Background. Method of fixation in THA is a contentious issue, with proponents of either technique citing improved implant survival and outcomes. Current comparisons rely on insufficiently powered studies with short-term follow up or larger poorly controlled registry studies. Patient factors are considered a key variable contributing to the risk of implant failure. One way to overcome this confounder is to compare the survival of cementless and cemented THAs patients who have undergone bilateral THAs with cemented hip on one side and cementless hip on the other. We compared stem survival of patients who have bilateral THA with one cemented stem in one hip and a cementless stem in the contralateral hip in the National Joint Registry. Methods. UK National Joint Registry is the largest registry of its kind in the world. This study included 2934 patients with 5868 THAs who underwent bilateral THAs s between 2003 and 2016. These patients had undergone bilateral sequential THAs within 3 years of each other: cemented THA on one side and cementless on the other, Patients had identical pre-operative American Society of Anaesthesiologists group for both THAs and same indication for surgery. Implant survival was compared using Cox regression with an endpoint of stem revision. Results. Ten-year all-cause survival of cementless stems was lower than for cemented stems (p<0.001), as was survival to aseptic loosening revision (p<0.001). Similar trends were seen across all age groups including young and old patients. There was a non-significant trend towards superiority of cemented stems in survival until periprosthetic fracture, dislocation and infection. Conclusion. Comparison of cementless with cemented stems within patients is a novel method to compare the outcomes of orthopaedic implants. Survival was better for cemented stems including for younger patients and aseptic loosening

Aims

This study reports the results of 38 total hip arthroplasties (THAs) in 33 patients aged less than 50 years, using the JRI Furlong hydroxyapatite ceramic (HAC)-coated femoral component.

Introduction

Varus alignment of the femoral component in total hip arthroplasty (THA) is thought to be a risk factor for implant loosening and early revision surgery. The purpose of this study was to evaluate whether the Exeter stem tolerates varus alignment and assess if this theoretical malalignment has an influence on clinical outcomes.

We have used human Embryonic Stem cells (hESC) and human Mesenchymal Stem Cells (hMSC) in rat models of bone repair in order to assess the efficacy of these cells for treatments of trauma and skeletal diseases. Graft survival is considered to be of key importance to efficacy of these treatments. Therefore the aim of this study was to develop a technique for identifying implanted cells in histological preparations without the need for genetic engineering of the implanted cells.

Methods: In our experiments hES and hMSC were pre-differentiated during cell culture towards the osteoblast lineage, and then implanted in a Demineralised Bone Matrix (DBM) carrier into an experimentally created full thickness calvarial bone lesion. The animals were sampled seven days and fourteen days after implantation into either immune deficient (RNU-Foxn1rnu) or immune competent (wild type) Sprague Dawley rats. Fluorescent In Situ Hybridisation (FISH) using whole human genome probes identified the human cells within the host lesion site.

Results: Our results have demonstrated that hESC and hMSC derived cells survive in both immune competent (wild type) and immune compromised (nude) animals for the initial seven days post implantation. On the other hand while both the hESC and hMSC derived cells are capable of surviving for at least 14 days in immune compromised animals they do not survive for this period of time in immune competent animals.

Discussion: It appears that the cell/DBM graft is not rejected within seven days even when exposed to the wild type hosts T cell response. However longer term survival required an immune deficient model that is lacking in a T cell response. This data points to interesting future studies regarding which components of the host response are responsible for xenogenic stem cell implant rejection.

Although data on uncemented short stems are available, studies on cemented short-stemmed THAs are limited. These cemented short stems may have inferior long-term outcomes and higher femoral component fracture rates. Hence, we examined the long-term follow-up of cemented short Exeter stems used in primary THA. Within the Exeter stem range, 7 stems have a stem length of 125 mm or less. These stems are often used in small patients, in young patients with a narrow femoral canal or patients with anatomical abnormalities. Based on our local database, we included 394 consecutive cemented stems used in primary THA (n=333 patients) with a stem length ≤125 mm implanted in our tertiary referral center between 1993 and December 2021. We used the Dutch Arthroplasty Registry (LROI) to complete and cross-check the data. Kaplan-Meier survival analyses were performed to determine 20-year survival rates with stem revision for any reason, for septic loosening, for aseptic loosening and for femoral component fracture as endpoints. The proportion of male patients was 21% (n=83). Median age at surgery was 42 years (interquartile range: 30–55). The main indication for primary THA was childhood hip diseases (51%). The 20-year stem survival rate of the short stem was 85.4% (95% CI: 73.9–92.0) for revision for any reason and 96.2% (95%CI: 90.5–98.5) for revision for septic loosening. No stems were revised for aseptic femoral loosening. However, there were 4 stem fractures at 6.6, 11.6, 16.5 and 18.2 years of follow-up. The stem survival with femoral component fracture as endpoint was 92.7% (CI: 78.5–97.6) at 20 years. Cemented short Exeter stems in primary THA show acceptable survival rates at long-term follow-up. Although femoral component fracture is a rare complication of a cemented short Exeter stem, orthopaedic surgeons should be aware of its incidence and possible risk factors

The Lubinus SP II is an anatomical femoral stem with high survivorship levels notably described in the Swedish Arthroplasty Register. As the clinical and economic burden of revision total hip arthroplasty (THA) and periprosthetic fracture (PPF) continues to increase, it has been suggested that use of anatomical stems may facilitate more uniform cement mantles and improve implant survival. The primary aim of this study was to determine the long-term survivorship and PPF rate of the Lubinus SP II 150mm stem in a single UK centre. Between January 2007 and April 2012, 1000 consecutive THAs were performed using the Lubinus SP II femoral stem in our institution. Patient demographics and operative details were collected in a prospective arthroplasty database. Patient records and national radiographic archives were then reviewed at a mean of 12.3 years (SD 1.3) following surgery to identify occurrence of subsequent revision surgery, dislocation or periprosthetic fracture. Mean patient age at surgery was 69.3 years (SD 10.1, 24–93 years). There were 634 women (63%). Osteoarthritis was the operative indication in 974 patients (97%). There were 13 revisions in total (4 for recurrent dislocation, 3 for infection, 6 for acetabular loosening) and 16 dislocations (1.6%). Stem survivorship at 10 years was 99.6% (95 % confidence interval [CI], 99.5%–99.7%) and at 15 years was 98.8% (98.7%–98.9%). The 15-year stem survival for aseptic loosening was 100%. Analysis of all cause THA failure demonstrated a survivorship of 99.1% (99.0%–99.3%) at 10 years and 98.2% (98.1%–98.3%) at 15 years. There were 4 periprosthetic fractures in total (0.4%) at mean 12.3 year follow-up. The Lubinus SP II stem demonstrated excellent survivorship, low dislocation rates and negligible PPF rates up to 15 years following primary THA. Use of anatomical stems such as the Lubinus SPII would appear to be a wise clinical and economic investment for patients and healthcare systems alike

The Olympia femoral stem is a stainless steel, anatomically shaped, polished and three-dimensionally tapered implant designed for use in cemented total hip arthroplasty (THA). The primary aim of this study was to determine the long-term survivorship, radiographic outcome, and patient reported outcome measures (PROMs) of the Olympia stem. Between May 2003 and December 2005, 239 patients (264 THAs) underwent a THA with an Olympia stem in our institution. PROMs were assessed using the Oxford Hip Score (OHS), EuroQol-5 dimensions (EQ-5D) score and patient satisfaction at mean 10-years following THA. Patient records and radiographs were then reviewed at a mean of 16.5 years (SD 0.7, 15.3 to 17.8) following THA to identify occurrence of complications or revision surgery for any cause. Mean patient age at surgery was 68.0 years (SD 10.9, 31–93 years). There were 156 women (65%, 176 THAs). Osteoarthritis was the indication for THA in 204 patients (85%). Stem survivorship at 10 years was 99.2% (95 % confidence interval [CI], 97.9%-100%) and at 15 years was 97.5% (94.6%–100%). The 15-year stem survival for aseptic loosening was 100%. Only one occurrence of peri-prosthetic fracture was identified, with no episodes of dislocation found. At a mean of 10 (SD 0.8, 8.7 –11.3) years follow-up, mean OHS was 39 (SD 10.3, range 7 – 48) and 94% of patients reported being very satisfied or satisfied. The Olympia stem demonstrated excellent 10-year PROMs, very high rates of stem survivorship and negligible peri-prosthetic fracture and dislocation rate at final follow-up beyond 15 years

The increasing number of total hip arthroplasty (THA) used in young patients will inevitably lead to more revision procedures at younger ages, especially since the outcome of primary THA in young patients is already inferior compared to older patients. However, these data are lacking in literature. The aim of this study was to determine the survival of both acetabular and femoral components placed during primary and revision hip arthroplasty in patients under 55 years using Dutch Arthroplasty Register (LROI) data. All primary THA registered in the LROI between 2007–2018 in patients under 55 years were selected (n=25,682). Subsequent cup- and stem revision procedures were included. Kaplan-Meier survival analyses were used to estimate the survival probability of primary and revised cup- and stem components. Mean follow-up of primary cups and stems was 5.8 years (SD 3.2) and 5.9 years (SD 3.2), respectively. In total, 659 cup revision procedures and 532 stem revision procedures were registered. Most common reason for cup revision was acetabular loosening (n=163), most common reason for stem revision was femoral loosening (n=202). Primary cup survival for any reason at 10 years follow-up was 96.1% (95%CI: 95.7–96.4). For primary stems, 10 year survival for any reason was 97.1% (95%CI: 96.7–97.3). Mean follow-up of all revision procedures was 4.1 years (SD 2.9). Out of 659 cup revisions, 113 cup re-revisions were registered. Survival of revised cups, with end-point cup re-revision for any reason was 82.2% (95%CI: 78.8–85.1) at 5 years follow-up. Out of 532 stem revisions, 89 stem re-revisions were registered. For revised stems, survival at 5 year follow-up, with endpoint stem re-revision for any reason was 82.0% (95%CI: 78.2–85.2). The outcome of revised acetabular and femoral components is worrisome, with a survival of 82% at 5 years follow-up. This information is valuable to provide realistic expectations for these young patients at time of primary THA

Aims. We compared implant and patient survival following intraoperative periprosthetic femoral fractures (IOPFFs) during primary total hip arthroplasty (THA) with matched controls. Patients and Methods. This retrospective cohort study compared 4831 hips with IOPFF and 48 154 propensity score matched primary THAs without IOPFF implanted between 2004 and 2016, which had been recorded on a national joint registry. Implant and patient survival rates were compared between groups using Cox regression. Results. Ten-year stem survival was worse in the IOPFF group (p < 0.001). Risk of revision for aseptic loosening increased 7.2-fold following shaft fracture and almost 2.8-fold after trochanteric fracture (p < 0.001). Risk of periprosthetic fracture of the femur revision increased 4.3-fold following calcar-crack and 3.6-fold after trochanteric fracture (p < 0.01). Risk of instability revision was 3.6-fold after trochanteric fracture and 2.4-fold after calcar crack (p < 0.001). Risk of 90-day mortality following IOPFF without revision was 1.7-fold and 4.0-fold after IOPFF with early revision surgery versus uncomplicated THA (p < 0.001). Conclusion. IOPFF increases risk of stem revision and mortality up to ten years following surgery. The risk of revision depends on IOPFF subtype and mortality risk increases with subsequent revision surgery. Surgeons should carefully diagnose and treat IOPFF to minimize fracture progression and implant failure. Cite this article: Bone Joint J 2019;101-B:1199–1208

The medium term results of the JRI Furlong Total hip replacement have been very impressive to date. We report the longest prospective series to date of a hydroxyapatite coated femoral prosthesis (Joint Replacement Instrumentation limited, London, UK) at 15–21 years follow up. We describe the long term clinical and radiological femoral stem survival of 331 consecutive JRI Furlong Hydroxyapatite coated total hip replacements in 291 patients at an average follow-up of 17.5 years (15 – 21 year). Two patients (0.6%) were lost to follow-up over the 21 years of the study period. Using revision of the femoral stem for any reason as an endpoint, we report a stem survival of 97.4 % (81.0 to 99.5). Using Aseptic loosening as an endpoint, stem survival was 100%. The average Merle, D’Aubine & Postel scores recorded for the patients was 5.63/6 for Pain, 5.42/6 for mobility and 4.50/6 for function. There were no cases of anterior thigh pain relating to the uncemented femoral stem. These results compare favourably with the best long term survival of cemented or uncemented femoral stems used in total hip replacements

Introduction. Primary fixation in uncemented Total Hip Replacement (THR) is achieved by implanting an appropriately sized stem. Last year, in our pilot study, we classified undersizing & reported the incidence of subsidence & radiolucent lines (RLL) in undersized uncemented stems. Now we report on a larger cohort of patients, reporting undersizing and its association with radiolucent lines and subsidence. Secondarily we report on the effect of using a collar, patients' BMI, and in a smaller group the five-year failure rate. Methods. A retrospective review of electronic records of 1337 cases who underwent THR using the Corail stem was carried out. 1204 (Collared 1042, Uncollared 162) had a minimum follow up of 1 year, 693 of those had a follow up of at least 5 years. Radiological review was carried out by 2 independent investigators. Results. 19.77% stems were undersized. There was significantly higher incidence of subsidence & RLL in undersized stems with more than 1 year follow up. There no significant increase in incidence of RLL in those with BMI greater than 30 (16.88% vs 18.81%). Analysis of undersized collared stems demonstrated that even in this sub group undersizing is associated with increased incidence of RLL (P 0.00001) & subsidence (P 0.0003). A five year follow up, the revision rate for aseptic loosening of stem was 3.09% in undersized stems & 0.29% in appropriately sized stems (P 0.06). Conclusions. Our study indicates undersizing of uncemented stems is associated with poorer radiological outcomes & there's a trend of higher revision rate at 5 year follow up. This reinforces the importance of implanting appropriately sized stem, as undersizing can potentially compromise stem survival in uncemented total hip arthroplasty

The April 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Impaction bone grafting for femoral revision hip arthroplasty with the Exeter stem; Effect of preoperative corticosteroids on postoperative glucose control in total joint replacement; Tranexamic acid in patients with a history of venous thromboembolism; Bisphosphonate use may be associated with an increased risk of periprosthetic hip fracture; A balanced approach: exploring the impact of surgical techniques on hip arthroplasty outcomes; A leap forward in hip arthroplasty: dual-mobility bearings reduce groin pain; A new perspective on complications: the link between blood glucose and joint infection risks.

The June 2023 Hip & Pelvis Roundup³⁶⁰ looks at: Machine learning to identify surgical candidates for hip and knee arthroplasty: a viable option?; Poor outcome after debridement and implant retention; Can you cement polyethylene liners into well-fixed acetabular shells in hip revision?; Revision stem in primary arthroplasties: the Exeter 44/0 125 mm stem; Depression and anxiety: could they be linked to infection?; Does where you live affect your outcomes after hip and knee arthroplasties?; Racial disparities in outcomes after total hip arthroplasty and total knee arthroplasty are substantially mediated by socioeconomic disadvantage both in black and white patients.

Aims

There are limited long-term studies reporting on outcomes of the Zimmer Modular Revision (ZMR) stem, and concerns remain regarding failure. Our primary aim was to determine long-term survival free from all-cause revision and stem-related failure for this modular revision stem in revision total hip arthroplasty (THA). Secondary aims included evaluating radiological and functional outcomes.

Aims

Endoprosthetic reconstruction following distal femur tumour resection has been widely advocated. In this paper, we present the design of an uncemented endoprosthesis system featuring a short, curved stem, with the goal of enhancing long-term survivorship and functional outcomes.

Aims

The Exeter short stem was designed for patients with Dorr type A femora and short-term results are promising. The aim of this study was to evaluate the minimum five-year stem migration pattern of Exeter short stems in comparison with Exeter standard stems.

Aims

The aim of this study is to report the long-term outcomes of instrumented femoral revisions with impaction allograft bone grafting (IBG) using the X-change femoral revision system at 30 years after introduction of the technique.

To report mid-term results of PJI treated with uncemented stems. : 80 hips of PJI after THA were treated with uncemented stems from 01/1993 to 12/2012 and followed prospectively. Selection occurred for one- (n=27) or two-stage (n=53) exchange according to the Liestal algorithm. Surgical approaches were transfemoral (n=58), transgluteal (n=9) or transtrochanteric (n=13). A monoblock (Wagner SL, n=58) or modular (Revitan, n=22) revision stem was implanted. On the acetabular side 44 Müller rings, 33 Burch-Schneider cages (combined with a cemented PE-cup) and 3 press-fit cups were used. Kaplan-Meier survival was calculated for endpoints (a) persistence of infection, (b) septic/aseptic stem loosening. Radiographs were analysed for (a) subsidence, (b) distal stem integration, (c) changes in cortical thickness, (d) proximal femur restoration, (e) radiolucency around stem/cup. Mean FU was 5.2 (2–15) years. PJI was eradicated in 77 of 80 hips (96%). 3 patients (all two-stage) had a treatment failure. 2 were treated successfully with an additional two-stage exchange. In the 3rd patient we were not able to control infection and exarticulation was performed. Furthermore, one stem was revised for aseptic loosening (5 years), 1 for a broken Wagner stem (7 years) and 1 for subsidence (8 months). Stem survival after 5 years was 93% (SD ±2.5 years). 2 cups were revised for aseptic loosening and 1 for recurrent dislocations. Subsidence ≥5mm was found in 6 hips and occurred always within 3 months after surgery independent of stem type (p=0.947) and approach (p=0.691). Proximal femoral remodelling after transfemoral approach was excellent or good in 71% (32 excellent, 9 good) with no difference between one-/two-stage exchanges (p=0.288). Initial distal stem integration was 65mm medial and 66mm lateral and increased to 8mm medial (p=0.716) and 10mm lateral (p<0.001). Cortical thickness was unchanged over the entire FU period (p=0.493). Radiolucencies were seen around 26 stems, only the stem revised after 5years was rated loose. Eradication of PJI was high using our established protocol even with uncemented revision stems. Mid-term survival was independent from one-/two-stage revision and comparable to results for aseptic loosening revision

Aims: The aim of this study is to report the pre-clinical validation and clinical experience with modular neck primary prosthesis. Introduction: Modular acetabular designs are widespread used in primary THA for their versatility while little experience is reported with modular femoral designs. Stem modularity could be useful when the anatomy is overthrown and for mini-incision approaches, providing an increased adaptability without any need for a large inventory or expensive custom made prostheses. Methods: The fretting-corrosion behavior of the neck-stem coupling and the amount of particulate released under simulated physiological activities were investigated. In vitro tests were performed in Ringer’s solution loading the stem up to 20 millions cycles (i.e. 20 yrs) according to ISO 7206. From January 1995 to December 2001, 864 primary surgeries were performed with a modular stem. There were 458 women and 406 men; the mean age was 55 years (16–81 years). The main pre-operative diagnosis was primary arthritis (58.1%), the second CHD (22.2%). The stem survival was estimated by the Kaplan-Meier method. Results: Evidence of primary corrosion was not found, conversely areas showing fretting damage were seen. The amount of fretted material was estimated in less than 1mg/year. Clinically 3 stems were revised, 2 for recurrent dislocation, 1 for stem subsidence, none for mechanical failure. At 6 years the estimated stem survival is 99.4%. Conclusions: Modular stems have shown excellent clinical and mechanical behavior. The amount of fretting debris product is negligible taking that a stable prosthesis is likely to produce more than 10mg/year of metal debris

In cementless Total Hip Arthroplasty (THA), some discussion persist in different continents, weather straight double tapered stems providing proximal metaphyseal fixation are preferable to more diaphyseal cylindrical fixation designs. With the objective of studying the grade of loosening of a straight double tapered stem and its survival rate, the authors analysed 257 THA with implanted Spotorno stems, followed up for a maximum of over 18 years (221 months), with an average of 110±57 months. The age of patients was 62±10 years in average, ranging from 18 to 86. Demographic data is analysed including, sex, height, weight and BMI. Main diagnosis was Primary Degenerative Osteoarthritis in 56% and Avascular Necrosis in 13% of all patients. Other diagnosis occurrence is presented, as well as the affected side, type of cup, head and stem size distributions. Clinical and functional evaluation of the THA showed Very Good and Good patient satisfaction grading in 78% of the cases and the average Harris Hip Score was 87, ranging from 49 to 98. In the Radiological evaluation, stem positioning, migration, osteolysis and distribution of radiolucent lines are quantified and described. 79 patients included in this study with 84 THA, died or were lost after a minimum of five years of complete clinical and radiological follow up. The most significant early and late complications of THA are presented and commented. THA requiring revision of the cup or stem for any cause, were 1 severe deep infection (0.4%), 4 cups loosened and migrated but not requiring revision of the stems (1.6%), 1 femoral osteolysis and loosening (0.4%) and 2 late traumatic femoral fractures (0.8%). From these, considering stem survival alone, a total of four stems (1.6%) underwent femoral revision as previously described, one due to infection, one due to loosening and two due to femoral fractures. Kaplan-Meyer cumulative survival analyses of the THA show a Spotorno stem survival rate of 98.4% at 18 years, with a confidence interval of 95%. In the experience of the authors, the Spotorno double tapered straight stem provides excellent clinical results, with high survival rate at longterm evaluation. The design of the stem allows for immediate progressive weight bearing without significant migration or thigh pain. Femoral proximal osteolysis or radiolucent lines are almost always associated with wear or loosening of the cup, that very often allow for revision of the cup without the need for revision of the stem