Background: This report presents the long term (over 20 years) experience with the use of a grit-blasted, press-fit femoral prosthesis.

Methods: The first 300 consecutive primary THA procedures using a collarless, three-dimensional tapered, straight, titanium alloy stem with a grit-blasted surface (performed in 299 patients) were evaluated up to twentytwo years. A cementless all-polyethylene socket in 80 percent of the cases, were used. Radiographic evaluation, performed by an independent observer using a zonal analysis method, included assessment of component migration, Engh’s implant-bone femoral fixation score, implant-bone demarcations, and periprosthetic osteolysis. The average duration of long-term radiographic follow-up was 12.6 years (range; 10 to 16 years).

Results: At last examination only five hips were lost to follow-up and 84 patients were deceased. The femoral revision rate was 7 percent (two hips for aseptic loosening, five hips for septic loosening, and twelve hips with osseointegrated stems for severe progressive femoral osteolysis) and the acetabular revision rate was 28% (revised for either socket migration or progressive peri-acetabular osteolysis or both). Survivorship, based on any revision (femoral or acetabular) was 89% at ten years and 65% at twenty years; survivorship of the femoral component was 95% at ten years and 89% at twenty years. The incidence of femoral periprosthetic osteolysis, was 47%, with 5% of distal endosteal osteolysis. Radiographic femoral implant-bone fixation was stable, bone-ongrowth in 97%; stable, fibrous-fixation in 1%.

Conclusions: The grit-blasted, press-fit, collarless, tapered femoral component continued to perform well clinically and radiographically up to twenty years of follow-up despite the challenging environment of peri-prosthetic osteolysis associated with the acetabular component design. This implant is still in use virtually without design modifications. This study demonstrates the durability of the results of the grit-blasted femoral component and indicates that such an implant offers a viable alternative for fixation without bone cement.

Introduction: T.H.A. revisions are constantly increasing: and it’s known that bone defects – expecially if severe like in rirevision cases – are the main problem to manage during the revision surgery. Since 1988, we have chosen to bypass the bone defects by using an “elastic” non-invading tapered stem (SL Wagner); morsel bone graft is rarely necessary, we never use a massive one. According to our philosophy in revisioning, stability should be obtained by a diaphysary anchorage as proximal as possible.

Methods: Our research concerns 150 cases of SL revision stems implanted from December ’88 to December ’91. The average age is 67 years old, complete clinical evaluation and survivorship analysis for the entire study cohort was performed from 8 to 12 years follow-up, radiographic analysis in 81 cases with 101 months avg. follow-up (min. 60 – max. 143).

Results and Discussion: 4 cases required rirevision; 20 patients deceased; 12 were lost to follow-up; 96 examinated.

Clinical evaluations show an average score of 78 (acc. to HHS); 82,3 percent of patients are pain free, while slight pain still persists in a 13,7 percent pain in a 3,9 percent.

The radiographic analysis has put into evidence only 1 case of mobilization, and suffering bone in 4 percent of cases; by contrast, 79,5 percent show astonishing endosteal bone formation.

The aim of this study is to evaluate techniques which may reduce intra and Post-Operative (PO) bleeding in hip surgery.

Methods: In this prospective study, from 9/2005 to 6/2006, we evaluated Blood Loss (BL) after primary total hip arthroplasty. Exclusion criteria were anti-coagulant drugs not discontinued 10 days before surgery and patients whose condition precluded weight bearing PO. We included total hip arthroplasty with posterior surgical approach, spinal anaesthesia, hypotensive surgery and peri-operative blood salvage (Ortho PAS, Euroset). When appropriate, the Mini-Invasive Approach (MIA) was used. In a different sub-set of patients, including some of the minimally invasive patients, a new bipolar Radio-Frequency sealer (TissueLink) was used. The PO program had pain control, LMWH for prevention of DVT, exercise from the day of surgery and walking on crutches from the next day. We analysed: blood loss after surgery and for 3 days; haemoglobin values (g/dL) before surgery and for 5 days PO; thigh circumference pre-op and at 5 days and adverse events such as transfusions and luxation. For the statistical evaluation the paired “t-test” was used, with a level of significance set at 95%. Differences and p values of < 0.05 were considered significant.

Results: 324 patients (mean age 68; range 23 to 89; 179 F & 145 M) were admitted to the study. Mean BL was 305ml intraoperative, 501ml at 6 hours PO, 304ml at 1day PO, 132ml at 2 days PO and trace at 3 days. Rather than simple unit measures, we analyzed the Percent Change in Hb from preoperative levels (%CHb). The patients had a mean %CHb of 23,09% at 1day PO, 26,67% at 2 days PO, 28,13% at 3 days and 29,07% at 5 days. Transfusion rates (TR; trigger set at Hb< 8g/dL) were related to the preoperative Hb and age. Overall TR was 15% (51/324), the prevalence of homologous transfusion was 7% (24/324). The TR for each Hb value: 21% (15/69) for Hb=12–13, 20% (20/98) for Hb=13–14, 17% (15/88) for Hb=14–15 and 5% (1/29) for Hb=15–16. The mean value of pain during rehabilitation was 3,11(VAS). MIA (53/324) was associated with reduced BL (mean %CHb at 1st day PO 19.12; TR 9%), but with high variability. The use of bipolar sealer (58/324) was associated with a significant reduction in overall BL (mean %CHb at 1st day PO 15.83; TR 5%) as well as a reduction of thigh swelling (37%) and of mean rehabilitation pain (30%; VAS=2.15).

Discussion: Reduced blood loss, reduced post-operative pain and a faster functional resumption are obtained with both the minimally invasive approach and the TissueLink sealer approach. In addition, MIA provides muscle preservation and the use of the TissueLink sealer provides reduced post-operative swelling.

Conclusion: This study shows that both the minimally invasive surgical approach and the use of an irrigated RF bipolar sealer can lead to reduced blood loss and faster functional resumption following hip surgery.

Introduction: The anatomic abnormalities associated with the dysplastic hip increase the complexity of hip arthroplasty, in addition previous femural osteotomy can deformate proximal femur.

Despite the fact that uncemented cup and stems are specifically designed for dysplasia to recover the true acetabular region in Crowe IV and sometimes Crowe III additional surgical procedure are required.

Purpose of the study is to analize surgical procedure and then reconstruction options on severe hip dysplasia.

Materials and methods: From 1984 till today 2308 cases of arthroplasty were performed in dysplastic hip, 565 cases have a previous femoral osteotomy; out of these 2308 cases 128 cases need treatment for corrections of femural side deformity.

64 cases were subjected to a greater trochanteric osteotomy. In 12 cases proximal femural shortening was associated. In 9 cases rotational abnormality and shortening were controlled with a distal femur osteotomy.

55 cases were treated by a shortening subtrochanteric osteotomy that allows corrections of any deformity. Only uncemented stems were used and in the majority of cases a specific device for displastic hip (Wagner Conus produced by Zimmer).

Discussion: Long-term results in these patients are steadily inferior to that in the general population (70% survival at 15 yrs). On femural side early failures are the reflection of learning curve and are due to insufficient fixation of the osteotomy.

Despite this, the more promising outcomes are concerning shortening subtrochanteric osteotomy with uncemented stem but only early and mid-term data are available.

The aim of this study is to evaluate which patients, if any, can be eligible for a rapid discharge from Hip Surgery Department at 24 hours after primary total hip arthroplasty.

Methods In this retrospective clinical trial were included all patients undergone to primary total hip arthroplasty in our Hip Surgery Department from January to June 2004. Exclusion criteria were preoperative anaemia (Hb< 12g/dL), coagulation disease, hip fracture, previous hip surgery and not-weight bearing indication after operation. All patients received an uncemented total hip arthroplasty with posterior surgical approach in regional anaesthesia. All patients had the same post-operative (PO) management including analgesia, prevention of DVT, immediate muscle exercises and physiotherapy for walking on crutches starting on the second PO day. The clinical history, vital parameters, haemoglobin (Hb) value before surgery and for 5 days PO, adverse events like luxation and transfusion were registered. For the statistical evaluation were used the paired “t-test” with a level of significance set at 95%. Differences and p values of < 0.05 were considered significant.

Results 234 patients (mean age 65y; range 21–91y) were admitted to the study. 128 women and 106 men. For the blood loss evaluation, the presence of no homogeneous preoperative Hb lead us to analyse the decrease rate of preoperative Hb (DRPH). The mean DRPH was: 22,47% at 1dayPO; 25,09% at 2 daysPO; 22,83% at 3 daysPO; 26,76% at 5 daysPO. For the safety evaluation were considered the incidence of transfusions (limit was set at Hb< 8g/dL) that were related to the preoperative Hb and the age. The transfusion incidence for each preoperative Hb (PrHb) value was: 14% (7/49) for 12< PrHb< 13; 11% (6/53) for 13< PrHb< 14; 11% (5/43) for 14< PrHb< 15; 7% (2/26) for 15< PrHb< 16g/dL. For age under 70y and PrHb> 14g/dL there were the lowest transfusion incidence: 3% (2/41). No adverse events were able to prevent patients from going to Rehabilitation Unit. All patients were able to do their own physiotherapical programme. Pain during physiotherapy was low (mean value of VAS = 3,47).

Discussion During the last decade the improvement of anaesthesiologic and surgical technique with minimally invasive soft tissue approach (small incision and little muscular sacrifice) lead to a significant reduction in adverse events after primary total hip arthroplasty. So the relative safety of this surgery justifies the growing importance of intensive rehabilitation and fast recovery. This study shows the safety of a rapid discharge from the Hip Surgery Department. The main adverse event after 24 hours PO is the necessity of blood transfusions, but the incidence rate of only 3%, like in patients with preoperative Hb> 14g/dL and age below 70 years, is not a problem for the physicians of the Rehabilitation Unit.

Conclusion This study confirms the possibility to perform a safe One Day Hip Surgery by an accurate selection of the patient.

Introduction In our experimental design we evaluated the osteogenic potential of h-bone marrow (hBM), h-mesenchymal stem cells (hMSC), bone morphogenetic protein (BMP-7) and the combination hMSC plus BMP-7. The aim of the study was to define the capacity to elicit bone formation of expanded hMSC alone and associated with BMP-7

Material and methods A rat femoral segmental defect model was used in this study. 12 male athymic rats were used. The institutional Animal Ethics Committee approved the study. Athymic rats test graft groups consisted of: G1-autoclaved bone and h-BM; G2-bone and h-MSC; G3-bone with BMP-7; G4-bone and h-MSC with BMP-7. h-BM aspirates were harvested from iliac crests of patients undergoing to THA. A plate has been fixed on the femurs with four cerclage wires before a femoral gap of 6mm has been realized in the diaphysis. Gap was filled with different graft. Defect was evaluated at 2, 4, 8, 12 weeks after implantation with radiographs. Evaluation of bone graft has been done using a Cook classification. Histological study with toluidine blue and safranine O at 12 weeks has been performed in each group.

Results At 8–12 weeks after surgery G1 shown non visible new bone formation, G2 minimal new disorganized bone and G3 disorganized new bone bridging graft to host at both ends. The G4 group show significant new bone and graft remodelling. Histological analysis confirmed the rx results.

Conclusion The association hMSC plus BMP-7 determines a significant activation of the osteogenic activity at 8 weeks that may have a remarkable impact on the future orthopedic surgery strategies.

It has been shown that mesenchymal stem cells (MSCs) and BMP are involved in bone formation. The aim of the study was to evaluate the osteogenic potential of human bone marrow (hBM), human expanded MSC (hexp-MSC), BMP-7, and hexp-MSC plus BMP-7, to treat a rat femoral segmental defect.

Sprague-Dawley (SD) and athymic rats (Nu) were used. SD rats where used in order to define surgical technique. Nu rats groups consisted of: G1-autoclaved bone and human bone marrow (hMNC); G2-bone and hexp-MSC; G3-bone with BMP-7 only; and G4-bone and hexp-MSC with BMP-7. A plate was attached to the femoral diaphysis with two cerclage wires. Then a 6-mm femoral gap was made and filled with a different graft. At regular intervals, the femoral defect was evaluated with radiographs, using a modified six-grade Cook classification.

At 8 weeks G1 showed non-visible new bone formation; G2 minimal new disorganised bone; G3 disorganised new bone bridging the graft to host at both ends; and G4 significant new bone and graft remodelling. Histological analysis confirmed these results.

Our results showed that although the osteogenic activity may be improved by hMSC (G2) as well as by BMP-7 (G3), the association hexp-MSC plus BMP-7(G4) produced graft osteointegration at 8 weeks after surgery. This may have a remarkable impact on future orthopaedics surgery strategies.

Xenografts of bovine bone were used successfully for years with a minimum acceptable rate of side effects in total hip revision arthroplasty for filling large bone defects. The great majority of them was withdrawn from the market when any biological product of bovine origin was considered as a potential carrier of prions infection. However, current EEC regulations permit their surgical therapeutic use if obtained from cattle under 6 months of age, which are supposed to be not at risk of prion transmission. Lubboc, a purified trabecular bone matrix containing only type-1 collagen and hydroxyapatite, fulfils this requirement. From 2001 to 2003 we used this product in fragments (chips) to fill bone defects of the acetabulum before screwing the acetabular rings in 37 patients. No massive grafts were implanted. Minimum follow-up was 12 months, maximum 27 months. Four subjects were lost to follow-up. The fate of the grafts was evaluated for evidence of union, remodelling, resorption, migration of the rings or fracture of the newly formed bone. No significant adverse events were registered. If the risk of transmitting infectious agents is excluded or minimised according to the present legislation, it seems unjustified to remove xenografts from the options available to orthopaedic surgeons, considering the problems of bone stock deficiency and reconstruction in hip arthroplasty revision surgery.

Human mesenchymal stem cells (hMSC), residing in the bone marrow, can be purified, expanded in cell culture and under appropriate stimuli may differentiate along the osteogenic, chondrogenic and adipogenic lineages. The aim of this study was to investigate the expansion capability and differentiation potential of MSCs obtained from femur, pelvis and acetabular cancellous bone of aged patients in order to establish whether these cells, isolated and expanded in vitro, can be used in a new approach in orthopaedic revision surgery.

In this preliminary study we enrolled 33 patients undergoing hip arthroplasty in order to investigate CFU-F frequency, expansion ability and differentiation potential of hMSC derived from three different anatomical sites: femural, pelvic and acetabular cancellous bone (ACB).

CFU-F frequency (CFU-F/10 ⁶ MNC) was 63 for pelvis (range 7–122), 90 for bone (39–132) and 47.5 for femur (7–124).CFU-F frequency was higher in ACB than in either pelvis (p=0.04) or femur (p=0.001). The patients were divided into three age groups: G1 ≤50 years (n=6), G2 50 −65 years (n=11), and G3 ≥65 years (n=16); however, CFU-F frequency did not show any statistically significant difference, although the frequency was lower at higher age.

We expanded in cell culture MSC of 16 patients from the three considered sites until the fourth passage. At the first passage there was a higher MSC recovery in ACB (median 12%) than in pelvis (median 8%; p< 0.004) and femur (median 3.8%; p< 0.0004). MSC recovery from pelvis was higher than in femur (p< 0.04). At the second and third passage MSC expansion was found to be significantly higher in ACB than in pelvis alone (median 3.1 vs 1.6, p< 0.01; 1.8 vs 1.2, p< 0.005, respectively), while at the fourth passage it became higher than in pelvis and femur (median 2.6 vs 1.4, p< 0.03; 2.6 vs 1.6, p< 0.0, respectively). At each culture passage, cells showed MSC features as supported by flow cytometry and by the multilineage differentiation potential.

hMSCs seem to have higher frequency in close association with bone; moreover, they show an increased expansion ability in vitro which is still mantained in elderly patients. As these progenitors can differentiate in bone, they seem to be the best choice for the effective repair of bone defects in revision surgery.

Aims: The purpose of this study is to review eight to eleven year results of a consecutive series of primary hybrid total hip arthroplasties. Methods: 193 patients (197 hips) received a cemented, polished, collarless, femoral component (Ra=1) in association with an uncemented acetabular component (166 grit-blasted titanium ßexible, 17 Ti mesh, and 14 Standard porous cups). Results: Mean age at surgery was 69.5 years (51–90). Most frequent diagnosis was osteoarthritis. Average follow-up was 9.2 years (8.5 to 11.2). 21 patients (23 hips) were lost to follow-up. 24 patients (25 hips) died prior to eight-years and none had undergone revision. Two femoral components, the only two with Grade D cement mantles, were revised for aseptic loosening at 23 and 111mos. One Ti mesh socket was revised for catastrophic poly wear at 113m and one ßexible cup for dislocation at 111m. The remaining 146 stems and cups were available for minimum 8year clinical review. 62 underwent complete radiographic review. Conclusions: Post-op Harris score was 89.3 (68–100). Pain relief was good or excellent in 95% of patients. X-rays revealed 1–2mm of femoral subsidence in 6 hips. Two cases of proximal (zones 7 and 1) femoral osteolysis were identiþed. A cemented polished femoral component and an uncemented acetabulum provide excellent clinical and radiographic results at average 9y follow up. Continued success appears likely in the absence of osteolysis or cement bone demarcation.