We present a study done to measure the change of angle of the acetabulum or cup, due to leg length discrepancy, deformity of hip and spine on standing. In 1998 a 3-dimensional reconstruction of hip model was prepared on CAD and the change of angle of the cup was measured as Functional Acetabular Inclination Angle (FAIA) with patient standing without squaring the pelvis. The FAIA on standing was compared with angle of the cup with patient in supine position with squared pelvis. The position of the cup changed on weight bearing due to multiple issues. The results showed that one centimetre of leg lengthening changed FAIA by 3°, 10° of abduction deformity resulted in apparent lengthening of 2.87 cm and loss of lordosis anteverted the cup on loading and vice-versa. We conclude that fixed hip deformities, leg length discrepancy and spine deformities can affect the angle of cup in hip replacement surgery and may prone to dislocations, impingement and segmental wear of the cup

Background. There is much research on metal on metal hip resurfacing arthroplasty (HRA) but few studies have reported the outcome with respect to implant characteristics from non-specialist centres. Aim. To report the survival, clinical and radiological outcomes of a single surgeon series of HRA with an average follow-up of 5 years. Methods. All consecutive HRAs performed by a single surgeon between 2002–2010 at a district general hospital were examined clinically and radiologically. The median follow-up was 61 months (12–102). Clinical assessment included the Oxford Hip Score (OHS) and University of Los Angeles (UCLA) Activity Score. Radiological assessment included implant position and various bony changes. Survival was defined as a need for revision of either component. Results. There were 75 HRA procedures (59 patients): 70 Birmingham, 2 Conserve, 2 Adept and 1 ASR. The median age was 58 years (25–75) with 46.7% (35) male and 53.3% (40) female. 4.2% (3) patients were lost to follow-up. The mean acetabular and femoral implant sizes were 54.8mm (48–64) and 48.2mm (42–58) respectively. The mean acetabular and femoral inclination angle was 45.4° (20.8–75.2°) and 138° (133–149.5°) respectively. Survival rate was 92% with 6 revisions due to aseptic loosening (3) and fracture (3). These failures were all predominantly female (5) with significantly smaller mean acetabular (50mm, p=0.036) and femoral (43.3mm, p=0.038) implant sizes. Moreover, they had a higher mean acetabular inclination angle of 47.8° (p=0.27). The mean OHS was 43.5 (25–48) and the mean UCLA activity score was 6.7 (3–10). Radiological findings included heterotopic ossification in 21.6% (16), radiolucent lines in 6.8% (5), femoral neck thinning in 2.7% (2) and notching in 5.4% (4). Discussion. HRA has been shown to have comparable clinical and radiological short-medium term outcomes in a non-specialist centre using different implants. Failed procedure rate is high and patients were predominantly female, with significantly smaller implants and a higher acetabular inclination angle. Vigilance is therefore required in case selection and in follow-up for such patients

The problem associated with ceramic on ceramic total hip replacement (THR) is audible noise. Squeaking is the most frequently documented sound. The incidence of squeaking has been reported to wide range from 0.7 to 20.9%. Nevertheless there is no study to investigate on incidence of noise in computer assisted THR with ceramic on ceramic bearing. The purpose of this study was to determine the incidence and risks factors associated with noise. We retrospectively reviewed 200 patients (202 hips) whom performed computer assisted THR (Orthopilot, B. Braun, Tuttlingen, Germany) with ceramic on ceramic bearing between March 2009 and August 2012. All procedures underwent uncemented THR with posterior approach by single surgeon. All hips implanted with PLASMACUP and EXIA femoral stem (B. Braun, Tuttlingen, Germany). All cases used BIOLOX DELTA (Ceramtec, AG, Plochingen, Germany) ceramic liner and head. The incidence and type of noise were interviewed by telephone using set of questionnaire. Patient's age, weight, height, body mass index, acetabular cup size, femoral offset size determined from medical record for comparing between silent hips and noisy hips. The acetabular inclination angle, acetabular anteversion angle, femoral offset, hip offset were reviewed to compare difference between silent hips and noisy hips. The audible noise was reported for 13 hips (6.44%). 5 patients (5 hips) reported click (2.47%) and 8 patients (8 hips) squeaked (3.97%). The mean time to first occurrence of click was 13.4 months and squeak was 7.4 months after surgery. Most common frequency of click was less than weekly (60%) and squeak was 1–4 times per week (50%). Most common activity associated with noise was bending; 40% in click and 75% in squeaking. No patients complained for pain or social problem. Moreover, no patient underwent any intervention for the noise. The noise had not self-resolved in any of the patients at last follow up. Age, weight, height and BMI showed no statistically significant difference between silent hips and click hips. In addition, there was also same result between silent hips and squeaking hips. Acetabular cup insert size and femoral offset stem size the results showed that there was no statistically significant difference between silent hips and click hips, also with squeaking hips. Acetabular inclination, angle acetabular anteversion angle, femoral offset, hip offset the results shown that only acetabular anteversion angle differed significantly between silent hips (19.94±7.78 degree) and squeaking hips (13.46±5.54 degree). The results can conclude that incidence of noise after ceramic on ceramic THR with navigation was 6.44 %. Squeaking incidence was 3.97% and click incidence was 2.47%. The only associated squeaking risk factor was cup anteversion angle. In this study, squeaking hip had cup anteversion angle significant less than silent hip

Background:. Metal-on-metal total hip arthroplasty (THA) implants have been widely debated due to the adverse wear issue related to the bearing surfacing. However, more recent studies have shown that the high metal ion problems that occur after surgery with this type of implant may not be exclusively related to the all metal bearing surfaces, but mainly due to the recently modified connecting tapers. Biomet is one of few companies who have not changed their original taper design for their THA implants. The purpose of this study was to present our up to eight-year clinical results. Method:. Between November 2004 and April 2011, all of the 196 cases in 167 patients (77 male vs. 89 female) performed by a single surgeon were included in this study. The Biomet Magnum/Jumbo metal-on-metal total hip arthroplasty implants were utilized for all of the cases. The average age was 59 ± 11 years at the time of surgery. Thirteen patients deceased from causes unrelated to THA. The primary diagnosis was OA in 124 cases; followed by AVN in 41 cases, dysplasia in 12 cases and other causes in the remaining 19 cases. The average acetabular component sizes were 54 ± 4 mm. Clinical and radiographic examinations were performed prospectively, and the results were analyzed. Results:. The mean duration of follow-up was 5 ± 2 years. There were four revisions: 1) one was due to an adverse wear issue with a cobalt level of 109 μg/l and a chromium level of 77 μg/l. The primary diagnosis was OA for this case. The acetabular inclination angle was 65°. The acetabular component was revised using the Biomet Magnum Tri-Spike component with the acetabular inclination angle of 41°; one year after the surgery, the metal ion level results showed a cobalt level of 2.4 μg/l and a chromium level of 9.7 μg/l with a Harris hip score of 100. This patient also has a total knee replacement on the same side. 2) one due to acetabular component loosening; the HHS was 100 two years after the revision 3) twodue to deep infection; the HHS was 93 at one year and 100 atbthree years after the revision correspondingly. The metal ion results were available for 114 patients at the time of this study. Four patients had metal ion levels ≥ 7 μg/l; three out of these four patients' levels were ≥10 μg/l and one out of these four had levels ≥15 μg/l. Using failure of any component as the end point, the Kaplan-Meier Survival rate was 99.5% at five years and 96.7% at eight years for the whole group. Conclusions:. This study suggests that Biomet metal-on-metal THA showed a high success rate with a low adverse wear rate. Our clinical results may suggest that all metal bearing surfaces may not be the key to the recent adverse wear issue. The surgical technique and taper problems in other implants may be the major causes. Further studies need to confirm our results

Hip resurfacing arthroplasty (HRA) is a bone conserving alternative to total hip arthroplasty. We present the early 1 and 2-year clinical and radiographical follow-up of a novel ceramic-on-ceramic (CoC) HRA in a multi-centric Australian cohort. Patient undergoing HRA between September 2018 and April 2021 were prospectively included. Patient-reported outcome measures (PROMS) in the form of the Forgotten Joint Score (FJS), HOOS Jr, WOMAC, Oxford Hip Score (OHS) and UCLA Activity Score were collected preoperatively and at 1- and 2-years post-operation. Serial radiographs were assessed for migration, component alignment, evidence of osteolysis/loosening and heterotopic ossification formation. 209 patients were identified of which 106 reached 2-year follow-up. Of these, 187 completed PROMS at 1 year and 90 at 2 years. There was significant improvement in HOOS (p< 0.001) and OHS (p< 0.001) between the pre-operative, 1-year and 2-years outcomes. Patients also reported improved pain (p<0.001), function (p<0.001) and reduced stiffness (p<0.001) as measured by the WOMAC score. Patients had improved activity scores on the UCLA Active Score (p<0.001) with 53% reporting return to impact activity at 2 years. FJS at 1 and 2-years were not significantly different (p=0.38). There was no migration, osteolysis or loosening of any of the implants. The mean acetabular cup inclination angle was 41.3° and the femoral component shaft angle was 137°. No fractures were reported over the 2-year follow-up with only 1 patient reporting a sciatic nerve palsy. There was early return to impact activities in more than half our patients at 2 years with no early clinical or radiological complications related to the implant. Longer term follow-up with increased patient numbers are required to restore surgeon confidence in HRA and expand the use of this novel product. In conclusion, CoC resurfacing at 2-years post-operation demonstrate promising results with satisfactory outcomes in all recorded PROMS

Protrusio acetabuli can be either primary or secondary. Primary or idiopathic protrusio is a rare condition of unknown etiology. Secondary protrusio may be associated with rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, osteomalacia, trauma and Paget's disease. Challenges in surgery include: lack of bone stock, deficient medial support to the cup, difficulty in dislocating the femoral head, and medialization of the hip joint center. Several surgical techniques have been described: use of cement alone without bone graft; morselised impacted autograft or allograft with a cemented cup; metal cages, reinforcement rings, and solid grafts. We describe our technique of impaction grafting using autologous bone and a cementless porous-coated hemispherical cup without the use of acetabular rings or cages in patients with an average age of 46 years. Protrusion was graded depending on distance of medial wall from Kohler's line as mild (1–5 mm medial), moderate (6–15 mm medial) and severe if it was more than 15 mm medial to the Kohler's line. All patients were operated in the lateral position using a modified Hardinge's anterolateral approach. Adductor tenotomy may be required in cases of severely stiff hips. After careful dislocation of the femoral head, it was sectioned in situ into slivers to facilitate obtaining the graft. The periphery was reamed and care was taken to preserve the membrane lining the floor of the defect. Morselised graft was impacted with hemispherical impactors and the trial cup 1–2 mm larger than the last reamer placed in the desired position. The final socket was then inserted. Femoral preparation was performed in routine fashion. The mean pre-operative Harris Hip Score of 52 improved to 85 points at a mean follow up of 4 years. The average acetabular inclination angle was 42 degrees. Our results have shown incorporation of the graft in all cases. There was no evidence of progression of the protrusio or cup loosening in any of the cases. Thus far, our hips have not shown osteolytic lesions. The technique described is a satisfactory biological solution of restoring bone stock particularly in young and middle-aged patients

INTRODUCTION. Traditionally, acetabular component insertion in direct anterior approach (DAA) total hip arthroplasty (THA) has been performed using fluoroscopic guidance. Handheld navigation systems can be used to address issues of alignment, cup placement and accuracy of measurements. Previous navigation systems have been used successfully in total knee arthroplasty (TKA) and has now been introduced in THA. We investigated the use of a new accelerometer-based, handheld navigation system during DAA THA to compare it to traditional means. This study aims to determine accuracy of acetabular cup placement as well as fluoroscopy times between two groups of patients. METHODS. Data was prospectively collected for a group of consecutive DAA THA procedures using a handheld navigation system (n=45) by a single surgeon. This was compared to data retrospectively collected for a group that underwent the same procedure without use of the navigation system(n=50). The time for use of the navigation system, including insertion of pins/registration, guiding cup position, and removal of pins, was recorded intraoperatively. Postoperative anteroposterior and cross-table lateral radiographs were used to measure acetabular inclination and anteversion angles. Targeted angles for all cases were 40° ±5 for inclination and 20° ±5 for anteversion. Intraoperative fluoroscopy exposure times were obtained from post-anesthesia care unit radiographs. RESULTS. Mean time of pin insertion/registration, cup positioning and removal was 180.5 seconds, 127.7 seconds and 26 seconds, giving a mean total time of 5.6 minutes. There were no significant differences in mean postoperative acetabular inclination angles between the navigation group as compared to the non-navigation group (39.8° vs 40.6°) (p = .2). There were no significant differences in mean postoperative acetabular anteversion angles between the navigation group as compared to the non-navigation group (24.3° vs 23.7°) (p=.5). Mean intraoperative fluoroscopy exposure times were significantly lower in the navigation group as compared to the non-navigation group (12.6 vs 22.2 seconds) (p<.0001). CONCLUSION. The findings demonstrated that a new handheld navigation system required minimal increase in operative time and was as accurate for cup positioning as fluoroscopically assisted DAA THA. Furthermore, there was a 45% reduction in fluoroscopy exposure time. Reduction in fluoroscopy time will lower radiation exposure for the surgeon and patients

Introduction. Studies of metal-on-metal (MoM) hip resurfacing arthroplasty (HRA) have reported high complication and failure rates due to elevated metal ion levels. These rates were shown to be especially high for the Articular Surface Replacement (ASR) HRA, possibly due to its unique design. Associations between metal ion concentrations and various biological and mechanical factors have been reported. Component positioning as measured by acetabular inclination has been shown to be of especially strong consequence in metal ion production in ASR HRA patients, but few studies have evaluated acetabular anteversion as an independent variable. The primary objective of this study was to evaluate the associations between component orientation, quantified by acetabular inclination and anteversion, and blood metal ions. Secondly, we sought to report whether conventional safe zones apply to MoM HRA implants or if these implants require their own positioning standards. Methods. We conducted a multi-center, prospective study of 512 unilateral ASR HRA patients enrolled from September 2012 to June 2015. At time of enrollment our patients were a mean of 7 (3–11.5) years from surgery. The mean age at surgery was 56 years and 24% were female. All subjects had complete demographic and surgical information and blood metal ions. In addition, each patient had valid AP pelvis and shoot-though lateral radiographs read by 5 validated readers measuring acetabular abduction and anteversion, and femoral offset. A multivariate logistic regression was used with high cobalt or chromium (greater than or equal to 7ppb) as the dependent variable. The independent variables were: female gender, UCLA activity score, age at surgery, femoral head size, time from surgery, femoral offset, acetabular abduction, and acetabular anteversion. Results. The average acetabular inclination angle was found to be 44.7° (20.6°–64.5°), and the average anteversion angle was 24° (0.2°–55.3°) (Figure 1). After controlling for the possible confounding variables, the factors contributing to elevated metal ions (≥ 7 ppb) were found to be time from surgery (OR = 1.29, p = 0.011), high abduction angle (– 55°) (OR = 4.40, p = 0.001), low anteversion angle (0°–10°) (OR = 3.82, p = 0.001), and female gender (OR = 3.45, p = 0.001). Discussion and Conclusion. We found that blood metal ion levels are affected by both acetabular inclination and anteversion (Figure 2). Furthermore, we observed that there was a high degree of variation in the positioning of these implants, and we conclude that those with high inclination and/or low anteversion angle should be most vigilantly monitored

Medical and Health care products Regulatory Agency (MHRA) released an alert in 2010 regarding metal on metal (MoM) bearings in hip arthroplasty owing to soft tissue reactions to Metal debris. Following this, we adopted a targeted screening protocol to review patients with this bearing couple. 218 Patients (252 hips), mean age 53.2 (25–71) years were assessed clinically using Oxford hip score (OHS) and X-ray examination. The mean follow up was 44.5 (12–71) months. Patients were considered at higher risk (118 patients/133 hips) if they had deterioration of OHS (50 hips), Small sized heads <50mm (114 hips), acetabular inclination >500 (37 hips), neck thinning (17 hips). These patients (107/118), (120/133 hips) were further investigated through measuring metal ion levels and magnetic resonance imaging (MRI). The mean blood levels of cobalt and chromium in this group were 6.7, 8.62 ug/L respectively. Metal ions increased significantly with high acetabular inclination angles (p=0.01, 0.004 respectively), but was not affected by the size of the head (p=0.13). MRI showed periprosthetic lesions around 28 hips (26 fluid collections, 2 pseudotumours). The screening protocol detected all patients who subsequently required elective revision. We believe that this protocol was beneficial in detecting problematic MoM hip replacements

Protrusio acetabuli can be either primary or secondary. Primary or idiopathic protrusio is a rare condition of unknown etiology. Secondary protrusio may be associated with rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, osteomalacia, trauma and Paget's disease. Challenges in surgery include lack of bone stock, deficient medial support to the cup, difficulty in dislocating the femoral head, and medialisation of the hip joint center. Several surgical techniques have been described: use of cement alone without bone graft; morsellised impacted autograft or allograft with a cemented cup; metal cages, reinforcement rings, and solid grafts. We describe our technique of impaction grafting using autologous bone and a cementless porous-coated hemispherical cup without the use of acetabular rings or cages in patients with an average age of 46 years. Protrusion was graded depending on distance of medial wall from Kohler's line as mild (1–5mm medial), moderate (6–15mm medial) and severe if it was more than 15mm medial to the Kohler's line. All patients were operated in the lateral position using a modified Hardinge's anterolateral approach. Adductor tenotomy may be required in cases of severely stiff hips. After careful dislocation of the femoral head, it was sectioned in situ into slivers to facilitate obtaining the graft. The periphery was reamed and care was taken to preserve the membrane lining the floor of the defect. Morsellised graft was impacted with hemispherical impactors and the trial cup 1–2mm larger than the last reamer placed in the desired position. The final socket was then inserted. Femoral preparation was performed in routine fashion. The mean preoperative Harris hip score of 52 improved to 85 points at a mean follow up of 4 years. The average acetabular inclination angle was 42 degrees. Our results have shown incorporation of the graft in all cases. There was no evidence of progression of the protrusio or cup loosening in any of the cases. Thus far, our hips have not shown osteolytic lesions. The technique described is a satisfactory biological solution of restoring bone stock particularly in young and middle-aged patients

Background. High cup abduction angles generate increased contact stresses, higher wear rates and increased revision rates. However, there is no reported study about the influence of cup abduction on stresses under head lateralisation conditions for ceramic-on-Ceramic THA. Material and method. A finite elements model of a ceramic-on-ceramic THA was developed in order to predict the contact area and the contact pressure, first under an ideal regime and then under lateralised conditions. A 32 mm head diameter with a 30 microns radial clearance was used. The cup was positioned with a 0°anteversion angle and the abduction angle was varied from 45° to 90°. The medial-lateral lateralisation was varied from 0 to 500 microns. A load of 2500 N was applied through the head center. Results. For 45° abduction angle, edge loading appeared above a medial-lateral separation of 30 μm. Complete edge loading was obtained above 60 μm medial-lateral separation. For 45 degrees inclination angle, as the lateralisation increased, the maximal contact pressure increased from 66 MPa and converged to an asymptotic value of 205 MPa. A higher inclination angle resulted in a higher maximum contact pressure. However, this increase in contact pressure induced by higher inclination angle, became negligible as the lateral separation increased. Discussion Both inclination angle and lateral displacement induced a large increase in the stresses in Ceramic-on-Ceramic THA. Edge loading appeared for a small lateralisation. The influence of acetabular inclination angle became negligible for a lateral displacement above 240 μm, as the stresses reached an asymptotic value

Introduction and Aims. In order to improve the longevity and design of an implant, a wide range of pre-clinical testing conditions should be considered including variations in surgical delivery, and patients' anatomy and biomechanics. The aim of this research study was to determine the effect of the acetabular cup inclination angle with different levels of joint centre mismatch on the magnitude of dynamic microseparation, occurrence and severity of edge loading and the resultant wear rates in a hip joint simulator. Methods. The six-station Leeds Mark II Anatomical Physiological Hip Joint Simulator and 36mm diameter ceramic-on-ceramic bearings (BIOLOX® delta) were used in this study. A standard gait cycle, with a twin-peak loading (2.5kN peak load and approximately 70N swing phase load), extension/flexion 15°/+30° and internal/external ±10° rotations, was applied. Translational mismatch in the medial-lateral axis between the centres of rotation of the head and the cup were considered. In this study, mismatches of 2, 3 and 4 (mm) were applied. Two acetabular cup inclination angles were investigated; equivalent to 45° and 65° in-vivo. These resulted in a total of six conditions [Figure 1] with n=6 for each condition. Three million cycles were completed under each condition. The lubricant used was 25% (v/v) new-born calf serum supplemented with 0.03% (w/v) sodium azide to retard bacterial growth. The wear of the ceramic bearings were determined using a microbalance (XP205, Mettler Toledo, UK) and a coordinate measuring machine (Legex 322, Mitutoyo, UK). The stripe wear was analysed using RedLux software. The dynamic microseparation displacement was measured using a linear variable differential transformer. Mean wear rates and 95% confidence limits were determined and statistical analysis (one way ANOVA) completed with significance taken at p<0.05. Results Increasing the medial-lateral joint centre mismatch from 2 to 3 to 4mm resulted in an increased dynamic microseparation [Figure 2]. A similar trend was observed for the wear. A higher level of medial-lateral mismatch increased the wear rate under both 45° and 65° cup inclination angle conditions [Figure 3]. The mean wear rates obtained under 65° were significantly higher compared to those obtained under the 45° cup inclination angle conditions for a given medial-lateral mismatch in the joint centre (p=0.02 for 2mm mismatch, p=0.02 for 3 mm mismatch, and p<0.01 for 4mm mismatch). Conclusions. The condition with the acetabular cups positioned at an inclination of 45° exhibited greater resistance to dynamic microseparation for any given medial-lateral mismatch in the centres of rotation. Higher wear rates correlated with higher levels of dynamic microseparation. These results highlight how different conditions can alter the severity of edge loading, and highlight the necessity of understanding how the surgical positioning can affect the occurrence of edge loading and wear. Future studies will look into the other factors which can influence the microseparation conditions such as joint laxity, swing phase load and version angles

Introduction. Long-term success of the cementless acetabular component has been depends on amount of bone ingrowth around porous coated surface of the implant, which is mainly depends on primary stability, i.e. amount of micromotion at the implant-bone interface. The accurate positioning of the uncemented acetabular component and amount of interference fit (press-fit) at the rim of the acetabulum are necessary to reduce the implant-bone micromotion and that can be enhancing the bone ingrowth around the uncemented acetabular component. However, the effect of implant orientations and amount of press-fit on implant-bone micromotion around uncemented acetabular component has been relatively under investigated. The aim of the study is to identify the effect of acetabular component orientation on implant-bone relative micromotion around cementless metallic acetabular component. Materials and Method. Three-dimensional finite element (FE) model of the intact and implanted pelvises were developed using CT-scan data [1]. Five implanted pelvises model, having fixed antiversion angle (25°) and different acetabular inclination angle (30°, 35°, 40°, 45° and 50°), were generated in order to understand the effect of implant orientation on implant-bone micromotion around uncemented metallic acetabular component. The CoCrMo alloy was chosen for the implant material, having 54 mm outer diameter and 48 mm bearing diameter [1]. Heterogeneous cancellous bone material properties were assigned using CT-scan data and power law relationship [1], whereas, the cortical bone was assumed homogeneous and isotropic [1]. In the implanted pelvises models, 1 mm diametric press-fit was simulated between the rim of the implant and surrounding bone. Six nodded surface-to-surface contact elements with coefficient of friction of 0.5 were assigned at the remaining portion of the implant–bone interface [1]. Twenty-one muscle forces and hip-joint forces corresponds to peak hip-joint force of a normal walking cycle (13%) were used for the applied loading condition. Fixed constrained was prescribed at the sacroiliac joint and pubis-symphysis [1]. A submodelling technique was implemented, in order to get more accurate result around implant-bone interface [1]. Results and Discussions. The peak implant-bone sliding interfacial micromotion was observed around 75 microns around superior and supero-posterior regions of the acetabulum, whereas, micromotion was below 50 microns around other regions (area). As compared to other regions, less implant-bone micromotions were observed at the central region of the acetabulum and anterior part of the acetabulum, where micromotions were varied in the range between 5 microns to 30 microns. Although, the generated peak implant-bone sliding micromotion around the uncemented acetabulum was not vary notably due to change in inclination angle of the acetabular component, changes in patterns of implant-bone micromotions were observed and as shown [Fig.1]. Results of the present study indicated that the positioning of the uncemented acetabular component have influence on patterns of implant-bone micromotion and that might have influence on bone ingrowth and long-term success of uncemented acetabular component

Introduction:. Uncemented acetabular component fixation has been considered the most reliable fixation method in contemporary metal-on-metal hip resurfacing arthroplasty (HRA). During prospective long-term follow-up of a HRA device, we have encountered a surprisingly high incidence of this complication and wish to alert surgeons and manufacturers of this problem. Methods:. The study group was comprised of all 373 HRAs performed by a single surgeon using this hybrid hip resurfacing implant from May 2001 to March 2005. The acetabular component features a dual-coated bone ingrowth surface of plasma-sprayed titanium plus hydroxylappatite. There were a total of 34 revisions identified at the time of this study. Results:. There were 5 other cases (1.3%) of late acetabular loosening all occurring greater than 8 years postoperatively at an average of 9 ± 1 years after the primary surgery. All of theses patients were functioning well with radiographically stable implants for at least 8 years. Intraoperative findings included debonding of large portions of the porous coating which remained adhered to the underlying bone. We concluded that these cases represented primary mechanical implant failures. There was a moderate amount of wear debris, presumably from the backside. There was no bone loss evident. There were no soft tissue masses. There were also 2 cases of adverse wear failure with pain and soft tissue masses diagnosed preoperatively with well-fixed implants. One of these patients also suffered component debonding prior to revision. Two (2/5; 40%) cases had an acetabular inclination angle ≥50°. Implant Debonding accounted for 5/8 (63%) of all acetabular failures and 14.7% (5/34) of all failures, while failure of ingrowth caused only 1/34 (3%) and adverse wear failures accounted for only 6% (2/34) of all failures. Conclusion:. We recommend that manufacturers re-evaluate the fixation strength of their own particular methods of bonding titanium plasma spray to a cobalt-chrome substrate, particularly in regards to fatigue failure and that they make improvements to ensure a longer duration of bone-implant fixation

Protrusio acetabuli can be either primary or secondary. Primary or idiopathic protrusio is a rare condition of unknown etiology. Secondary protrusio may be associated with Rheumatoid Arthritis, Ankylosing spondylitis, osteoarthritis, osteomalacia, trauma and Paget's disease. Challenges in surgery include lack of bone stock, deficient medial support to the cup, difficulty in dislocating the femoral head, and medialisation of the hip joint centre. Several surgical techniques have been described: use of cement alone without bone graft; morsellised impacted autograft or allograft with a cemented cup; metal cages, reinforcement rings, and solid grafts. We describe our technique of impaction grafting using autologous bone and a cementless porous-coated hemispherical cup without the use of acetabular rings or cages in patients with an average age of 46 years. Protrusion was graded depending on distance of medial wall from Kohler's line as mild (1–5 mm medial), moderate (6–15 mm medial) and severe if it was more than 15 mm medial to the Kohler's line. All patients were operated in the lateral position using a modified Hardinge's anterolateral approach. Adductor tenotomy may be required in cases of severely stiff hips. After careful dislocation of the femoral head, it was sectioned in situ into slivers to facilitate obtaining the graft. The periphery was reamed and care was taken to preserve the membrane lining the floor of the defect. Morsellised graft was impacted with hemispherical impactors and the trial cup 1–2 mm larger than the last reamer placed in the desired position. The final socket was then inserted. Femoral preparation was performed in routine fashion. The mean pre-operative Harris hip score of 52 improved to 85 points at a mean follow up of 4 years. The average acetabular inclination angle was 42 degrees. Our results have shown incorporation of the graft in all cases. There was no evidence of progression of the protrusio or cup loosening in any of the cases. Thus far, our hips have not shown osteolytic lesions. The technique described is a satisfactory biological solution of restoring bone stock particularly in young and middle-aged patients

Introduction. Adverse wear related failure (AWRF) after metal-on-metal hip resurfacing arthroplasty (HRA) has been described as a new failure mechanism. We describe the results of revision of these failures. Methods. Between July 1999 and Jan 2014, a single surgeon performed 3407 HRA. Nine (9/3407; 0.3%) cases in 8 patients were revised due to AWRF. In two additional revisions for AWRF the primary HRA was done elsewhere. There were a total of 11 revisions (9 women, 2 men) for AWRF cases reported in this study. The primary diagnoses were OA in 7 and dysplasia in 4. At the time of the primary surgery, the average age was 50±5 years and the average BMI was 27±4. The average femoral component sizes were 46±3mm. Only the acetabular component was revised in eight cases, both components were revised in 4 cases (revised to THA), three of these four used metal on metal bearings. A postop CT was requested for all patients after revision. 4 scans were of sufficient quality to analyze implant positions. Algorithms for metal artifact reduction were utilized to obtain high quality 2D images (Figure 1); 3D CAD models of the bones and implants were regenerated in order to calculate the acetabular inclination and anteversion angle (Figure 2). Results. Prior to revision, all 11 cases had acetabular inclination angles on standing radiographs (AIA) greater than 50° (mean 56. 0. range: 51°-60°) and Cobalt blood levels greater than 10ug/L (mean 94±64ug/L, range: 12–173 ug/L). Chromium levels were a mean of 50±33ug/L (range: 8–111 ug/L). 3D studies showed fluid collections and metalosis was seen in all cases. The mean follow-up length after revision was 2.4±1 years. In 4 cases the postop CT could be used to accurately measure implant positions resulting in a mean AIA=34°±9° and a mean anteversion angle of 18°±4°. Metal ion tests were available for 7 cases at least 1 year after revision. Cobalt levels were reduced to a mean of 4.1±3.1 ug/L (range: 1.5–6.2 ug/L) and Chromium levels fell to 6.3±2.9 ug/L (range: 3.4–10.9 ug/L). The mean HHS was 93±15. There was one failure of acetabular component fixation, which required repeat revision. Her latest HHS was 100 one year after the second surgery. For all revisions, the mean operative time was 123±15 min, incision length was 5±1 inches, estimated blood loss was 258±82 cc, and hospital stay was 1.3±0.5 days. There were no other major complications including no nerve palsies, vascular injuries or abductor mechanism disruptions. No patients limped. Conclusion. Our study suggests AWRF in HRA can successfully be revised with metal-on-metal surfaces. Revision of the femoral component is not necessary despite the abnormal wear. Correction of the steep AIA is the key to success. This confirms the concept that edge loading, leading to a high wear state, rather than allergy to metal is the cause of these failures

Background. The current orthopaedic literature demonstrates a clear relationship between acetabular component positioning, polyethylene wear and risk of dislocation following Total Hip Arthroplasty (THA). Problems with edge loading, stripe wear and squeaking are also associated with higher acetabular inclination angles, particularly in hard-on-hard bearing implants. The important parameters of acetabular component positioning are depth, height, version and inclination. Acetabular component depth, height and version can be controlled with intra-operative reference to the transverse acetabular ligament. Control of acetabular component inclination, particularly in the lateral decubitus position, is more difficult and remains a challenge for the Orthopaedic Surgeon. Lewinnek et al described a ‘safe zone’ of acetabular component orientation: Radiological acetabular inclination of 40 ± 10° and radiological anteversion of 15 ± 10°. Accurate implantation of the acetabular component within the ‘safe zone’ of radiological inclination is dependent on operative inclination, operative version and pelvic position. Traditionally during surgery, the acetabular component has been inserted with an operative inclination of 45°. This assumes that patient positioning is correct and does not take into account the impact of operative anteversion or patient malpositioning. However, precise patient positioning in order to orientate acetabular components using this method cannot always be relied upon. Hill et al demonstrated a mean 6.9° difference between photographically simulated radiological inclination and the post-operative radiological inclination. The most likely explanation was felt to be adduction of the uppermost hemipelvis in the lateral decubitus position. The study changed the practice of the senior author, with target operative inclination now 35° rather than 40° as before, aiming to achieve a post-operative radiological inclination of 42° ± 5°. Aim. To determine which of the following three techniques of acetabular component implantation most accurately obtains a desired operative inclination of 35 degrees:. Freehand. Modified (35°) Mechanical Alignment Guide, or. Digital inclinometer assisted. Methods. 270 patients undergoing primary uncemented THA were randomised to one of the three methods of acetabular component implantation. Target operative inclination for all three techniques was 35°. Operative inclination was measured intra-operatively using both a digital inclinometer and stereophotogrammetric system. For both the freehand and Mechanical Alignment Guide implantation techniques, the surgeon was blinded to intra-operative digital inclinometer readings. Results. The freehand implantation technique had an operative inclination range of 25.2 – 43.2° (Mean 32.9°, SD 2.90°). The modified (35°) Mechanical Alignment Guide implantation technique had an operative inclination range of 29.3 – 39.3° (Mean 33.7°, SD 1.89°). The digital inclinometer assisted technique had an operative inclination range of 27.5 – 37.5° (Mean 34.0°, SD 1.57°). Mean unsigned deviation from target 35° operative inclination was 2.92° (SD 2.03) for the freehand implantation technique, 1.83° (SD 1.41) for the modified (35°) Mechanical Alignment Guide implantation technique and 1.28° (SD 1.33) for the digital inclinometer assisted technique. Conclusions. When aiming for 35° of operative inclination, the digital inclinometer technique appears more accurate than either the freehand or Mechanical Alignment Guide techniques. In order to improve accuracy of acetabular component orientation during Total Hip Arthroplasty, the surgeon should consider using such a technique

Introduction:. One reason that young and active patients choose hip resurfacing arthroplasty (HRA) rather than stemmed total hip arthroplasty (THA) is that they wish to return to high impact sports after their operation. Few studies have addressed the outcome in hip arthroplasty patients who choose to participate in high impact sports post-operatively. We therefore wanted to determine if the durability of HRA in highly active patients was decreased. Methods:. From 5/2001 to 5/2011, a single surgeon performed 2434 HRA cases in 2013 patients. The study group consists of all patients that had a UCLA Activity score of 9 or 10 at any point after surgery in our prospective database. There were 936 (38%) cases in 776 patients who reported participating in high impact sports at some point after surgery. This group was compared to the entire database. The mean age of the study group was 50 ± 8 years, which was significantly younger than the entire group (P = 0.0007). 82% of the study group was male compared to 73% in the entire group (P < 0.0001). 85% of the primary diagnoses were osteoarthritis in the study group compared to 78% in the entire group (P < 0.0001), followed by dysplasia (8%) and osteonecrosis (4%). Results:. For the study group, the average follow-up length was 4 ± 2 years. 389 (42%) cases had at least 5 years follow-up. 10 (1%) revisions were identified: five (0.5%) due to femoral component loosening; two (0.2%) due to adverse wear; two (0.2%) for acetabular component loosening; one (0.1%) for acetabular fracture. There was no difference in the failure rate due to any specific complication type. The Kaplan-Meier survivorship rate was 99.5% at 5 years and 95.8% at 10 years, which compared to 96.9% at 5 years and 91.6 at 10 years for the entire group. 61 cases had the acetabular inclination angles >50°; 2 of which were revised for adverse wear related failures. Metal ion test results were available for 52% cases in the study group. Metal ion levels were ≥7 μg/L in 18 (1.9%) cases and ≥10 μg/L in 11 (1.2%). Excluding the failed cases, the average Harris hip scores were 99 ± 3 for the study group which was significantly better than the entire group (P < 0.0001). Discussion:. When compared to the entire database, hip resurfacing patients that participate in high impact sports after surgery have a significantly higher HHS; they have a similar 10-year survivorship of 95.8%; they have a similar low adverse wear failure rate of 0.2%. We therefore conclude that a patient's activity level has little effect on the 10 year outcome of HRA and that restrictions are therefore not necessary after hip resurfacing

Introduction. Since Smith-Peterson's glass mold arthroplasty in 1939, hip resurfacing arthroplasty was developed and introduced to orthopaedic surgery field but it had many problem like early loosening. Recently it is being popular for some indication as development of new implant design and manufacturing. There are still many suggested advantages of hip resurfacing arthroplasty. These include bone conservation, improved function as a consequence of retention of the femoral head and neck and more precise biomechanical restoration, decreased morbidity at the time of revision arthroplasty, reduced dislocation rates, normal femoral loading and reduced stress-shielding, simpler management of a degenerated hip with a deformity in the proximal femoral metaphysic, an improved outcome in the event of infection, and a reduced prevalence of thromboembolic phenomena as a consequence of not using instruments in the femur. But, there are limited or inconsistent data to support some of these claims regarding the benefits of hip resurfacing including the potential for a more natural feel because of the minimal disturbance of the proximal part of the femur resulting in a better and faster functional outcome. We evaluate the short term results of hip resurfacing arthroplasty using custom patient-specific tooling for prosthesis placement for better standardization. Materials and Methods. 40 cases, 36 patients(male:20, female:16) those of who were candidates of a Hip Resurfacing procedure, participated in the study. Mean follow up period was 2.5 years (8 months ∼3 years). A CT scan was performed on each patient and a 3D model was generated using the computer tomography dataset. From this model a bone-surface skin was extracted and this data set was used to create a personalized jig. Detailed analysis of the native bone structure was then used to preoperatively plan the appropriate size and position of the implant. A mean 7 degree corrective valgus angle was prescribed on all cases. Postoperative radiological datasets were superimposed onto preoperative plan position and offsets were measured. Operative times were recorded per step during the procedure. Surgeon comfort and ease of use was also noted. Results. Mean preop and postop implant position tolerance within 3 degrees. Mean postop implant stem-shaft angle was 136°(122°∼142°) and mean acetabular inclination angle was 41°(37°∼50°). Mean Harris hip scores was improved from 48.4 points preoperatively to 93.8 at final follw up. There were two cases (in one patient) of loosening of femoral metal head (See Figure 1.) with angulation and migration in avascular necsosis (postoperative 6 months) and one case of femoral neck fracture (postoperative 1.5 year) so we revised to primary total hip surgery. Mean surgical time was recorded to 55 minutes(35∼75). Personalized jig utility was positive with no intra-operative complications. Conclusion. “Femoral neck referencing personalized jigs” provides a surgeon an easy to use, accurate alignment tool to simplify a demanding hip resurfacing procedure with very predictable outcome but long term follow up and much cases are needed

Introduction:. More and more metal-on-metal hip resurfacing arthroplasty (HRA) implants have been used for active younger patients because of its higher success rate and better function outcomes for this group of patients compared to the traditional total hip arthroplasty (THA). One of the advantages of HRA is femoral neck preservation, which provides better bone structure in case a revision is necessary in the future. However, some believe that the outcomes after revision of hip resurfacing were not as good as the traditional THA. The purpose of this study was to provide our outcomes of the revisions, due to various causes, from over 3000 HRAs. Method:. Between May 2001 and April 2013, a single surgeon performed 3180 HRA. During that same period, 88 required revision (2.8%). Among them, the primary causes of the revision were acetabular component loosening in 22 cases; femoral component loosening in 21; femoral neck fracture in 19; adverse wear in eight; deep infection in four; and other causes for the rest. 68 of these revisions were performed by the same surgeon, while the remainder were revised elsewhere. 53 among these 68 cases had reached a minimum follow-up of two years and were included in this report. In 96%(51/53) of cases, the revision bearing was a large metal type including in 6/8 cases of adverse wear failure. There were eight cases of adverse wear with ion levels elevated above 10 μg/L, metalosis and inflammatory reaction seen at the time of revision. All of these cases had acetabular inclination angles larger than 50°. 7/8 of these cases were revised to another large metal bearing with improved acetabular component position. We analyzed the clinical scores, complications and radiographic results and compared them between these groups. Results:. The mean follow-up after the HRA revision was 5.4 ± 2.5 years (2–11 years). No patients died. No patient was lost from follow-up. The average age at the time of revision was 52 ± 11 years. The average operation time was 114 ± 42 minutes and the average hospital stay was 2 ± 1 days. All eight cases revised for adverse wear failures had extensive grey metalosis seen in surgery. There was no significant metalosis seen in the remainder. There were no failures requiring repeat revision. The average Harris hip score was 95 ± 11 at the latest follow-up. The mean UCLA score was 6 ± 2. The five year survivorship was 100%. Four complications were identified. There were two cases of recurrent dislocation that were treated with closed reduction. There was one superficial wound breakdown at 4 months without deep infection that resolved after debridement. There was one low energy pelvic fracture that was treated nonoperatively. There were no sciatic nerve palsies, thromboembolic events or significant medical complications. Conclusions:. Our results demonstrated that revision after hip resurfacing has a high success rate. Also, the revisions for adverse wear failure are most likely not due to the metal on metal bearing surfaces. In 7/8 cases, revisions were performed using another large metal bearing with improved acetabular component positioning, resulting in complete resolution of the problem