Ion levels in the serum and urine of patients with metal-on-metal hip resurfacing implants can provide a means to monitor bearing wear. This presentation will discuss the current results, now out to 5 years for the Conserve Plus resurfacing. In particular, the effect of bilateral implantation on ion levels was examined

Forty-eight patients were studied. Forty-three of these cases were initially implanted with a unilateral resurfacing. Nine of these cases subsequently were implanted with a resurfacing implant on the contra-lateral side 4 to 48 months following the first implantation (staged implantations). Five cases had bilateral resurfacings done simultaneously. All surgeries were done in one institution by a single surgeon. Serum and urine samples were collected pre-operatively, and at 4 months, 12 months and annually thereafter. The samples were analysed for cobalt and chromium using atomic absorption spectrometry with a detection limit of 0.3 to 0.03ng/ml respectively. The data were compared between the groups and also correlated with UCLA activity scores, cup angle, BMI and component size.

All patients showed a rise in ions following implantation. The simultaneous bilateral levels were higher at all time periods compared with the staged bilaterals monitored at the same time point for the second hip, for example cobalt serum at 12 month uni = 2.24, simultaneous bilat = 2.53, staged bilat = 2.05ng/ml, and at 4 years uni = 1.20, simultaneous bilat = 2.93, staged bilat = 2.27ng/ml. There was no correlation between ion levels and UCLA activity score, gender, component size or cup angle (but only 4 hips had cups > 55 degrees).

Bilateral metal-on-metal hip resurfacings performed simultaneously resulted in higher levels of metal ions, particularly chromium, compared to staged implantations monitored at the same time periods. With the exception of a small number of outliers, the levels in this group of hip resurfacings were within the range of metal levels reported for other metal-on-metal total hips.

Introduction: The purpose of the present study was to assess the clinical results of metal-on-metal hip resurfacing for the treatment of hip arthrosis in patients with a BMI of 30 or more.

Materials and Methods: From a consecutive series of over 1000 Conserve® Plus metal-on metal hybrid resurfacings, 148 hips were resurfaced in 138 patients with a BMI of 30 or more at the time of surgery. Average age was 49.4 years (range, 18 to 72) with 88% male. The average weight was 104.6 kg (range 74 to 164) and average BMI 33.4 (30.0 to 46.4). “Idiopathic” OA was the dominant etiology with 80.0%. The femoral metaphyseal stem was cemented in 43 hips and press-fit in the remaining 105. All acetabular components were press-fit.

Results: Average follow-up was 6.2 years (range, 2.0 to 10.2). UCLA hip scores improved significantly (pain: 3.5 to 9.4; walking: 5.9 to 9.5; function: 5.4 to 9.2; activity: 4.3 to 7.1). There were no cases of acetabular or femoral component loosening. 2 hips (1.4%) were revised, 1 for femoral neck fracture and one for acetabular cup protrusio the day after surgery in a bilateral patient with poor bone quality. 3 hips (2.0%) have radiolucencies about the femoral stem. All are asymptomatic and none have progressed for an average of 5.2 years (range 4.5 to 6.8). There were no revisions for any reason and no radiolucencies observed in patients with a BMI of 35 or more (n=27).

Conclusions: Metal-on-metal resurfacing arthroplasty of the hip is performing extremely well in patients with high BMI, in contrast with the results of conventional THR. These results are in agreement with our previous finding that weight is protective of prosthesis durability with resurfacing. This could be explained by a greater fixation area on the femoral side, a greater bone mineral density, and a slightly reduced (but still high) activity level in this patient population compared to patients with a BMI less than 30 (7.1 vs 7.6, p=0.002).

Eighty-three patients (ninety hips) with well-fixed cementless socket retained during revision of a femoral component were reviewed. At revision, 33% of patients had acetabular osteolysis and 52% were grafted. At mean follow-up 9.6 years (5.5 – 15.9) after femoral revision and 14.8 years (7.1–20.2) after primary arthroplasty, survivorship was 96.5% (95% CI, 91.5% to 100%) at five years and 81%(95% CI, 61% to 99%) at ten years after femoral revision. Revision of a cementless acetabular component solely on the basis of the duration that it was in vivo or whether a previous revision had been done does not appear to be warranted.

Removal a well fixed cementless acetabular component can result in an increased operative morbidity. Data that can be used to predict the long-term survival of retained well-fixed cementless acetabular components are therefore needed.

Retention of the well-fixed cementless acetabular component during femoral revision is a predictable technique.

Revision of a cementless acetabular component solely on the basis of the duration that it was in vivo or whether a previous revision had been done does not appear to be warranted.

Eighty-three consecutive patients (ninety hips) in whom a well-fixed cementless socket had been retained during revision of a femoral component were reviewed. Mean patient age was fifty-four. At the time of revision, 33% of the patients had acetabular osteolysis of which 52% were grafted. At a mean follow-up 9.6 years (5.5 – 15.9) after femoral revision and 14.8 years (7.1–20.2) after primary arthroplasty, 94.5% of the sockets remained in place. With any revision as end point, survivorship was 96.5%(95% CI, 91.5% to 100%) at five years and 81%(95% CI, 61% to 99%) at ten years after femoral revision. With failure of cementless socket as end point (i.e. loosening, deficient locking mechanism), survivorship was 100% (95% CI, 100%) and 94% (95% CI, 82%–100%) at five and ten years after femoral revision and 100% (95% CI, 100%) and 94% (95% CI, 82%–100%) at ten and fifteen years after primary arthroplasty. No cases showed recurrence or expansion of pelvic osteolysis. The overall incidence of dislocation was 15%.

Ninety-four hips with a mean patient age 34.2 (range 15– 40) with a metal/metal surface arthroplasty (SA) were reviewed with 71% men and 14% with previous surgery. The Chandler risk index was calculated as well as the SA risk index (SARI). At a mean follow-up three years, three hips were converted at a mean of twenty-seven months (two to fifty), and ten patients had significant radiological changes. Mean SARI for the thirteen problematic hips versus remaining hips was significantly higher, 4.7 and 2.6, respectively (p=0.00). If SARI > 3 the relative risk of early problems is twelve times greater than if SARI ≤3.

The purpose of this study was to evaluate the early outcome of a hybrid metal on metal surface arthroplasty of the hip in patients forty years and younger and identify potential risk factors.

Surface Arthroplasty Risk Index can help identify patients who may be at increased risk of early failure following metal on metal surface arthroplasty.

Proper patient selection and careful surgical technique may minimize early failures with the re-introduction of surface arthroplasty of the hip.

Ninety-four hips mean age 34.2 (range 15– 40) with metal/metal surface arthroplasty (SA) were reviewed with 71% men and 14% with previous surgery. The Chandler risk index was calculated and SA risk index (SARI). Mean follow-up three years (range 2–5), three hips were converted at a mean of twenty-seven months (2–50), and ten patients had significant radiological changes. Mean SARI for these thirteen problematic hips versus remaining hips was significantly higher, 4.7 and 2.6, respectively (p=0.00). The mean angle between the prosthesis stem and femoral shaft in the problematic group was significantly smaller than the remaining hips (p=0.03): 133° and 139°, respectively. If SARI > 3 the relative risk of early problems is twelve times greater than if SARI ≤3.

Fifty-six hips, mean age 40.4 underwent surface arthroplasty (SA) and twenty-eight hips, mean age 37.2 underwent hemiresurfacing (HSR). Diagnosis was osteo-necrosis in all. UCLA hip function and activity score, SF-12 physical, and Harris Hip score were significantly (p< 0.05) better for SA versus HSR. However, 2 SA were revised to THR, and 5 had evidence of femoral loosening. There was no evidence of femoral loosenings in the hemiresurfacing group. The median femoral component size was significantly larger in HSR than SA. Although the functional results are inferior with HSR, patients are at greater risk of femoral loosening with the full surface arthroplasty.

To determine if differences in outcome exist between HSR and MMSA at five years of follow-up in a group of patients with Ficat Stage III and IV osteonecrosis.

Treatment of osteonecrosis of the hip in the young adult still remains a challenge. The continued use of conservative prosthetic solutions should help minimize the morbidity of revision hip surgery.

Although the functional clinical outcome of MMSA is superior to HSR, patients are at greater risk of femoral loosening. Use of a larger femoral component in MMSA may decrease the risk of femoral loosening.

Eighty-four hips with osteonecrosis were treated with a resurfacing implant: fifty-six with a metal-metal SA, mean age 40.4 and twenty-eight, mean age 37.2 with a hemiresurfacing when the acetabular cartilage was minimally damaged. Male/female ratio was 73%/27% for HSR and 87%/13% for MMSA. Mean follow-up of 4.5 years, UCLA hip scores were significantly (p< 0.05) better for MMSA versus HSR for function (9.3 vs. 7.9) and activity (6.8 vs. 5.5) but not for pain (9.3 vs.8.6) and walking (9.5 vs. 9.0). SF-12 scores were comparable for the mental component but significantly better in the MMSA group (48.4 vs. 38.1, p= 0.001) for the physical component. Harris Hip Score was significantly better for MMSA (92.3 vs. 83.3, p=0.001). 2 MMSA were revised to THR, and five presented with evidence of femoral loosening. There was no evidence of femoral loosenings in HSR. Median femoral component size was significantly larger for HSR (50.0 vs. 46.0, p= 0.001).

During hip resurfacing arthroplasty, excessive valgus positioning or surgical technique can result in notching of the femoral neck. Although mechanical weakening and subsequent fracture of the femoral neck are well described, the potential damage to the retinacular vessels leading to an ischaemic event is relatively unknown. Using laser Doppler flowmetry, we measured the blood flow in 14 osteoarthritic femoral heads during routine total hip replacement surgery, before and after notching of the femoral neck. In ten hips there was a reduction in blood flow of more than 50% from the baseline value after simulated notching of the femoral neck. Our results suggest that femoral head vascularity in the osteoarthritic state is similar to the non-arthritic state, where damage to the extraosseous vessels can predispose to avascular necrosis. Surgeons who perform resurfacing arthroplasty of the hip should pay careful attention to these vessels by avoiding excessive dissection around the femoral neck and/or notching.

Introduction and Aims: The importance in assessing clinical outcome is critical in evaluation of total hip replacement. There is now a sufficient body of evidence that activity level is correlated to wear of total hip replacement and wear to the longevity of that implant. The purpose of this study was, using the UCLA activity scale, to evaluate how activity relates to both health-related and disease-specific questionnaires.

Method: One hundred and fifty-two patients who underwent primary hip arthroplasty filled out the health-related questionnaire – SF-12 survey, which has a mental and physical component – with an average score of 50 in the general population for each category. The same day they were clinically evaluated, using the UCLA and Harris hip scoring systems. All patients were evaluated by the same surgeon; at least two years post-surgery, with an average follow-up of 5.2 years. Patient average age at surgery was 52.4, with 66% male. To assess the strength of the relationship between SF-12, UCLA and Harris scores, linear regression analysis was used.

Results: All individual UCLA scores were significantly correlated (p< 0.05) to SF-12 physical component, except for walking. When the single item UCLA activity score was added to Harris hip score, R squared raised from 0.43 to 0.53 in predicting quality of life. The single item Activity from the UCLA scoring system explained 38% of the variability in SF-12 physical component. With the linear regression analysis, all individual UCLA scores were independently significantly correlated (p< 0.05) to SF-12 physical component, except for walking. When the single item UCLA activity score was added to Harris hip score, R squared raised from 0.43 to 0.53 in predicting quality of life represented by the physical component of the SF-12.

Conclusion: Our study has shown that the UCLA activity scale is not only important to assess wear of the bearing surface, but also provides additional information in assessing the clinical outcome of total hip replacement. The single item Activity from the UCLA scoring system explained 38% of the variability in SF-12 physical component and demonstrates the need to integrate activity in outcome measurements after hip arthroplasty.

Introduction and Aims: There is a relationship between the anatomy of the hip joint and the development of arthritis. A common cause of hip pain in the young adult that can lead to arthritis is acetabular dysplasia. More recently, femoroacetabular impingement has been described as another cause of hip pain. The purpose of our study was to evaluate the applicability of pelvic computed tomography (CT) with three-dimensional surface rendering to evaluate femoro-acetabular impingement.

Method Thirty-six hips (30 patients; 17 males; 13 females) with persistent hip pain, mean age 41 (37–52), underwent three-dimensional CT of the pelvis, as well as MRI arthrography with gadolinium enhancement. On 3D CT, the concavity of the femoral head-neck junction (offset), alpha angle as described by Notzli was calculated to depict the anterior femoral neck contour. The concavity of the posterior aspect of the head neck junction was measured as the beta angle. The same measurements were made in 20 hips, consisting of randomly selected patients with no prior history of hip pathology or pain (mean age 37; 13 males; eight females).

Results The mean alpha angle for the symptomatic group was 66.4 (39–94) and 43.8 (39.3–48.3) for the control group (p=0.001). All symptomatic hips had abnormal findings on MRA: labral tears in all; cartilage delamination/ulceration in 14 hips; herniation pits in six hips. The majority of labral tears and delamination were located in the antero-superior quadrant. In the surgical treated group, all MRA findings were confirmed. The mean beta angle was significantly smaller (increase concavity) in the symptomatic versus the controls: 40.2 versus 43.8 (p=0.011). Interestingly in the symptomatic group the beta angle was significantly lower than the alpha angle (p< 0.02), but not in the controls.

Conclusion: 3D CT with surface rendering and multiplanar reformation is useful to determine degree of bone buttressing of the anterior femoral head-neck junction quantitatively assessed by alpha angle measurement, which is elevated in patients with femoro-acetabular impingement. With a greater posterior concavity i.e. small beta angle in the symptomatic group versus the control, subclinical slipped femoral epiphysis remains a plausible cause of this deformity.

Purpose: The purpose of this work was to evaluate clinical and radiographic factors affecting early outcome of resurfaced hip prostheses in young adults.

Material and methods: Among 119 hybrid resurfaced prostheses with a metal-on-metal bearing implanted in patients aged 40 years or less, 94 were retained for analysis at minimum two years follow-up or failure. Mean age was 34.2 years (15–40), 71% of the patients were men and 14% had had a prior hip operation. A risk index (SARI) was developed from the Chandler index.

Results: Mean follow-up was three years (2–5). Items of the UCLA score improved: pain 3.1 versus 9.2, walking 5.8 versus 9.4 (p=0.00). Three hips required revision total hip arthroplasty at mean 27 months (2–50) and ten patients had radiographically significant modifications. Comparing these 17 hips with the 47 others, indexes showed 4.7 versus 2.6 for the SARI (p=0.000) and 2.6 versus 2.8 for the Chandler score (p=0.358). There was no correlation with reconstruction mechanics, function, walking or scoring. Valgus implantation of the femoral piece and the lateral lever arm were significantly correlated (r=0.39, p< 0.001).

Discussion: If the SARI was > 3, the relative risk of early complications was 12-fold higher than if the SARI was 3. Because of the distinct fixation of the femoral implant, a SARI=2 was attributed when there was a cyst in the femoral head and weight was < 82 kg (lower weight correlated with smaller implant, r=0.60). This index can be used to improve patient selection in order to define the role of arthroplasty resurfacing in the treatment of hip degeneration.

Aims: determine risk factors associated with component loosening so that measures can be implemented to improve component durability. Methods: The þrst 300 patients with Wright Medical Conserve Plusª metal-on-metal hip resurfacings were analyzed radiographically for radiolucencies and failed components were analyzed histologically after the components were sectioned. The group average age was 48 years, 75% were male, and most were operated for OA. At an average of 3 years, 7 hips required revision for femoral loosening, none for acetabular loosening. These included 4 of the þrst 100 cases, 1 in the 2nd 100, 2 in the 3rd 100. Radiographic lucencies were found in 9 of the 1st 100, and 3 in each of the of the 2nd and third 100. Results: The etiology of femoral loosening was found to be multifac-torial and risk factors included: substandard bone preparation, presence of large cysts or bone defects, cement technique, and patient activity.

The short metaphyseal stem serves as a useful Ç barometer È for þxation and impending loosening. Conclusions: Femoral loosening can be minimized by better patient selection and by excellent bone preparation and cement technique. Patients with compromised bone stock may still be successfully resurfaced if the extent of the defects is not excessive and/or the stem is cemented in.

Aims: Examine the short term failures of the Wright Medical Conserve Plusª metal-on-metal hip resurfacing to determine risk factors, so that measures could be implemented to prevent future failures. Methods: Two hundred and ninety six Conserve Plus hip resurfacings were performed in an FDA IDE multi-center trial. 9 femoral neck fractures occurred in 3 of the 9 centers. The time to failure ranged from less than 1 week to 21 weeks. The revised resurfaced heads were sectioned and examined by micro-radiography and histology, along with pre and post-operative radiographs and clinical histories that were discussed with the surgeons. Results: Several risk factors were identiþed including poor bone quality large or multiple cysts in the femoral head or neck, leaving reamed bone uncovered, improper implant placement and incorrect patient selection. Lessons learned from this analysis resulted in no further neck fractures to date in 369 additional Conserve Plus components that have now been implanted. Conclusions: Osteoarthritic femoral necks rarely fracture and neck fracture in resurfaced femoral heads can be largely prevented by better patient selection, improved surgical technique to prevent neck notching and better implant placement.

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

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

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

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

Purpose: Removing a non-cemented cup can increase operative morbidity destroying bone stock. Data are thus needed concerning the long-term behaviour of non-cemented acetabular implants left in place after revision of the femoral component of a total hip arthroplasty.

Methods: We studied clinical and radiological outcome at five and fifteen years in a consecutive series of 83 patients (88 hips) with a non-cemented acetabular implant that was left in place after revision of the femoral component of a total hip arthroplasty. Mean age of the patients at revision surgery was 54 years. Two types of acetabular implants had been used: 69 titanium screen and 19 with a porocoat surface. All revisions were performed for isolated loosening of the femoral component. At revision, 33% of the patients had an osteolytic acetabulum and 52% had a bone graft.

Results: At mean follow-up of 7.5 years after revision (acetabular implants in situ for 11.6 years on the average), the mean UCLA function scores, preoperatively and at last follow-up were, respectively, pain 3.8 versus 8.9, gait 6.3 versus 8.4; function 5.8 versus 7.9; activity 4.8 versus 6.1. Six acetabular implants required a revision procedure at 7.5 years (mean, range 2 – 14 years) after the femoral revision (acetabular implants in situ for 13.3 years on the average) or acetabular loosening (n=1), conversion to a metal-on-metal bearing (n=1), and for repeated dislocation and infection (n=1). There were no hips with recurrent or worsening osteolysis.

Discussion: The duration of implantation or prior revision would not appear to be sufficient to justify removing a non-cemented acetabular implant. Presence of osteolysis does not appear to affect long-term fixation of the non-cemented acetabular implant after femoral revision. We recommend removing the acetabular screw at revision in order to correctly assess the component’s fixation.