Traditionally, an inpatient hospital stay has been required for joint replacement surgery. The three primary drivers of cost for joint replacement have been implant cost, other hospital charges and postoperative rehabilitation costs. The three primary reasons that have made hospitalization necessary are pain control, blood loss / transfusion, and monitoring patients with comorbidities. Advances in surgical technique, implants, comprehensive blood management, and multimodal pain management have allowed a marked reduction in the hospital stay required and have eliminated the need for extensive formal rehabilitation. The purpose of this study is to evaluate if hip resurfacing can be performed safely and cost-effectively as an outpatient procedure. We present the short-term outcome of our first 125 hip resurfacings done as an outpatient procedure performed by two experienced surgeons. Young patients without major medical co-morbidities were selected. The average age was 53±7 years old (range: 38 to 66), there were 98 men and 27 women. The mean ASA score was 1.7±0.5 (range 1 to 3). The diagnosis was OA in 92, dysplasia in 22, and osteonecrosis in 9, and trauma in 2. There were no major complications noted in the first 6 weeks postoperative. There was one ER visit, and there were no hospitalizations required.Purpose
Methods
Traditionally an inpatient hospital stay has been required for all joint replacement surgery. The three primary drivers of cost for joint replacement have been implant cost, other hospital charges and postoperative rehabilitation costs. The three primary reasons that have made hospitalization necessary are pain control, therapy and possible transfusion. Advances in surgical technique, implants, comprehensive blood management, and multimodal pain management have allowed a marked reduction in the hospital stay required, eliminated the need for extensive formal rehabilitation. The purpose of this study is to evaluate if hip resurfacing can be performed safely and cost-effectively as an outpatient procedure. We present the short-term outcome of our first 77 hip resurfacings done as an outpatient procedure performed by two experienced surgeons. Young patients without major medical co-morbidities were selected. The average age was 53±6 years old (range: 38 to 66), there were 57 men and 20 women. The mean ASA score was 1.6±0.5 (range 1 to 2). The diagnosis was OA in 56, dysplasia in 17, avascular necrosis in 2, and others in 2.Introduction
Methods
Dysplasia has long been identified as a high-risk group for total hip replacement(THR). The underlying causes include younger age, underlying joint deformity, and greater tissue laxity. A higher failure rate has also been identified for hip resurfacing arthroplasty (HRA) in these patients. Many experts have advised avoiding HRA in these patients, although comparative studies are not available. We do not practice patient selection, because THR has not been proven any more reliable for these patients. Instead, we have taken the approach of studying the causes of failure and finding methods to improve the results of HRA in dysplasia patients. We have identified three primary failure modes for the young women who typically have dysplasia: failure of initial acetabular ingrowth (FAI), adverse wear related failure (AWRF), and early femoral failure (EFF: femoral neck fracture and head collapse). Improvements in technique to address all of these failure modes were in place by 2008: acetabular components with supplemental fixation for severe deformities (trispike), guidelines and intraoperative x-ray techniques to eliminate malpositioned acetabular components resulting in edge-loading, uncemented femoral fixation and a bone management protocol that has eliminated early femoral failure. Group I includes 142 cases done before 2008 and Group II includes 168 cases with minimum 2-year follow-up done after this date. Two-year failure rates improved from 5% (8/142) to 0.6% (1/168) and 5-year Kaplan-Meier survivorship improved from 93% to 99%. In Group II we have had only one failure (femoral neck fracture) in 168 dysplasia cases with 2–5 year follow-up. There have been no failures of acetabular ingrowth, no AWRF, no femoral head collapse, no failures of femoral ingrowth, no femoral loosenings, no dislocations and no nerve palsies. All acetabular components placed since 2008 meet our published RAIL (relative acetabular inclination limit) guidelines, which we have shown to be 99% reliable in avoiding high on levels and AWRF. Both groups were 70% female. With a mean bearing size 48mm (high-risk for HRA). There was also no differences in DEXA scan T score, BMI, ASA score, length of incision (4 inches) HHS, or patients participating in impact sports (UCLA activity score 9&10). In Group II the mean age was 3 years greater (52), the mean operative time was 20 minutes shorter (96 minutes), estimated blood loss was 120 ml less (140ml) and the mean hospital stay was one day shorter (2 days) probably reflective of greater experience in this single surgeon series. We have demonstrated that with sufficient surgeon experience and properly designed implants, hip resurfacing can be performed with a failure rate that is lower than most reports on THR for this disorder.
Adverse wear related failure (AWRF) after metal-on-metal hip resurfacing arthroplasty (HRA) has been described as a new failure mechanism. We describe the results of revision of these failures. Between July 1999 and Jan 2014, a single surgeon performed 3407 HRA. Nine (9/3407; 0.3%) cases in 8 patients were revised due to AWRF. In two additional revisions for AWRF the primary HRA was done elsewhere. There were a total of 11 revisions (9 women, 2 men) for AWRF cases reported in this study. The primary diagnoses were OA in 7 and dysplasia in 4. At the time of the primary surgery, the average age was 50±5 years and the average BMI was 27±4. The average femoral component sizes were 46±3mm. Only the acetabular component was revised in eight cases, both components were revised in 4 cases (revised to THA), three of these four used metal on metal bearings. A postop CT was requested for all patients after revision. 4 scans were of sufficient quality to analyze implant positions. Algorithms for metal artifact reduction were utilized to obtain high quality 2D images (Figure 1); 3D CAD models of the bones and implants were regenerated in order to calculate the acetabular inclination and anteversion angle (Figure 2).Introduction
Methods
A recent report based on the NARA database (Nordic Arthroplasty Register Association) found that the 10-year survivorship of patients under 50 with traditional total hip arthroplasty was only 83% in 14,600 cases. The purpose of this study was to compare our experience using metal-on-metal hip resurfacing arthroplasty (HRA) to treat these patients. from May 2001 to Feb 2012, a single surgeon performed 1029 metal-on-metal HRA in 855 patients younger than 50 years old. Three different implants were used in consecutive groups of patients, first the Corin hybrid HRA (182); then the Biomet hybrid HRA (306); and finally the Biomet uncemented HRA (541). The primary diagnoses were OA (707); dysplasia (125); osteonecrosis (98); post-trauma (28); Legg-Calve-Perthes (27) and others (44). The average age was 43±6 years; 74% were men; the average BMI was 27±4; mean femoral component size was 50±4 (range 40–62); the average T-score was 0±1. 37% of our patients reported a UCLA Activity level of 9 or 10 (impact sports). Six died with causes unrelated to their HRAs. The rate of follow-up was 94%. Our patients were not selected by any criteria except the surgeon's technical ability to perform an HRA.Introduction
Methods
Most metal-on-metal hip resurfacing implants currently being used worldwide utilize bone ingrowth fixation on the acetabular side, but cement fixation remains the standard method of fixation on the femoral side. Our hypothesis is that bone ingrowth fixation of a fully porous-coated component is superior to cement fixation of the femoral hip resurfacing component. From March 2007 to Jan 2009, 429 consecutive metal-on-metal hip resurfacing arthroplasties were performed by a single surgeon in 396 unselected patients using Biomet uncemented femoral and acetabular components. All of these were at least 5-years postop. Three patients died with causes unrelated to their hip arthroplasty. The three most common primary diagnoses were osteoarthritis in 318 (74%) cases, dysplasia in 66 (15%) hips, and osteonecrosis in 19 (4%) hips. The average size of the femoral component was 50 ± 4 cm. All pre-operative, intra-operative, and post-operative data were prospectively collected and entered into our database for review. All patients are allowed unrestricted activity including impact sports after 6 months.Introduction
Methods
Backside wear has been previously reported through The present study investigated the contribution of backside wear to the total wear in the PFC Sigma rotating platform mobile bearing TKR. In addition, the wear results were compared to the computed wear rates of the PFC Sigma fixed bearing TKR, with two different bearing materials. The commercially available PFC Sigma rotating platform mobile bearing and PFC Sigma fixed bearing total knee replacements, size 3 (DePuy, UK) were tested, with either conventional or moderately cross-linked (5 MRad) GUR1020 UHMWPE bearing materials. The computational wear model for the knee implants was based on the contact area and an independent experimentally determined non-dimensional wear coefficient [1,2,3]. The experimental wear test for the mobile bearing was force controlled using the ISO anterior-posterior force (ISO14243-1-2009). However, due to time limitation of the explicit simulation required to run the force controlled model, the simulation was run using the AP displacements taken from the experimental knee simulator which was run under the ISO AP force. The Sigma fixed bearing TKR was run under high level of anterior-posterior displacements (maximum of 10 mm).Introduction:
Materials and Methods:
Uncemented acetabular component fixation has been considered the most reliable fixation method in contemporary metal-on-metal hip resurfacing arthroplasty (HRA). During prospective long-term follow-up of a HRA device, we have encountered a surprisingly high incidence of this complication and wish to alert surgeons and manufacturers of this problem. The study group was comprised of all 373 HRAs performed by a single surgeon using this hybrid hip resurfacing implant from May 2001 to March 2005. The acetabular component features a dual-coated bone ingrowth surface of plasma-sprayed titanium plus hydroxylappatite. There were a total of 34 revisions identified at the time of this study.Introduction:
Methods:
Metal-on-metal total hip arthroplasty (THA) implants have been widely debated due to the adverse wear issue related to the bearing surfacing. However, more recent studies have shown that the high metal ion problems that occur after surgery with this type of implant may not be exclusively related to the all metal bearing surfaces, but mainly due to the recently modified connecting tapers. Biomet is one of few companies who have not changed their original taper design for their THA implants. The purpose of this study was to present our up to eight-year clinical results. Between November 2004 and April 2011, all of the 196 cases in 167 patients (77 male vs. 89 female) performed by a single surgeon were included in this study. The Biomet Magnum/Jumbo metal-on-metal total hip arthroplasty implants were utilized for all of the cases. The average age was 59 ± 11 years at the time of surgery. Thirteen patients deceased from causes unrelated to THA. The primary diagnosis was OA in 124 cases; followed by AVN in 41 cases, dysplasia in 12 cases and other causes in the remaining 19 cases. The average acetabular component sizes were 54 ± 4 mm. Clinical and radiographic examinations were performed prospectively, and the results were analyzed.Background:
Method:
More and more metal-on-metal hip resurfacing arthroplasty (HRA) implants have been used for active younger patients because of its higher success rate and better function outcomes for this group of patients compared to the traditional total hip arthroplasty (THA). One of the advantages of HRA is femoral neck preservation, which provides better bone structure in case a revision is necessary in the future. However, some believe that the outcomes after revision of hip resurfacing were not as good as the traditional THA. The purpose of this study was to provide our outcomes of the revisions, due to various causes, from over 3000 HRAs. Between May 2001 and April 2013, a single surgeon performed 3180 HRA. During that same period, 88 required revision (2.8%). Among them, the primary causes of the revision were acetabular component loosening in 22 cases; femoral component loosening in 21; femoral neck fracture in 19; adverse wear in eight; deep infection in four; and other causes for the rest. 68 of these revisions were performed by the same surgeon, while the remainder were revised elsewhere. 53 among these 68 cases had reached a minimum follow-up of two years and were included in this report. In 96%(51/53) of cases, the revision bearing was a large metal type including in 6/8 cases of adverse wear failure. There were eight cases of adverse wear with ion levels elevated above 10 μg/L, metalosis and inflammatory reaction seen at the time of revision. All of these cases had acetabular inclination angles larger than 50°. 7/8 of these cases were revised to another large metal bearing with improved acetabular component position. We analyzed the clinical scores, complications and radiographic results and compared them between these groups.Introduction:
Method:
One reason that young and active patients choose hip resurfacing arthroplasty (HRA) rather than stemmed total hip arthroplasty (THA) is that they wish to return to high impact sports after their operation. Few studies have addressed the outcome in hip arthroplasty patients who choose to participate in high impact sports post-operatively. We therefore wanted to determine if the durability of HRA in highly active patients was decreased. From 5/2001 to 5/2011, a single surgeon performed 2434 HRA cases in 2013 patients. The study group consists of all patients that had a UCLA Activity score of 9 or 10 at any point after surgery in our prospective database. There were 936 (38%) cases in 776 patients who reported participating in high impact sports at some point after surgery. This group was compared to the entire database. The mean age of the study group was 50 ± 8 years, which was significantly younger than the entire group (Introduction:
Methods:
761 cases in 613 patients with minimal two years follow-up had both metal ion levels and quality pelvis X-ray identified in our database and are included in this study. The UCLA activity score, femoral shaft angle, body mass index, weight, American Society of Anesthesiologists (ASA) score, combined range of motion (CROM), diagnosis, age, implant brand, gender, AIA, bearing size, and duration of implantation were analyzed to determine the potential risk factors for elevated metal ion levels with use of uni- and multi-variable logistic regression models. A safe zone for hip resurfacing (RAIL: Relative Acetabular Inclination Limit) was calculated based on implant size and AIA on AP pelvis X-ray. For AIA below the RAIL, there were no adverse wear failures or dislocations, and only 1% of cases with ion levels above 10 μg/L. We have not found a lower limit of AIA where failures occurred. Other than high inclination angle and small bearing size, female gender was the only other factor that correlated with high ion levels in the multivariate analysis. We have described the robust “safe zone” for acetabular component position based on metal ion levels in a large patient cohort for metal-on-metal hip resurfacing arthroplasty. Our study suggests that adverse wear failures with hip resurfacing may be highly predictable and avoidable. If the AIA is below the RAIL, rare dislocations are also prevented.
