Introduction. Primary stability is achieved by the press fit technique, where an oversized component is inserted into an undersized reamed cavity. The major geometric design of an acetabular shell is hemispherical type. On the other one, there are the hemielliptical type acetabular shells for enhanced peripheral contact. In the case of developmental dysplasia of the hip (DDH), the aseptic loosening may be induced by instability due to decreased in the contact area between the acetabular shell and host bone. The aim of this study was to assess the effect of reaming size on the primary stability of two different outer geometry shells in DDH models. Materials and methods. The authors evaluated hemispherical (Continuum Acetabular Shell, Zimmer Biomet G.K.) and hemielliptical (Trabecular Metal Modular Acetabular Shell, Zimmer Biomet G.K.) acetabular shells. Both shells had a 50 mm outer diameter and same tantalum 3D highly porous surface. An acetabular bone model was prepared using a solid rigid polyurethane foam block with 20 pcf density (Sawbones, Pacific Research Laboratories Inc.) as a synthetic bone substrate. Press fit conditions were every 1 mm from 4 mm under reaming to 2 mm over reaming. To simulate the acetabular dysplasia the synthetic bone substrate was cut diagonally at 40°. Where, the acetabular inclination and cup-CE angle were assumed to 40° and 10°, respectively. Acetabular components were installed with 5 kN by a uniaxial universal testing machine (Autograph AGS-X, Shimadzu Corporation). Primary stability was evaluated by lever-out test. The lever-out test was performed in 4 mm undersized to 2 mm oversized reaming conditions. Lever out moment was calculated from the multiplication of the maximum load and the moment arm for primary stability of the shell. The sample size was 6 for each shell type. Results. The hemisphererical acetabular shell had the maximum lever out moment in 3 mm under reaming condition (7.4 ± 0.4 N·m). The hemielliptical acetabular shell had the maximum lever out moment in 1 mm under reaming condition (8.7 ± 0.8 N·m). Furthermore, the lever out moment of the hemielliptical acetabular shell was significantly 1.2 times greater by the t-test than the hemispherical acetabular shell under the maximum primary fixation conditions. Discussion. The risk parameter of the acetabular loosening is indicated the lack of lateral bony support. The hemielliptical shell was not adversely effected more than the hemispherical shell. Furthermore, the reaming condition of the most primary fixation on the hemielliptical shell was 1 mm under reaming, and was a more general operating procedure than the hemispherical shell (3 mm under reaming). From this study, it was suggested that the hemielliptical shell might be expected excellent clinical outcomes in severe acetabular dysplasia hips. For any figures or tables, please contact authors directly

A retrospective single-center review has been performed to gather clinical data on the use of polycarbonate-urethane (PCU) as an articulating bearing material inside a cobalt-chrome (Co-Cr) press-fit acetabular shell. As of January 2010, the Co-Cr shell and PCU liner have been implanted into 25 total hip patients which were retrospectively followed. The indications for use were in 24 cases of osteoarthritis, and 1 revision case. No patient was lost to follow-up. The average follow-up time was 17.6 months (range 8-27). The average age of these patients was 67.9 (range 44-84), the sex distribution was 14 female and 11 male patients, of whom 15 were right and 10 left side. 24 patients received a total hip replacement with the metal acetabular system and a cementless femoral stem and 1 patient received the metal acetabular shell coupled to a cemented resurfacing head. None of the cases has had a dislocation, revision, dislodgement, or infection. At follow-up, the mean Harris hip score was 98 points (80-99). X-rays showed good bone-implant contact without any osteolysis or bone rarefaction. A detailed review of the clinical data of these patients shows that a PCU liner inserted into a Co-Cr acetabular shell is as safe and effective as other commonly used acetabular shells in other total hip systems currently available. No new or unintended adverse or device-related events were discovered with the clinical use of PCU in a Co-Cr acetabular shell

INTRODUCTION. Deformation of modular acetabular press-fit shells is a topic of much interest for surgeons and manufacturer. Such modular components utilise a titanium shell with a liner manufactured from metal, polyethylene or ceramic. Initial fixation is achieved through a press-fit between shell and acetabulum with the shell mechanically deforming upon insertion. Shell deformation may disrupt the assembly process of inserting the bearing liner into the acetabular shell for modular systems. This may adversely affect the integrity and durability of the components and the tribology of the bearing. OBJECTIVE. Most clinically relevant data to quantify and understand such shell deformation can be achieved by cadaver measurements. ATOS Triple Scan III was identified as a measurement system with the potential to perform those measurements. The study aim was to validate an ATOS Triple Scan III optical measurement system against a co-ordinate measuring machine (CMM) using in-vitro testing and to check capability/ repeatability under cadaver lab conditions. METHODS. Two sizes of custom-made acetabular shells were deformed using a uniaxial/ two-point loading frame and measured repeatedly at different loads. Roundness measurements were performed using both the ATOS Triple Scan III optical system and a co-ordinate measuring machine and then compared. The repeatability was also tested by measuring shells pre and post insertion in a cadaver lab multiple times. RESULTS. The in-vitro comparison with CMM demonstrated a maximum difference of 5 µm at the rim and 9 µm at the measurement point closest to the pole of the shell. Deviation between the two systems increased towards the pole for the in-vitro measurements. However as press fit shells are designed to be loaded at the rim, this is likely where the maximum deflection will occur as a result of the highest force. Therefore, the increased difference between the systems towards the pole is of less importance compared with accuracy at the rim. Maximum repeatability was below 1 µm for the CMM and 3 µm for the ATOS Triple Scan III optical system. Repeatability of the ATOS Triple Scan III optical system was comparable between pre insertion (below 2 µm) and post insertion (below 3 µm) measurements in the cadaver lab. In addition these values were comparable to the repeatability measured during the in-vitro validation study (below 3 µm). This proves high repeatability not only for in-vitro conditions, but also for the cadaver lab as well. CONCLUSIONS. This study supports the view that the ATOS Triple Scan III optical system fulfils the necessary requirements to accurately measure shell deformation in cadavers. As a result, the authors propose further studies using cadavers to identify the impact of other factors upon shell deformation. Other factors to be measured include bone strength, shell diameter, under reaming and wall thickness

Revision total hip replacements are likely to have higher complication rates than primary procedures due to the poor quality of the original bone. This may be constrained to achieve adequate fixation strength to prevent future “aseptic loosening” [1]. A thin, slightly flexible, acetabular component with a three dimensional, titanium foam in-growth surface has been developed to compensate for inferior bone quality and decreased contact area between the host bone and implant by better distributing loads across the remaining acetabulum in a revision situation. This is assumed to result in more uniform bone apposition to the implant by minimizing stress concentrations at the implant/bone contact points that may be associated with a thicker, stiffer acetabular component, resulting in improved implant performance.[2] To assemble the liner to the shell, the use of PMMA bone cement is recommended at the interface between the polyethylene insert and the acetabular shell as a locking mechanism configuration may not be ideal due to the flexibility in the shell [3]. The purpose of this study was to quantify the mechanical integrity of a thin acetabular shell with a cemented liner in a laboratory bench-top total hip revision condition. Two-point loading in an unsupported cavity was created in a polyurethane foam block to mimic the contact of the anterior and posterior columns in an acetabulum with superior and inferior defects. This simulates the deformation in an acetabular shell when loaded anatomically [4]. The application has been extended to evaluate the fatigue performance of the Titanium metal foam Revision Non-Modular Shell Sequentially Cross Linked PE All-Poly Inserts and its influence on liner fixation

Introduction. A majority of the acetabular shells used today are designed to be press-fit into the acetabulum. Adequate initial stability of the press-fit implant is required to achieve biologic fixation, which provides long-term stability for the implant. Amongst other clinical factors, shell seating and initial stability are driven by the interaction between the implant's outer geometry and the prepared bone cavity. The goal of this study was to compare the seating and initial stability of commercially available hemispherical and rim-loading designs. Materials and Methods. The hemispherical test group (n=6) consisted of 66mm Trident Hemispherical shells (Stryker, Mahwah NJ) and the rim-loading test group (n=6) consisted of 66mm Trident PSL shells (Stryker, Mahwah NJ). The Trident PSL shell outer geometry is hemispherical at the dome and has a series of normalizations near the rim. The Trident Hemispherical shell outer geometry is completely hemispherical. Both shells are clinically successful and feature identical arc-deposited roughened CpTi with HA coatings on their outer geometry. Hemispherical cavities were machined in 20pcf polyurethane foam blocks (Pacific Research Laboratories, WA) to replicate the press-fit prescribed in each shell's surgical protocol. The cavity for the hemispherical design was machined to 65mm (1mm-under ream) and the cavity for the rim-loading design was machined to 67mm (1mm- over ream). Note that the rim-loading design features ∼2mm build-up of material at the rim when compared to the hemispherical design. The shells were seated into the foam blocks using a drop tower (Instron Dynatup 9250G, Instron Corporation, Norwood, MA) by applying 7 impacts of 6.58J/ea,. The number and energy of impacts are clinically relevant value obtained from surgeon data collection through a validated measurement technique. Seating height was measured from the shell rim to the cavity hemispherical equator (top surface foam block) using a height gage, thus, a low value indicates a deeply seated shell. A straight torque out bar was assembled to the threads at the shell dome hole and a linear load was applied with a MTS Mechanical Test Frame (MTS Corporation, Eden Prairie, MN) to create an angular displacement rate of 0.1 degrees/second about the shell center. Yield moment of the shell-cavity interface, representing failure of fixation, was calculated from the output of force, linear, displacement, and time. Two sample T-tests were conducted to determine statistical significance. Results. Seating height for the rim-loading design was 0.041 ± 0.005in (1.0 ± 0.1mm) compared to 0.049 ± 0.008in (1.2 ± 0.2mm) for the hemispherical design. Initial stability for the rim-loading design was 33.5 ± 2.9Nm compared to 29.9 ± 4.1Nm for the hemispherical design. Discussion. This study evaluated the seating height and initial stability of two different acetabular shell designs. Results indicate that there is no evidence for a difference in seating height (p > 0.05) and initial stability (p > 0.05) between rim-loading and hemispherical designs

1) INTRODUCTION. Acetabular fixation in cementless total hip arthroplasty (THA) relies on new technology for stability and survivorship of the implant. A highly porous 3D titanium coating was developed with a biologically inspired pore structure to improve initial friction fixation with mechanical stability and long term biological fixation. Ongoing research is investigating potential radiographic phenomenons these coatings produce, resulting in the presence of lucent lines. The purpose of this study was to evaluate clinical and radiographic outcomes of a 3D highly porous-coated titanium acetabular shell. 2) METHODS. One hundred and sixty-two cases as part of a non-randomized, post-market, multicenter study received a primary cementless THA. Clinical outcomes including the Harris Hip Score (HHS), Lower Extremity Activity Scale (LEAS), Short Form 12 (SF12), and EuroQol 5D Score (EQ-5D) were collected preoperatively and at six weeks, one year postoperative. Additionally, radiographs, radiographic parameters and techniques were analyzed for institutional differences. 3) RESULTS. Significant postoperative improvements were seen in pain, function and quality of life outcomes through one year. The HHS improved significantly (p< 0.0001) by 28.9 points at six weeks and 41.7 points at one year postoperative (Figure 1), with 53.4% of patients scoring Excellent or Good at six weeks and 87.5% at one year (Figure 2). Pain and physical functioning reported by the SF-12, EQ-5D and LEAS showed further clinical improvements at one year (Figure 1). Radiographically, 9.5% of cases reviewed displayed ‘radiolucent lines’ of less than 2mm in all three acetabular zones at six weeks. These cases only displayed radiolucent lines in one zone at the one year timepoint (Figure 3). Patients with radiolucent lines reported an average HHS score of 77 and 96 at six weeks and one year, respectively, with no radiographic failures or any revisions to date. The radiographic parameters and techniques were collected to analyze differences between the imaging techniques between institutions. Institutions utilizing digital radiography with an automatic exposure control technique, had cases where ‘radiolucent lines’ were present. One institution utilizing computed radiography with a manual technique did not have any cases display ‘radiolucent lines’. 4) DISCUSSION and CONCLUSION. Despite the appearance of transient radiographic lucent lines, patients in this study have shown positive clinical outcomes and initial stability through one year postoperative. These results do not correlate with the presence of radiolucent lines. Additionally, there may be a correlation between the imaging techniques and the presence of ‘radiolucent lines.’ As this device is still widely implanted using the same surgical technique, longer follow-up is needed to confirm a true biologic fixation and survivorship of the shell

Background. Instability and dislocation are some of the most important postoperative complications and potential causes of failure that dual mobility total hip arthroplasty (THA) systems continue to address. Studies have shown that increasing the relative head size provides patients implanted with smaller and larger cups increased stability, greater ROM and a lesser incidence of impingement, without compromising clinical results. The purpose of the current study was to review clinical outcomes in three groups of primary THA patients receiving a dual mobility acetabular shell. Methods. In two US based, post-market, multicenter studies, 450 patients received a primary cementless dual mobility THA. Patients were split into three groups based on cup size: ≤ 50mm, 52mm–56mm, and ≥ 58mm. Harris Hip Scores (HHS), Short Form 12 Physical Components (SF12 PCS), Lower Extremity Activity Scores (LEAS), and Euroqol 5D Score (EQ-5Ds) were collected preoperatively and through 2 years postoperative. Results. The current study displays gender differences among the three groups, with 90% female patients in the ≤ 50mm group, 66% male patients in the 52mm–56mm group and 100% males in the largest cup size group. A posterior/posterolateral approach was used in 94% of cases. The mean age range among the 3 groups was 60.5–61.7 and the two most common concurrent medical conditions were cardiovascular and musculoskeletal. There were no differences observed in clinical outcomes among any of the groups, all of which displayed significant increasing trends through 2 years postoperative (Figure 1). The HHS increased significantly from an average preoperative score of 54.5 to 92.9 and 93.7 at 1 and 2 years. Clinically significant improvements were seen at 2 years in SF12 PCS (+16.5) and the LEAS (+2.4) (Figures 1 and 3). The EQ-5D TTO increased from 0.62 preoperative to 0.91 at 2 years postoperative (Figure 2). There have been no failures due to dislocation reported in the current study population. Conclusion. Positive clinical outcomes for primary THA patients receiving a dual mobility system were seen in the current study, supporting their effectiveness. Regardless of the relative head size, all patients showed significant improvements postoperative with continued stability. As the primary risk factors for instability can include gender, age and increased comorbidities, the contemporary dual mobility system used in this study can address each patient's anatomic differences, improving quality of life and reducing the risk for dislocation, as well as the significant cost implications

Introduction:. The management strategy regarding optimally addressing polyethylene wear with a well-fixed acetabular shell remains controversial. The purpose of the present study was to document outcomes of cementation of a highly cross-linked polyethylene (PE) liner into a well-fixed acetabular metal shell in 36 hips. Materials & Methods:. We identified 37 patients (39 hips) who had undergone revision THA by cementation of a highly cross-linked PE liner into a well-fixed metal shell between June 2004 and April 2009. Of these patients, one (1 hip) died before the end of the 3-year evaluation and another was lost to follow-up. Thus, the study cohort consisted of 35 patients (36 hips). There were 23 males (24 hips) and 12 female (12 hips) patients with a mean age at time of revision surgery of 57.6 years (range, 38–79 years). All operations were performed by a single surgeon using only one type of liner. Clinical and radiographic evaluation was performed at a mean of 6.1 years (range, 3–8 years) postoperatively. Results:. Mean Harris hip score improved from 58.1 (range, 39–81 points) preoperatively to 91.3 (range, 45–100 points) postoperatively (p < 0.001). Of the 36 hips, 29 (80.1%) had an excellent result, 6 (16.7%) a good result, and 1 (2.8%) a poor result. The patient with a poor clinical result had aseptic cup loosening with a greater trochanteric fracture at 2 years postoperatively and was treated by acetabular cup revision and internal fixation of the fracture. However, no case of PE liner dislodgement from the cement or of dissociation of the PE-cement construct from the metal shell was encountered. At last follow-up, no new osteolytic lesion was identified and previous osteolytic lesions filled with bone graft were completely or partially incorporated. Other complications included 1 incomplete peroneal nerve palsy and 1 dislocation. Conclusions:. The results of this study and previous reports demonstrated that cementation of highly cross-linked PE liner into well-fixed metal shell could provide good midterm durability

INTRODUCTION. Deformation of modular acetabular press-fit shells is of much interest for surgeons and manufacturers. Initial fixation is achieved through press-fit between shell and acetabulum with the shell mechanically deforming upon insertion. Shell deformation may disrupt the assembly process of modular systems and may adversely affect integrity and durability of the components and tribology of the bearing. The aim of the study was to show shell deformation as a function of bone and shell stiffness. METHODS. The stiffness of the generic shells was determined using a uniaxial/ two point loading frame by applying different loads, and the change in dimension was measured by a coordinate measurement machine (CMM). Cadaver lab deformation measurements were done before and after insertion for 32 shells with 2 wall thicknesses and 11 shell sizes using the ATOS Triple Scan III (ATOS) optical system previously validated as a suitable measurement system to perform those measurements. Multiple deformation measurements per cadaver were performed by using both hip sides and stepwise increasing the reamed acetabulum by at least 1 mm, depending on sufficient residual bone stock. The under-reaming was varied between 0mm and 1mm, respectively. From the deformations, the resulting forces on the shells and bone stiffness were calculated assuming force equilibrium as well as linear-elastic material behaviour in each point at the rim of the shell. RESULTS. Radial stiffness for shells with 3 mm wall thickness ranged between 6257 N/mm and 2920 N/mm, with 4 mm wall thickness it ranged between 14341 N/mm and 6875 N/mm. The radial shell deformation ranged between 3 µm and 187 µm. The resulting maximum radial forces acting on the shells ranged between 26 N and 916 N. From these values, bone stiffness [N/mm] at the point of the maximum deformation has been calculated. Adding the bone stiffness and the shell stiffness using the equation for serial springs, one obtains a positive correlation between total stiffness and maximum deformation. DISCUSSION. The measured deformation values are within the same order of magnitude previously published [Lin 2006, Squire 2006]. The large variations of resulting maximum forces exhibit the need to further investigate shell deformation using commercial shell systems. The calculated bone stiffness at the point of the maximum deformation seems to be a valid predictor for expected shell deformation, but this also needs more data. A future goal is to determine expected shell deformation from bone data as a design rational

BACKGROUND. During revision hip arthroplasty, removal of a well-fixed, ingrown metal acetabular component may not be possible. Therefore, a new polyethylene liner can be cemented into the existing shell via the cement locking mechanism. We report the indications, technique, and results of cementing an acetabular liner into a well-fixed cementless acetabular shell. PATIENTS AND METHODS. All patients were given informed consent to participate in this study, and the study was approved by our hospital institutional review board. Of 95 revision total hip arthroplasty (THA) between 2005 and 2014, five hips in 5 patients (4 female and a male) were operated by the cemented socket into metal shell technique. The mean age was 70.6 years (range, 59–84 years) (Table 1). Operative Technique. All operations were performed with the patient in the lateral decubitus position and using a posterolateral approach without osteotomy of the greater trochanter. After removal of broken polyethylene liner, an all-polyethylene socket (manufactured by Kyocera Corporation, Osaka, Japan) was cemented in the metal shell. In case of small metal shell, bone bed around the shell were augmented by the use of an impaction morselized allogeneic bone grafting, and the socket was cemented both in the metal shell and in the bone bed (Fig. 1). Postoperative Regimen. On the third postoperative day, the patients began a rehabilitation programmed by clinical path under the supervision of a physiotherapist. The use of crutches for ambulation was begun on the 10th to 14th postoperative day, with progressive weight-bearing as tolerated. Time to full weight-bearing was 3 to 4 weeks postoperatively. RESULTS. All of the cemented sockets functioned well and there were no failure cases during average follow-up period of 5 years (range, 0.7–9.5 years). DISCUSSION. Cementation of polyethylene liners into well-fixed metal shells has become a popular option during revision total hip arthroplasty (THA). Failure was always observed at the metal shell/cement interface whenever it did occur. The cement locking mechanism can be strengthened by roughening the backside of a smooth polyethylene liner to improve the cement-polyethylene interface, or by using an all-polyethylene acetabular component that is designed to be used with cement. Saw roughening of the polyethylene liner strengthens the poly-cement interface. We have used the all-polyethylene acetabular component with macrotexture anchoring form to cement fixation. To perform this procedure, an adequate shell diameter is necessary to accept an acetabular liner that will enable 2 mm of cement mantle around it. If an oversized polyethylene liner is cemented into a small acetabular metal shell, then there is the theoretical risk that the increased shear force will damage the cement locking mechanism, thus leading to failure of the construct. The case 1 in the current series, the hips had this situation, but no loosening occurred at final follow-up of 9.5 years postoperatively (Fig. 1). CONCLUSIONS. We reported good results with the use of a “cemented cup in cementless cup” technique in revision THAs, although follow-up periods were short-term to midterm. To view tables/figures, please contact authors directly

Total hip arthroplasty (THA) is an effective treatment for symptomatic hip osteoarthritis (OA). Computer-navigation technologies in total knee arthroplasty show evidence-supported survivorship advantages and are used widely. The aim of this study was to determine the revision outcome of hip commercially available navigation technologies. Data from the Australian Orthopaedic Association National Joint Replacement Registry from January 2016 to December 2020 included all primary THA procedures performed for osteoarthritis (OA). Procedures using the Intellijoint HIP® navigation were identified and compared to procedures inserted using ‘other’ computer navigation systems and to all non-navigated procedures. The cumulative percent revision (CPR) was compared between the three groups using Kaplan-Meier estimates of survivorship and hazard ratios (HR) from Cox proportional hazards models, adjusted for age and gender. A prosthesis specific analysis was also performed. There were 1911 procedures that used the Intellijoint® system, 4081 used ‘other’ computer navigation, and 160,661 were non-navigated. The all-cause 2-year CPR rate for the Intellijoint HIP® system was 1.8% (95% CI 1.2, 2.6), compared to 2.2% (95% CI 1.8, 2.8) for other navigated and 2.2% (95% CI 2.1, 2.3) for non-navigated cases. A prosthesis specific analysis identified the Paragon/Acetabular Shell THAs combined with the Intellijoint HIP® system as having a higher (3.4%) rate of revision than non-navigated THAs (HR = 2.00 (1.01, 4.00), p=0.048). When this outlier combination was excluded, the Intellijoint® system group demonstrated a two-year CPR of 1.3%. There was no statistical difference in the CPR between the three groups before or after excluding Paragon/Acetabular Shell system. The preliminary data presented demonstrate no statistical difference in all cause revision rates when comparing the Intellijoint HIP® THA navigation system with ‘other’ navigation systems and ‘non-navigated’ approaches for primary THAs performed for OA. The current sample size remains too small to permit meaningful subgroup statistical comparisons

Introduction. A variety of porous coatings and substrates have been used to obtain fixation at the bone-implant interface. Clinical studies of porous tantalum, have shown radiographically well-fixed implants with limited cases of loosening. However, there has been limited retrieval analysis of porous tantalum hip implants. The purpose of this study was to investigate factors affecting bone ingrowth into porous tantalum hip implants. Methods. 126 porous tantalum acetabular shells and 7 femoral stems, were collected under an IRB-approved multicenter retrieval program. Acetabular shells that were grossly loose, cemented or complex revisions were excluded. Shells with visible bone on the surface were chosen. 20 acetabular shells (10 primary) and all femoral stems were dehydrated, embedded, sectioned, polished and bSEM imaged (Figure-1). Main shell revision reasons were infection (n=10,50%), femoral loosening (n=3,15%) and instability (n=3,15%). Analyzed implants were implanted for 2.3±1.7 years (shells) and 0.3±0.3 years (stems). Eight slices per shell and 5–7 slices per stem were analyzed. The analysis included bone area/pore area (BA/PA), BA/PA zonal depth analysis, extent of ingrowth and maximum depth of bone ingrowth. BA/PA zone depths were: Zone-1 (0–500um), Zone-2 (500–1000um) and Zone-3 (1000um-full depth). Nonparametric statistical tests investigated differences in bone measurements by location within an implant and implant type (Friedman's Variance and Kruskal-Wallis). Post-hoc Dunn tests were completed for subsequent pairwise comparisons. Spearman's rank correlation identified correlations between bone measurements and patient related variables (implantation time, age, height, weight, UCLA Activity Score). Statistical analyses were performed using PASW Statistics package. Results. BA/PA was not significantly different between acetabular shells (3.6±3.3%) and femoral stems (5.8% ± 3.9%, p=0.068). Extent of ingrowth was similar between shells (42 ± 28%) and stems (47±26%, p=0.825). Acetabular shells (76±23%) and stems (82±23%, p=0.707) had a similar maximum ingrowth depth. There were 9 shells and 2 stems (Figure-2) with full bone ingrowth into the porous tantalum substrate. When bone did not bridge the entire depth, a superficial layer of dense trabecular bone integrated with the porous layer was often observed. Localized regions of increased ingrowth were observed around screw holes. BA/PA in the superior region (4.1±2.4%) of the acetabular shells was significantly higher than in the inferior region (2.0±2.1%, p=0.047, Figure-3). Acetabular shells BA/PA in Zone-1(10.8%) was significantly higher than Zone-2 (4.9%, p=0.013) and Zone-3 (1.6%, p<0.001). BA/PA was significantly higher in Zone-1 (10.8%) than Zone-3 (2.3%, p=0.043) for femoral stems. There were no correlations between patient variables and bone measurements. Discussion. Our results demonstrate that bone ingrowth in porous tantalum hip components is concentrated in the superficial 500 um (Zone-1). This may provide the opportunity to reduce the thickness of the porous layer thus conserving more bone in future designs. Bone ingrowth in the acetabular shells was preferentially located around screw holes and superior region, similar to previous studies of other cementless designs. Only 40% of analyzed acetabular shells had implantation times greater than 2 years. Further work focused on longer term retrievals will increase understanding of the bone-implant interface. This study was supported by Zimmer and NIH (NIAMS) R01 AR47904

In revision total hip arthroplasty (THA), acetabular reconstruction while dealing with severe bone loss is a challenge. The porous tantalum revision acetabular shells have been in use for the past decade. Several reports have documented successful use at early to mid-term follow up. There is, however, very little literature around the long-term survival and quality of life outcome with the use of these shells. We reviewed the results of 46 acetabular revisions with Paprosky 2 and 3 acetabular bone defects reconstructed with a hemispheric, tantalum acetabular shell and multiple supplementary screws. There were 31 females. Average age at revision was 64 years (range 23–85 years). The mean and median follow up was 11 years (range 10–12 years, SD 1). Morselised femoral allograft was used in 34 hips to fill contained cavitary defectes. Bulk femoral allografting was performed in 2 hips. At a minimum follow-up of 10 (range 10–12) years, the survivorship of the porous tantalum acetabular shell, with revision of the shell as end point was 96%. The minimum 10-year survivorship with hip revision for any reason as end point was 92%. We noted excellent pain relief (mean WOMAC pain 92.6) and good functional outcome (mean WOMAC function 90.3, mean UCLA 5); and generic quality of life measures (mean SF-12 physical component 48.3; mean SF-12 mental component 56.7). Patient satisfaction with pain relief, function and return to recreational activities were noted to be excellent. Cementless acetabular revision with the tantalum acetabular shell demonstrated excellent clinical and quality of life outcomes at minimum 10-year follow-up. As far as we are aware this is the first report of minimum 10-year follow up of use of this technique for revision hip arthroplasty

Iliopsoas tendonitis after total hip arthroplasty (THA) can be a considerable cause of pain and patient dissatisfaction. The optimal cup position to avoid iliopsoas tendonitis has not been clearly established. Implant designs have also been developed with an anterior recess to avoid iliopsoas impingement. The purpose of this cadaveric study was to determine the effect of cup position and implant design on iliopsoas impingement. Bilateral THA was performed on three fresh frozen cadavers using oversized (jumbo) offset head center revision acetabular cups with an anterior recess (60, 62 and 66 mm diameter) and tapered wedge primary stems through a posterior approach. A 2mm diameter flexible stainless steel cable was inserted into the psoas tendon sheath between the muscle and the surrounding membrane to identify the location of the psoas muscle radiographically. CT scans of each cadaver were imported in an imaging software. The acetabular shells, cables as well as pelvis were segmented to create separate solid models of each. The offset head center shell was virtually replaced with an equivalent diameter hemispherical shell by overlaying the outer shell surfaces of both designs and keeping the faces of shells parallel. The shortest distance between each shell and cable was measured. To determine the influence of cup inclination and anteversion on psoas impingement, we virtually varied the inclination (30°/40°/50°) and anteversion (10°/20°/30°) angles for both shell designs. The CT analysis revealed that the original orientation (inclination/anteversion) of the shells implanted in 3 cadavers were as follows: Left1: 44.7°/23.3°, Right1: 41.7°/33.8°, Left2: 40/17, Right2: 31.7/23.5, Left3: 33/2908, Right3: 46.7/6.3. For the offset center shells, the shell to cable distance in all the above cases were positive indicating that there was clearance between the shells and psoas. For the hemispherical shells, in 3 out of 6 cases, the distance was negative indicating impingement of psoas. With the virtual implantation of both shell designs at orientations 40°/10°, 40°/20°, 40°/30° we found that greater anteversion helped decrease psoas impingement in both shell designs. When we analyzed the influence of inclination angle on psoas impingement by comparing wire distances for three orientations (30°/20°, 40°/20°, 50°/20°), we found that the effect was less pronounced. Further analysis comparing the offset head center shell to the conventional hemispherical shell revealed that the offset design was favored (greater clearance between the shell and the wire) in 17 out of 18 cases when the effect of anteversion was considered and in 15 out of 18 cases when the effect of inclinations was considered. Our results indicate that psoas impingement is related to both cup position and implant geometry. For an oversized jumbo cup, psoas impingement is reduced by greater anteversion while cup inclination has little effect. An offset head center cup with an anterior recess was effective in reducing psoas impingement in comparison to a conventional hemispherical geometry. In conclusion, adequate anteversion is important to avoid psoas impingement with jumbo acetabular shells and an implant with an anterior recess may further mitigate the risk of psoas impingement

Polyimide (MP-1, MMATech, Haifa, Israel), is a high performance aerospace thermoplastic used for its lubricity, stability, inertness and radiation resistance. A wear resistant thin robust bearing is needed for total hip arthroplasty (THR). After independent laboratory testing, in 2006, the author used the material as a bearing in two Reflection (Smith and Nephew, USA) hip surgeries. The first, a revision for polyethylene wear, survives with no evidence of wear, noise, new osteolysis or complications related to the MP-1 bearing after 16 yrs. The second donated his asymptomatic MP-1 hip at 6.5yrs for post-mortem examination. There were no osteoclasts, cellular reaction bland in contrast to that of polyethylene. In 2013 a clinical study with ethical committee approval was started using a Biolox Delta (Ceramtec, Germany) head against a polyimide liner in 97 patients. MMATech sold all liners, irradiated: steam 52:45. Sixteen were re-machined in New Zealand. Acetabular shells were Delta PF (LIMA, Italy). The liner locked by taper. The cohort consisted of 46:51 M:F, and ages 43 to 85, mean 65. Ten received cemented stems. For contralateral surgery, a ceramic or polyethylene liner was used. Initial patients were lower demand, later, more active patients, mountain-biking and running. All patients have on-going follow up, including MP-1 liner revision cases. There has been no measurable wear, or osteolysis around the acetabular components using weight-bearing radiographs. Squeaking within the first 6 weeks was noted in 39 number of cases and subtle increase in palpable friction, (passive rotation at 50 degrees flexion), but then disappeared. There were 6 revisions, four of which were related to cementless Stemsys implants (Evolutis, Italy) fixed distally with proximal linear lucencies in Gruen zones 1 and 7, and 2 and 6. No shells were revised and MP-1 liners were routinely changed to ceramic or polyethylene. The liners showed no head contact at the apex, with highly polished contact areas. There were no deep or superficial infections, but one traumatic anterior dislocation at 7 years associated with 5 mm subsidence of a non-collared stem. The initial squeaking and increased friction was due to the engineering of the liner / shell composite as implanted, not allowing adequate clearance for fluid film lubrication and contributed to by shell distortion during impaction. The revised bearings were “equatorial” rather than polar, and with lack of wear or creep this never fully resolved. Where the clearance was better, function was normal. The “slow” utilization was due to my ongoing concern with clearances not being correct. The revision of 4 Stemsys stems, tribology issues may have contributed, but non “MP-1” / Stemsys combinations outside this study have shown the same response, thought to be due to de-bonding of the hydroxyapatite coating. With correct engineering and clearances, a 3.6 mm thick MP-1 bearing, a surface Ra<0.5, steam sterilized, shows no appreciable wear, and with confidence, can be used as a high performance THR bearing

In primary total hip replacements there are numerous options available for providing hip stability in difficult situations (i.e. Down's syndrome, Parkinson's disease). We have considered constrained liners in some of these cases. However, in the revision situation in general and in revision for recurrent dislocation situation specifically it is important to have all options available including tripolar constrained liners in order to optimise the potential for hip stability as well as function of the arthroplasty. Even with the newer options available dislocation rates of higher than 10–15% have been reported following revision surgery at institutions where high volumes of revision surgery are performed. Because of the deficient abductors, other soft tissue laxity and the requirement for large diameter cups revision cases will always have more potential for dislocation. In these situations in the lower demand patient, constraint has provided excellent success in terms of preventing dislocation and maintaining implant construct fixation to bone at intermediate- term follow-up. Hence in these situations tripolar constrained liners remains the option we utilise. We are also confident in using this device in cases with instability or laxity where there is a secure well- positioned acetabular shell. We cement a dual mobility constrained liner in these situations using the technique described below. Present indication for tripolar constrained liners: low demand patient, large outer diameter cups, instability with well-fixed shells that are adequately positioned, abductor muscle deficiency or soft tissue laxity, multiple operations for instability. Technique of cementing liner into shell: score acetabular shell if no holes, score liner in spider web configuration, all one or two millimeters of cement mantle. Results. Constrained Dual Mobility Liner. For Dislocation: 56 Hips, 10 yr average f/u, 7% failure of device, 5% femoral loosening, 4% acetabular loosening. For Difficult Revisions:101 hips, 10 yr average f/u, 6% failure of device, 4% femoral loosening, 4% acetabular loosening. Cementing Liner into Shell: 31 hips, 3.6 yr average f/u (2–10 years), 2 of 31 failures

In the revision situation in general and for recurrent dislocation specifically, it is important to have all options available including tripolar constrained liners in order to optimise the potential for hip stability as well as function. Even with the newer options available, dislocation rates of higher than 5% have been reported in the first two years following revision surgery at institutions where high volumes of revision surgery are performed (Wera et al). Because of the deficient abductors, other soft tissue laxity and the requirement for large diameter cups, revision cases will always have more potential for dislocation. In these situations, in the lower demand patient, tripolar constrained liners provided excellent success in terms of preventing dislocation and maintaining implant construct fixation to bone at intermediate term follow-up. Hence in these situations, tripolar with constraint remains the option we utilise in many cases. We are also confident in using this device in cases with instability or laxity where there is a secure well positioned acetabular shell. We cement a tripolar constrained liner in these situations using the technique described below. Present indication for tripolar constrained liners: low demand patient, abductor muscle deficiency or soft tissue laxity, large outer diameter cups, multiple operations for instability, instability with well-fixed shells that are adequately positioned. Technique of cementing liner into shell: score acetabular shell if no holes, score liner in spider web configuration, all one or two millimeters of cement mantle. Results: Constrained Tripolar Liner - For Dislocation: 56 Hips; 10 year average f/u; 7% failure of device, 5% femoral loosening, 4% acetabular loosening. Constrained Tripolar Liner - For Difficult Revisions: 101 hips; 10 year average f/u; 6% failure of device, 4% femoral loosening, 4% acetabular loosening. Cementing Liner into Shell: 31 hips; 3.6 year average f/u (2–10 years); 2 of 31 failures. We, like others, are trying to define cases where dual mobility will be as successful or more successful than tripolar constrained liners

In primary total hip replacements there are numerous options available for providing hip stability in difficult situations (i.e. Down's syndrome, Parkinson's disease). However, in the revision situation in general and in revision for recurrent dislocation specifically, it is important to have all options available including dual mobility constrained liners in order to optimise the potential for hip stability as well as function of the arthroplasty. Even with the newer options, available dislocation rates of higher than 5% have been reported in the first two years following revision surgery at institutions where high volumes of revision surgery are performed. Because of the deficient abductors, other soft tissue laxity and the requirement for large diameter cups, revision cases will always have more potential for dislocation. In these situations in the lower demand patient and where, a complex acetabular reconstruction that requires time for ingrowth before optimal implant bone stability to occur isn't present, dual mobility with constraint has provided excellent success in terms of preventing dislocation and maintaining implant construct fixation to bone at intermediate term follow-up. Hence in these situations dual mobility with constraint remains the option we utilise. We are also confident in using this device in cases with instability or laxity where there is a secure well-positioned acetabular shell. We cement a dual mobility constrained liner in these situations using the technique described below. Present indication for dual mobility constrained liners: low demand patient, large outer diameter cups, instability with well-fixed shells that are adequately positioned, abductor muscle deficiency or soft tissue laxity, multiple operations for instability. Technique of cementing liner into shell: score acetabular shell if no holes, score liner in spider web configuration, all one or two millimeters of cement mantle. Results: Constrained Dual Mobility Liner – For Dislocation: 56 Hips, 10 year average follow-up, 7% failure of device, 5% femoral loosening, 4% acetabular loosening. For Difficult Revisions: 101 hips, 10 year average follow-up, 6% failure of device, 4% femoral loosening, 4% acetabular loosening. Cementing Liner into Shell: 31 hips, 3.6 year average follow-up (2–10 years), 2 of 31 failures

Introduction. Acetabular revision surgery remains a technically demanding procedure with higher failure rates than primary total hip arthroplasty (THA). An acetabular component with three dimensional porous titanium and anatomic screw holes (Figure 1) was designed to allow the cup to be positioned anatomically and provide reliable fixation. Methods. A prospective multicenter study of 193 cases (190 patients) was conducted to assess the midterm clinical outcomes of the revision titanium acetabular shell. Radiographs, demographics, Harris Hip Score (HHS), and Short Form 36 (SF-36) were collected preoperatively, at 6 weeks, 3 months, and annually thereafter to 5 years. The mean duration of follow-up was 3.36 years. The Paprosky classification was assessed intraoperatively. Short Form 6D (SF-6D) utility values were obtained by transforming SF-36 scores through the Brazier method and were analyzed for effect size. Results. At time of surgery, mean patient age was 63.5 years and mean BMI was 28.1. 69 of the 193 cases were graded as 3A or 3B according to the Paprosky classification method. For all cases, Harris Hip Scores improved significantly (p < 0.001) from a preoperative mean score of 53.60 to a mean score of 86.15 at 1 year. These significant gains were maintained through 5 years, with a mean score of 87.35 at the 5-year time point. The Harris Hip Scores for Paprosky 3A and 3B cases also improved significantly (p < 0.001) from a preoperative mean score of 48.11 to a mean score of 85.45 at 1 year. These significant gains were maintained through 5 years, with a mean score of 85.65 at the 5-year time point. Among the radiographs independently reviewed to date, no cup migration or unstable cups have been identified. There were 12 acetabular shell re-revisions reported, for infection (7), aseptic loosening (4) and recurrent dislocation (1). Three of the cases revised for aseptic loosening were Paprosky type 3A, and one was 3B. For all cases, a clinically significant improvement in health utility was achieved by 3 months postoperative, with an effect size of 0.54. Clinically significant scores were maintained throughout the follow-up period, reaching an effect size of 0.64 at 5 years. Effect sizes were larger for cases with Paprosky classifications of 3A and 3B than the overall study population at all time points, reaching clinical significance at 3 months with an effect size of 0.64, and continuing to increase to an effect size of 1.19 at 5 years. Conclusion. Even in patients with severe acetabular defects, next generation highly porous acetabular components with three dimensional porous titanium and anatomic screw holes provide excellent stability, predictable midterm biologic fixation, pain, and reduction, and improved clinical function and health utility

In primary total hip replacements there are numerous options available for providing hip stability in difficult situations i.e. Down's syndrome, Parkinson's disease. However, in the revision situation, in general, and in revision for recurrent dislocation situations specifically, it is important to have all options available including dual mobility constrained liners in order to optimise the potential for hip stability as well as function of the arthroplasty. Even with the newer options available dislocation rates of higher than 5% have been reported in the first two years following revision surgery at institutions where high volumes of revision surgery are performed [Della Valle, Sporer, Paprosky unpublished data]. Because of the deficient abductors, other soft tissue laxity and the requirement for large diameter cups, revision cases will always have more potential for dislocation. In these situations in the lower demand patient and where, a complex acetabular reconstruction that requires time for ingrowth before optimal implant bone stability to occur isn't present, dual mobility with constraint has provided excellent success in terms of preventing dislocation and maintaining implant construct fixation to bone at intermediate term follow-up. Hence in these situations dual mobility with constraint remains the option we utilise. We are also confident in using this device in cases with instability or laxity where there is a secure well-positioned acetabular shell. We cement a dual mobility constrained liner in these situations using the technique described below. Present indication for dual mobility constrained liners: low demand patient, abductor muscle deficiency or soft tissue laxity, large outer diameter cups, multiple operations for instability, and instability with well-fixed shells that are adequately positioned. Technique of cementing liner into shell: score acetabular shell if no holes; score liner in spider web configuration; all one or two millimeters of cement mantle. Results. Constrained Dual Mobility Liner. For Dislocation: 56 Hips 10 yr average f/u, 7% failure of device, 5% femoral loosening, 4% acetabular loosening. For Difficult Revisions: 101 hips 10 yr average f/u, 6% failure of device, 4% femoral loosening, 4% acetabular loosening. Cementing Liner into Shell: 31 hips 3.6 yr average f/u (2–10 years), 2 of 31 failures