Abstract. Cemented total hip arthroplasty (THA) in the younger patient has historically been associated with higher wear and revision rates. We carried out a retrospective study of a prospectively collected database of patients at Wrightington hospital undergoing cemented THA under 55 years of age to determine acetabular wear and revision rates. Between August 2005 and December 2021 a cohort of 110 patients, 56 males and 54 females, underwent Cemented Total Hip Replacement through a posterior approach. Mean age at operation was 50yrs (35–55). The mean follow up was 6 years 9 months (0–16 years). 3 patients were lost to follow-up. Of the remaining 107 patients, Conventional and cross lined polyethylene were used in 54 and 53 patients respectively. Ceramic heads were used in 102 patients. 22.225mm and 28mm heads were used in 60 and 47 patients respectively. Clinical outcomes were assessed by Merle d'Aubigne and Postel scores which showed significant functional improvement. Linear wear was measured on plain radiographs using TRAUMA CAD and cup loosening was assessed by classification of Hodgkinson et al. No cases were revised during the observed follow up period. The mean wear rate in conventional and crosslinked polyethylene cups were 2.31mm (0.1–4.6) and 1.02mm (0.1–2.6) respectively. Cemented THA with both conventional and crosslinked polyethylene provides excellent survival rates in adults under the age of 55 years and crosslinked polyethylene may further improve these results due to improved wear rates

Purpose

It is generally accepted that the cement mantle surrounding the femoral component of a cemented total hip arthroplasty (THA) should be complete without any defects, and of at least 2 mm in thickness. Radiographic evaluation is the basis for assessment of the cement mantle. The adequacy of radiographic interpretation is subject to debate. Poor interobserver and intraobserver reproducibility of radiographic cement mantle assessment has been reported. In this study, 3D template software was used that allow anatomical measurements and analysis of three-dimensional digital femura geometry based on CT scans. The purpose of this study is to analyze the three-dimensional cement mantle thickness of cemented hip stem.

Hypothesis

Successful total hip arthroplasty (THA) in the presence of developmental dysplasia of the hip (DDH) depends on restoration of the anatomic centre of hip rotation and may require simultaneous femoral osteotomy. Techniques using uncemented components are widely reported. In osteopenic bone an all-cemented technique may be more appropriate; however, the outcome following this procedure is not known. We present the results of a series of thirty-five cemented THA with simultaneous subtrochanteric osteotomy.

Introduction

We have investigated the long-term (minimum follow-up period; 10 years) clinical results of the total hip arthroplasty (THA) using K-MAX HS-3 tapered stem.

Introduction

The global rapid growth of the aging population has some likelihood to create a serious crisis on health-care and economy at an unprecedented pace. To extend Healthy Life Expectancy (HALE) in a number of countries, it is desired more than ever to investigate characteristic and prognosis of numerous diseases. This enlightenment and recent studies on patient-reported outcome measures (PROMs) will drive the increasing interest in the quality of life among the world.

The demand for primary THAs by 2030 would rise up to 174% in USA. It is expected that the number of the elderly will surge significantly in the future, thus more septuagenarian and octogenarian are undergoing THA. Moreover, HALE of Japanese female near the age of 75 years, followed to Singapore, is still increasing. Therefore, concerns exist about the PROMs of performing THA in this age-group worldwide. Nevertheless almost the well-established procedure, little agreement has been reached to the elderly. We aimed to clarify the mid-term PROMs after THA over 75-year old.

Purpose

The purpose of the present study is to assess 5–10 years' follow-up results after acetabular impaction bone grafting (IBG) in primary cemented total hip arthroplasty (THA) for cases with acetabular bone defect.

Orthopaedics has been earmarked as one of the specialties that could make significant savings in the National Health Service. A large number of young adults are receiving total hip replacements and there has been a trend towards using uncemented implants. We describe the clinical and functional results at minimum 19 year follow up of cemented total hip replacements in patients under the age of fifty-five in our health region between 1990 and 1997.

104 cemented THRs performed in 100 patients under 55 years were included in this study. The follow-up data had been collected prospectively in the University database. 88.46% hips showed good to excellent results at final follow-up with a mean Harris hip score of 87.9±8.64. Revision was performed in 2 hips (1.92%), one for aseptic acetabular loosening and the other for late haematogenous infection. Probable radiological loosening was seen in 14 acetabular components (14.89%) and 4 femoral components (4.25%) at final follow-up. The mean rate of acetabular wear was 0.12mm/year and was not influenced by gender or diagnosis. The mean follow-up was 21.68±2.11 years (range 19 to 26 years) and the survivorship at 19 years was 98.07%.

The GIRFT report looked at the economic aspect of implant selection and found that the cost of uncemented implants was almost double that of the cemented implants. Savings of atleast £10 million a year can be made if cemented implants were used. We recommend that in a publically funded health system like the NHS, cemented implants can be used in patients under 55 with good long term functional outcomes and large savings in the healthcare costs.

Introduction

Especially in young patients, total hip implants with proven long-term follow-up data should be used. Despite this, almost all patients under 30 years old will face a revision of their hip prosthesis during their life time because of their life expectancy. Therefore, all the used implants should be revisable with reliable outcome. Although, several studies have evaluated the outcome of different THA implants in patients under 30, only few report the long term follow-up of 10 years or more. None of them present the outcome of the revised total hips.

The ideal operative treatment of displaced sub capital femoral fractures in the elderly is controversial. Recently, randomised controlled trials have suggested a better outcome with the use of total hip arthroplasty (THA) to treat displaced intra capsular fractures of the femur for elderly patients in good health. More recently the concept of dual mobility cups is being promoted to avoid dislocations in this cohort of patients. However, overall there is limited evidence to support the choice between different types of arthroplasty. Dislocation remains a main concern with THA, especially when a posterior approach is used.

We analysed the outcome of 115 primary THR (112 cements and 3 uncemented) THR using a posterior approach with soft tissue repair in active elderly patients presenting with displaced intra capsular femoral neck fractures. Size 28 mm head was used in 108 and a size 32 mm head in the rest. All surgery was performed by specialist hip surgeons.

Satisfactory results were noted in terms of pain control, return to pre-morbid activity and radiological evidence of bone implant osteo-integration. The 30-day mortality was nil. There were two dislocations and only one needed revision surgery due to recurrent dislocation.

In conclusion, with optimal patient selection, THA seems to provide a good functional outcome and pain relief in the management of displaced intracapsular femoral neck fractures. Excellent outcome can be achieved when done well using the standard cemented THR and with 28mm head. A good soft tissue repair and a specialist hip surgeon is preferable.

Background

Surgeons always must take into account that a primary total hip arthroplasty (THA) in a young patient will be revised in the future, this because of the long life expectancy of young THA patients and the limited durability of prosthetic implants in these patients. Therefore we would like to accentuate the revisability of a primary THA in this specific and high demanding patient population.

Introduction

Total hip arthroplasties in younger patients often requires revision because these patients frequently have acetabular deficiencies, which hamper proper implantation of the cup essential for good long-term prosthesis survival. For 30 years, we have used a biological acetabular-reconstruction technique with bone-impaction grafting in all patients <50 years with an acetabular deficiency at surgery, always in combination with a cemented total hip implant.

Cemented Total Hip Arthroplasty gives good results for 10 or more years, but is too often complicated by a combination of mechanical loosening, wear debris and osteolysis. Patients require an implant which will last the rest of their life. Cemented hips may not survive and a better alternative is needed. Furlong hydroxyapatite ceramic coated (HAC) implants have been used for more than 19 years and to date there are 2248 primary hip arthroplasties. Fixation of the implants with HA ceramic is entirely satisfactory; histological studies from post-mortem specimens have confirmed that there is good cancellous bone fixation to the HA. The hydroxyapatite behaves like bone and is replaced by creeping substitution. This results in a Perfect Fit with no intervening fibrous tissue. Fixation is therefore maintained. Aseptic loosening is rare; eleven components. Polythene wear is a problem. Those patients with ceramic/polythene couples who have now reached about 15 years since surgery are showing wear of the liner evidenced by eccentricity of the ceramic head in the liner. Three of these have completely destroyed the liner and the titanium shell. Ceramic/ceramic bearings do not seem to wear, although there have been occasional fractures of alumina. For the last two years Biolox Delta, a stronger compound ceramic material, has been available from Ceramtec. There are no reports of any fractures. Patients who have a life expectancy of more than 10 or 15 years should be fitted with an HA coated implant with ceramic bearing surfaces. This may provide the answer for the long-lasting hip prosthesis

Cemented total hip arthroplasty (THA) has become an extremely successful operation with excellent long-term results. Although showing decreasing popularity in North America, it always remained a popular choice for the elderly patients in Europe and other parts of the world. Various older and recent studies presented excellent long-term results, for cemented fixation of the cup as well as the stem. Besides optimal component orientation, a proper cementing technique is of major importance to assure longevity of implant fixation. Consequently a meticulous bone bed preparation assures the mechanical interlock between the implant component, cement and the final bone bed. Preoperative steps as proper implant sizing/ templating, ensuring an adequate cement mantle thickness, and hypotensive anesthesia, minimising bleeding at the bone cement interface, are of major importance. First the fossa pyriformis should be clearly identified, including the posterolateral entry point of the prosthesis. The femoral neck cut is usually 1.5cm to 2cm above the minor trochanter, based on the preoperative planning and implant type. Opening of the canal is done with an awl or osteotome, followed by any blunt tipped instrument, to follow the intramedullary direction. A box osteotome opens the lateral portion of the femoral neck, gently to preserve as much cancellous bone as possible. Sequential broaching follows carefully and according to the planning, to ensure preservation of 2mm to 3mm cancellous bone for interdigitation. Some systems might require over-broaching by one size. Trialing is done with the broach. Following, irrigation using a long nozzle pulsatile lavage, reduces the chance for fat embolism. A cement restrictor is then placed 1.5cm to 2cm distal to the tip of the stem, to ensure an adequate cement mantle distally. A second complete pulsatile irrigation of the canal follows, to minimise bleeding, followed by a dry sponge. Cement mixing is vacuum based in the meantime, usually 60–80g. We prefer the use of low dose antibiotic laden cement in our set up. Two to three minutes after mixing, the cement is applied rapidly in a retrograde technique, with a cement gun placing the nozzle tip against the cement restrictor. The gun is “pushed” out during the application, rather than being withdrawn from the canal. Proximal pressurization is first done by thumb, then with a proximal seal for 1 minute. The stem is inserted slowly using steady manual pressure, in the center of the cement mantle, however should never be impacted. The stem is aligned with the previously defined lateral entry point and is held in position until the cement hardens. The desired outcome is a cement interdigitation into cancellous bone for 2mm to 3mm and an additional mantle of 2mm pure cement

Cemented total hip arthroplasty (THA) has become an extremely successful operation with excellent long-term results. Although it always remained a popular choice for the elderly patients in many countries, recent trends show an increased use of non-cemented stems in all age populations in many national registries. So far, there has been no clear age associated recommendation, when a cemented stem should be used. Described major complications such as periprosthetic fractures are usually associated at age >75 years, in many registries. Uncemented stems perform better than cemented stems in recent registries; however, unrecognised intraoperative femoral fractures may be an important reason for early failure of uncemented stems. Experimental studies have indicated that intraoperative fractures do affect implant survival, in addition it has been shown that intraoperative and direct postoperative fractures increase the relative risk of revision during the first 6 postoperative months significantly. Furthermore it has been clearly shown, that uncemented stems were more frequently revised due to periprosthetic fracture during the first 2 postoperative years than cemented stems. Although often associated reduction of femoral bone quality in especially female patients >60 years, uncemented fixation has become the standard in most scenarios worldwide. Based on the implant fixation type: metaphyseal vs. diaphyseal of various uncemented stems, major attention should be, however, drawn to the intraoperative bone quality during the broaching process, especially for metaphyseal fixation stem types. Although cementless distal fixation can be achieved in thick cortices still in many patients, the incidence of associated thigh pain needs to be considered for some implant types. Furthermore small femoral canals might generate certain implant-bone size mismatch in relation to the proximal femur, thus nonoptimal fixation could be achieved. Consequently proper implant planning is mandatory preoperatively. In any cemented THA, a proper cementing technique is of major importance to assure longevity of implant fixation. This also includes proper implant sizing/ templating, ensuring an adequate cement mantle thickness, which might be restricted in a small diameter femur. The desired outcome is a cement interdigitation into cancellous bone for 2–3mm and an additional mantle of 2mm pure cement. Consequently proper planning in small diameter patients, prevents sizing problems, while in few cases special/individualised stem sizes might be considered. In summary attention needs to be drawn on small diameter stems, to prevent fractures and achieve proper implant fixation, in both uncemented and cemented fixation types. Proper implant planning preoperatively might be more important than in usual cases, while sometimes individual /small implant types might become necessary

Cemented total hip arthroplasty has become an extremely successful operation with excellent long term results. Although showing decreasing popularity in North America, it always remained a popular choice for the elderly patients in Europe and other parts of the world. Besides optimal component orientation, a proper cementing technique is of major importance to assure longevity of implant fixation. Consequently a meticulous bone bed preparation assures the mechanical interlock between the implant component, cement and the final bone bed. Cementing the acetabular side should include preservation of the transverse acetabular ligament and clear identification of the medial wall. Medialisation and deepening of the socket are important at reaming, to ensure a containment of the cup. The contact of the cup to cancellous bone should be maximised. Either smaller reamers or 4–6mm anchoring holes can be drilled to the superior sclerosis. Smaller defects can be curettage, while larger ones might require cancellous bone grafting. Of major importance is the thoroughly pulsatile jet lavage with saline to irrigate the cancellous bone bed, to reduce fat and blood lamination. After final irrigation, before cementation, dry sponges are slightly impacted into the cavity, to dry it out. Cementation usually requires 40g of high viscosity bone cement. Immediate pressurisation of the cement into the bone bed should start after a general application time in our institution between 2.5 to 3 minutes after mixing; with either a sterile glove filled with a sponge or designated company specific pressuriser. Sustained pressurisation should be done for 1 minute. The original cup should be 3–4mm smaller than the last reamer, to ensure circumferential cement mantle. Insertion principle includes medialisation first, followed by gradual angulation of the cup. In appropriate position, a balled pressuriser maintains pressure without further moving of the implant, until cement hardening. Remnant cement can be removed with osteotomes, while remaining osteophytes should be flush with implant. Femoral Side: First the fossa pyriformis should be clearly identified, including the posterolateral entry point of the prosthesis. The femoral neck cut is usually 1.5–2cm above the minor trochanter, based on the preoperative planning and implant type. Opening of the canal is done with an awl or osteotome, followed by any blunt tipped instrument, to follow the intramedullary direction. A box osteotome opens the lateral portion of the femoral neck, gently to preserve as much cancellous bone as possible. Sequential broaching follows carefully and according to the planning, to ensure preservation of 2–3mm cancellous bone for interdigitation. Some systems might require over-broaching by one size. Trialing is done with the broach. Following, irrigation using a long nozzle pulsatile lavage, reduces the chance for fat embolism. A cement restrictor is then placed 1.5–2cm distal to the tip of the stem, to ensure an adequate cement mantle distally. A second complete pulsatile irrigation of the canal follows, to minimise bleeding, followed by a dry sponge. Cement mixing is vacuum based in the meantime, usually 60–80g. We prefer the use of low dose antibiotic laden cement in our set up. Two to three minutes after mixing, the cement is applied rapidly in a retrograde technique with a cement gun, placing the nozzle tip against the cement restrictor. The gun is “pushed” out during the application, rather than being withdrawn from the canal. Proximal pressurisation is first done by thumb, then with a proximal seal for 1 minute. The stem is inserted slowly using steady manual pressure, in the center of the cement mantle, however, should never be impacted. The stem is aligned with the previously defined lateral entry point and is held in position until the cement hardens. The desired outcome is a cement interdigitation into cancellous bone for 2–3mm and an additional mantle of 2mm pure cement