Aims. It is important to analyze objectively the hammering sound in cup press-fit technique in total hip arthroplasty (THA) in order to better understand the change of the sound during impaction. We hypothesized that a specific characteristic would present in a hammering sound with successful fixation. We designed the study to quantitatively investigate the acoustic characteristics during cementless cup impaction in THA. Methods. In 52 THAs performed between November 2018 and April 2022, the acoustic parameters of the hammering sound of 224 impacts of successful press-fit fixation, and 55 impacts of unsuccessful press-fit fixation, were analyzed. The successful fixation was defined if the following two criteria were met: 1) intraoperatively, the stability of the cup was retained after manual application of the torque test; and 2) at one month postoperatively, the cup showed no translation on radiograph. Each hammering sound was converted to sound pressures in 24 frequency bands by fast Fourier transform analysis. Basic patient characteristics were assessed as potential contributors to the hammering sound. Results. The median sound pressure (SP) of successful fixation at 0.5 to 1.0 kHz was higher than that of unsuccessful fixation (0.0694 (interquartile range (IQR) 0.04721 to 0.09576) vs 0.05425 (IQR 0.03047 to 0.06803), p < 0.001). The median SP of successful fixation at 3.5 to 4.0 kHz and 4.0 to 4.5 kHz was lower than that of unsuccessful fixation (0.0812 (IQR 0.05631 to 0.01161) vs 0.1233 (IQR 0.0730 to 0.1449), p < 0.001; and 0.0891 (IQR 0.0526 to 0.0891) vs 0.0885 (IQR 0.0716 to 0.1048); p < 0.001, respectively). There was a statistically significant positive relationship between body weight and SP at 0.5 to 1.0 kHz (p < 0.001). Multivariate analyses indicated that the SP at 0.5 to 1.0 kHz and 3.5 to 4.0 kHz was independently associated with the successful fixation. Conclusion. The frequency bands of 0.5 to 1.0 and 3.5 to 4.0 kHz were the key to distinguish the sound characteristics between successful and unsuccessful press-fit cup fixation. Cite this article: Bone Jt Open 2024;5(3):154–161

Aims. It is important to analyze objectively the hammering sound in cup press-fit technique in total hip arthroplasty (THA) in order to better understand the change of the sound during impaction. We hypothesized that a specific characteristic would present in a hammering sound with successful fixation. We designed the study to quantitatively investigate the acoustic characteristics during cementless cup impaction in THA. Methods. In 52 THAs performed between November 2018 and April 2022, the acoustic parameters of the hammering sound of 224 impacts of successful press-fit fixation, and 55 impacts of unsuccessful press-fit fixation, were analyzed. The successful fixation was defined if the following two criteria were met: 1) intraoperatively, the stability of the cup was retained after manual application of the torque test; and 2) at one month postoperatively, the cup showed no translation on radiograph. Each hammering sound was converted to sound pressures in 24 frequency bands by fast Fourier transform analysis. Basic patient characteristics were assessed as potential contributors to the hammering sound. Results. The median sound pressure (SP) of successful fixation at 0.5 to 1.0 kHz was higher than that of unsuccessful fixation (0.0694 (interquartile range (IQR) 0.04721 to 0.09576) vs 0.05425 (IQR 0.03047 to 0.06803), p < 0.001). The median SP of successful fixation at 3.5 to 4.0 kHz and 4.0 to 4.5 kHz was lower than that of unsuccessful fixation (0.0812 (IQR 0.05631 to 0.01161) vs 0.1233 (IQR 0.0730 to 0.1449), p < 0.001; and 0.0891 (IQR 0.0526 to 0.0891) vs 0.0885 (IQR 0.0716 to 0.1048); p < 0.001, respectively). There was a statistically significant positive relationship between body weight and SP at 0.5 to 1.0 kHz (p < 0.001). Multivariate analyses indicated that the SP at 0.5 to 1.0 kHz and 3.5 to 4.0 kHz was independently associated with the successful fixation. Conclusion. The frequency bands of 0.5 to 1.0 and 3.5 to 4.0 kHz were the key to distinguish the sound characteristics between successful and unsuccessful press-fit cup fixation. Cite this article: Bone Jt Open 2024;4(3):154–161

We selected randomly a consecutive series of 162 patients requiring hip replacement to receive either a cementless, hemispherical, modular, titanium acetabular cup or a cemented, all-polyethylene cup. These replacements were performed by two surgeons in four general hospitals. The same surgical technique was used and a 26 mm metal-head femoral component was used in every case. After exclusions, 115 hips were studied for differences in rates of wear and osteolysis. The mean clinical follow-up was eight years and the mean radiological follow-up, 6.5 years. The cementless cups wore at a mean rate of 0.15 mm per year and the cemented cups at 0.07 mm per year. This difference was significant (p < 0.0001). Our findings in this mid-term study suggest that cementless cups wear more than cemented cups

In total hip arthroplasty (THA), cementless cup without screw holes has the putative benefits of maximizing host bone contact and reducing osteolysis by eliminating channels to backside wear particles. However, supplemental trans-acetabular screws cannot be used. 74 hips in 60 patients receiving same model of cementless cup without screw holes (Depuy Duraloc 100 HA cup) from 6/1999 to 3/2003 were prospectively followed up. All patients were allowed to have immediate full weight bearing. Age at THA was 53 ± 13 (range 24–74) years. Osteonecrosis was the leading hip disease (45% of hips). Survivorship was assessed using revision of the cup as the end point. Radiological parameters, including lateral opening angle, vertical and horizontal migration distances of the cups were measured. Paired t-test was used to compare between the measurements in early postoperative period and at final follow up. 51 hips were assessed at minimum 20 years follow-up. The mean follow-up was 22.6 (range 21 – 25) years. All the cups were well fixed. There were two cup revisions. Conventional polyethylene (PE) was used in both hips; osteolysis occurred 17 and 18 years later. Both cups were well fixed but were revised, one due to cup mal-positioning, one due to need in upsizing the articulation. 14 other hips were revised but these cups were well fixed and not revised; 9 loosened stems (most were cemented Elite plus stems), 5 PE wear and osteolysis (all were conventional PE). At 20 years, the survivorship of cups was 96.1%. Changes in lateral opening angle, vertical and horizontal migration distances were 0.44±1.59°, 0.01±1.52mm and -0.32±1.47mm respectively, without statistical significance. This study provided evidence of excellent long-term survivorship of cementless cup without screw holes. Immediate postoperative weight-bearing also did not lead to cup migration in the long-term

The increasing need for total hip replacement (THR) in an ageing population will inevitably generate a larger number of revision procedures. The difficulties encountered in dealing with the bone deficient acetabulum are amongst the greatest challenges in hip surgery. The failed acetabular component requires reconstruction to restore the hip centre and improve joint biomechanics. Impaction bone grafting is successful in achieving acetabular reconstruction using both cemented and cementless techniques. Bone graft incorporation restores bone stock whilst providing good component stability. We provide a summary of the evidence and current literature regarding impaction bone grafting using both cemented and cementless techniques in revision THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:98–102.

Aims. Manual impaction, with a mallet and introducer, remains the standard method of installing cementless acetabular cups during total hip arthroplasty (THA). This study aims to quantify the accuracy and precision of manual impaction strikes during the seating of an acetabular component. This understanding aims to help improve impaction surgical techniques and inform the development of future technologies. Methods. Posterior approach THAs were carried out on three cadavers by an expert orthopaedic surgeon. An instrumented mallet and introducer were used to insert cementless acetabular cups. The motion of the mallet, relative to the introducer, was analyzed for a total of 110 strikes split into low-, medium-, and high-effort strikes. Three parameters were extracted from these data: strike vector, strike offset, and mallet face alignment. Results. The force vector of the mallet strike, relative to the introducer axis, was misaligned by an average of 18.1°, resulting in an average wasted strike energy of 6.1%. Furthermore, the mean strike offset was 19.8 mm from the centre of the introducer axis and the mallet face, relative to the introducer strike face, was misaligned by a mean angle of 15.2° from the introducer strike face. Conclusion. The direction of the impact vector in manual impaction lacks both accuracy and precision. There is an opportunity to improve this through more advanced impaction instruments or surgical training. Cite this article: Bone Joint Res 2024;13(4):193–200

In primary total hip arthroplasty (THA) for patients with Crowe II or higher classes developmental dysplasia of the hip (DDH) or rapidly destructive coxopathy (RDC), the placement of the cup can be challenging due to superior and lateral acetabular bone defects. Traditionally, bone grafts from resected femoral heads were used to fill these defects, but bulk graft poses a risk of collapse, especially in DDH with hypoplastic femoral heads or in RDC where good quality bone is scarce. Recently, porous metal augments have shown promising outcomes in revision surgeries, yet reports on their efficacy in primary THA are limited. This study retrospectively evaluated 27 patients (30 hips) who underwent primary THA using cementless cups and porous titanium acetabular augments for DDH or RDC, with follow-up periods ranging from 2 to 10 years (average 4.1 years). The cohort included 22 females (24 hips) and 5 males (6 hips), with an average age of 67 years at the time of surgery. The findings at the final follow-up showed no radiographic evidence of loosening or radiolucency around the cups and augments, indicating successful biological fixation in all cases. Clinically, there was a significant improvement in the WOMAC score from an average of 39.1±14.7 preoperatively to 5.1±6.4 postoperatively. These results suggest that the use of cementless cups and porous titanium acetabular augments in primary THA for DDH and RDC can lead to high levels of clinical improvement and reliable biological fixation, indicating their potential as a viable solution for managing challenging acetabular defects in these conditions

Highly crosslinked polyethylene (HXLPE) has been used with great clinical success in total hip arthroplasty (THA) since its debut in the late 1990's. However, reports regarding this bearing couple in its second decade of service are still scant. The aim of this study was to 1. Determine the long term clinical and radiological results and 2. Investigate what factors affect wear rates using a metal-on-HXLPE bearing articulation. 55 THA's using a single brand of HXLPE liner, cementless cup and 28mm hip ball were performed in 44 patients. Age, sex, and Charlson Comorbidity Index (CCI) and need for revision surgery were recorded. Linear and volumetric wear was determined using the Martell method. Mean age at operation was 51.2 (29–73 +/− 12.1) years. Mean duration of follow up was 16.9 years (range 15.0–20.1 +/− 1.1 years). Osteolysis was not present in the latest follow up radiographs. Median linear and volumetric wear rate was 0.035mm/year (95% CI 0.031–0.047) and 7.12mm. 3. /year (95% CI 6.92–17.25) respectively. Acetabular component position was not found to be related to both linear and volumetric wear. No significant difference was found in the linear and volumetric wear rates of thinner and thicker liners (8mm or below and > 8mm) (p=0.827 and p=0.843 respectively). HXLPE is associated with very low linear and volumetric wear rates which has virtually obviated osteolysis and has translated to excellent survivorship even at long term follow up. In-vivo oxidation does not appear to be of clinical concern at this point in its service cycle

There are few reports describing the technique of managing acetabular protrusio in primary total hip replacement. Most are small series with different methods of addressing the challenges of significant medial and proximal migration of the joint centre, deficient medial bone and reduced peripheral bony support to the acetabular component. We describe our technique and the clinical and radiological outcome of using impacted morsellised autograft with a porous-coated cementless cup in 30 primary THRs with mild (n = 8), moderate (n = 10) and severe (n = 12) grades of acetabular protrusio. The mean Harris hip score had improved from 52 pre-operatively to 85 at a mean follow-up of 4.2 years (2 to 10). At final follow-up, 27 hips (90%) had a good or excellent result, two (7%) had a fair result and one (3%) had a poor result. All bone grafts had united by the sixth post-operative month and none of the hips showed any radiological evidence of recurrence of protrusio, osteolysis or loosening. By using impacted morsellised autograft and cementless acetabular components it was possible to achieve restoration of hip mechanics, provide a biological solution to bone deficiency and ensure long-term fixation without recurrence in arthritic hips with protrusio undergoing THR. Cite this article: Bone Joint J 2013;95-B, Supple A:37–40

Aims

Large acetabular bone defects encountered in revision total hip arthroplasty (THA) are challenging to restore. Metal constructs for structural support are combined with bone graft materials for restoration. Autograft is restricted due to limited volume, and allogenic grafts have downsides including cost, availability, and operative processing. Bone graft substitutes (BGS) are an attractive alternative if they can demonstrate positive remodelling. One potential product is a biphasic injectable mixture (Cerament) that combines a fast-resorbing material (calcium sulphate) with the highly osteoconductive material hydroxyapatite. This study reviews the application of this biomaterial in large acetabular defects.

Aims

Limited implant survival due to aseptic cup loosening is most commonly responsible for revision total hip arthroplasty (THA). Advances in implant designs and materials have been crucial in addressing those challenges. Vitamin E-infused highly cross-linked polyethylene (VEPE) promises strong wear resistance, high oxidative stability, and superior mechanical strength. Although VEPE monoblock cups have shown good mid-term performance and excellent wear patterns, long-term results remain unclear. This study evaluated migration and wear patterns and clinical and radiological outcomes at a minimum of ten years’ follow-up.

Aims

Instability is a common cause of failure after total hip arthroplasty. A novel reverse total hip has been developed, with a femoral cup and acetabular ball, creating enhanced mechanical stability. The purpose of this study was to assess the implant fixation using radiostereometric analysis (RSA), and the clinical safety and efficacy of this novel design.

Aims

The aim of this study was to evaluate the suitability of the tapered cone stem in total hip arthroplasty (THA) in patients with excessive femoral anteversion and after femoral osteotomy.

Introduction. In total hip arthroplasty (THA), a high radiographic inclination angle (RI) of the acetabular component has been linked to an increased dislocation rate, liner fracture, and increased wear. In contrast to version, we have more proven boundaries when it comes to a safe zone for angles of RI. Although intuitively it seems easier to achieve a target RI, most studies demonstrate a lack of accuracy and the trend towards a high RI with all surgical approaches when using a freehand technique or a mechanical guide. This is due to pelvic motion during surgery, which can be highly variable. The current study had two primary aims, each with a different primary outcome. The first aim was to determine how accurate a surgeon could obtain the target operative inclination (OI) during THA when using a cementless cup using a digital protractor. The second aim was to determine how accurate a surgeon can estimate the target OI to obtain a RI of 40° based on the patient's hip circumference as demonstrated in a previous study. Methods. In this prospective study, we included 200 consecutive patients undergoing uncemented primary THA in the lateral decubitus position using a posterior approach. Preoperatively, the surgeon determined the target OI based on the patient's hip circumference (22.5°, 25°, 27.5° or 30°). Intraoperatively, the effective OI was measured with the aid of a digital inclinometer after seating of the acetabular component. Six weeks postoperatively anteroposterior pelvic radiographs were made and two evaluators, blinded to the effective OI, measured the RI of the acetabular component. The safe zone for inclination was defined as 30°-45° of inclination. Results. The mean difference between the target OI and the effective OI of the acetabular component was −0.7° SD 1.4 (95% CI −0.9° to −0.5°). The difference between the target and effective OI was less than 1° in 108 patients (54%), less than 2° in 160 patients (80%) and less than 3° in 186 patients (93%). In 14 patients (7%) the difference was 3°-5°. The mean RI was 37.9° SD 4.7 (95% CI 37.2° to 38.5°). The mean difference between the RI and effective OI was 11.5° SD 4.7 (95% CI 10.8° to 12.1°). Overall, 188 cups (94%) were within the inclination safe zone. When analysing the RI outliers, 1 could have be avoided if a better target OI was chosen and 2 could have been avoided if the difference between the target and effective OI would have been smaller. For the remaining 9 outliers (75%) the difference between the RI and effective OI was in the upper and lower 7. th. percentile, indicating more or less than average motion of the pelvis in these patients. Discussion and Conclusions. When using a digital protractor, the mean difference between the target OI and the effective OI of the acetabular component was less than 3° in 93% and less than 5° in all patients. The use of a digital protractor allows surgeons to accurately implant the acetabular component in the desired OI in a cheap and easy way. By adjusting the target OI based on the patient's hip circumference, 94% of the acetabular components were placed within an inclination safe zone of 30°-45°. Most outliers were caused by more of less than average intraoperative pelvic motion

Since the universal failure of first generation smooth threaded cups in primary total hip arthroplasty (THA), the screw-in concept of cementless acetabular cup fixation has been largely abandoned. We hypothesised that grit-blasted titanium conical cement free threaded cup shows stable long-term fixation. 198 Alloclassic total hip arthroplasties were performed in 179 patients, mean age 66 years old (22–85). 193 hips were analyzed after a mean follow-up of 10 years (1–25 years). Results were excellent or good in 184 hips (95%). Postel-Merle d'Aubigne score increased from 10.3 (range 1 to 15) pre-operatively to 16.7 (12 to 18) points and 151 hips (78%) were pain free at last FU. Radiographic signs indicating successful cup osseointegration were noted in 92% of hips. Polyethylene wear > 0.1mm/year was observed in 6 hips (3%). The main cause of re-operation/revision surgery was recurrent dislocation (9/17cases, 53%). 2 threaded cups were revised for any reason and the revision per cent observed acetabular component years was 0.10 at 10 years average FU. 20 year-survival of the metal back was 98.8% (77.2–99.9%) and 100% (79.6–100%) for revision for any reason and revision for aseptic loosening, respectively. Despite minimum PE thickness of 6.5mm and use of alumina ceramic 28mm heads, conventional polyethylene liner wear was the weak link of the acetabular reconstruction;. This study shows excellent long-lasting bone anchorage through bone on-grown of grit-blasted titanium threaded cup. Despite universal outstanding longevity in the worldwide literature, CSF threaded cups were retrieved from the European market in March 2017 due to insufficient sales, indicating that evidence base medicine may not be the major criteria influencing surgeons' choice

Aims

To compare long-term survival of all-cemented and hybrid total hip arthroplasty (THA) using the Exeter Universal stem.

Aims

Recurrent infection following two-stage revision total hip arthroplasty (THA) for prosthetic joint infection (PJI) is a devastating complication. The purpose of this study was to report the survival of repeat two-stage revision hip arthroplasty, describe complications, and identify risk factors for failure.

Aims

Using a systematic review, we investigated whether there is an increased risk of post-operative infection in patients who have received an intra-articular corticosteroid injection to the hip for osteoarthritis prior to total hip arthroplasty (THA).

We performed 114 consecutive primary total hip arthroplasties with a cementless expansion acetabular component in 101 patients for advanced osteonecrosis of the femoral head. The mean age of the patients at surgery was 51 years (36 to 62) and the mean length of follow-up was 110 months (84 to 129).

The mean pre-operative Harris hip score of 47 points improved to 93 points at final follow-up. The polyethylene liner was exchanged in two hips during this period and one broken acetabular component was revised. The mean linear wear rate of polyethylene was 0.07 mm/year and peri-acetabular osteolysis was seen in two hips (1.9%). Kaplan-Meier analysis indicated that the survival of the acetabular component without revision was 97.8% (95% confidence interval 0.956 to 1.000) at ten years.

Our study has shown that the results of THA with a cementless expansion acetabular component and an alumina-polyethylene bearing surface are good.

Symptomatic hip osteonecrosis is a disabling condition with a poorly understood aetiology and pathogenesis. Numerous treatment options for hip osteonecrosis are described, which include non-operative management and joint preserving procedures, as well as total hip replacement (THR). Non-operative or joint preserving treatment may improve outcomes when an early diagnosis is made before the lesion has become too large or there is radiographic evidence of femoral head collapse. The presence of a crescent sign, femoral head flattening, and acetabular involvement indicate a more advanced-stage disease in which joint preserving options are less effective than THR. Since many patients present after disease progression, primary THR is often the only reliable treatment option available. Prior to the 1990s, outcomes of THR for osteonecrosis were poor. However, according to recent reports and systemic reviews, it is encouraging that with the introduction of newer ceramic and/or highly cross-linked polyethylene bearings as well as highly-porous fixation interfaces, THR appears to be a reliable option in the management of end-stage arthritis following hip osteonecrosis in this historically difficult to treat patient population.

Cite this article: Bone Joint J 2013;95-B, Supple A:46–50.