuarial survival curves were plotted.

Results: At minimum ten years follow-up, 187 patients (204 hips) were living and had not required revision at mean follow-up of 11.7±2.5 years (10–14), 15 patients (15 hips) had revision of the acetabular and/or femoral element, 54 patients (58 hips) had died, and 30 patients (34 hips) were lost to follow-up. The mean preoperative function score was 11.2±2.5 (4–16) versus 17.5±0.5 (10–18) at last follow-up (Wilcoxon rank test, p< 0.001). Cumulative survival at 13 years, taking radiographic loosening of the femoral piece as the endpoint, was 78.9±5.8% (95%CI 67.6–90.3%) for unpolished implants versus 97.3±2.6 (95%CI 92.2–100) for polished implants. The difference was significantly different (p< 0.001).

Discussion: The results of this analysis indicate that radiographic survival of unpolished cemented femoral pieces is significant inferior compared with polished pieces. The increased adherence of the femoral cement is probably the cause of increased shear stress at the bone-cement interface. The respective influence of section and surface remain to be determined.

Aims: The purpose of this retrospective study was to report on the treatment of migrated ununited greater trochanter following total hip arthroplasty. Methods: Between January 1986 and December 1999, 72 non-unions of the greater trochanter in 71 patients were treated using a trochanteric claw plate. The mean age of the patients was 66 ± 11 years. The average time to re-operation was 8 months. Fixation of the non-united greater trochanter was performed using a claw plate only in 47 hips, and the association of frontal wires with a claw plate in the remaining 25 hips. The main criterion for evaluation was the consolidation of the greater trochanter judged as follows: bony consolidation (no pain, no Trendelenboug gait, radiologic fusion); fibrous consolidation (moderate pain, no Trendelenboug gait, radiologic fusion difficult to assess); and non-union (Trendelenboug gait and/or absence of radiologic fusion). Results: The average follow-up of the series was 4 years (1 to 14 years). The mean d’Aubigné score significantly increased from 13.5 preoperatively to 15.9 at last follow-up (paired signs test, p < 0.0001). Bony consolidation was obtained in 51 hips, fibrous in 9, whereas repeat non-union occurred in 12. The only predictive factor for union was the use frontal wires in association with a claw plate that provided 87.5% of unions and no failure (Chi square test, p = 0.006). Conclusions: This study indicated that non-union of the greater trochanter following total hip arthroplasty can be successfully treated with frontal wires in conjunction with a trochanteric claw plate.

Aims: The purpose of this prospective randomized study was to report on the minimal 10-year follow-up results of a consecutive series of cemented total hip arthroplasty according to the surface finish of the femoral implant. Methods: Between January 1988 and December 1989, 311 total hip arthroplasties were performed in 286 patients. Implants were of Charnley Kerboull design combining a 22.2-mm femoral head and an all-polyethylene socket. The cemented femoral implant was available in two configurations: polished (Ra = 0.4 μm) and matte (Ra = 3 μm). The polished stem (MK III, Stryker Howmedica) was implanted in 166 hips, and the matte stem (CMK 3, Vecteur Orthopedic) in the remaining 145. The mean age of the patients was 63.6 years. Results: At the minimum 10-year follow-up evaluation, 187 patients (204 hips) were still alive and had not been revised at a mean of 11.7 years (10–14 years), 15 patients (15 hips) had been revised, 54 patients (58 hips) had died from unrelated causes, and 30 patients (34 hips) were lost to follow-up. The mean d’Aubigné hip score was 17.7 ± 0.3 at the latest follow-up. The survival rate at 13 years, using radiologic loosening as the end-point, was 97.3 ± 2.6% (95% confidence interval, 92.2 to 100%) for polished stems, versus 78.9 ± 5.8% (95% confidence interval, 67.6 to 90.3%) for matte stems (log-rank test, p = 0.0001). Conclusions: This study demonstrated that cemented fixation of femoral stems was significantly more reliable in the long-term with a polished surface.

Aims: The aim of this open prospective study was to evaluate the minimum 2-year follow-up outcome of a consecutive series of low friction total hip arthroplasties combining zirconia on polyethylene. Methods: Between January 1997 and June 1999 fifty-five total hip arthroplasties were performed in 51 patients. The mean age was 52.2 ± 12 years. The 22.2-mm femoral head made of zirconia ceramic was secured to the femoral component through a Morse taper that had an angle of 11°25 for 27 hips and 5°40 for 33 hips. All prostheses were of Charnley-Kerboull design. Clinical results were evaluated according to the Merle d’Aubigné hip score. Wear of the acetabular component and periprosthetic osteolysis was measured on serial radiographs of the pelvis. Results: The mean follow-up of the series was 32 months (24 to 48 months). No patient was lost to follow-up. The mean functional hip score significantly increased from 12.2 ± 2.6 preoperatively to 17.8 ± 0.2 at the latest follow-up (paired Student’s t test, p < 0.0001). None of the acetabular or femoral component had migrated. Wear of the socket was always undetectable on plain radiographs. However, lytic endosteal lesions of the calcar were observed in 19 of the 55 arthroplasties (34.5%). These lytic lesions appeared between the first and second postoperative year. Conclusions: Early calcar osteolysis observed in this study can be related to either run-in wear or to preliminary severe wear. The authors do not recommend further use of zirconia ceramic until long-term follow-up studies are available.

Aims: The purpose of this retrospective study was to report on the minimum 10-year follow-up results of a consecutive series of cemented low friction total hip arthroplasties performed for avascular necrosis of the femoral head. Methods: One hundred and twenty-two THAs in 96 patients were performed between January 1980 and December 1990. All prostheses were of Charnley- Kerboull design, combining a 22.2-mm femoral head and an all-polyethylene socket. Both components were cemented. The mean age of the series was 50.8 ± 13.3 years (21–85 years). Eighty hips were graded Ficat III and 42 hips were graded Ficat IV. Results: At the minimum 10-year follow-up evaluation, 59 patients (75 hips) were still alive and had not been revised at a mean of 13.9 years (10–21 years), 7 patients (7 hips) had been revised, 20 patients (24 hips) had died from unrelated causes, and 10 patients (16 hips) were lost to follow-up. The mean dñAubignŽ hip score was 17 ± 1 at the latest follow-up. The mean wear rate for unrevised hips was 0.07± 0.06 mm per year. Revision was performed for polyethylene wear associated with periprosthetic osteolysis in 6 hips and for deep sepsis in one. Three hips had recurrent dislocations. The survival rate at 15 years, using revision for any reason as the end-point, was 88.5% (95% conþdence interval, 80.2 to 96.9%). Conclusions: This series indicated that Charnley Kerboull low friction total hip arthroplasty for avascular necrosis could provide satisfactory long-term clinical and radiologic results.

Controversy exists with regard to the thickness of cement mantles that are necessary around the femoral components of cemented total hip arthroplasties. Conventional teaching, based on bench-top or computor models and theoretical analyses, as well as post-mortem & follow-up studies, suggests that the cement mantle should be complete and not less than 2–3mm in thickness. Mantles that are less than this are held to be at risk from mechanical failure in the long term; if they are incomplete, focal lysis may occur and progress to aseptic loosening.

However, long term experience with a number of French cemented femoral components suggests that these conventions may be erroneous. These French femoral components include the Charnley-Kerboull (stainless steel) and the Ceraver Osteal (Ti6Al4V) stems, in both of which the underlying design principle is that the stem should completely fill the femoral canal, the cement then being used purely to fill the gaps. Such a design philosophy implies that the cement mantles will be very thin, and since both of these stems are straight and the femoral medullary canal is not, the mantles may not only be thin, but also in places incomplete.

Conventional teaching would suggest that any stem utilising mantles of this type would fail from a combination of focal lysis and cement fracture. Yet the long term results of both of these stems have been outstandingly good, with extremely low levels of aseptic loosening and endosteal lysis, irrespective of the bearing combinations being used. Both these stems have a surface finish of Ra < 0.1 microns. A third French design, the Fare stem, manufactured from Ti6Al4V and based on the same principles, was associated with bad results when manufactured with a rough (> 1.5 microns) surface, and appreciably better results after the surface roughness was changed to < 0.1 microns.

These findings, that constitute the ‘French Paradox’, have profound implications for the mechanical behaviour of cement in the femur and for the mechanisms that underlie stem failure from loosening.

Eighty-nine patients (8 males, 81 females) with an average age of 52 years had 119 high dislocations (Crowe IV, 30 bilateral and 59 unilateral). The patients underwent 118 total hip arthroplasties between 1970 and 1986 using original or modified Charnley prostheses. Only 39 patients had not had a previous operation. Pain in the hip associated with stiffness and limitation in activity was the main indication for surgery. Back or knee pain was the chief complaint of 11 patients. Pre-operatively and post-operatively, a thorough assessment of the patients was made including hips, pelvis lumbosacral spine, knee, leg length discrepancy and static body balance.

The operation was performed through a transtrochanteric approach. A small socket was always inserted and cemented into the true acetabulum augmented by an autogenous graft, and a straight femoral component implanted at the level of the lesser trochanter. Muscle releases and tenotomies were not performed. Twenty-nine patients (35 hips) had died or were lost to follow-up. Sixty patients were still alive at the last examination in 1996, and regularly seen with a mean follow-up of 16 years. The mean follow-up of the whole series was 12.8 years.

At the last examination, clinical results according to the d’Aubigne rating system were classified as excellent 59.3%, very good 15.2%, good 15.2%, fair 5.1%, and poor 5%. Only 10 patients had a persistent waddling gait and a positive Trendelenburg sign. The results were slightly less good when a major femoral angulation needed an alignment osteotomy.

One femoral and seven acetabular loosenings were revised. In addition, five hips were revised for severe polyethylene wear and osteolysis before definite loosening, and two hips for heterotopic ossifications. The rate of revision was 12.7%. At twenty years, the survival rate was 99% for the femoral component and 87% for the socket, cemented fixation as end point, whereas the cumulative survival rate of the prosthesis was 78%, revision as end point.

The leg shortening, mean 4.84 cm (range 3-8 cm), was accurately corrected 63 times and within 1 cm 42 times. The lengthening was an average of 3.80 cm (2 to 7 cm). Leg length discrepancy was, on the whole, reduced as much as possible (mean 2.6 cm pre-operatively, 0.4 cm post-operatively). Of the 18 pre-operative painful knees, 10 were greatly improved, but four of these needed an operation.

Lateral pelvic tilt was corrected in more than 50%, pelvic frontal asymmetry was substantially reduced, as well as lordosis and lateral curve of the lumbar spine. As a result, low back pain has been relieved in 40 patients, but two required a laminectomy for a lumbar canal stenosis.

Total hip arthroplasty on high riding hips may be a wonderful operation, but this operation is full of pitfalls, technically demanding, and may represent a serious risk of complication. A successful result depends on a complete pre-operative assessment of the patient, a perfectly performed surgical procedure, and a reasonable selection of its indications.

Purpose: New surfaces have been developed to reduce polyethylene wear. The zircone ceramic surface appears to have a theoretical advantage due to its interesting tribologic properties. The purpose of this prospective study was to assess clinical and radiological outcome at a minimal two years follow-up in a consecutive series of total hip arthroplasties using the polyethylene zircone junction.

Material and methods: La series included 56 total hip arthroplasties performed in 49 patients (30 women and 19 men), mean age 52.2 ± 12 years (25–76). Primary degenerative hip disease was the aetiology in 43% of the cases, dysplasia in 27%. The femoral component was made of 316L steel with a 11°25 Morse cone for 27 hips and a 5°40 cone for 29 hips. The femoral head measured 22.2 mm and was made of polycrystaline zircone ceramic stabilised in the tragonal form with yttrium (Y-TZP). All the arthroplasties were performed via transtrochanteric access using cemented Charnley-Kerboull implants. Clinical outcome was assessed with the Merle-d’Aubigné score. Classical landmarks on the AP pelvis views were used to assess implant migration. Cup wear was measured using the Livermore method. Actuarial survival curves were plotted.

Results: Mean follow-up was 32 months (24–48). None of the patients were lost to follow-up. The mean functional score at last follow-up was 17.8±0.2 (16–18) versus 12.2±2.6 before arthroplasty (Student t test for paired variables, p < 0.0001). No cases of migration of the femoral or acetabular component were observed. Acetabular wear was always less than the precision of the measurement method. Osteolytic lesions were however observed as endosteal defects in the Merkel region measuring less than 1 cm2, observed in 18 out of the 56 hips (32%). These osteolytic lesions generally appeared between the first and second year and did not appear to progress.

Discussion: Osteolysis in the Merkel region appeared early for one third of the hips, despite the absence of cup polyethylene wear. It would be reasonable to be prudent when using zirone ceramic heads. We are continuing our close follow-up of this group of patients. In addition, measurements of wear and migration are being made using the EBRA method.

Purpose of the study: Extensive loss of femoral bone subsequent to implant loosening raises an unsolved problem. The purpose of this work was to examine mid-term results of 18 iterative total hip arthroplasties with femoral reconstruction using massive allografts performed between 1986 and 1997.

Materials and methods: Using the Vives classification, the femoral bone lesions were grade 3 (n = 2) and grade 4 (n = 16). The reconstruction was achieved with radiated massive allografts measuring 11 to 35 cm implanted in a split host femur. Charnley-Kerboull implants with a long stem were cemented in the reconstructed femurs.

Results: Mean follow-up was 4 years 10 months (range 2 to 9 years). Nine complications in 7 hips were observed: 6 trochanter nonunions, two recurrent prosthesis dislocations and 1 femoral fracture. At last follow-up, the functional result was excellent or very good in 12 hips (Merle d’Aubigné classification). A stable fixation persisted for 15 implants and 3 had loosened. Graft-host femur consolidation was achieved in all cases except 1. There were 3 cases with extensive resorption of the graft including 2 associated with loosening of the femoral component.

Discussion: Reconstruction of the femur after extensive bone loss using a massive allograft appears to be a useful method for restoring bone tissue and providing immediate mechanical support for the femur.