Purpose of the study: The purpose of this study was to confirm long-term changes in frontal alignment after wedge osteotomy(even for with an «ideal» postoperative wedge angle of 3–6°), that the frontal alignment is correlated with functional degradation and also with femorotibial skeletal torsion.

Material and methods: A non-consecutive retrospective series of 70 patients aged 57.5 on average at surgery for medial open-wedge tibial osteotomy were reviewed at 10–25 years. Goniometry measurements were obtained in the upright position after healing. Tibial and femoral torsion values were measured on the CT scan. Functional outcome at last follow-up was noted good, fair or poor.

Results: Postoperatively 80% percent of the knees presented frontal realignment within the 3–6° range. At last follow-up frontal alignment had changed on average 10° for 40% of knees. The change in frontal alignment resulted from a deterioration of the medial or lateral joint space and in 80% was associated with poor functional outcome. Knees which preserved valgus of 3–6° at last follow-up had statistically better results than the rest of the series. There was a correlation between valgus frontal misalignment and femoral torsion greater than 14° (anteversion) and between varus frontal misalignment and femoral torsion less than 14°. There thus appeared to be a linear correlation between postoperative changes in the correction and femoral torsion.

Conclusion: Good functional outcome of open wedge tibial osteotomy is correlated with stability of the axial correlation over time. Achieving postoperative valgus of 3–6° does not appear to be sufficient for stable axial correction. To achieve long-term preservation of the axial correction, it would be preferable to modulate the postoperative correction according to the degree of femoral torsion.

Mechanical failure in total hip arthroplasty is usually due to aseptic loosening related to wear particles as seen with polyethylene bearing. Alumina has been proposed for avoiding wear problems. In vitro and mid-term clinical studies showed tribological advantages but early acetabular fixation issues. Since alumina on alumina bearing is currently used with new fixation techniques, updated evaluations of the ancient series are informative regarding the long-term tolerance of alumina in vivo.

In this paper, we investigated 104 consecutive lumina on alumina cemented total hip arthroplasties (CER-VAER-OSTEAL, Roissy, France) implanted 20 years ago in 81 patients (from 1979 to 1983). Alumina femoral head was 32 mm in diameter. Alumina acetabular socket and titanium femoral stem were cemented. The clinical evaluation used Postel Merle d’Aubigné score. Radiological wear and appearance of osteolysis or loosening were noted for establishing actuarial curves. When accessible, histological samples from revision procedures were analyzed.

Six infected cases were not taken into account later. The average follow-up was 11 years, reaching 18 years in 38 cases. Twenty-three hip were revised for changing 23 acetabular sockets, 12 femoral heads, and 1 femoral stem. We noted 1 femoral head fracture, 24 definite ace-tabular loosenings, 12 probable acetabular loosenings, and 3 definite femoral loosenings. Radiological acetabular osteolysis was present in 4 cases, always limited to De Lee zone 1, and associated with loosening. Radiological wear was below eye detection. Peri-prosthetic tissue showed non-specific histological reaction to cement particles. Survival rate at 20 years was 61.4% in term of revision (57.1% and 95.2% concerning acetabular and femoral defininte loosening).

Beside the high rate of cemented fixation failure of the socket, loosened and non loosend cases showed an excellent tolerance of alumina on alumina bearing in the long-term, with minimal wear and osteolysis. This may also have protected the femoral component from complications.

Purpose: Alumina is a bioinert ceramic used for total hip arthroplasty as an alternative to metal-on-polyethylene bearings which can wear producing massive osteolysis and loosening. The purpose of this retrospective analysis was to examine the Ceraver combination implant which uses a cemented smooth titanium femoral stem, a 32 mm alumina head, and a cemented alumina cup.

Material and methods: Between December 1979 and February 1983. 104 total hip arthroplasties were performed in 81 patients, mean age 57.8 years (2.1–70.9). The main indication was primary degenerative disease (71 hips). The Postel Merle d’Aubigné score was used for clinical assessment. Plain x-rays were used to establish the actuarial survival curves using the Harris criteria for radiological loosening for the cup and the Massin criteria for the femoral piece. Periprosthetic femoral and acetabular osteolysis were noted. Histological samples taken during revision procedures were analysed.

Results: Six hips with suppuration were not retained for analysis. The clinical scores for the other 98 hips were, at last follow-up: excellent in 34, very good in 21, good in 16, fair in 21, and poor in 6. Mean follow-up was eleven years and reached 18 years for 38 hips. Fracture of the alumina head (n=1), aseptic certain radiographic loosening of the cup (n=24), probable radiolographic loosening of the cup (n=12), and certain radiographic loosening of the femoral piece (n=3) were noted. Revision was required for 23 hips for replacement of the cup (n=23), the head (n=12), or the femoral stem (n=1). There were no cases of massive radiographic osteolysis. The histological examination of surgical specimens obtained at revision were normal in all cases (very moderate aseptic foreign body reaction). Excepting the cases of suppuration, the estimated actuarial survival without revision at 20 years was 61.4% (57.1% for he radiographic cup loosening criteria and 95.2% for the radiographic femoral implant criteria).

Discussion: This analysis confirms the long-term biotolerance of the alumina-alumina bearing despite the poor maintenance of the cemented alumina cup. It also confirms the good maintenance of the cemented smooth titanium femoral stem.

Conclusion: Cup anchorage must be improved to use the alumina-alumina bearing which does not cause osteolysis nor histological reactions.

Between January 1988 and January 1991 we performed 100 consecutive cemented total hip replacements using a zirconia head, a titanium alloy stem and a polyethylene cup. We reviewed 78 of these hips in 61 patients in detail at a mean of 5.8 years (1 to 9).

Aseptic loosening was seen in 11 hips (14%). Eight needed revision. In total, 37 cups (47.5%) showed radiolucent lines, all at the cement-bone interface, with 18 (23%) involving all the interface. Of the 78 femoral implants, 17 (21.7%) showed radiolucent lines, and two, which had a complete line of more than 1 mm thick, definite endocortical osteolyses. There was also an abnormally high incidence of osteolysis of more than 2 mm at the calcar.

Survivorship analysis showed that only 63% were in situ at eight years. These worrying results led us to abandon the use of zirconia heads, since at the same hospital, using the same femoral stem, cement and polyethylene cup, but with alumina femoral heads, the survival rate was 93% at nine years. We discuss the possible reasons for the poor performance of zirconia ceramic.

A 65-year-old man presented with a painful hip five years after a cemented replacement. Histological examination of a biopsy taken from tissue surrounding the femoral implant showed infiltration of a squamous-cell carcinoma. Further investigation revealed a primary growth in the left lung. This rare example of a metastasis in relation to a joint replacement illustrates the necessity for histological examination of the tissue adjacent to a loose prosthesis.