Introduction

Biological repair of acetabular bone defects after impaction bone grafting (IBG) in total hip arthroplasty could facilitate future re-revisions in case of failure of the reconstruction again using the same technique. Few studies have analysed the outcome of these acetabular re-revisions.

Introduction

Impaction bone grafting (IBG) is a reliable technique for acetabular revision surgery with large segmental defects. However, bone graft resorption and cup migration are some of the limitations of this tecnique. We assess frequency and outcome of these complications in a large acetabular IBG series.

Aims: A prospective study of the long term fixation of an all- polyethylene acetabular component with a 2mm rim for cement pressurisation, and methylmethac-rylate spacer beads for optimal cement mantle thickness. Methods: A consecutive series of 1348 hip arthroplasty patients aged between 23 and 94 (average 68 years) has been prospectively studied between 1993 and 2002. The cemented Ultima (De Puy) stem and cup were used via an anterolateral approach by 6 surgeons in a District General Hospital. Clinical and radiological assessment was at 0, 2, 5, 6, 7 and 8 years. Detailed assessment of the cup has been carried out to determine cases of clinical or radiological failure, quality of cement fixation to bone, and the profile of the cement mantle. Results: 875 patients have been followed up for a minimum of 2 years, 52 for a minimum of 8 years. The cumulative survival rate of the cup using revision for aseptic loosening as an endpoint at 8 years was 98% and using radiological evidence of loosening as an endpoint was 96%. There were no cases with less than 2 mm of cement mantle thickness and good quality bone cement interface was seen in all on the initial postoperative films indicating adequate pressurisation. Conclusions: The design of the Ultima polyethylene cup has been successful in achieving good cement pressurisation during implantation, an even cement mantle thickness, and clinical success rates which compare favourably with other cemented acetabular components.

Aims: To reconstruct acetabular bone stock loss in revision hip surgery, from 1979 on we have used a biologic reconstruction method with tightly impacted cancellous allografts in combination with a cemented polyethylene cup. Methods: This studies presents the clinical and radiological results of 62 consecutive acetabular revisions in 58 patients at a mean of 16.5 years (15–20 years) followup. The Kaplan-Meier survivorship for the cup with end-point revisions for any reason was 79% at fifteen years followup (95% C.I.: 67–91%). Results: Excluding two revisions for septic loosening at 3 and 6 years, the survivorship with end point aseptic loosening was 84% at fifteen years years (95% C.I.: 73–95%). At review there were no additional radiological loosenings, although 7 acetabular reconstructions showed radiolucent lines in one or two zones. Conslusions: This acetabular bone impaction technique using large morselized bone chips (range 0.7–1.0 cm) and a cemented cup is a reliable reconstruction technique, even after a 15–20 years followup.

This study was to analyze the minimum ten years clinical and radiological results of revision total hip arthroplasties using allogenic impaction bone graft and cemented cup in acetabular bone deficiency.

Fifty two revision total hip arthroplasties that had been performed in forty nine patients between March 1992 and June 1997 and had followed more than minimum ten years were included in this study. The clinical and radiological results were evaluated by Harris hip score and roentgenography including anterior-posterior view of pelvis and lateral view of operated hip.

The mean Harris hip score was 47 points preoperatively, 81 points at three years, 84 points at seven years, and 82 points at ten years after revision. In radiological evaluation, osseous union between grafted bone and host bone was seen within four months in 47 hips, a complete grafted bone-cement radiolucent line of two millimeter or more in at least one zone was seen in 5 hips at two years, 7 hips at seven years, and 2 hip at 10 years follow-up.

We recommend the technique using allogenic impaction bone graft and cemented cup to reconstruct the acetabular cavitary defect in revision total hip arthroplasties.

Introduction The results of THA in patients with post-traumatic arthritis are inferior to those in nontraumatic arthritis, both after cemented and noncemented THA. This increased failure rate is caused by the bone stock loss and the abnormal anatomy. We studied the outcome of acetabular bone impaction grafting and a cemented cup in 20 cases at 3 to 18 years follow-up.

Materials and Methods Between January 1984 and January 2000 in 20 consecutive patients bone impaction grafting was used for arthritis after previous acetabular fracture, grafting was done in all for bone stock loss. There were 14 men and 6 women. The average age at THA was 53.3 years (range, 35 to 75 years). Defects were classified according to the AAOS acetabular defect classification (3 type I defects, 10 type II defects, 5 type III defects and 2 type V). Metal meshes were used in 6 medial wall and in 3 peripheral wall defects. In 15 cases autograft bone chips were used, in 5 both auto- and allograft was used. Grafts were impacted using impactors and a hammer and a PE cup was cemented. At review in January 2003 no patient was lost.

Results Two patients died during follow up after 3 and 4 years respectively, deaths were not related to surgery and data are included. The mean follow up was 9.5 years (range, 3 to 18 years). The pre-operative Harris hip score was 44 (32–61). During follow up a cup revision was performed in two cases; one for a culture proven septic loosening 14.5 years after surgery and the other for aseptic loosening at 15.3 years after surgery. Both revised cups were radiologically loose at revision. At review the 16 surviving hips had an aver. Harris hip score of 93 points (range, 62 to 100 points). Fourteen hips were free of pain, one patient had slight and one had mild pain.

Radiologically, none of these 16 cups was loose. However, two of the cups migrated more than 5 mm (e.g. 6 and 8 mm) relative to the initial post-operative X-ray. At review, both patients were symptom free.

The Kaplan-Meier survival rate of the cup with endpoint revision for any reason was 100% at ten years and 80% (95% CI, 62–98%) after 15 years; with endpoint cup revision for aseptic loosening the survival was 100% both at 10 and 15 years.

Conclusion The acetabular bone impaction grafting technique with a cemented cup is a biologically attractive technique to reconstruct the bone stock loss after posttraumatic arthritis with good long-term survival, even after long follow-up.

Aims: The effects of bone graft washing and bone graft particle size on initial cup stability in an acetabular model were studied. Methods: From fresh human femoral heads large (8–12 mm) and small (2–4) grafts were produced. Four different groups were tested; large washed, large unwashed, small washed and small unwashed. An AAOS type 3 combined defect was reconstructed in a synthetic acetabular model using a metal mesh and screws. Bone grafts were impacted in a standardized way using a hammer and metal impactors. Cement was pressurized and a PE cup was inserted. Cups were dynamically loaded with 1500 N and 3000 N for 15 minutes using an MTS-device, RSA was used to calculate 3-D cup migrations. Next a lever-out test of the cup was done in a displacement (16¡/minute) controlled test. After testing CT scans of the cups were made to quantify cement layer roughness, as a measurement of cement penetration. Results: Cups reconstructed with large washed bone grafts migrated signiþcantly less during mechanical compression and withstood signiþcantly higher lever-out moments. Washing improved cup stability for both small and large grafts, however only signiþcantly for the larger bone grafts. A signiþcantly higher cement penetration depth was found for all large bone grafts, washing did not inßuence cement penetration depth. Discussion: For acetabular revisions with bone impaction grafting we recommend to use large washed bone grafts.

In this prospective study we studied the effect of the inclination angle of the acetabular component on polyethylene wear and component migration in cemented acetabular sockets using radiostereometric analysis.

A total of 120 patients received either a cemented Reflection All-Poly ultra-high-molecular-weight polyethylene or a cemented Reflection All-Poly highly cross-linked polyethylene acetabular component, combined with either cobalt–chrome or Oxinium femoral heads. Femoral head penetration and migration of the acetabular component were assessed with repeated radiostereometric analysis for two years. The inclination angle was measured on a standard post-operative anteroposterior pelvic radiograph. Linear regression analysis was used to determine the relationship between the inclination angle and femoral head penetration and migration of the acetabular component.

We found no relationship between the inclination angle and penetration of the femoral head at two years’ follow-up (p = 0.9). Similarly, our data failed to reveal any statistically significant correlation between inclination angle and migration of these cemented acetabular components (p = 0.07 to p = 0.9).

As there are many reports describing avascular reactions to metal debris (ARMD) after Metal-on-Metal Hip Arthroplasty (MoMHA), the use of MoMHA, especially hip resurfacing, is decreasing worldwide. In cases of ARMD or a rise of metal ion blood levels, revision is commended even in pain free patients with a well integrated implant. The revision of a well integrated implant will cause bone loss. As most of the patients with a hip resurfacing are young and a good bone stock is desirable for further revision surgeries, the purpose of this study was to evaluate the stability of a cemented polyethylene cup in a metal hip resurfacing cup. Two different hip resurfacing systems were investigated in this study (ASR™, DePuy Orthopaedics, Leatherhead, UK; Cormet™, Corin Group, Cirencester, UK).

Six different groups were formed according to the treatment and preparation of the cement-cup-interface (table 1). Before instilling cement in groups 1, 3, 5 the surface, which was contaminated with blood, was cleaned just using a gauze bandage. In groups 2, 4, 6 saline, polyhexanid and a gauze were used to clean the surface prior to the cement application. In group one and two the polyethylene cup (PE) was cemented either into Cormet™ or ASR™, just the ASR™ was further investigated in group three to six. A monoaxial load was applied while the cup was fixed with 45 degrees inclination (group 1–4) and 90 degrees inclination (group 5, 6: rotatory stability) and the failure torque was measured. In contrast to group 1 and 2, the cement penetrated the peripheral groove of the ASR™ in groups 3–6. The mean failure torque of five tests for each group was compared between the groups and the implants.

The ASR™ showed mean failure torque of 0.1 Nm in group one, of 0.14 Nm in group two, of 56.9 Nm in group three, of 61.5 Nm in group four, of 2.96 Nm in group five and of 3.04 Nm in group six. The mean failure torque of the Cormet™ was 0.14 Nm both in groups one and two (table 2). In groups 1–6 there were no significant differences between the different preparations of the interface. Furthermore, in groups 1 and 2 there were no significant differences between the Cormet™ and the ASR™. The mean failure torque of group 4 was significant increased compared to group 3 (p=0.008).

We saw an early failure of the cement fixation due to the smooth surface of the Cormet™ and the ASR™ components in groups 1, 2, 5, 6. In contrast to other hip resurfacing cups the ASR™ has a peripheral groove, which was not cemented except in groups 3 and 4 and therefore the lever-out failure torque was significant increased in these groups. Nevertheless, the groove did not provide stability of the cement-PE compound in case of rotatory movements. In conclusion we do not recommend the use of these methods in clinical routine. The complete removal of hip resurfacing components seems to be the most reasonable procedure.

1. Prosthetic acetabular cups of the Charnley and McKee-Farrar designs were cemented into cadaveric pelves using different procedures for preparing the acetabulum.

2. The torsional moments needed to loosen these cups were measured.

3. The torsional moments so measured were found to be from about four to more than twenty times higher than the frictional moments measured in independent tests on the two designs of prosthesis.

4. It is argued that late looseness of the acetabular component after total hip replacement, in the absence of infection, seems most likely to be due to thermal damage to the bone occurring at the time of polymerisation of the cement, and to subsequent bone resorption.

5. Surgical preparation of the acetabulum should include removal of all the articular cartilage and cleaning of the acetabular fossa, but the drilling of additional holes in the floor of the acetabulum seems unimportant.

6. The possibility of fatigue fracture in bone as a factor contributing to late loosening is an argument in favour of metal-on-polyethylene prostheses with their lower frictional moments, although the importance of this factor cannot be estimated.

Purpose: Treatment of Ficat III and IV femoral head necrosis is a serious challenge and a controversial issue due to the young age of the patients and disappointing results obtained with total hip arthroplasty (THA). We reviewed our experience with the cemented adjusted cup to identify factors leading to surgical revision and assess long-term clinical outcome.

Material and methods: Sixty hips presenting necrotic heads were treated by cemented adjusted cups. Mean age of the patients was 33.6 years (range 18–51); 23% women and 77% men. The Ficat classification was: grade II 6%, grade III 85%, grade IV 9%. Mean necrotic Kerboull angle was 192°. In addition, the status of the acetabular cartilage was recorded at surgery: grade I normal 17%, grade II fissuration 30%, grade IIIA fibrillation without osteophytes 28%, grade IIIB fibrillation with osteophytes 10%, grade IV partial erosion reaching subchondral bone 10%.

Results: At mean follow-up of 7.8 years (range 1 – 21 years), there were no cases of dislocation, femur neck fracture, or osteolysis. Mean UCLA score showed significant improvement in pain (from 4.5 to 8.1), walking (6.1 to 8.8), function (5.3 to 7.6), and activity (4.2 to 5.8). Five-, ten-, and fifteen-year survival rates were 81, 57, and 40% respectively. Fifteen hips required THA, twelve for acetabular cartilage wear, one for femoral loosening, and one for infection. A positive correlation (p = 0.005) was observed between the duration of signs preoperatively and degradation of the acetabular cartilage, suggesting a relationship also with shorter prosthesis survival. The Kerboull necrosis angle and Ficat grade were not correlated with prosthesis survival.

Discussion: Survival of the adjusted cup is better when symptoms have been perceptible for less than one year, probably because the acetabular cartilage is less damaged. These results are better than those with other conservative solutions such as osteotomy or vascularised graft which do not reach 80% survival at five years and which provide less effective pain relief. If necessary, conversion to a THA can be performed without compromising clinical outcome.

Introduction

The Exeter RimFit™ flanged cemented cup features ultra-highly cross-linked polyethylene and was introduced onto the market in the UK in 2010. We aimed to examine the rates of radiolucent lines observed when the Rimfit™ cup was implanted using a ‘rimcutter’ technique with the cup sitting on a prepared acetabular rim, and a ‘trimmed flange’ technique were the flange is cut so that it sits inside the prepared acetabular rim.

Introduction: There has been a renewed interest in metal-on-metal articulation in hip joint Arthroplasty. The reason for having metal-on-metal articulation is to reduce the volume of wear particles that are produced with THR. The outcome of reduced particle formation will hopefully be reduced osteolysis.

Methods: We reviewed the results of 139 primary hip arthroplasties (130 patients) performed using Metasul articulation and cemented Weber cup. Six patients were lost to follow-up leaving 133 hips (124 patients) for review with at least 5-year follow-up. The acetabular socket was the cemented Weber cup and Bone grafting of the acetabulum and application of a reinforcement ring was done where necessary. Cemented CF-30 femoral stem was used in all patients but one (PFMR). The study was conducted retrospectively based on the information collected from hospital notes and Orthocom database. Immediate post-operative films were seen to measure the cup and stem inclination and quality of cementing using the Barracks grading system.

Results: There were 102 females and 22 males in the cohort. Mean age was 73 years (SD-7.46, range 58–86). Left to right hip ratio was 52:81. Most common Pre-operative diagnosis was Osteoarthritis (103) followed by Intracapsular fracture neck of femur (20). The average follow-up was 7.23 years (range 5–10.9). Mean pre-operative Harris hip score was 42.09 and mean post-operative hip scores were 90.01, 86.84, 87.42 and 84.63 at 1-year, 3-year, 5-year and final follow-up with the corresponding pain scores were 42.9, 41.84, 41.56 and 41.56 respectively. Only two hips were revised for aseptic loosening of the cup with a 93.4% implant survivorship at 12 years. There was no case of aseptic stem loosening. No untoward systemic effects were noted in the cohort.

Discussion: We believe that in our study Metasul metal-on-metal articulation has shown satisfactory results with regards to aseptic loosening and reduction in osteolysis in medium-term.

Revision hip surgery is reportedly rising inexorably yet not all units report this phenomenon. The outcome of 1143 consecutive Corin TaperFit primary hip arthroplasties (957 patients) performed between 1995 and 2010 is presented. The implants were cemented under pressurisation and combined the TaperFit stem with Ogee flanged cups.

Data was gathered from local arthroplasty database and case note review of revised joints. 13 hips have been revised (1.1%). Cumulative prosthesis survival is 0.99 +/− 0.0. Two femoral stems were revised (0.2%); one at 6 months for sepsis, one at 14 days after dislodgment during reduction of dislocation. No revisions were undertaken for aseptic loosening of the stem or cup, nor for thigh pain. 32 patients (32 hips) ≥15 year follow up, 13 survive today and none have been revised (0%). Of the 471 with ≥10 year follow up, 38 were aged ≤50 at time of surgery and 1/38 has been revised to date (PLAD for dislocation).

The strong population stability in this region, supported by independent investigation by Scottish Arthroplasty Project, endorses the accuracy of the data quoted. The low incidence of revision in this cohort, and absence of revision for aseptic loosening (mean follow up 8.03 years +/− SD 3.94; range 18 months to 16yrs 2 months), substantially supports the longevity and use of cemented, double-taper, polished, collarless femoral stems in combination with cemented polyethylene cups in primary hip arthroplasty in all patient age groups.

We have prospectively followed up 191 consecutive primary total hip replacements utilising a collarless polished tapered (CPT) femoral stem, implanted in 175 patients between November 1992 and November 1995. At a mean follow-up of 15.9 years (range 14 – 17.5) 86 patients (95 hips) were still alive (25 men and 61 women) and available for routine follow up. Clinical outcome was determined from a combination of the Harris (HHS) and Oxford (OHS) hip scores. Radiological assessment was with antero-posterior radiographs of both hips and a lateral radiograph of the operated hip. The radiographs were evaluated using well-recognised assessment techniques. There was no loss to follow up, with clinical data available on all 95 hips. Five patients were too frail to undergo radiographic assessment, therefore radiological assessment was performed on 90 hips (95%). At the latest follow-up, the mean HHS was 78 (range 28 – 100) and the mean OHS was 36 (range 15 – 48). Stems subsided within the cement mantle, with a mean total subsidence of 2.1mm (range 0.4 – 24). Higher grades of heterotopic bone formation were significantly associated with males (p<0.001) and hypertrophic osteoarthritis (p<0.001). Acetabular wear was associated with increased weight (p<0.001) and male sex (p=0.005). Amongst the cohort, only 1 stem (1.1%) has been revised due to aseptic loosening. This patient required reaming of their canal prior to implantation, as a result of a previous femoral osteotomy. The rate of stem revision for any cause was 7.4% (7 stems), of which 4.2% (4 stems) resulted from infection following revision of the acetabular component. Twenty patients (21.1%) required some sort of revision procedure; all except 3 of these resulted from failure of the acetabular component. Cemented cups had a significantly lower revision burden (2.7%) than Harris Galante uncemented components (21.8%) (p<0.001). The CPT stem continues to provide excellent radiological and clinical outcomes at 15 years following implantation. Its results are consistent with other polished tapered stem designs. Cup failure remains a problem and is related in part to inadequate bearings and biological abnormalities

The aim of this study was to measure polyethylene wear in uncemented metal-backed cups and compare it with cemented ultra-high molecular weight (UHMW) polyethylene cups in a controlled double-blind study. The study group was made up of 91 patients aged 50 to 70 years undergoing THR for unilateral OA of the hip between February 1995 and July 2002. The male to female ratio was 40:60. In all patients, a cemented stem and 28-mm ceramic head was inserted, using a third-generation cementing technique and UHMW polyethylene. Patients were randomly allocated to receive either a cemented or uncemented acetabular cup. Eight patients were lost to follow-up. Cemented cups were used in 28 patients (mean age 64 years). The mean thickness of the polyethylene was 9.6 mm (7.5 to 12.5). The mean liner thickness in the metal-backed cups was 8.9 mm (7 to 12.2). In measuring wear, baseline 3-month postoperative radiographs were compared with the most recent follow-up radiographs and Martell software was used. The polyethylene in metal-backed cups had a mean wear rate of 0.49 mm at 4.7 years, with a mean annual wear rate of 0.12 mm. The cemented polyethylene cups had a mean wear rate of 0.45 mm at 5.3 years, with a mean annual wear rate of 0.11 mm. The study is ongoing. Currently we conclude that there is no significant difference in the annual wear rate of polyethylene in uncemented metal-backed cups and cemented cups

Between 1982 and 1997, twenty-six children between the age of 2 and 15 (mean age 10. 6 years) underwent proximal femoral replacement. Twenty have survived and all but three have reached skeletal maturity. Sequential radiographs have been reviewed with particular reference to acetabular development and fixation of the prostheses. Initially a cemented acetabular component was inserted, but recently uncemented implants and unipolar femoral heads that exactly fit the acetabulum have been used. In older children the acetabulum develops normally and the components remain well fixed. One of nine children over thirteen years with a cemented acetabulum needed revision for loosening and one suffered recurrent dislocations. In younger children the acetabulum continues to develop at the triradiate cartilage, so a cemented acetabulum grows away from the ischiopubic bar. As the component is fixed proximally, it becomes increasingly vertical and will almost inevitably loosen. In our study six of eight children under 13 years of age with a cemented acetabulum needed revision for loosening. Unipolar replacements in younger children tend to erode the superior acetabular margin. Femoral head cover is difficult to maintain, and of four unipolar implants in children under thirteen, two required acetabular augmentation. Cemented cups may be unsuitable for children under thirteen years but our results are not statistically significant. In this age group, unipolar implants may be more appropriate but they have serious potential complications. In children over thirteen, cemented implants survive longer. The number of uncemented implants in our study is too small to comment on long-term survival

Aims

There is a paucity of long-term studies analyzing risk factors for failure after single-stage revision for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). We report the mid- to long-term septic and non-septic failure rate of single-stage revision for PJI after THA.

Aims

Radiostereometric analysis (RSA) studies of vitamin E-doped, highly crosslinked polyethylene (VEPE) liners show low head penetration rates in cementless acetabular components. There is, however, currently no data on cemented VEPE acetabular components in total hip arthroplasty (THA). The aim of this study was to evaluate the safety of a new cemented VEPE component, compared with a conventional polyethylene (PE) component regarding migration, head penetration, and clinical results.

Deficiencies of acetabular bone stock at revision hip replacement were reconstructed with two different types of allograft using impaction bone grafting and a Burch-Schneider reinforcement ring. We compared a standard frozen non-irradiated bone bank allograft (group A) with a freeze-dried irradiated bone allograft, vitalised with autologous marrow (group B). We studied 78 patients (79 hips), of whom 87% (69 hips) had type III acetabular defects according to the American Academy of Orthopaedic Surgeons classification at a mean of 31.4 months (14 to 51) after surgery. At the latest follow-up, the mean Harris hip score was 69.9 points (13.5 to 97.1) in group A and 71.0 points (11.5 to 96.5) in group B. Each hip showed evidence of trabeculation and incorporation of the allograft with no acetabular loosening.

These results suggest that the use of an acetabular reinforcement ring and a living composite of sterile allograft and autologous marrow appears to be a method of reconstructing acetabular deficiencies which gives comparable results to current forms of treatment.