We report the incidence of osteolysis in the femur, tibia, and patella of 44 consecutive patients (60 knees) who were followed for more than seven years after cementless knee arthroplasty with a Porous-Coated Anatomic prosthesis. The average age of the patients was 56.5 years (17 to 73); the operative diagnosis was osteoarthritis (33 knees), rheumatoid arthritis (17), tuberculous arthritis (7) and post-traumatic arthritis (3). All patellae were resurfaced. No femoral or tibial component was loose at the final follow-up examination. Thirty patellar components were loose of which six had been revised. Radiographs revealed osteolysis in 90% of the tibial plateaux and in 80% of the 30 intact patellar prostheses. No osteolysis was seen around any femoral component. In 50 knees (83%) the average wear of the polyethylene liner was 2.5 mm in the medial compartment and 1.7 mm in the lateral compartment. Four of 60 knees (6.7%) were revised for complete wear of the polyethylene liner of the tibial component. Fixation of the tibial and patellar components without cement fails to seal the interface between bone and prosthesis and allows the migration of polyethylene particulate debris which causes osteolysis

We reviewed 12 patients six years after they had undergone total hip replacement with a cementless prosthesis, the Ribbed Hip System (Waldemar Link GmbH & Co, Hamburg, Germany). Aseptic loosening of one or both components had necessitated revision surgery in seven patients, in five within two years of operation. In view of our experience we question the wisdom of allowing the uncontrolled use of new prosthesis without postoperative surveillance

Aims

Our intention was to investigate if the highly porous biological fixation surfaces of a new 3D-printed total knee arthroplasty (TKA) achieved adequate fixation of the tibial and patellar components to the underlying bone.

We report the short-term results of 100 cementless total hip replacements in 52 severely dysplastic and 48 totally dislocated hips, with some new technical solutions to the problems involved. In cases with a very narrow iliac bone, the acetabular screw ring is seated below the true cotyloid area. In hips with tight flexor and abductor muscles or with deformities of the proximal femur, various osteotomies were performed. Special attention was paid to careful pre-operative planning and precise operative technique. In spite of a high complication rate the results were generally good and even patients who required reoperation were satisfied with the final result

We have developed a CT-based navigation system using infrared light-emitting diode markers and an optical camera. We used this system to perform cementless total hip replacement using a ceramic-on-ceramic bearing couple in 53 patients (60 hips) between 1998 and 2001. We reviewed 52 patients (59 hips) at a mean of six years (5 to 8) postoperatively. The mid-term results of total hip replacement using navigation were compared with those of 91 patients (111 hips) who underwent this procedure using the same implants, during the same period, without navigation. There were no significant differences in age, gender, diagnosis, height, weight, body mass index, or pre-operative clinical score between the two groups. The operation time was significantly longer where navigation was used, but there was no significant difference in blood loss or navigation-related complications. With navigation, the acetabular components were placed within the safe zone defined by Lewinnek, while without, 31 of the 111 components were placed outside this zone. There was no significant difference in the Merle d’Aubigne and Postel hip score at the final follow-up. However, hips treated without navigation had a higher rate of dislocation. Revision was performed in two cases undertaken without navigation, one for aseptic acetabular loosening and one for fracture of a ceramic liner, both of which showed evidence of neck impingement on the liner. A further five cases undertaken without navigation showed erosion of the posterior aspect of the neck of the femoral component on the lateral radiographs. These seven impingement-related mechanical problems correlated with malorientation of the acetabular component. There were no such mechanical problems in the navigated group. We conclude that CT-based navigation increased the precision of orientation of the acetabular component and control of limb length in total hip replacement, without navigation-related complications. It also reduced the rate of dislocation and mechanical problems related to impingement

We investigated the radiographic and clinical course of 31 patients in whom a bulk acetabular allograft had been used during the cementless revision of a total hip replacement. Two patients died and two were lost to follow-up within 24 months, but of the remaining 27 acetabular components, 12 (44%) showed radiographic evidence of instability at a mean of 46 months. Five of these have been revised. In the 12 failures, signs of instability had been noted at an average of 29 months (1 to 60). Failures during the first 24 months were usually due to technical errors, later failures to gradual migration of the cup into the graft. The cups with the greatest amount of their surface supported by grafts were most likely to migrate, but this migration was usually asymptomatic. Screw fixation of the cup, used in 24 cases, appeared to control the mechanism of failure. Femoral head allografts and distal femoral allografts had been used, with failure in 6 of 16, and 6 of 11 respectively; distal femoral allografts were used only for large defects. The insidious course of late cup migration and graft failure necessitates close radiographic follow-up of patients treated with bulk allografts

We have carried out a prospective study comparing the results at five years in patients older than 75 years of age undergoing hydroxyapatite-coated, cementless total knee replacement (TKR) with those who were younger. The Knee Society clinical rating scores were recorded before and after operation. Of 559 patients undergoing TKR, 135 were in the elderly age group. The knee scores at five years or more showed comparable results, with patients under 75 years of age reaching a score of 183 and those aged 75 years or over reaching 174. These differences were predominantly due to the functional component of the score. We conclude that elderly patients do just as well as the younger group using this prosthesis

A leading problem with cementless hip replacement is thigh pain, probably due to some degree of loosening. This is most pronounced during activities such as stair climbing or getting up from a chair. Our study compares the immediate fixation of three stems in widespread clinical use, using a cadaver test simulation in which the femur was horizontal, and cyclic forces acted vertically downward on the prosthetic head with gradual increments of load. We implanted and tested 18 pairs of femurs, making analyses between stem types by right to left comparisons. We found no statistically significant differences in loosening between cementless AML and PCA prostheses, but cemented stems withstood greater loads than uncemented stems by a factor of five or more

Cementless femoral stems are currently preferred for total hip replacement (THR) in the United States. Improvements in stem design, instrumentation and surgical technique have made this technology highly successful, reproducible, and applicable to the vast majority of patients requiring a THR. However, there are ongoing developments in some aspects of stem design that influence clinical results, the incidence of complications and their inherent adaptability in accommodating the needs of individual patients. Here we examine some of these design features.

Cite this article: Bone Joint J 2013;95-B, Supple A:53–6.

In this study we present our experience with four generations of uncemented total knee arthroplasty (TKA) from Smith & Nephew: Tricon M, Tricon LS, Tricon II and Profix, focusing on the failure rates correlating with each design change. Beginning in 1984, 380 Tricon M, 435 Tricon LS, 305 Tricon 2 and 588 Profix were implanted by the senior author. The rate of revision for loosening was 1.1% for the Tricon M, 1.1% for the Tricon LS, 0.5% for the Tricon 2 with a HA coated tibial component, and 1.3% for the Profix TKA. No loosening of the femoral component was seen with the Tricon M, Tricon LS or Tricon 2, with no loosening seen of the tibial component with the Profix TKA. Regarding revision for wear, the incidence was 13.1% for the Tricon M, 6.6% for the Tricon LS, 2.3% for the Tricon 2, and 0% for the Profix. These results demonstrate that improvements in the design of uncemented components, including increased polyethylene thickness, improved polyethylene quality, and the introduction of hydroxyapatite coating, has improved the outcomes of uncemented TKA over time.

We reviewed the results of 545 consecutive total hip replacements using a cementless non-coated high-density polyethylene acetabular component combined with a cemented Muller stem at five to 10 years. In all, 421 patients (445 hips) were available for review, 118 by questionnaire and 303 by examination and radiography. Of these, 86% had a good or excellent result. We found a high rate of radiological loosening of the cup after the sixth year, and a high rate of clinical loosening after the eighth year. Loosening was commoner in women, in younger patients and where a smaller size of acetabulum had been used. Calcar resorption was significantly related to loosening of the acetabulum. Loosening appeared to be mainly due to polyethylene debris produced by micro-movement of the acetabulum against the bone, which had resulted in a giant cell foreign body reaction and subsequent bone erosion. We have abandoned the use of this prosthesis and suggest that direct contact between bone and polyethylene should be prevented by a coating of metal or some other material

Aims

Cementless femoral stems must be correctly sized and well-seated to obtain satisfactory biological fixation. The change in sound that occurs during impaction of the femoral broach is said to indicate good fit, but this has not been widely studied. We set out to find whether the presence or absence of these sound changes could predict correct sizing.

Adult human cadaver pelves were tested to determine micromotion at the prosthesis-bone interface in cementless hemispherical acetabular components during simulated single-limb stance. The micromotion of non-press-fit components with screw fixation in response to cyclic loads to a maximum of 1500N was compressive (interface closing) at the superior iliac rim and distractive (interface opening) at the inferior ischial rim; that of press-fit components was compressive all around the acetabular rim regardless of screw fixation. Adding screws to the component decreased the micromotion at the site of the screw, but sometimes increased it at the opposite side. Two dome screws with the press-fit component decreased the micromotion at the superior iliac rim but at the inferior ischial rim there was either no change or increased movement. A press-fit cup shows less micromotion than a non-press-fit cup with screw fixation. The addition of screws to a press-fit cup does not necessarily increase the initial stability

Aims

Our aim was to report survivorship data and lessons learned with the Corail/Pinnacle cementless total hip arthroplasty (THA) system.

The measurement of bone mineral density in defined areas around metal implants has improved with the development of dual-energy X-ray absorptiometry. We used this technique to compare the bone mineral density adjacent to metal cementless femoral implants with that of identical regions of bone in normal proximal femora. We studied the anteroposterior views only of 72 femora which contained total hip implants and 34 non-operated femora. We compared the regional bone mineral density of bone adjacent to proximally porous-coated and distally porous-coated implants of one design, to measure the relative differences in the remodelling changes induced by different amounts of porous coating. We also measured differences in bone density with time and with variations in implant size (and therefore stiffness). The greatest decrease in bone mineral density (34.8%) occurred in the most proximal 1 cm of the medial femoral cortex around relatively stiff, extensively porous-coated implants. The next most severe decrease (20% to 25%) was in the next most proximal 6 cm of the medial femoral cortex. Small, progressive decreases in bone mineral density continued for five to seven years after implantation

Aims

The purpose of this study was to evaluate the biological fixation of a 3D printed porous implant, with and without different hydroxyapatite (HA) coatings, in a canine model.

Aims

To date, there is insufficient evidence available to compare the outcome of cemented and uncemented fixation of the humeral stem in reverse shoulder arthroplasty (RSA).

This was a randomised controlled trial studying the safety of a new short metaphyseal fixation (SMF) stem. We hypothesised that it would have similar early clinical results and micromovement to those of a standard-length tapered Synergy metaphyseal fixation stem. Using radiostereometric analysis (RSA) we compared the two stems in 43 patients. A short metaphyseal fixation stem was used in 22 patients and a Synergy stem in 21 patients. No difference was found in the clinical outcomes pre- or post-operatively between groups. RSA showed no significant differences two years post-operatively in mean micromovement between the two stems (except for varus/valgus tilt at p = 0.05) (subsidence 0.94 mm (sd 1.71) vs 0.32 mm (sd 0.45), p = 0.66; rotation 0.96° (sd 1.49) vs 1.41° (sd 2.95), p = 0.88; and total migration 1.09 mm (sd 1.74) vs 0.73 mm (sd 0.72), p = 0.51). A few stems (four SMF and three Synergy) had initial migration > 1.0 mm but stabilised by three to six months, with the exception of one SMF stem which required revision three years post-operatively. For most stems, total micromovement was very low at two years (subsidence < 0.5 mm, rotation < 1.0°, total migration < 0.5 mm), which was consistent with osseous ingrowth. The small sample makes it difficult to confirm the universal applicability of or elucidate the potential contraindications to the use of this particular new design of stem.

Cite this article: Bone Joint J 2015; 97-B:595–602.

Between 1988 and 1998 we implanted 318 total hip replacements (THRs) in 287 patients using the Plasmacup (B. Braun Ltd, Sheffield, United Kingdom) and a conventional metal-on-polyethylene articulation. The main indications for THR were primary or secondary osteoarthritis.

At follow-up after a mean 11.6 years (7.6 to 18.4) 17 patients had died and 20 could not be traced leaving a final series of 280 THRs in 250 patients. There were 62 revisions (22.1%) in 59 patients. A total of 43 acetabular shells (15.4%) had been revised and 13 (4.6%) had undergone exchange of the liner. The most frequent indications for revision were osteolysis and aseptic loosening, followed by polyethylene wear. The mean Kaplan-Meier survival of the Plasmacup was 91% at ten years and 58% at 14 years. Osteolysis was found around 36 (17.1%) of the 211 surviving shells. The median annual rate of linear wear in the surviving shells was 0.12 mm/year and 0.25 mm/year in those which had been revised (p < 0.001). Polyethylene wear was a strong independent risk factor for osteolysis and aseptic loosening. The percentage of patients with osteolysis increased proportionately with each quintile of wear-rate.

There is a high late rate of failure of the Plasmacup. Patients with the combination of this prosthesis and bearing should be closely monitored after ten years.

We report our experience of revision total hip replacement (THR) using the Revitan curved modular titanium fluted revision stem in patients with a full spectrum of proximal femoral defects. A total of 112 patients (116 revisions) with a mean age of 73.4 years (39 to 90) were included in the study. The mean follow-up was 7.5 years (5.3 to 9.1). A total of 12 patients (12 hips) died but their data were included in the survival analysis, and four patients (4 hips) were lost to follow-up. The clinical outcome, proximal bone regeneration and subsidence were assessed for 101 hips.

The mean Harris Hip Score was 88.2 (45.8 to 100) after five years and there was an increase of the mean Barnett and Nordin-Score, a measure of the proximal bone regeneration, of 20.8 (-3.1 to 52.7). Five stems had to be revised (4.3%), three (2.9%) showed subsidence, five (4.3%) a dislocation and two of 85 aseptic revisions (2.3%) a periprosthetic infection.

At the latest follow-up, the survival with revision of the stem as the endpoint was 95.7% (95% confidence interval 91.9% to 99.4%) and with aseptic loosening as the endpoint, was 100%. Peri-prosthetic fractures were not observed.

We report excellent results with respect to subsidence, the risk of fracture, and loosening after femoral revision using a modular curved revision stem with distal cone-in-cone fixation. A successful outcome depends on careful pre-operative planning and the use of a transfemoral approach when the anatomy is distorted or a fracture is imminent, or residual cement or a partially-secured existing stem cannot be removed. The shortest appropriate stem should, in our opinion, be used and secured with > 3 cm fixation at the femoral isthmus, and distal interlocking screws should be used for additional stability when this goal cannot be realised.

Cite this article: Bone Joint J 2014;96-B:889–95.