Purpose of the study: The limitations of cemented fixation of alumina cups was demonstrated in 1983. At that time, a new metal-backed cup with a titanium ring for screw fixation and a massive alumina insert was introduced. Since the 1990s, the high rat of mobilization of screwed cups, confirmed by midterm studies, has led to the use of more stable cups. The purpose of this study was to follow the clinical and radiological course of screwed cups implanted for more than 20 years, evaluating the real need for surgical revision.

Material and methods: We reviewed independently a consecutive series of 117 prostheses implanted in 105 patients in 1984–1986. All patients had a screwed cup with an alumina insert, a cemented stem, and a 32 mm alumina head. We retained for study patients aged less than 65 years and excluded revision procedures or patients with prior infection. The clinical assessment was made with the Postel-Merle-d’Aubigné (PMA) score: for eight patients, all data were collected during a phone interview. Radiologically, cups were considered to be mobilized if the change in inclination was greater than 6° or the protrusion greater than 5 mm. Actuarial survival was calculated with the Kaplan-Meier method.

Results: Four prostheses in three patients were lost to follow-up before one year. Mean follow-up was 12.62±6.3 years (maximum 21 years). Fourteen patients had died, twelve had had revision and fifteen were lost to follow-up at more than one year. The mean PMA score improved from 11 preoperatively to 17 at last follow-up. Radiographically, 62% of the cups did not present any sign of mobilization. Four percent exhibited a periprosthetic lucent line around the stem. Considering all results together, four outcome categories could be distinguished: A: good clinical result and no radiological change (58.4%); B: good clinical result and presence of a radiological problem (15%); C: poor clinical result and no radiological unchanged; D: poor clinical result and radiological problem (n21.8%) (including revisions). For category B, the cups showed a 20° mobilization. For these patients, revision was not planned because of very satisfactory quality-of-life for age and activity level. All patients in category C had co-morbid conditions explaining the poor clinical result. Category D included revision procedures which had already been performed (73%) and symptomatic cup mobilizations (27%) measured at 13–31°: revision was planned for most of these patients. The 10-year survival was 82%, all revisions considered; at 15 years, the survival was 66.6%, warranting the change in acetabular fixation made in 1989. The decrease in survival from 82.5% at 10 to 66.6% at 15 years shows that this change was indeed necessity.

Conclusion: Good quality-of-life was achieved for 74% of patients at mean follow-up of 13 years. It would be useful to continue following the patients in category B to check whether cup mobilization has been arrested with a certain degree of adaptation. Furthermore, patients who had a revision were free of osteolysiss and the second operation was generally quite uneventful, usually with preservation of the stem and sometimes even the alumina head which was not deteriorated.

Purpose: At a time when total knee arthroplasty (TKA) with an ultra-congruent tibial plateau or a mobile plateau are advocated by many, the question is whether TKA with a fixed plateau preserving the posterior cruciate ligament (PCL) should be abandoned. We analysed the results of 500 Wallaby I TKA with preservation of the PCL and presenting asymmetrical and divergent femoral condyles with a fixed, also assymetrical tibial plateau, at mean follow-up of seven years (1–10).

Material and methods: This prospective multicentric study was performed by junior and senior surgeons. Mean patient age was 70.11 years and 91.4% of the patients had primary or secondary degenerative disease. Prior surgery had been performed in 130 knees, mainly for osteotomy (n=40, mostly tibial) and revision of uni-compartmental or total prostheses (n=18). The mean preoperative IKS knee score was 26.11 points, the function score was 29.54. Preoperative alignment was correct for 11.26% of the knees, 27.16% presented > 4° valgus and 61.56% > 3° varus. Nearly all tibial and patellar pieces were cemented. 5.8% of the femoral pieces were not cemented. A prosthesis was implanted on the patella in all knees except four. There were two early infections, one popliteal sciatic paralysis and twelve wound healing problems. General mobilisation under general anaesthesia was performed in 53 knees (10.6%).

Results: Twenty-two patients were not retained for analysis, fifteen lost to follow-up and seven deceased at one year. Among the 478 knees followed for one to ten years, there were six late infections (1.25%), one aseptic bipolar loosening (0.2%), 25 patellar fractures (5.23%) including three which required revision (two cerclage, one prosthesis removal), three periprosthetic femur fractures without effect on the clinical or radiographic outcome, one traumatic tear of the medial collateral ligament, and two secondary tears of the PCL without clinical consequences. There were no revisions for instability, generally considered the most frequent reason for TKA revision. The mean postoperative IKS score was 90.6 points and the function score was 59.7 points basically due to patient age and comorbidity. The eight-year survival (Kaplan-Meier method) was 98.2% (95%CI: 99.4–96.9) irrespective of the reason for revision and 99.2% (95%CI 100–98.4%) if the revision was performed for a mechanical problem. Radiographically, more than 70% of the knees were aligned (between 3° valgus and 2° varus) and more than 90% were between 5° valgus and 5° varus. Although it was difficult to measure radiographically polyethylene wear, there was only one case of > 2 mm wear with osteolysis found in 50 knees selected randomly among the knees with more than seven years follow-up.

Conclusion: This study, like others reported by authors preserving the PCL, show that preservation of the PCL limits the risk of instability, allowing excellent clinical and radiographic outcome without important polyethylene wear, opening perspectives for good long-term results.

Purpose: Total hip arthroplasty after failure of femoral osteotomy raises high risk of complications. Outcome has been controversial. The purpose of this retrospective analysis was to evaluate the difficulties and results.

Material and methods: Between March 1974 and January 1995, 68 patients (82 hips), 51 women and 17 men, mean age 59±11.5 years (32–84) underwent surgery. Initial indications were mainly acetabular and/or femoral dysplasia (n=47 hips) or congenital dislocation (n=21 hips). Mean time between osteotomy and arthroplasty was 13.8±8.4 years (10 months-45 years). We used cemented titanium femoral stems (Ceraver Ostal) with an alumina (n=66) or polyethylene (n=16) cup. An alumina-alumina bearing was used in 67 hips (81%). Functional outcome was assessed with the Postel-Merle-d’Aubligné score. Radiological analysis searched for lucent lines and signs of wear. The actuarial survival was determined.

Results: One patient (1 hip) was lost to follow-up. Thirteen patients (14 hips) died of intercurrent causes. Six hips required revision for aseptic loosening (isolated cup loosening in five and bipolar loosening in one) at 8.5 years on average (4.5–12). There were 22 intraoperative complications (27%) including 18 fractures or femoral stem misalignments and four cases of damage to the acetabular fundus. Other complications included one postoperative dislocation, two sciatic nerve palsies with partial recovery, and one non-union of the greater trochanter. There were no infections. At maximum follow-up (11.8±4.7 years, ragne 5.4–20), the mean functional score was 16.5 (15–18) versus 9.9 (6–14) preoperatively (p< 0.05). There were no femoral lucent lines. A complete lucent line around the cup was observed in eleven hips including six with a massive cemented alumina cup. Considering revision for aseptic loosening as failure, cumulative survival at 12 years was 82% (95%IC 67–96%) for the cup and 98% (92–99.7%) for the femoral stem.

Discussion: These results confirm the high risk of intraoperative complications of total hip arthroplasty performed for failure of femoral osteotomy. Architectural changes expose these patients to technical problems. The survival of the implants appears to be relatively unaffected by the prior procedure but the functional results are slightly less satisfactory then for primary arthroplasties.

Aim: The aim of the study was to analyze the results of hybrid alumina prothesis using a pressþt metal backed socket and a cemented stem in young and active patients. Methods: From 1990 to 1992, 71 hybrid alumina-onalumina hip replacements were performed in 62 consecutive patients under age 55, with a mean age of 46 years at surgery. There were 56 primary procedures and 15 revision procedures. The prostheses included a cemented Ti alloy stem, a 32-mm alumina head, and a press-þt metal backed socket with an alumina insert. Results: 3 patients (4 hips) died from unrelated causes. 4 hips had revision surgery for deep infection, unexplained persistant pain, fracture of alumina head, and socket aseptic loosening. The 9-year survival rate was 93.7% if revision for any cause was the end point, and 98.4% if revision for aseptic loosening was the end point. Results in surviving patients with a minimal 5-year followup and an average followup of 8 years (57 hips) were excellent in 47 hips (82.5%), very good in 8 hips (14%), good in 1 hip and fair in one hip. 38% of the sockets had a thin and partial lucent line and 1 socket had a complete lucency less than 1mm thick. One stem had isolated femoral osteolysis. There was no detectable component migration nor acetabular osteolysis. Conclusion: Hybrid alumina prosthesis gave satisfactory results at mid term in active patients. Press-þt metal backed socket appeared as a reliable method of acetabular þxation in alumina-alumina hip replacement. Excellent results of cemented stem þxation may be related to low wear debris production.

Between 1990 and 1992, we implanted 71 hybrid alumina-on-alumina hip arthroplasties in 62 consecutive patients under the age of 55 years, with a mean age of 46 years at surgery. There were 56 primary and 15 secondary procedures. The prostheses involved a cemented titanium alloy stem, a 32 mm alumina head, and a press-fit metal-backed socket with an alumina insert. Three patients (four hips) died from unrelated causes. Four hips had revision surgery for either deep infection, unexplained persistent pain, fracture of the alumina head, or aseptic loosening of the socket. The nine-year survival rate was 93.7% with revision for any cause as the end-point and 98.4% with revision for aseptic loosening as the end-point.

The outcome in the surviving patients (50 patients, 57 hips) with a minimum five-year follow-up (mean eight years) was excellent in 47 hips (82.5%), very good in eight (14%), good in one and fair in one. A thin, partial, lucent line, mainly in zone III was present in 38% of the sockets and one socket had a complete lucency less than 1 mm thick. One stem had isolated femoral osteolysis. There was no detectable component migration nor acetabular osteolysis.

This hybrid arthroplasty gave satisfactory medium-term results in active patients. The press-fit metal-backed socket appeared to have reliable fixation in alumina-on-alumina hip arthroplasty. The excellent results using cemented fixation of the stem may be related to the low production of wear debris.

Aims: Mid and long term results of a continuous series, including learning curve, of 500 TKR cruciate sparing implanted between September 1992 and February 1995 by different surgeons of GUEPAR (staff members and residents) Material: Patients average age70.3 years (26–93). Etiology: Primary OA 74%, post traumatic 6%, RA 6%, associated aetiology in 14% (osteonecrosis, microcristalline arthropathy...). No previous surgery in 325 knees. 175 knees operated before (tibial osteotomy: 37, femoral osteotomy: 4, patella:13, other knee surgery: 74% knee arthroplasty mainly unicompartmental: 19.) Operation procedureby medial approach, except 16 lateral (3.2%) and 6 tibial osteotomy (1.2%). Lateral retinacular release in 19.6% aligned patella and 29.2% subluxed or luxed patella. Per operative complications: PCL weakness (24), tibial plateau fissure (16), condylar fracture (1), patellar fracture (3) without consequence on weight bearing. Although anatomic shape of Wallaby 1 trochl, 86.5% inlay and 11.1% resurfacing patellar component have been done. Very few patella (2%) are not resurfaced at the beginning of our experience. Postoperative complications: No specific earliest complications related to the prosthesis. Latest compliations are: 2 infections in the first month treated by lavage debridement with total recovery and 6 latest infections (> 5th month) with prosthesis removed. 1 bipolar aseptic loosening, 1 patellar loosening without fracture and only 2 of 21 patellar fractures have been fixed by wires. 3 reoperations for persistent pain: 2 patella resurfacing and 1 patellar lateral retinacular release, 3 periprosthetic femoral fractures, 2 fixed by plate, 1 treated by conservative treatment with good results.1 medial collateral ligament rupture after trauma revised with another prosthesis. 5 Sudeck syndrome. Results: Femoro tibial alignment is good (between 3° valgus and 2° varus) in 71.1% and reach 90% if between 5° valgus and 5° varus in%. 38 patients (38 knees: 7.6%) are deceased or lost for follow-up before 1 year (without any revision); 462 knees (92.4%) are follow-up between 1 to 5 years and 381 (76.%) more then 5 years. According to International Knee Score results on these 381 knees are: 104∞ of average flexion (pre op. 109∞), 90.6% had any or mild pain. IKS Knee score 90,6 (45–100) (pre op. 25) IKS function score: 59,7 (0–100) (pre op. 28,5) Survival rates at 8 years: 98.2%(confidence interval of 95%: 99.4–96.9) for removed prosthesis whatever the reasons, and 99.2% (confidence interval of 95% 100–98.4)for revision for mechanical failure only. Conclusions: Encouraging results with a true condylar divergent device encourage us to continue Alignment has to be improved, perhaps with navigation tools.

Purpose: Alumina resistance to wear is now well established. In the eighties, improvement in manufacturing processes and implant design led to a significant reduction in the risk of fracture but failure of acetabular fixation remained a cause leading to revision. The purpose of this work was to present our results with a consecutive series of press-fit cementless metal backed alumina-alumina THA implanted between 1990 and 1992 in patients aged less than 55 years.

Material and methods: The series included 62 patients and 71 hips. Mean age at surgery was 46 years (range 21 – 54). A cemented titanium femoral stem with a 32-mm alumina head was implanted with a press-fit metal-backed cup with an alumina insert. Three patients (4 hips) died. Four hips required revision for infection (n=1), unexplained pain (n=1), fracture of the alumina head (n=1), and aseptic cup loosening (n=1). At nine years the survival rate was 93.7% taking revision for all cause as the end point and 98.4% taking revision for aseptic loosening as the end point.

Results: Fifty patients (57 hips) were reviewed with at least five years follow-up (mean 8 years, range 6–11 years). According to the Postel-Merle d’Aubigné score, functional outcome was excellent or very good in 96% of the patients. A minimal partial lucent line was observed around 38% of the cups, mainly in zone III and one cup exhibited a complete line measuring < 1 mm. Isolated osteolysis of the femur was observed in one hip. There was no case with acetabular osteolysis or implant migration.

Discussion: Combining a cemented stem with a pressfit metal backed cup has provided very satisfactory mid-term results in these active patients. Use of a press-fit hemispheric cup has been found to be a reliable fixation method for alumina cups and improves results of Al-AL THA significantly. In light of the excellent resistance of the alumina cups against wear, these results can be expected to continue for a long period.

We have carried out a prospective, randomised study designed to compare the long-term stability of the stem of cementless femoral implants with differing surface configurations. A total of 50 hips (46 patients) was randomised into two groups, according to whether the medullary stem had been grit blasted (GB) or coated with hydroxyapatite (HA). Both femoral prostheses were of the same geometrical design. We used Ein Bild Roentgen Analyse femoral component analysis (EBRA-FCA) to assess the stability of the stem. The mean follow-up was for 8.66 years.

The mean migration of the stem was 1.26 mm in the HA group compared with 2.57 mm in the GB group (Mann-Whitney U test, p = 0.04). A mixed model ANOVA showed that the development of subsidence was statistically different in the two groups during the first 24 months. After this subsidence increased in both groups with no difference between them. Our results indicate that, with the same design of stem, HA coating enhanced the stability of the femoral stem when compared with GB stems.

We made a semiquantitative study of the comparative histology of pseudomembranes from 12 loose cemented ceramic-ceramic and 18 metal-polyethylene total hip replacements. We found no significant difference in cellular reaction between the two groups, but there was a major difference in the origin of the particulate debris. In the metal-polyethylene group, polyethylene of articular origin was predominant, while in the ceramic-ceramic group the cellular reaction appeared to be a response to zirconia ceramic particles used to opacify cement used for fixation.

Isolation and characterisation of the debris showed that the zirconia particles formed the greatest proportion (76%) in ceramic-ceramic hips, while alumina debris of articular origin formed only 12%.

Our study has indicated that aseptic loosening of ceramic cups is not due to a response to debris generated at the articular interface, but to mechanical factors which lead to fragmentation of the cement.

After an allogenic bone-marrow transplant, a vascular necrosis of the femoral head may affect young adults, producing destructive lesions which require hip replacement. We have reviewed 27 consecutive such total hip arthroplasties (THA) at a minimal follow-up of two years. Of these, 20 were primary operations for Ficat (1985) stage-III and stage-IV lesions, and seven were revisions after the failure of previous surgery. The median age at operation was 30 years (17.5 to 44). The prostheses had a cemented, collared titanium-alloy stem, an alumina-alumina joint, and a press-fit socket. Seven had a titanium-alloy metal back and 20 had all-alumina cups of which six had to be cemented.

At an average follow-up of five years, no patient had been lost to follow-up. One had died from septicaemia after two years and another with chronic graft-versus-host disease developed a deep infection 2.5 years postoperatively and had a successful revision. There were no revisions for aseptic loosening. The clinical results on the Merle d’Aubigné and Postel (1954) scale were very good or excellent in 23 hips (88%), good in one and fair in two. Ten hips showed incomplete acetabular radiolucencies less than 1 mm thick, but there were no radiolucent lines around the stems.

We conclude that for these difficult patients THA with ceramic joints and careful technique provides the best short- and medium-term option after the failure of medical treatment.

Total hip replacement using an alumina head and socket and a titanium alloy stem is evaluated in a series of patients under 50 years of age. Between April 1977 and December 1986, 86 such replacements were performed in 75 patients, but mainly because patients had difficulty travelling from Africa, only 71 hips were followed up adequately; of these, 56 were primary procedures and 15 revisions. Survivorship analysis showed that 98% of the prostheses were retained for 10 years. On clinical and radiological examination 51 of the 71 hips were stable and acceptable, 15 had radiological changes on the acetabular side, and one on the femoral side; four other cases had clinical and radiological changes suggesting impending failure, possibly because fixation of the socket was inadequate. There were no differences between the results of the primary procedures and those of revisions. In these young patients, the results seem better with alumina-on-alumina hips than with other varieties, possibly because of their remarkably low wear.