We report the outcome of 320 primary Total Hip Arthroplasties (THA) with minimum 10-year follow-up (range 10ā17 years, mean 12.6 years), performed by a single surgeon in Tauranga New Zealand, with the Exeter Contemporary Flanged all-polyethylene cup and Exeter femoral stem via a posterior approach. The aim of the study is to compare the results with the published results from the design centre and create a baseline cohort for further outcomes research in this centre. All patients were prospectively followed at 6 weeks, 1 year, 5 years, 10 years, (and 15 years when available). Of 333 cases that matched the inclusion criteria, 13 procedures in 12 patents were excluded because of concomitant bone grafting and/or supplementary cage fixation, leaving 320 primary THA procedures in 280 patients, including 26 bilateral procedures in 13 patients. Mean follow-up of the surviving cases was 12.6 (range 5.0-17.1) years. There were 12 revisions ā 2 for fracture, 5 for instability, 1 for impingement pain and 4 for infection. There were no revisions for aseptic cup loosening. Kaplan-Meier survivorship with revision for aseptic loosening as the endpoint was 100% at 15.0 years (with minimum 40 cases remaining at risk). All-cause acetabular revision in 12 cases result in a Kaplan-Meier survival of 95.9% (95% CI: 93.5 to 98.3%).
Abstract.
Our objective was to examine revision rates and patient reported outcome scores (PROMS) for cemented and uncemented primary total knee joint replacement (TKJR) at six months, one year and five years post-operatively. Patients and Methods: This matched cohort study involved secondary analyses of data collected as part of a large prospective observational study monitoring outcomes following knee replacement in Christchurch, New Zealand.
Source of the study: University of Auckland, Auckland, New Zealand. Unicompartmental knee arthroplasty (UKA) is effective for patients with isolated compartment osteoarthritis, however the procedure has higher revision rates. Long-term survivorship and accurate characterisation of revision reasons are limited by a lack of long-term data and standardised revision definitions. We aimed to identify survivorship, risk factors and revision reasons in a large UKA cohort with up to 20 years follow-up. Patient, implant and revision details were recorded through clinical and radiological review for 2,137 consecutive patients undergoing primary medial UKA across Auckland, Canterbury, Counties Manukau and WaitematÄ DHB between 2000 and 2017. Revision reasons were determined from review of clinical, laboratory, and radiological records for each patient using a standardised protocol. To ensure complete follow-up data was cross-referenced with the New Zealand Joint Registry to identify patients undergoing subsequent revision outside the hospitals. Implant survival, revision risk and revision reasons were analysed using Cox proportional-hazards and competing risk analyses. Implant survivorship at 15 years was comparable for cemented fixed-bearing (cemFB; 91%) and uncemented mobile-bearing (uncemMB; 91%), but lower for cemented mobile-bearing (cemMB; 80%) implants. There was higher incidence of aseptic loosening with cemented implants (3ā4% vs. 0.4% uncemented, p<0.01), osteoarthritis (OA) progression with cemMB implants (9% vs. 3% cemFB/uncemMB; p<0.05) and bearing dislocations with uncemMB implants (3% vs. 2% cemMB, p=0.02). Compared with the oldest patients (ā„75 years), there was a nearly two-fold increase in risk for those aged 55ā64 (hazard ratio 1.9; confidence interval 1.1-3.3, p=0.03). No association was found with gender, BMI or ASA.
The initial success of modern total hip arthroplasty can in large part be attributed to the reliable fixation of the femoral component with the use of acrylic bone cement. Early success with cement led to a common pathway of development in North America and the European countries. Much of the early to mid-term research concentrated on refinement of variables related to the methodology and technique of cement fixation. Scandinavian registries were subsequently able to report on improved survivorship with better cementing technique. The net effect has been standardisation towards a small number of cemented implants with good long-term outcomes representing the majority of stems implanted in Sweden, for example. In North America, during the mid-term development of THA in the late 1980's, the term ācement diseaseā was coined and the cemented THA saw a precipitous decline in use, now to the point where many American orthopaedic residents are completing training never having seen a cemented THA. Modern uncemented femoral components can now claim good long-term survivorship, perhaps now comparable to cemented fixation. However, this has come at a cost with respect to the premium expense applied to the implant itself as well as lineage of failed uncemented constructs. The last several years have seen a proliferation of uncemented implants, usually at a premium cost, with no demonstrated improvement in survivorship. Osteolysis has not been solved with uncemented implants and cement disease has largely been recognised as a misnomer. Long-term outcomes of cemented femoral fixation have consistently demonstrated excellent survivorship, even in the younger age group.
The initial success of modern total hip arthroplasty can in large part be attributed to the reliable fixation of the femoral component with the use of acrylic bone cement. Early success with cement led to a common pathway of development in North America and the European countries. Much of the early- to mid-term research concentrated on refinement of variables related to the methodology and technique of cement fixation. Scandinavian registries were subsequently able to report on improved survivorship with better cementing technique. The net effect has been standardisation towards a small number of cemented implants with good long-term outcomes representing the majority of stems implanted in Sweden, for example. In North America, during the mid-term development of THA in the late 1980's, the term ācement diseaseā was coined and the cemented THA saw a precipitous decline in use, now to the point where many American orthopaedic residents are completing training never having seen a cemented THA. Modern uncemented femoral components can now claim good long-term survivorship, perhaps now comparable to cemented fixation. However, this has come at a cost with respect to the premium expense applied to the implant itself as well as lineage of failed uncemented constructs. The last several years have seen a proliferation of uncemented implants, usually at a premium cost, with no demonstrated improvement in survivorship. Osteolysis has not been solved with uncemented implants and cement disease has largely been recognised as a misnomer. Long-term outcomes of cemented femoral fixation have consistently demonstrated excellent survivorship, even in the younger age group.
Durable humeral component fixation in shoulder arthroplasty is necessary to prevent painful aseptic loosening and resultant humeral bone loss. Causes of humeral component loosening include stem design and material, stem length and geometry, ingrowth vs. ongrowth surfaces, quality of bone available for fixation, glenoid polyethylene debris osteolysis, exclusion of articular particulate debris, joint stability, rotator cuff function, and patient activity levels. Fixation of the humeral component may be achieved by cement fixation either partial or complete and press-fit fixation. During the past two decades, uncemented humeral fixation has become more popular, especially with short stems and stemless press fit designs.
Total knee replacement (TKA) is one of the most successful procedures in orthopaedic surgery. Although originally limited to more elderly and less active individuals, the inclusion criteria for TKA have changed, with ever younger, more active and heavier patients receiving TKA. This broadening of indications coincided with the widespread adoption of modular cemented and cementless TKA systems in the 1980's, and soon thereafter wear debris related osteolysis and associated prosthetic loosening became major modes of failure for TKA implants of all designs. Initially, tibial components were cemented all polyethylene monoblock constructs. Subsequent long-term follow-up studies of some of these implant designs have demonstrated excellent durability in survivorship studies out to twenty years. While aseptic loosening of these all polyethylene tibial components was a leading cause of failure in these implants, major polyethylene wear-related osteolysis around well-fixed implants was rarely (if ever) observed.
Femoral revision in cemented THA might include some technical difficulties, based on loss of bone stock and cement removal, which might lead to further loss of bone stock, inadequate fixation, cortical perforation or consequent fractures.
Restoration of an anatomical hip centre frequently requires limb lengthening, which increases the risk of nerve injury in the treatment of Crowe 4 DDH. The objective was to perform a prospective evaluation of SDTSO with
The use of a cemented implant instead of a spacer has been proposed due to the improved function in comparison with a spacer. Unfortunately the removal of a conventional cemented stem can be challenging. The use of a short cemented stem can overcome this problem. Between July 2011 and May 2013, 10 infected hips were treated with a short cemented stem as a spacer. The infected implants were cemented in 6 cases and cementless in 4 cases. Mean time from index operation was 3 years (range 0 to 8 years). It was the first treatment for infection in all cases. Antibiotic loaded cement and an all-poly cup was used in all cases. The bugs were staph aureus and staph epidermidis in most cases. A Friendly short cemented stem with specific cement restrictor and standard cementing tecnique was used in all cases. This stem has been successfully tested in over 200 patients and approved by TUV to be released on the marked. In all cases, the infection was successfully cured with antibiotics for a period ranging from 3 to 5 months. 2 patients were revised after the infection was cured for recurrent dislocation. No recurrent infection was found at the latest follow up. One stage revision is gaining in popularity for the decreased morbidity and better quality of life of the patients. Weak points of one-stage revision are slightly inferior results in terms of eradication of the infection and the fact that it can be done only with cemented implants.
The alumina on alumina articulation in THA has induced less macrophage reaction and cytokine section than polyethylene bearings. Thus THA using alumina on almina articulation has induced little periprosthetic osteolysis. However alumina fracture is still a concern. We had underwent 100 THAs that it was a cemented polyethylene backed acetabular component with an alumina inlay(ABS Cup; Kyocera, Kyoto, Japan), PHS stem(Kyocera) and 28mm alumina femoral head. This system was formerly used in only Japan, over 10 years results have not reported yet. We retrospectively reviewed 94 patients(100 hips) with cemented alumina on alumina THAs to identify factors relating to alumina failure, and to evaluate mid-term(>10years) results. 16 patients died from unrelated causes within 10 years of the operation and 14 patients was lost to follow up. The remaining 70 patients(79 Hips) were evaluated after a mean follow-up of 10 years. We performed clinical evaluation using the JOA score, and radiological evaluation was performed that inclination and anteversion angle of cup measurement with 2D template system at anteroposterior radiograph. On the radiographs at the final examination, radiolucency and osteolysis were evaluated around the acetabular component, and around the femoral component. These evaluations were scheduled for 3,6,9, and 12 months and yearly thereafter. All the operations were performed by same surgeon, at same center. Cumulative survival rates were calculated using the Kaplan-Meier method with failure defined as the end point of revision for alumina failure or for any reason. To compare groups with and without alumina failures in age, BMI, gender, activity, function, abduction angle, size of component, or existence of radiolucent lines, we used the nonparametric Mann-Whitney U-test. The mean age of the patients at surgery was 63.0 years. The mean follow up term was 13.8 years. Inclination and anteversion mean angle of cup were 45.6Ā°and 14.2Ā°.Ć£ĆÆĀæĀ½ĆÆĀæĀ½Revision surgery was performed because of alumina inlay failure in 4hips(2 fractures and 2 dissociation;5.1%), loosening in 2 hips(2 cup loosenings; 2.5%) recurrent dislocation in 1 hip, and femoral fracture in 1 hip, no deep infection and DVT. The 10-year survival rate was 92.4% with revision for any reason and 95.9% with revision for alumina failure as the end point. We detected 3 ceramic failures at a mean of 8.9 years(4.1ĆÆĀ¼ĆÆĀæĀ½12.5) after the index operation. There were no differences in BMI, function, cup angles(inclination and anteversion), and cup loosening among the 4hips with alumina failure. But there were differences in age, gender, and activity with alumina failure. This alumina on alumina THA yielded passably mid-term results, but it was occurred a high rate of catastrophic alumina inlay failure. In July 2000, we discontinued use of this type of THA to avoid alumina failure. This ABS cup was banned in 2002, because of numerous alumina failures. We suggest all patients with this type of acetabular component be followed carefully.
Total knee replacement (TKR) is one of the most successful procedures in orthopaedic surgery. Although originally limited to more elderly and less active individuals, the inclusion criteria for TKR have changed, with ever younger, more active and heavier patients receiving TKR. Currently, wear debris related osteolysis and associated prosthetic loosening are major modes of failure for TKR implants of all designs. Initially, tibial components were cemented all polyethylene monoblock constructs. Subsequent long-term follow-up studies of these implants have demonstrated excellent durability in survivorship studies out to twenty years. Aseptic loosening of the tibial component was one of the main causes of failure in these implants.
Joint registries suggest a downward trend in the use of uncemented Total Knee Replacements (TKR) since 2003, largely related to reports of early failures of uncemented tibial and patella components. Advancements in uncemented design such as trabecular metal may improve outcomes, but there is a scarcity of high-quality data from randomised trials. 319 patients <75 years of age were randomised to either cemented or uncemented TKR implanted using computer navigation. Patellae were resurfaced in all patients. Patient outcome scores, re-operations and radiographic analysis of radiolucent lines were compared. Two year follow up was available for 287 patients (144 cemented vs 143 uncemented). There was no difference in operative time between groups, 73.7 v 71.1 mins (p= 0.08). There were no statistical differences in outcome scores at 2 years, Oxford knee score 42.5 vs 41.8 (p=0.35), International Knee Society 84.6 vs 84.0 (p=0.76), Forgotten Joint Score 66.7 vs 66.4 (p=0.91). There were two revisions, both for infection one in each group (0.33%). 13 cemented and 8 uncemented knees underwent re-operation, the majority of these being manipulation under anaesthetic (85.7%), with no difference (8.3% vs 5.3%, 95% CI -2.81% to 8.89%, p = 0.31). No difference was found in radiographic analysis at 2 years, 1 lucent line was seen in the cemented group and 3 in the uncemented group (0.67% v 2.09%, 95%CI -4.1% to 1.24%, p = 0.29). We found no difference in clinical or radiographic outcomes between cemented and uncemented TKR including routine patella resurfacing at two years. Early results suggest there is no difference between cemented and uncemented TKR at 2 years with reference to survivorship, patient outcomes and radiological parameters.
The optimal method of fixation for primary total hip replacements (THR), particularly fixation with or without the use of cement is still controversial. In a systematic review and meta-analysis of all randomized controlled trials (RCT) comparing cemented versus uncemented THRS available in the published literature, we found that there is no significant difference between cemented and uncemented THRs in terms implant survival as measured by the revision rate. Better short-term clinical outcome, particularly an improved pain score can be obtained with cemented fixation. However, the results are unclear for the long-term clinical and functional outcome between the two groups. No difference was evident in the mortality and the post operative complication rate. On the other hand, the Radiographic findings were variable and do not seem to correlate with clinical findings as differences in the surgical technique and prosthesis design might be associated with the incidence of osteolysis. We concluded in our review that
Introduction. Humeral radiolucent lines after anatomic TSA (aTSA) have been well described; however, little clinical consequences have been attributed to them. The recent emergence of shorter humeral stems has demonstrated higher incidences of humeral radiolucencies than has been reported historically with standard length components. This large scale database analysis quantifies and compares the clinical outcomes of aTSAs with and without radiolucent humeral lines using one specific prosthesis to determine their impact on clinical outcomes. Methodology. This is a multicenter, retrospective, case controlled radiographic and clinical review. Preoperative and postoperative data was analyzed from 671 aTSA patients with a minimum of 2 years followup. 538 of these 671 aTSA patients had full radiographic followup (80.2%) and were included in this study; these patients had an average followup of 45.3 months). 459 patients had noncemented humeral stems; whereas, 79 patients had cemented humeral stems. Radiographs were reviewed at latest follow up for humeral radiolucent lines based on the technique described by Gruen et al. Patients were evaluated and scored pre-operatively and at latest follow-up using the SST, UCLA, ASES, Constant, and SPADI scoring metrics; ROM was also recorded. A Student's two-tailed, unpaired t-test was used to identify differences in pre-operative, post-operative, and improvement in results, where p<0.05 denoted a significant difference. Results. All patients demonstrated significant improvements in pain and function following treatment with the primary shoulder arthroplasty. 14 patients (8 female, avg: 65.6 yrs; 6 male, avg: 61.7 yrs) were observed to have radiolucent lines around the humeral component (2.6%). The rate of humeral radiolucent lines was observed to be significantly higher in patients with cemented (7.6%) vs. noncemented (1.7%) humeral stems (p = 0.0025). Pre-operatively, no difference was noted in any clinical metric score between patients with or without radiolucent humeral lines. (Figure 1) However post-operatively, patients with radiolucent humeral lines had significantly worse ASES (p=0.0087), UCLA (p=0.0371), SST (p=0.0341), and SPADI (p=0.0051) scores (Figure 2) and significantly lower improvements in outcomes according to ASES (p=0.0120) and SPADI (p=0.0247) scores (Figure 3), relative to patients without radiolucent humeral lines. Additionally, radiolucent lines had a more profound effect on cemented stems (as compared to noncemented stems), where cemented stems with radiolucent humeral liners were associated with significantly lower post-operative outcomes and significantly lower improvements in outcomes. Finally, patients with humeral radiolucent lines had a significantly higher complication rate (21.4% vs 4.6%, p = 0.004) as compared to the complication rate of patients without radiolucent humeral lines. Conclusions. The study demonstrated a relatively low incidence of humeral radiolucent lines with anatomic TSA.
ZrN-multilayer coating is clinically well established in total knee arthroplasty [1-3] and has demonstrated significant reduction in polyethylene wear and metal ion release [4,5]. The goal of our study was to analyze the biotribological behaviour of the ZrN-multilayer coating on a polished cobalt-chromium cemented hip stem. CoCr28Mo6 alloy hip stems with ZrN-multilayer coating (CoreHipĀ®AS) were tested versus an un-coated version. In a worst-case-scenario the stems with ceramic heads have been tested in bovine serum in a severe cement interface debonding condition under a cyclic load of 3,875 N for 15 million cycles. After 1, 3, 5, 10 & 15 million cycles the surface texture was analysed by scanning-electron-microscopy (SEM) and energy-dispersive x-ray (EDX). Metal ion concentration of Co,Cr,Mo was measured by inductively coupled plasma mass spectroscopy (ICP-MS) after each test interval. Based on SEM/EDX analysis, it has been demonstrated that the ZrN-multilayer coating keeps his integrity over 15 million cycles of severe stem cemented interface debonding without any exposure of the CoCr28Mo6 substrate. The ZrN-multilayer coated polished cobalt-chromium cemented hip stem has shown a reduction of Co & Cr metal ion release by two orders of a magnitude, even under severe stem debonding and high interface micro-motion conditions. ZrN-multilayer coating on polished cobalt-chromium cemented hip stems might be a suitable option for further minimisation of Co & Cr metal ion release in total hip arthroplasty. Clinical evidence has to be proven during the next years.
Recent registry data from around the world has strongly suggested that using cemented hip hemiarthroplasty has lower revision rates compared to cementless hip hemiarthroplasty for acute femoral neck hip fractures. The adoption of using cemented hemiarthroplasty for hip fracture has been slow as many surgeons continue to use uncemented stems. One of the reasons is that surgeons feel more comfortable with uncemented hemiarthroplasty as they have used it routinely. The purpose of this study is to compare the difference in revision rates of cemented and cementless hemiarthroplasty and stratify the risk by surgeon experience. By using a surgeons annual volume of Total Hip Replacements performed as an indicator for surgeon experience. The Canadian Joint Replacement Registry Database was used to collect and compare the outcomes to report on the revision rates based on surgeon volume. This is a large Canadian Registry Study where 68447 patients were identified for having a hip hemiarthroplasty from 2012-2020. This is a retrospective cohort study, identifying patients that had cementless or cemented hip hemiarthroplasty. The surgeons who performed the procedures were linked to the procedure Total Hip Replacement. Individuals were categorized as experienced hip surgeons or not based on whether they performed 50 hip replacements a year. Identifying high volume surgeon (>50 cases/year) and low volume (<50 cases/year) surgeons. Hazard ratios adjusted for age and sex were performed for risk of revision over this 8-year span. A p-value <0.05 was deemed significant. For high volume surgeons, cementless fixation had a higher revision risk than cemented fixation, HR 1.29 (1.05-1.56), p=0.017. This pattern was similar for low volume surgeons, with cementless fixation having a higher revision risk than cemented fixation, HR 1.37 (1.11-1.70) p=0.004 We could not detect a difference in revision risk for cemented fixation between low volume and high volume surgeons; at 0-1.5 years the HR was 0.96 (0.72-1.28) p=0.786, and at 1.5+ years the HR was 1.61 (0.83-3.11) p=0.159. Similarly, we could not detect a difference in revision risk for cementless fixation between low volume and high volume surgeons, HR 1.11 (0.96-1.29) p=0.161 Using large registry data, cemented hip hemiarthroplasty has a significant lower revision rate than the use of cementless stems even when surgeons are stratified to high and low volume. Low volume surgeons who use uncemented prostheses have the highest rate of revision. The low volume hip surgeon who cements has a lower revision rate than the high volume cementless surgeon. The results of this study should help to guide surgeons that no matter the level of experience, using a cemented hip hemiarthroplasty for acute femoral neck fracture is the safest option. That high volume surgeons who perform cementless hemiarthroplasty are not immune to having revisions due to their technique. Increased training and education should be offered to surgeons to improve comfort when using this technique.
Recent registry data from around the world has strongly suggested that using cemented hip hemiarthroplasty has lower revision rates compared to cementless hip hemiarthroplasty for acute femoral neck hip fractures. The adoption of using cemented hemiarthroplasty for hip fracture has been slow as many surgeons continue to use uncemented stems. One of the reasons is that surgeons feel more comfortable with uncemented hemiarthroplasty as they have used it routinely. The purpose of this study is to compare the difference in revision rates of cemented and cementless hemiarthroplasty and stratify the risk by surgeon experience. By using a surgeons annual volume of Total Hip Replacements performed as an indicator for surgeon experience. The Canadian Joint Replacement Registry Database was used to collect and compare the outcomes to report on the revision rates based on surgeon volume. This is a large Canadian Registry Study where 68447 patients were identified for having a hip hemiarthroplasty from 2012-2020. This is a retrospective cohort study, identifying patients that had cementless or cemented hip hemiarthroplasty. The surgeons who performed the procedures were linked to the procedure Total Hip Replacement. Individuals were categorized as experienced hip surgeons or not based on whether they performed 50 hip replacements a year. Identifying high volume surgeon (>50 cases/year) and low volume (<50 cases/year) surgeons. Hazard ratios adjusted for age and sex were performed for risk of revision over this 8-year span. A p-value <0.05 was deemed significant. For high volume surgeons, cementless fixation had a higher revision risk than cemented fixation, HR 1.29 (1.05-1.56), p=0.017. This pattern was similar for low volume surgeons, with cementless fixation having a higher revision risk than cemented fixation, HR 1.37 (1.11-1.70) p=0.004 We could not detect a difference in revision risk for cemented fixation between low volume and high volume surgeons; at 0-1.5 years the HR was 0.96 (0.72-1.28) p=0.786, and at 1.5+ years the HR was 1.61 (0.83-3.11) p=0.159. Similarly, we could not detect a difference in revision risk for cementless fixation between low volume and high volume surgeons, HR 1.11 (0.96-1.29) p=0.161 Using large registry data, cemented hip hemiarthroplasty has a significant lower revision rate than the use of cementless stems even when surgeons are stratified to high and low volume. Low volume surgeons who use uncemented prostheses have the highest rate of revision. The low volume hip surgeon who cements has a lower revision rate than the high volume cementless surgeon. The results of this study should help to guide surgeons that no matter the level of experience, using a cemented hip hemiarthroplasty for acute femoral neck fracture is the safest option. That high volume surgeons who perform cementless hemiarthroplasty are not immune to having revisions due to their technique. Increased training and education should be offered to surgeons to improve comfort when using this technique.