We reviewed 120 consecutive primary total hip replacements in 109 patients in whom a Freeman uncemented metal-backed component had been used. Acetabular components were used with a Freeman neck-retaining stem in one of three configurations: cemented smooth stem, uncemented smooth stem or uncemented ridged stem. After a mean follow up of 72 months (62 to 113) there were nine cases of aseptic loosening; a survivorship at eight years of 83%. In addition, more than one-third of the remaining surviving cups showed loosening radiologically. The Freeman acetabular component demonstrated a characteristic pattern of loosening on radiographs. The high incidence of aseptic loosening can be explained by poor design and material failure.

We have reviewed 202 consecutive primary hip replacements using a Freeman cemented femoral component after a mean period of follow-up of 64 months (23 to 113). There was only one revision for aseptic loosening. Retention of the femoral neck may act to reduce the torsional and shear forces at the implant-cement interface and may provide a seal against the migration of polyethylene-laden joint fluid in the potential joint space. The cemented Freeman femoral component with retention of the femoral neck was successful for up to nine years.

We reviewed a consecutive series of 527 uninfected hip replacements in patients resident in the UK which had been implanted from 1981 to 1993. All had the same basic design of femoral prosthesis, but four fixation techniques had been used: two press-fit, one HA-coated and one cemented. Review and radiography were planned prospectively. For assessment the components were retrospectively placed into two groups: those which had failed from two years onwards by aseptic femoral loosening and those in which the femoral component had survived without revision or recommendation for revision.

All available radiographs in both groups were measured to determine vertical migration and examined by two observers to agree the presence of radiolucent lines (RLLs), lytic lesions, resorption of the neck, proximal osteopenia and distal intramedullary and distal subperiosteal formation of new bone. We then related the presence or absence of these features and the rate of migration at two years to the outcome with regard to aseptic loosening and determined the predictive value of each of these variables.

Migration of ≥2 mm at two years, the presence of an RLL of 2 mm occupying one-third of any one zone, and subperiosteal formation of new bone at the tip of the stem were predictors of aseptic loosening after two years. There were too few lytic lesions to assess at two years, but at five years a lytic lesion ≥2 mm also predicted failure. We discuss the use of these variables as predictors of femoral aseptic loosening for groups of hips and for individual hips.

We conclude that if a group of about 50 total hip replacements, perhaps with a new design of femoral stem, were studied in this way at two years, a mean migration of < 0.4 mm and an incidence of < 10% of RLLs of 2 mm in any one zone would predict 95% survival at ten years.

For an individual prosthesis, migration of < 2 mm and the absence of an RLL of ≤2 mm at two years predict a 6% chance of revision over approximately ten years. If either 2 mm of migration or an RLL of 2 mm is present, the chances of revision rise to 27%, and if both radiological signs are present they are 50%. If at five years a lytic lesion has developed, whatever the situation at two years, there is approximately a 50% chance of failure in the following five years.

Our findings suggest that replacements using a limited number of any new design of femoral prosthesis should be screened radiologically at two years before they are generally introduced. We also suggest that radiographs of individual patients at two years and perhaps at five years should be studied to help to decide whether or not the patient should remain under close review or be discharged from specialist follow-up.

We compared the radiological appearances and survival of four methods of fixation of a femoral stem in 538 hips after follow-up for five or ten years. The fixation groups were: 1) press-fit shot-blasted smooth Ti-Al-V stem; 2) press-fit shot-blasted proximally ridged stem; 3) proximal hydroxyapatite (HA) coating; and 4) cementing.

Survival analysis at five to ten years showed better results in the HA-coated (100% at five to six years) and cemented stems (100% at 5 to 6 years) than in the two press-fit groups. There was a higher mean rate of migration in the smooth and ridged Ti-Al-V shot-blasted press-fit groups (0.8 mm/year and 0.6 mm/year, respectively) when compared with the HA-coated and cemented prostheses (both 0.3 mm/year). More radiolucent lines and osteolytic lesions were seen in the press-fit groups than in either the HA-coated or cemented implants, with a trend for a lower incidence of both in the HA compared with the cemented group. Proximal osteopenia increased in the press-fit and cemented prostheses with time, but did not do so in the HA group. There was a higher incidence of resorption of the femoral neck with time in the cemented group than in the other three.

We conclude that the HA and the cemented interfaces both provide secure fixation with a trend in favour of HA. The cemented prosthesis meets the suggested National Institutes of Health definition of ‘efficacious’ at ten years.