Aims

Our aim in this study was to describe a continuing review of 11 total hip arthroplasties using 22.225 mm Alumina ceramic femoral heads on a Charnley flanged femoral component, articulating against a silane crosslinked polyethylene.

Objectives

Metal-on-metal (MoM) hip resurfacing was introduced into clinical practice because it was perceived to be a better alternative to conventional total hip replacement for young and active patients. However, an increasing number of reports of complications have arisen focusing on design and orientation of the components, the generation of metallic wear particles and serum levels of metallic ions. The procedure introduced a combination of two elements: large-dimension components and hard abrasive particles of metal wear. The objective of our study was to investigate the theory that microseparation of the articular surfaces draws in a high volume of bursal fluid and its contents into the articulation, and at relocation under load would generate high pressures of fluid ejection, resulting in an abrasive water jet.

Increasing follow-up identifies the outcome in younger patients who have undergone total hip replacement (THR) and reveals the true potential for survival of the prosthesis. We identified 28 patients (39 THRs) who had undergone cemented Charnley low friction arthroplasty between 1969 and 2001. Their mean age at operation was 17.9 years (12 to 19) and the maximum follow-up was 34 years. Two patients (4 THRs) were lost to follow-up, 13 (16 THRs) were revised at a mean period of 19.1 years (8 to 34) and 13 (19 THRs) continue to attend regular follow-up at a mean of 12.6 years (2.3 to 29). In this surviving group one acetabular component was radiologically loose and all femoral components were secure. In all the patients the diameter of the femoral head was 22.225 mm with Charnley femoral components used in 29 hips and C-stem femoral components in ten. In young patients who require THR the acetabular bone stock is generally a limiting factor for the size of the component. Excellent long-term results can be obtained with a cemented polyethylene acetabular component and a femoral head of small diameter.

The design of the Charnley total hip replacement follows the principle of low frictional torque. It is based on the largest possible difference between the radius of the femoral head and that of the outer aspect of the acetabular component. The aim is to protect the bone-cement interface by movement taking place at the smaller radius, the articulation. This is achieved in clinical practice by a 22.225 mm diameter head articulating with a 40 mm or 43 mm diameter acetabular component of ultra-high molecular weight polyethylene.

We compared the incidence of aseptic loosening of acetabular components with an outer diameter of 40 mm and 43 mm at comparable depths of penetration with a mean follow-up of 17 years (1 to 40).

In cases with no measurable wear none of the acetabular components were loose. With increasing acetabular penetration there was an increased incidence of aseptic loosening which reflected the difference in the external radii, with 1.5% at 1 mm, 8.8% at 2 mm, 9.7% at 3 mm and 9.6% at 4 mm of penetration in favour of the larger 43 mm acetabular component.

Our findings support the Charnley principle of low frictional torque. The level of the benefit is in keeping with the predicted values.

Of the 11 054 Charnley low-frictional torque arthroplasties carried out at our hospital between 1962 and 1977, 110 (94 patients) had a minimum follow-up of 30 years with a mean of 32.3 years (30.0 to 40.5). The mean age of the patients at operation was 43.3 years (17.0 to 65.0) and 75.7 years (51.0 to 97.0) at follow-up. Overall, 90% of hips (99) were free from pain and activity was reported as normal in 58% of the patients.

A total of 13 hips (11.8%) were revised at a mean follow-up of 32.3 years (30.0 to 39.5), with wear and loosening of the acetabular component as the main indications.

The clinical results did not reflect the mechanical state of the implant. Follow-up with sequential radiographs of good quality is essential. Revision for radiological changes alone must be accepted if gross loss of bone stock is to be avoided.

Improvements in the design, materials and operative technique, based on the long-term outcome, are highlighted.

We studied survival to 38 years after Charnley low-friction arthroplasty of the hip. We used revision as an end-point, while adopting a policy of regular follow-up and early revision for radiological changes alone if indicated.

Between November 1962 and June 2005, 22 066 primary low-friction arthroplasties (17 409 patients) had been performed at Wrightington Hospital by more than 330 surgeons. By June 2006, 1001 (4.5%) hips had been revised and 1490 patients (2662 hips, 12%) had died. At 31 years, where a minimum of 40 hips were still attending follow-up, survival with revision for infection as an endpoint was 95%, for dislocation 98%, for a fractured stem 88.6%, for a loose stem 72.5% and for a loose acetabular component 53.7%. Wear and loosening of the ultra-high-molecular-weight polyethylene acetabular component were the main long-term problems.

We conclude that regular follow-up after hip replacement is essential and that all operative findings should be recorded at revision.

We reviewed 1039 revision total hip replacements where an angle-bore acetabular component was used. After a mean follow-up of nine years (0 to 20.6), the incidence of revision for dislocation was 2.1% (22 revisions), a success rate of 97.9%. In 974 revisions, where the indication was other than dislocation, the success rate was 98.5%. Of the 65 revisions for dislocation, 58 (89.2%) were successful after the first revision and a further five after the second revision, an overall success of 96.9%. Two patients elected to have their implants removed. Dislocation after revision of failed total hip replacement is a complex issue. There is often no single cause and no simple solution. The angle-bore acetabular component, in combination with a 22.225-mm diameter femoral head, offers a high level of success.

We report the results of our continued review of 11 total hip arthroplasties using 22.225 mm alumina ceramic femoral heads on a Charnley flanged stem, articulating with chemically cross-linked polyethylene. There was an initial bedding-in of up to 0.41 mm at the articular surface in the first two years. This had not progressed further, at a minimum follow-up of 15 years. Radiographically no femoral or acetabular component showed loosening or osteolysis.

Since wear and loosening of the ultra-high-molecular-weight polyethylene cup are factors which limit the life of an arthroplasty we have attempted to identify factors associated with either low wear (0.02 mm/year or less) or high wear (0.2 mm/year or more). In a series of 1434 Charnley low-friction arthroplasties (1092 patients) 190 (13.2%) showed low wear while 149 (10.4%) showed high wear. We used chi-squared test to assess the significance of various factors.

The significant factors of the low-wear group were female gender (p = 0.042), rheumatoid arthritis (p = 0.014), Charnley grade C (p = 0.03) and varus position of the stem (p = 0.003). The use of acetabular cement pressurisation (p = 0.07) and medialisation of the cup (p = 0.07) approached significance.

In the high-wear group there was a predominance of men (p = 0.042) with osteoarthritis (p = 0.006) as the underlying hip pathology, and the stem in a valgus position (p = 0.023). Support of the cup by the rim of the acetabulum approached significance (p = 0.07). There was no statistical significance between the two groups for revision for aseptic loosening of the stem or fracture of the stem (p = 0.49). There was a highly significant difference (p < 0.0001) between the two groups for revision for wear and aseptic loosening of the cup, 5.3% compared with 39%.

Changes in the cup geometry are probably sufficient to explain the increasing incidence of loosening and revisions with the increasing depth of penetration of the cup. There is much to be gained from the use of a low-wearing ceramic-ultra-high-molecular-weight combination. Tissue reaction to the polyethylene particles cannot be the cause of aseptic loosening of the stem.

We have prospectively studied the wear of enhanced ultra-high molecular-weight polyethylene (Hylamer) in combination with a zirconia femoral head of 22.225 mm diameter on a cemented, triple-tapered, collarless, polished stem, the C Stem.

The 71 patients who underwent total hip arthroplasty had a mean follow-up of six years (3 to 8). No patient died or was lost to follow-up. The clinical results were excellent with 96% of patients satisfied. There were no revisions. Two cups were considered to be loose radiologically. One was avulsed from the cement in a skiing accident, with a periprosthetic fracture of the femur, but has remained stable for more than seven years. One femur shows radiological appearances which are compatible with a healing infection. One femoral component is at risk of loosening. The mean rate of penetration of the cup was 0.22 mm/year (0.06 to 0.55).

Our results appear to be within the guidelines set by the National Institute of Clinical Excellence. We have discontinued the use of Hylamer despite excellent clinical results and no revisions to date because the high initial rates of penetration did not settle to the expected low levels within the anticipated time.

Between November 1962 and December1990 a group of 1092 patients, 668 women and 424 men, under the age of 51 years at the time of surgery, underwent 1434 primary Charnley low-frictional torque arthroplasties and are being followed up indefinitely. Their mean age at operation was 41 years (12 to 51). At the latest review in June 2001 the mean follow-up had been for 15 years 1 month. Of the 1092 patients 54 (66 hips) could not be traced, 124 (169 hips) were known to have died and 220 (248 hips) had had a revision procedure. At a mean follow-up of 17 years and 5 months, 759 patients (951 hips) are still attending. In this group satisfaction with the outcome is 96.2%.

The incidence of deep infection for the whole group was 1.67%. It was more common in patients who had had previous surgery (hemi- and total hip arthroplasties excluded), 2.2% compared with 1.5% in those who had not had previous surgery, but this difference was not statistically significant (p = 0.4). There were fewer cases of deep infection if gentamicin-containing cement was used, 0.9% compared with 1.9% in those with plain acrylic cement, but this was not also statistically significant (p = 0.4). There was a significantly higher rate of revision in patients who had had previous hip surgery, 24.8% compared with 14.1% in those who had not had previous surgery (p < 0.001).

At the latest review, 1.95% are known to have had at least one dislocation and 0.4% have had a revision for dislocation. The indication for revision was aseptic loosening of the cup (11.7%), aseptic loosening of the stem (4.9%), a fractured stem (1.7%), deep infection (1.5%) and dislocation (0.4%).

With revision for any indication as the endpoint the survivorship was 93.7% (92.3 to 95.0) at ten years, 84.7% (82.4 to 87.1) at 15 years, 74.3% (70.5 to 78.0) at 20 years and 55.3% (45.5 to 65.0) at 27 years, when 55 hips remained ‘at risk’.

The calcar femorale is a vertical plate of bone lying deep to the lesser trochanter and is formed as a result of traction of the iliopsoas which separates the femoral cortex into two distinct layers, the calcar femorale and the medial femoral cortex. They fuse together proximally to form the medial femoral neck. A stem placed centrally will abut against the calcar femorale with little or no space for cement. Clearing of the calcar will offer space for a cement layer, which will support the stem proximally on the posterior aspect. We compared two consecutive groups of Charnley low-friction arthroplasties, with and without clearing of the calcar.

In 330 patients who had an arthroplasty without clearing the calcar, there were ten revisions for aseptic loosening of the stem and six other stems were considered ‘definitely loose’, giving a rate of failure of 4.8%. In 111 patients in whom the calcar was cleared there was only one revision for aseptic loosening and no stems were classed as ‘definitely loose’, giving a rate of failure of 0.9%.

Survivorship analysis has again shown the need for long-term follow-up; the differences became clear after ten years but because of the relatively small numbers, statistical analysis is not yet applicable.

We now clear the calcar femorale routinely and advocate optimal access to the medullary canal and insertion of the stem in the area of the piriform fossa.

We have designed a modular cemented femoral component for revision of failed total hip arthroplasty in which deficiency of the proximal femur is such as to require a variable extrafemoral portion of the stem. We present the results of the first 74 operations in 72 patients; 56 of the patients had grade-3 or grade-4 femoral deficiency as defined by Gustilo and Pasternak and 24 had fractures of the proximal femur, of which 22 were periprosthetic. There was or had been infection in 19 hips.

At a mean follow-up of 5 years 9 months (1 to 12 years) nine stems were radiologically loose of which three had been revised. There were no failures in 45 cases in which there was fixation of the distal stem of 10 cm or more. Dislocation occurred in nine patients and there were four cases of infection in the 19 which were, or had been, infected previously. There were no neurovascular complications and no intraoperative femoral fractures.

The femoral bone stock improved radiologically in 45 hips of which 29 showed considerable reformation of the proximal femur; 27 remained unchanged and two showed increasing osteoporosis.

Between 1983 and 1988 we carried out 45 Charnley low-friction arthroplasties with autografts from the femoral head in 41 patients for developmental dysplasia of the hip.

The preoperative radiographs were assessed for the severity of DDH according to the classifications of Crowe et al, Hartofilakidis et al and Sharp. The postoperative and follow-up radiographs were analysed for coverage of the socket by the graft, for loosening and for the outcome of the fixation of the bone graft. Two patients died (two hips) at four and seven years after THR from causes unrelated to the surgery and were excluded from the final radiological analysis. The mean age of the patients at the time of operation was 46 years 3 months. The autograft of the femoral head covered a mean 26% (16 to 35) of the acetabular component. All the grafts united. Some degree of resorption of the bone graft occurred in 27 patients, and always involved the lateral part of the graft, which was beyond the margin of the socket. After a mean follow-up of 11 years there had been no revisions and 38 patients had no pain or only slight discomfort. One socket migrated and four others were fully demarcated.

Our findings indicate that the Charnley LFA with an autograft of the femoral head for DDH remains successful at a follow-up of 15 years.

We reviewed 261 patients with 320 Charnley low-friction arthroplasties who had a mean follow-up of 22 years 10 months (20 to 30). Of these, 93.9% considered the operation to be a success; 82.3% were free from pain and 11.6% had occasional discomfort. Satisfactory function was achieved in 59.6% and 62% had an excellent range of movement.

The clinical results did not correlate well with the radiological appearance; radiologically loose components did not affect the clinical outcome. The main long-term problem was wear and loosening of the UHMWPE cup. Our findings suggest that the radiological appearance of the arthroplasty is a more reliable indication of the state of the arthroplasty than the clinical results.

We report the results of our continued review of 14 hip arthroplasties using alumina ceramic femoral heads with cross-linked polyethylene cups.

There have been no complications and a very low rate of penetration. This was 0.02 mm per year after an initial ‘bedding-in’ period of two years. There has been no change in the mean rate between our earlier study at six years and the current results at 10 to 11 years.

The use of these bearing surfaces appears to reduce the potential amount of polyethylene debris and may provide the next logical stage in the development of the Charnley low-friction arthroplasty.