Since 1977 we did implant ceramic on ceramic THR in younger and active population. In 1991 we published (JBJS B N°4) data's in a consecutive group of patients under 50 years of age. What about the same patients for more than 30 years? Eighty-six hips in 75 patients, 41 males 34 females, mean age 43 (18 to 50), mean weight 68 kg (36 to 100), Charnley class: 38 A, 28 (38 hips) B, 9 patients (10 hips) C. Sixty-six primary procedures, 20 revisions (18 failed arthroplasties: 6 THR, 5 resurfacing, four single cup, two hemiarthroplasty, one bipolar), one after acetabular fractures. Four hips previously infected. Eight Patients deceased (8 hips) prosthesis still in place, ten lost to follow-up before 2 years, eight hips in 8 patients were revised before the review, partially followed: from 2 to 20 years: 35, completely followed: 25 hips in 23 patients resuming in: No pain in 20, slight pain in 2, severe disability in 3 not related to the hip, no radiolucent lines in 22, radiolucent lines in 3, no osteolysis in 25. Revision for: early sepsis in one, socket loosening in 8 (3 revisions cases), femoral head fractures in 2: one extra small head (22mm) for Crowe 3 DDH, one fractured at 24 years. Inertness, stability related to fibrous tissue generation, no noise.
Despite pure alumina have shown excellent long-term results in patients undergoing total hip arthroplasty (THA), alumina matrix composites (AMCs) composed of alumina and zirconium oxide are more commonly used. There are no comparative studies between these two different ceramics. We performed a retrospective case-control study to compare results and associated complications between AMC from two manufacturers and those with pure alumina from another manufacturer. 480 uncemented THAs with ceramic on ceramic (CoC) bearing surfaces (288 men and 192 women; mean age of 54.1 ± 12.4 years), were implanted from 2010 to 2015. Group 1: 281 THAs with pure alumina; Group 2A: 142 with AMC bearing in a trabecular titanium cup. Group 2B: 57 hips with AMC bearing with a porous-coated cup.Introduction and Objective
Materials and Methods
Fracture risks are the most common argument against the use of Ceramic on ceramic (CoC) hip implants. Question: is ceramic material at risk in case of severe local trauma? Over a long period, we tried to identify patients with a CoC prosthesis (Ceraver Osteal°)who did sustain a trauma. This was conducted in three different institutions. Eleven patients were found: 9 males and 2 females aged 17 to 70 years at time of index surgery. Accident occurred 6 months to 15 years after index: one car accident, five motorcycle accident, five significant trauma after a fall, including one ski board accident. Consequences of these trauma were: six fractures of the acetabulum with socket loosening in 4 that needed revision, two femoral shaft fracture, one orifed and one stem exchanged, one traumatic hip dislocation associated to loosening of the socket revised at 10 years, and one traumatic loosening of the socket. Ten had no consequence on ceramic integrity. One experienced a fracture of the patella from a dashboard trauma, a liner shipping was discovered during socket revision 2 years later. This is the only case of possible relation between trauma and ceramic fracture. In a more recent longitudinal study on 1856 CoC prosthesis performed from 2010 to 2021, 29 severe traumas were identified with no consequence on Ceramic material. From this limited case study, it can be assumed that Pure Alumina Ceramic well designed and manufactured, will not break after a significant trauma.
The objective of this study was to determine whether the bearing surface is a risk factor for revision after late dislocation in total hip arthroplasty (THA). Data from primary THAs were extracted from the New Zealand Joint Registry over a 13-year period. The mean age of patients was 68.9 years; 53.2% were female. The surgical approach used was posterior in 66% of THAs, lateral in 29% and anterior in 5%. There were 53,331 (65.1%) metal-on-polyethylene THAs, 14,093 (17.2%) ceramic-on-polyethylene, 8,177 (10.0%) ceramic-on-ceramic, 461 (0.5%) ceramic-on-metal, 5910, and (7.2%) metal-on-metal. The primary endpoint was late revision for dislocation, with ‘late’ defined as greater than one year post-operatively. 73,386 hips were available for analysis. The overall revision rate was 4.3% (3,130 THAs), 1.1% (836) were revised for dislocation. Only 0.65% (470) hips were revised for dislocation after the first post-operative year. The unadjusted hazard ratios (HR) showed significantly higher rates of revision for dislocation in ceramic-on-polyethylene (HR 2.48; p=0.001) and metal-on-polyethylene (HR 2.00; 95% p =0.007) compared to ceramic-on-ceramic. However, when adjusted for head size, age and surgical approach, only ceramic-on-polyethylene (HR 2.10; p=0.021) maintained a significantly higher rate of revision, whereas metal-on-polyethylene approached significance (HR 1.76; 95% p = 0.075). In New Zealand, dislocation is the most common reason for revision, ahead of aseptic loosening of the acetabular component. The relationships between bearing materials and risk of revision for late dislocation is controversial. However, in this study ceramic-on-ceramic shows lower risk rates for revision than other bearing surface combinations. Low wear and less debris, limited peri-articular inflammatory reaction and an healthy fibrotic pseudo-capsule are potential factors determining long-term stability of the hip joint.
Acetabular fractures management is controversial since, despite a good anatomical reduction, clinical outcome is not satisfactory very often and the probability of a total hip arthroplasty (THA) is high. Surgical treatment include long operating times, large approach, blood loss, neural and muscle damage, and a high risk of failure and secondary osteoarthritis related to bone necrosis, cartilage damage, and bone loss. We hypothesized that the acetabular fracture management affected the clinical and radiological outcome of THA after posttraumatic arthritis. We compared 49 patients (49 hips) initially treated conservatively followed some months later by THA in conjunction with acetabular reconstruction (group 1); and 29 patients (29 hips) who had undergone THA after a failed osteosynthesis (group 2). There were more associated fractures according to Letournel in group 2. The mean age was 59.3±15.8 years for group 1 and 52.9±15.2 years for group 2. The mean delay between fracture and THA was 75.4±5 months for group 1 and 59.4±5 for group 2. The mean follow-up was 11.7 in group 1 and 10.2 in group 2. Preoperative bone defect was similar. We used bone autograft in 13 hips (26.5%) in group 1 and four (13.6%) in group 2. We used acetabular reconstruction plates in 2 hips with a pelvic discontinuity in group 1. Complications, clinical outcome according to Harris Hip Score, and radiological reconstruction were compared. Two-way ANOVA with repeated measures were used for comparison.Introduction
Materials and Methods
Different pathologies, deformities, bone defects, previous surgeries and polyethylene wear limit the survival of total hip arthroplasty (THA) in young patients. We compare preoperative status and outcome in 171 young and very young patients (207 hips) who underwent a ceramic-on-ceramic THA. Sixty-three (77 hips) were less than 30 years old (group 1) and 108 (130) were between 30 and 40 years old. Mean follow-up was 11.3 years. Two-way ANOVA with repeated measures were used to analyse clinical and radiological changes. Juvenile rheumatoid arthritis (JRA) was the most frequent diagnosis in group 1 and avascular necrosis in group 2. Charnley class type C, low activivity, previous surgery and osteoporotic bone were more frequent in group 1 patients. There were 2 cup revisions for aseptic loosening in group 1 and 4 in group 2. Survivorship analysis at 15 years was 96.7% (95% IC 92.2 a 100) for group 1 and 96.1% (95% IC 92.2 to 100) for group 2 (p=0.749). Despite the worse preoperative status in group 1 patients, clinical outcome was similar in both groups. Severe dysplasia had the worst clinical result and avascular necrosis the best. Patients with Charnley class C and JRA showed the most improvement. Radiographic reconstruction of the abduction angle was worse in group 1 (p=0.02). No osteolysis or complications derived from ceramic use were found. We conclude that despite the worse preoperative status in group 1 patients, clinical and radiographic results were good in both groups of patients who received a ceramic-on-ceramic THA.
Recent studies about hip stability after total hip arthroplasties (THA) concerned differences regarding bearings: ceramic on ceramic (CoC) presenting less dislocations on the long term compared to metal or ceramic on polyethylene. The hypothesis is a difference in the healing process of periarticular tissues, with a stronger fibrous tissue for the first one, and more foreign body reaction, joint effusion with the others. NMR Imaging of the pelvis showing both hips using novel MR MAVRIC program for metal artefacts suppression, were performed in 10 patients, 15 THA and 2 non-pathological contralateral hips. Eight hips had CoC bearings, 3 of which were impacted cementless bulky ceramic implant, and 5 had a metal back. 7 hips had CoP bearings, 4 of which were cemented. Native capsules showed a mean thickness of 6.6mm. For CoC bearings, capsule thickness ranged from 7mm to 9.6 mm with a mean thickness of 8mm. For CoP bearings, capsule thickness ranged from 3mm to 8.4mm, with a mean thickness of 6.1mm. Neocapsule appeared clearly in all COC bearings observed, while for CoP, sometimes it was less dense with fatty aspect, 3 hips out of 7 having a very thin capsule under 4mm. It is possible to observe and quantify new capsule after THR and measure differences although not significant regarding bearings on limited number of samples. More patients might be included, but the tendencies observed here might explain better long term stability in vivo observed with Coc.
In the year 1977 we started to use ceramic on ceramic total hip (Ceraver*). The prosthesis was cemented on both sides. Ceramic was medical grade with relative large grains and high porosity. The stem was made of titanium alloy smooth and oxidized. In 1990 we published the results of 86 hips in 75 patients who were less than 50 years of age at time of operation (1). Recently we tried to reach the same patients, looking specifically to those who could have more than 20 or 30 years follow-up. This study design included all patients operated between 1977 and 1986 and having less than 50 years of age at time of surgery. Eighty six hips in 75 patients, 34 females and 41 men. Mean age was 43 (from 18 to 50) nine had a BMI in excess. 66 hips were performed primaries while 20 consisted in revision procedure including 6 total hip revisions, 5 resurfacing, 4 single cup, 3 hemiarthroplasty, and 2 acetabula fractures. Four of these had a past history of infection. Preoperative diagnosis were secondary osteoarthritis in 41, AVN in 26, primary OA in 3, Rheumatoid arthritis in 12, tuberculosis in 2 and hemophilic in two.Introduction
Material and methods
Starting in 1977 a new cemented stem made of titanium alloy (with vanadium) was designed regarding some principle: rectangular shape, smooth surface covered with thin layer of titanium oxide, filling the medullar cavity. As a consequence: a thin layer of cement. It was designed with a collar. Initial Cementing technique used dough cement, vent tube and finger packing; then we applied cement retractor low viscosity cement and sometimes Harris Syringe. At the moment we went back to initial technique plus a cement retractor made of polyethylene. Many papers looked at long term follow up results depicting about 98 to 100 percent survivors at 10 years and 95 to 98% at 20 years (Hernigou, Hamadouche, Nizard, El Kaim). Clinical as well as radiological results are available. Radiological results depicted some radiolucent lines that appeared at the very long term. They could be related to friction between the stem and the cement. As advocated by Robin Ling, he called “French paradox” the fact that if a cemented prosthesis is smooth and fills the medullary cavity, long term excellent results could be expected. This was the case with stainless steel Kerboull shape, the Ling design (Exeter)and the Ceraver design. The majority of these stems were implanted with an all alumina bearing system. And in some occasion, when revision had to be performed, the stem was left in place (108 cases over 132 revisions) Our experience over more than 5000 stems implanted is outstanding (see figure 1: aspect after 30 years). Discussion other experience with cemented titanium stem were bad (Sarmiento, Fare). We suspect that this was related either to the small size of this flexible material, or to the roughness of its surface. If one uses titanium cemented stem it must be large enough and extra smooth.
Hard-on-hard bearing surface have been accepted as a valuable alternative for young and active patients needing a hip replacement because these combinations are resistant to wear. Initial development of alumina-on-alumina bearings faced complications such as fractures, and socket loosening. But, with the increasing number of prostheses implanted, noise occurrence appeared as a new complication. The primary aim of the present survey was to quantify the prevalence of having noise in a population receiving alumina-on-alumina hip arthroplasty. Two hundred and eighty-four ceramic-on-ceramic hips were performed in 238 patients (126 males and 112 females) from January 2003 to December 2004. The average age at the index operation was 52.4 ± 13.4 years (range, 13 to 74 years). We used the same type of prosthesis for all patients manufactured in all cases by Ceraver-Osteal®. Clearance between femoral and insert was between 20 and 50 microns in order to achieve minimal wear. The survey was conducted by an independent surgeon who did not participated in patients care during the last 6 months of 2007. He interviewed the patients by phone with a standardized questionnaire (appendix) that aimed to assess if noise was present and the characteristics of this noise if present. No suggestion was done on how they could describe the noise and they felt free to use the word that they considered to be the most adapted. Satisfaction was evaluated asking if the patient was very satisfied, satisfied or dissatisfied with its prosthesis. When the noise was present, the X-ray was independently evaluated to assess if sign of component fracture was present. Four patients (six hips) died of unrelated cause during the follow-up. Three patients (three hips) lived outside France and could not be followed (1.3%). Nine patients (ten hips) could not be traced and are considered lost to follow-up (3.8%). Two hundred and twenty-two patients with 265 hips were therefore surveyed. Among these 265 hips, 28 experienced noise generation (10.6%). It was defined as a snap for 6 patients, as a cracking sound by 6, as rustling by 6 patients, as a squeaking by 7 patients (2.6%), a tinkling by 2 patients, one patient was unable to define the sound she felt. No factor related to the patient influenced the occurrence of noise. Twelve patients were dissatisfied with the result of the hip prosthesis, 5 of them experienced noise (41.7%); 210 were satisfied or very satisfied 23 of them experienced noise (11%); this difference was significant (p=0.002). No patients required revision for noise. The origins of noise occurrence are unknown but several hypotheses can be suggested. Squeaking may be due to absence of sufficient lubrication. Other types of noise can be due to microseparation, occult dislocation, impingement between the femoral neck and the acetabular rim but demonstration remain an issue.
Femoral revision is frequent, due to femoral loosening, thigh pain, recurrent dislocation, osteolysis or sepsis. Whatever the reason, with the exception of some difficult septic cases, our strategic approach is similar. Some of our expertise concern femoral stem retrieval. Our reconstruction strategy is different if we are revising total hip in active and young patient or if it is an old and inactive one. First step is always an large “en bloc” tissue excision. For old and inactive, it is sometimes possible to retain the stem if not loosed and perform a “in cement” cementation; In this group we select usually metal or alumina on polyethylene couple and cemented implants; In young and active, we select alumina on alumina combination which resumed in cementless acetabular fixation, and cementless or cemented stem. Stem retrieval of a well fixed cementless stem is performed via a large transtrochanteric approach associated with a transfemoral one. Repair is performed using cerclage and long cemented stem. Cement retrieval is performed since 9 years using Ultra sound (Oscar*) material, which in our hand is very successful specially for cement retractor retrieval. Then medullary canal is reamed in order to get a bloody healthy bone receive either a cemented or sometimes a cementless stem, depending on the bone quality. To compensate femoral bone destruction and enhance cemented stem fixation, we used a modified Ling technique replacing allogenic morcellised bone by hydroxyapatite granules. Granules of 5 mm in diameter are made of 70% HA and 30% of β TCP. Mechanical resistance is excellent and biological activity is high. Thus stem stability can be obtained easily. This can be done either with a cemented or a cementless stem (about 60 cases). In case of very severe bone loss and osteolysis, we performed massive allogenic bone transplant associated with long cemented stem and distal HA granules with cement.(17 cases). As we usually performed one stage revision for septic cases, strategy is not different; It is only in selected cases with many sepsis recurrence and specially aggressive bacteria that we performed a two stage procedure.
an abundant vascular network, presence of cells expressing transcription factor CBFA1, very few inflammatory CD14+ cells (macrophages), an extracellular matrix positive for type I collagen.
evaluate new therapeutic strategies for bone regeneration in conditions close to clinical situations, study the role of the membrane in bone repair. The presence of a pseudosynovial membrane might:
be a barrier against the diffusion of bone morphogenetic proteins outside the lesion and potentially be a reservoir of stem and vascular cells which could be useful for new technologies.
Since 1977 we did implant all alumina (Al2O3) bearings total hip prostheses. A lot of data were documented concerning tissue reaction, in vivo wear behaviour, fractures, and clinical outcome. Ceramic materials retrieved at revision were analysed. In some cases, wear was as low as a few microns for a 15-year period in use. This is two thousand times less than a regular metal on polyethylene sliding couple. and 100 times less than a metal on metal prosthesis. Fracture mechanism is related to crack propagation into the material. During the first period, the fracture rate was in the range of 2%; it then dropped to less than 0.1 %. Few fractures could not be explained by technical or design mistakes. Clinical outcome: More than 4000 total hips in selected young and /or active patients were implanted. In a recently reported series of consecutive patients operated by P.Boutin during the year 1980, 118 hips in 106 patients were included. Mean age was 62 years. At the twenty-year follow-up evaluation, forty-five patients (fifty-one hips) were still alive and had not been revised, twenty-five patients (twenty-five hips) had undergone revision of either or both components, twenty-seven patients (thirty hips) had died from unrelated causes, and nine patients (twelve hips) were lost to follow-up. The mean Merle d’Aubigné hip score was 16.2 ± 1.8 at the latest follow-up. Survival of the cup at twenty years with revision for any reason as the end-point was 85.6 percent for cementless cups versus 61.2 % for cemented cups, respectively. Survival of the stem at twenty years with revision for any reason as the end-point was 84.9 % for cementless stems versus 87.3% for cemented stems. Wear of the prosthetic components was undetectable on plain radiographs. No fracture of the alumina socket or head was recorded. Another study concerned a more recent design of the socket which consisted in a metal back titanium alloy shell covered with a pure titanium mesh with an alumina liner. The nine year survival rate was 98.4% with revision for aseptic loosening as the end point. Conclusion This alumina on alumina bearing provides interesting results without any physical limitation specially in young and active patients.
Effectiveness of total hip arthroplasty (THA) for acute fracture of the femoral neck is still debated. The purpose of this retrospective controlled study was to compare the results of THA done for fracture of the femoral neck with a similar group of matched THAs done for osteoarthritis (OA). From 1993 to 2000, 25 patients (25 hips) had THA for displaced femoral neck fracture. There were 18 women and 7 men, with a mean age of 73+/− 8.5 years (range, 55 to 93 years). The control group was composed of 25 patients (27 hips) who had THA for primary OA. Patients were matched for age, sex, medical comorbidity, surgical approach, prosthesis, and surgeon. Cemented implants with a Me-PE couple were used in the great majority. All patients had radiographic assessment. Functional results were rated according to the grading system of Merle d’Aubigné. One patient (one hip) was lost to follow-up in each group. The mean follow-up was 6 years (range, 3.5 to 10 years). No revision was performed in this series. Complications included one postoperative dislocation in both groups. At the last follow up evaluation, 21 hips and 23 hips were classified excellent or very good in the “fracture” group and in the control group respectively. No progressive radiolucent line and no osteolysis were recorded. Mean annual PE wear was 0.096 +/− 0.094 (range, 0 to 0.26 mm) in the studied group compared with 0.125+/− 0.095 (range, 0 to 0.24 mm) in the control (p=0.30). THA for acute femoral neck fracture and THA for OA provided comparable mid to long term results in elderly patients.
From 1979 to 2002, 131 total hip replacement were performed consecutively in patients less than 30 years of age (13 to 30,7 mean 24;2) in 75 patients (44 in males and 31 in females. Seventy six in 57 patients could have more than 2 years follow-up and will presented hereby. Regarding the type of prosthesis, 59 stem were cemented and 16 cementless. Five different socket were implanted: 6 screw-in metal back: 8 bulky cemented, 23 bulky cementless, 13 metalback press fit with titanium mesh and 26 HA covered. Underlying diseases were Avascular necrosis in 46, 8 inflammatory disease, 6 after infected articulation, epiphysiolysis in 4 and acetabular fracture in 3. 48 were done primarily, 28 were a revision procedure and 10 had some past history of infection. Mean follow up was 7,84 years (range 1,13-22,9). One patient (two hips deceased at 1,1 year. One hips was lost to follow-up. 73 had complete clinical and radiological evaluation. Nine hips were revised from 2,97-18,64 years after the index procedure (mean 8,53). In 7 only the socket was revised, in two both components. Two of these were infected (secondary infection in one). Of the remaining: 45 had no pain, 18 slight uncommon pain, 10 were classified 5 and 8 had some limp. Radiological evaluation: 56 had no lucent lines nor subsidence, 4 had some radiolucent line none progressive and 1 had a complete lucent line: and is considered as impending failure. In no case osteosysis was documented. With the exception of socket loosening due to non optimal design of the initial system (bulky alumina cemented or cementless) the overall results are in favor of theis material in young and active patients.
Between 1990 and 1992, we implanted 71 hybrid alumina-on-alumina hip arthroplasties in 62 consecutive patients under the age of 55 years, with a mean age of 46 years at surgery. There were 56 primary and 15 secondary procedures. The prostheses involved a cemented titanium alloy stem, a 32 mm alumina head, and a press-fit metal-backed socket with an alumina insert. Three patients (four hips) died from unrelated causes. Four hips had revision surgery for either deep infection, unexplained persistent pain, fracture of the alumina head, or aseptic loosening of the socket. The nine-year survival rate was 93.7% with revision for any cause as the end-point and 98.4% with revision for aseptic loosening as the end-point. The outcome in the surviving patients (50 patients, 57 hips) with a minimum five-year follow-up (mean eight years) was excellent in 47 hips (82.5%), very good in eight (14%), good in one and fair in one. A thin, partial, lucent line, mainly in zone III was present in 38% of the sockets and one socket had a complete lucency less than 1 mm thick. One stem had isolated femoral osteolysis. There was no detectable component migration nor acetabular osteolysis. This hybrid arthroplasty gave satisfactory medium-term results in active patients. The press-fit metal-backed socket appeared to have reliable fixation in alumina-on-alumina hip arthroplasty. The excellent results using cemented fixation of the stem may be related to the low production of wear debris.
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.
In order to avoid the consequences of polyethylene wear in a high-risk population, 128 alumina-alumina total hip arthroplasty were implanted in 116 consecutive patients of 40 years old or less. Osteonecrosis and sequellae of congenital hip dislocation were the main etiologies representing 71% of the hips. The same titanium alloy cemented stem was implanted in all hips. Four alumina acetabular component fixations were used: cemented plain alumina socket (41 hips), screw-in ring with an alumina insert (22 hips), a press-fit plain alumina socket (32 hips) and a press-fit titanium metal back with an alumina insert (33 hips). Eight patients (11 hips) died during the follow-up period. Sixteen revisions were documented, 12 for ace-tabular aseptic loosening, 3 for bipolar loosening (2 were septic), and 1 for unexplained pain. Eighty-nine hips were followed radiologically for two to twenty years. No femoral nor acetabular osteolysis were observed with an average follow-up of 8.4 years. Wear was unmeasurable. Four additional sockets showed definite migration. The respective survival rate at 7 years were 91.4% for the cemented cup, 88.8% for the screw-in ring, 95.1% for cementless press-fit plain alumina socket and 94.3% for the metal-back press-fit component. The ten-year survival rate was 88.0% for the cemented socket and 88.8% for the screw-in ring. The fifteen-year survival rate was 76.7% for the cemented socket. The occurrence of a graft was the only prognostic factor with a 62.6% survival rate at ten years for the grafted hips and a 90.1% for the non-grafted hips (p=0.004). The alumina-alumina bearing surfaces for young patients appeared as a valuable alternative to standard metal-polyethylene system. There is a need to improve socket fixation if we want to have a survival of the arthroplasty as long as the life expectancy of this increasing and demanding population. The last design with a fully coated HA titanium shell and an alumina liner seems to fulfill the requirements.
There are also intraoperative risks of neural damage: sciatic nerve as well as gluteus medius nerve. On the other hand , modern surgical technique including an alumina against alumina bearing could allow very long term survival without any activity limitation and this even in very young patients. Secondary procedure after a failed osteosynthesis provides statistically worse functional results than primary total hip. The surgery is more difficult because of hardware retrieval, nerve dissection, bone reconstruction and remaining muscular dysfunction.
There were 22 neural disorder; 19 sciatic palsies; 13 post trauma; 4 post osteosynthesis; 2 post THR; 3 gluteus medius palsy. 7 sepsis: 4 post osteosynthesis, 3 post THR (including 2 post osteosynthesis).
Many weak results could have been avoided by doing fine primary surgery. We could expect better functional results with less complications regarding sepsis, nerve damage, muscle preservation if we perform a primary total hip in conjunctions with acetabular reconstruction. Osteosynthesis is still recommended for simple acetabular fracture with large displacement involvement of the posterior wall or one column not comminuted.
Severe acetabular fractures are difficult to treat. Complications include blood loss, neural damage, long operating times, and a high risk of sepsis and failure. Even when the fracture is ideally stabilised, there is a major risk of secondary osteoarthritis. This can be related to bone necrosis, cartilage surface damage, bone loss. However, even in young patients modern surgical techniques, including use of an alumina-against-alumina bearing, may facilitate long-term survival without limitation of activity. Functionally, the results of secondary procedures after failed osteosynthesis are statistically worse than after primary total hip arthroplasty (THA). The surgery is difficult because of material retrieval difficulties, nerve dissection, bone reconstruction and remaining muscular dysfunction. We reviewed the results of 80 THA procedures done between 1980 and 1998 to treat 58 acetabular fractures. The mean age of our 57 patients (39 men and 18 women) was 50 years (21 to 80). The mean delay between fracture and THA was 10 years in 22 patients who had undergone osteosynthesis and six years in 35 patients who had been treated conservatively. The mean follow-up period was 5,5 years (6 months to 20 years). There were eight instances of socket loosening, two of which were septic and six aseptic. Two of these patients had screw-in prostheses and six had cemented. There were 19 sciatic palsies, 13 of which developed after trauma, four after osteosynthesis and two after THA. There were three cases of gluteus medius palsy. In two of four cases of sepsis that occurred after osteosynthesis, sepsis recurred after THA, and in one patient sepsis developed after THA. In this limited series, patients who underwent THA after osteosynthesis did not have as good an outcome as those in whom initial orthopaedic treatment was followed some weeks later by THA. We believe many poor results could have been avoided with better primary surgery. Functional results are likely to be better, and the incidence of complications lower, if primary THA is performed in conjunction with acetabular reconstruction. Of course, for treatment of simple acetabular fracture involving major displacement of the posterior wall, one column osteosynthesis is still recommended.
Alumina-on-alumina bearings in total hip arthroplasty (THA) were introduced about 30 years ago. Theoretically, their excellent tribological properties and low debris generation provide a solution to osteolysis. The 24-year experience of the Paris group suggests that osteolysis is no longer a problem. Any need for revision was related to mechanical failure rather than to debris, except in a few cases in which a pros-thesis that had been loose for many years resulting in metal-on-ceramic impingement. Cemented socket and screw-in ring metal-backed alumina yielded poor results. The recent improvements in alumina quality and in ceramic fixation, using cementless fully coated hydroxyapatite material, may provide a solution in active young patients. Preliminary results of the first 100 THA procedures using a cementless stem and socket and 32-mm alumina head, and alumina liner secured with a Morse taper, are very encouraging. One socket required revision because of poor initial surgery in a severe acetabular fracture. Patients ranged in age from 14 to 71 years (median 45 years).
We have carried out a prospective, randomised study designed to compare the long-term stability of the stem of cementless femoral implants with differing surface configurations. A total of 50 hips (46 patients) was randomised into two groups, according to whether the medullary stem had been grit blasted (GB) or coated with hydroxyapatite (HA). Both femoral prostheses were of the same geometrical design. We used Ein Bild Roentgen Analyse femoral component analysis (EBRA-FCA) to assess the stability of the stem. The mean follow-up was for 8.66 years. The mean migration of the stem was 1.26 mm in the HA group compared with 2.57 mm in the GB group (Mann-Whitney U test, p = 0.04). A mixed model ANOVA showed that the development of subsidence was statistically different in the two groups during the first 24 months. After this subsidence increased in both groups with no difference between them. Our results indicate that, with the same design of stem, HA coating enhanced the stability of the femoral stem when compared with GB stems.
We compared and quantified the modes of failure and patterns of wear of 11 Mittelmeier and 11 Ceraver-Ostal retrieved alumina-alumina hip prostheses with reference to the corresponding clinical and radiological histories. Macroscopic wear was assessed using a three-dimensional co-ordinate measuring machine. Talysurf contacting profilometry was used to measure surface roughness on a microscopic scale and SEM to determine mechanisms of wear at the submicron level. The components were classified into one of three categories of wear: low (no visible/measurable wear), stripe (elliptical wear stripe on the heads and larger worn areas on the cups) and severe (macroscopic wear, large volumes of material lost). Overall, the volumetric wear of the alumina-alumina prostheses was substantially less than the widely used metal and ceramic-on-polyethylene combinations. By identifying and eliminating the factors which accelerate wear, it is expected that the lifetime of these devices can be further increased.
Limited success in regenerating large bone defects has been achieved by bridging them with osteoconductive materials. These substitutes lack the osteogenic and osteoinductive properties of bone autograft. A direct approach would be to stimulate osteogenesis in these biomaterials by the addition of fresh bone-marrow cells (BMC). We therefore created osteoperiosteal gaps 2 cm wide in the ulna of adult rabbits and either bridged them with coral alone (CC), coral supplemented with BMC, or left them empty. Coral was chosen as a scaffold because of its good biocompatibility and resorbability. In osteoperiosteal gaps bridged with coral only, the coral was invaded chiefly by fibrous tissue. It was insufficient to produce union after two months. In defects filled with coral and BMC an increase in osteogenesis was observed and the bone surface area was significantly higher compared with defects filled with coral alone. Bony union occurred in six out of six defects filled with coral and BMC after two months. An increase in the resorption of coral was also observed, suggesting that resorbing cells or their progenitors were present in bone marrow and survived the grafting procedure. Our findings have shown that supplementation of coral with BMC increased both the resorption of material and osteogenesis in defects of a clinical significance.
We made a semiquantitative study of the comparative histology of pseudomembranes from 12 loose cemented ceramic-ceramic and 18 metal-polyethylene total hip replacements. We found no significant difference in cellular reaction between the two groups, but there was a major difference in the origin of the particulate debris. In the metal-polyethylene group, polyethylene of articular origin was predominant, while in the ceramic-ceramic group the cellular reaction appeared to be a response to zirconia ceramic particles used to opacify cement used for fixation. Isolation and characterisation of the debris showed that the zirconia particles formed the greatest proportion (76%) in ceramic-ceramic hips, while alumina debris of articular origin formed only 12%. Our study has indicated that aseptic loosening of ceramic cups is not due to a response to debris generated at the articular interface, but to mechanical factors which lead to fragmentation of the cement.
After an allogenic bone-marrow transplant, a vascular necrosis of the femoral head may affect young adults, producing destructive lesions which require hip replacement. We have reviewed 27 consecutive such total hip arthroplasties (THA) at a minimal follow-up of two years. Of these, 20 were primary operations for Ficat (1985) stage-III and stage-IV lesions, and seven were revisions after the failure of previous surgery. The median age at operation was 30 years (17.5 to 44). The prostheses had a cemented, collared titanium-alloy stem, an alumina-alumina joint, and a press-fit socket. Seven had a titanium-alloy metal back and 20 had all-alumina cups of which six had to be cemented. At an average follow-up of five years, no patient had been lost to follow-up. One had died from septicaemia after two years and another with chronic graft-versus-host disease developed a deep infection 2.5 years postoperatively and had a successful revision. There were no revisions for aseptic loosening. The clinical results on the Merle d’Aubigné and Postel (1954) scale were very good or excellent in 23 hips (88%), good in one and fair in two. Ten hips showed incomplete acetabular radiolucencies less than 1 mm thick, but there were no radiolucent lines around the stems. We conclude that for these difficult patients THA with ceramic joints and careful technique provides the best short- and medium-term option after the failure of medical treatment.
We report 17 patients who had grafting of the common peroneal nerve after traction injuries. Sixteen were reviewed at a median follow-up of 36 months. The nerve gap ranged from 7 to 20 cm. A functionally satisfactory result was achieved in six patients (37.5%), a fair result in six and a poor result in four. Seven patients had, in addition, a posterior tibialis tendon transfer; this improved the result in five. Grafting produced some satisfactory results even when the nerve gap was as long as 20 cm.
Total hip replacement using an alumina head and socket and a titanium alloy stem is evaluated in a series of patients under 50 years of age. Between April 1977 and December 1986, 86 such replacements were performed in 75 patients, but mainly because patients had difficulty travelling from Africa, only 71 hips were followed up adequately; of these, 56 were primary procedures and 15 revisions. Survivorship analysis showed that 98% of the prostheses were retained for 10 years. On clinical and radiological examination 51 of the 71 hips were stable and acceptable, 15 had radiological changes on the acetabular side, and one on the femoral side; four other cases had clinical and radiological changes suggesting impending failure, possibly because fixation of the socket was inadequate. There were no differences between the results of the primary procedures and those of revisions. In these young patients, the results seem better with alumina-on-alumina hips than with other varieties, possibly because of their remarkably low wear.
Between October 1972 and December 1980, 139 post-traumatic brachial plexus palsies were operated upon by the same surgeon. The results of 63 are reported with a follow up of at least three years for the 32 complete palsies and two years for the 31 partial palsies. The protocol for examination and surgical repair is described. Major repairs were performed in 48, including suture, interfascicular grafting and nerve transfer. The remaining 15 had a neurolysis. The results are given for each type of lesion and for each kind of repair. Two series of complete palsies, one treated operatively, the other conservatively, are compared. It is concluded that surgical repair gives good results in partial palsies and in some complete palsies. Nerve transfer or graft gives some improvement but the usefulness of the limb remains disappointing.