Laura Kull

Revision of the acetabular component without cement after total hip arthroplasty. Three to six-year follow-up.

One hundred and thirty-eight consecutive revisions of an acetabular component were performed in 132 patients between 1983 and 1986. The revision prosthesis was a hemispherical component that was coated with porous titanium mesh and was secured to the pelvis with a variable number of screws. There were seventy-five women and fifty-seven men, and the mean age at the time of the revision was fifty-two years (range, twenty to seventy-nine years). Due to defects in the acetabulum, 80 per cent of the hips were treated with bone grafts, usually a mixture of local autogenous graft and freeze-dried allograft. One hundred and twenty-four patients (129 hips) were available for follow-up, at a mean of forty-four months (range, thirty-six to eighty months). Seven hips (5 per cent) were revised again: four because of infection and three because of instability. There were no revisions for loosening without infection, and none of the components migrated in the absence of infection. Radiolucent lines were common and usually corresponded to regions in which allograft had been used. All bone grafts united by twelve months. Non-contained medial grafts underwent a phenomenon of resorption, consolidation, and remodeling to a sclerotic rim by twenty-four months. There were no complications related to placement of the screws. The results in this series were superior to results of revisions of acetabular components with the use of cement, which were associated with rates of failure of almost 10 per cent after a similar duration of follow-up. The technique of maximization of host-bone coverage and of packing of all defects with cancellous autogenous graft or allograft, or both, was successful for all classes of acetabular deficiencies.

Primary total hip arthroplasty using noncemented porous-coated femoral components in patients with osteonecrosis of the femoral head

Ninety consecutive total hip arthroplasties in 73 patients with osteonecrosis of the femoral head yielded 81 hips in 64 patients (37 men and 27 women) available for evaluation after a 4-8-year follow-up period. The average age at surgery was 39.9 years (range, 20-66 years). Osteonecrosis etiology was idiopathic in 13 hips, alcohol-induced in 15, femoral neck fracture in 12, and slipped capital femoral epiphysis in 2. The remaining 39 cases were related to steroids, which were administered for a variety of reasons. Two types of noncemented, porous-coated, straight-stem femoral components and three types of acetabular components were utilized. Good or excellent clinical results were recorded in 80.2% of the patients. Average Harris hip scores improved from 52.9 to 87.9 points. Nine patients required revision of at least one component and were significantly younger than those with unrevised components. A revision rate of 24.1% was recorded in patients under 35 years of age at the time of primary surgery. Good or excellent clinical results were seen in 92.3% of the idiopathic cases, 86.7% of the alcohol-induced cases, 77.8% of the renal transplant cases, and 62.5% of the systemic lupus erythematosus cases. The overall mortality rate at the follow-up evaluation was 14%; it was 50% in renal transplant patients. Analysis of the clinical results based on the implants showed no significant differences in Harris hip scores or pain and function scores. While total hip arthroplasty using noncemented porous-coated femoral stems appears to give better results than cemented procedures in patients with osteonecrosis of the femoral head, the results appear to be inferior to those reported in patients with other diagnoses.

Revision of the Acetabular Component without Cement after Total Hip Arthroplasty. A Follow-up Note Regarding Results at Seven to Eleven Years*

The results of revision of the acetabular component without cement, performed for aseptic loosening, were reported previously after a mean of forty-four months for 138 hips (132 patients). After an additional mean duration of follow-up of almost five years, twelve patients (twelve hips) had died before they could be followed long enough for the later study and nine patients (eleven hips) had been lost to follow-up; thus, a total of 111 patients (115 hips) were available for follow-up at a mean of 100 months (range, seventy-eight to 135 months). Between the earlier and later times of follow-up, six additional acetabuli had had a repeat revision: one, for recurrent dislocation; two, for infection; and three (which were stable), at the time of a revision of the femoral stem. No revision of the acetabular cup was performed because of aseptic loosening, and no cup was noted to have migrated. Radiographs were available for 105 patients (109 hips) at a mean of ninety-eight months (range, seventy-eight to 135 months). Five (5 per cent) of the 109 cups were surrounded by a complete radiolucent line and three (3 per cent), by a partial progressive radiolucent line. A radiolucent line adjacent to a screw was seen in association with two cups (2 per cent), and osteolysis was noted at the margin of four cups (4 per cent). Revision of the acetabular component with a porous-coated, nearly hemispherical fiber-metal component inserted without cement was associated with a high rate of excellent results at the seven to eleven-year follow-up examination.

Primary Total Hip Arthroplasty with a Porous-Coated Acetabular Component. Seven-to-Ten-Year Results*

One hundred and eighty-four patients who had been managed, between 1984 and 1985, with a total of 204 consecutive primary total hip arthroplasties with insertion of a Harris-Galante type-I acetabular component without cement were prospectively studied. There were eighty-two men (45 per cent) and 102 women (55 per cent). The mean age at the time of the operation was fifty-two years (range, twenty to eighty-four years). One hundred and fifty-seven patients (173 hips) were available for clinical review at a mean of 104 months (range, seventy-eight to 126 months). At this time, the mean preoperative Harris hip score of 52 points (range, 12 to 79 points) had improved to a mean of 90 points (range, 44 to 100 points). Two patients (two hips) had had an exchange of an excessively worn polyethylene liner. One patient (one hip) had had débridement and grafting of an area of massive retroacetabular osteolysis. Two stable acetabular components (1 per cent) had been revised at the time of femoral revision. None of the cups had been revised because of aseptic loosening. Radiographic examination of 150 patients (165 hips) at a mean of 104 months (range, seventy-eight to 126 months) revealed that 156 cups (95 per cent) were stable. Eight cups (5 per cent) were considered to be possibly unstable, with a radiolucent line between the prosthesis and the bone that was one millimeter wide or less in at least four of five zones; two of the eight had a complete radiolucent line in all zones. One component, which had been implanted with a bulk allograft from a femoral head, migrated more than two millimeters in the first two years and then stabilized without complication. Osteolysis was seen in seven acetabula (4 per cent) and was limited to the periphery of the cup in six. Survivorship analysis at ten years revealed that the acetabular component had a 99 per cent chance of survival (95 per cent confidence interval, 0.98 to 1.0) with revision or aseptic loosening as the end point and a 97 per cent chance of survival (95 per cent confidence interval, 0.95 to 1.0) with revision, aseptic loosening, or reoperation because of a problem related to the acetabular component as the end point.

Hybrid total hip arthroplasty: 7- to 10-year results.

One hundred fifty consecutive hybrid total hip arthroplasties in 139 patients were performed using an uncemented hemispheric porous coated acetabular component (HGP-I) with screws and a femoral component (Precoat) cemented with contemporary cementing technique. The average patient age was 67 years (range, 39-85 years). No patients were lost to followup. Eighty-six patients (91 hips) were alive for an average clinical followup of 103 months (range, 84-127 months); 81 hips had corresponding radiographic analysis. The average Harris hip score preoperatively was 47 points and increased to 88 points at followup. Ninety-five percent of patients had absent or slight pain. Aseptic loosening occurred in 2 femoral components (1.3%), 1 of which was revised for secondary osteolysis. Both hips had suboptimal cement mantles (C-2 or D grades). No femoral osteolysis was seen in stable components. Two acetabular components migrated; 1 secondary to preoperative irradiation osteonecrosis and 1 secondary to a bulk autogenous graft. Acetabular osteolysis without loosening developed in 2 patients (1.3%). Using revision and radiographic loosening as the end point, the probability of both components surviving 10 years was 96.9%, 98.6% for the acetabular component, and 98.4% for the femoral component. These results show that hybrid total hip arthroplasty offers excellent clinical function and exceptional 10-year survivorship.

Complications of a cable grip system

From a group of 643 total hip arthroplasties, 98 patients required trochanteric osteotomies, and in 68 the trochanteric osteotomies were repaired with the Dall-Miles cable grip system (Howmedica, Rutherford, NJ). Trochanteric nonunion occurred in 17 of these patients (25%), with fraying and fragmentation of the cable present in 15 (88%). Of the 51 patients with radiographic union, 18 (35%) also had signs of fraying and fragmentation. Bone destruction around the cable in the area of the lesser trochanter was seen in seven patients (10%). Large deposits of metal debris at the inferior border of the acetabulum were seen in eight hips (12%). Multifilament cable did not appear to offer significant advantages over standard monofilament wire, and the potential problems of fraying, fragmentation, and free-floating metallic debris must be considered.

Revision total hip arthroplasty without cement: subsidence of proximally porous-coated femoral components.

We prospectively studied the intermediate-term results of forty-nine revision total hip arthroplasties without cement that were performed because of aseptic loosening of a cemented femoral component in forty-five consecutive patients; the mean duration of follow-up was sixty-five months (range, forty-five to eighty-seven months). A curved, long-stem, titanium-alloy, non-circumferentially porous-coated femoral component was implanted in each hip. Preoperatively, a staging system was used to classify deficiencies of femoral bone stock according to the loss of cancellous or cortical bone in the metaphysis and diaphysis. Forty-one hips (84 per cent) had cortical or ectatic cavitary bone loss in the metaphysis. The mean Harris hip score significantly improved from 54 points preoperatively to 84 points at the time of the latest follow-up examination (p < 0.001). Twenty-seven patients (twenty-eight hips; 57 per cent) had at least two millimeters of subsidence of the femoral component during the first postoperative year. Eight patients (eight hips; 16 per cent) had no further progression of subsidence. Twenty-one patients (twenty-two hips; 45 per cent) had at least two millimeters of subsidence on two separate postoperative evaluations and therefore were considered to have progressive subsidence. Seventeen patients (nineteen hips; 39 per cent) had no measurable subsidence and were considered to have a stable femoral component. One of these seventeen patients had had a bilateral femoral revision and had progressive subsidence on one side. There was a positive trend for an association between subsidence and the degree of preoperative femoral bone deficiency (p = 0.10), but there was no association between subsidence and the fit of the prosthesis in the metaphysis and diaphysis or the fill of the canal of the femur (p > 0.50). There was no significant loss of bone in the hips with either a stable or a subsided femoral component (p > 0.50), and qualitative reconstitution of the cortex was noted in eleven (52 per cent) of the twenty-one most severely deficient (stage-III) femora. Survivorship analysis showed that, at seventy-two months, there was a 96 per cent chance of survival of the component (95 per cent confidence limits, 0.89 to 1.0) with revision as the end point but only a 37 per cent chance of survival (95 per cent confidence limits, 0.15 to 0.59) with revision or progressive subsidence as the end point.(ABSTRACT TRUNCATED AT 400 WORDS)

Revision total hip arthroplasty using a cementless acetabular component. Technique and results.

Are the midterm results (range, 7-11 years) for revision of the acetabulum with a cementless hemispherical component comparable with other published revision techniques at similar followup? One hundred thirty-eight acetabular revisions for aseptic loosening were done in 132 patients using a cementless hemispherical component coated with titanium mesh and inserted with supplemental screw fixation. Twelve patients died, 9 were lost to followup, and 6 could not return for followup, leaving 111 patients (115 hips) with a mean of 100 months of followup. Thirteen hips required revision (11%): 4 were done for recurrent dislocations, and 6 for sepsis; 3 stable cups were revised (at the time of stem revision). No cup was revised for aseptic loosening. Radiographic review was available for 105 patients (109 hips) at mean 98-month followup (78-135 months). A complete radiolucency was seen in 4% of the cups, a partial progressive radiolucency in 3%, and a partial nonprogressive radiolucency in 54%; no radiolucency was present in 39%. A screw radiolucency was seen in 2%, and osteolysis at the cup margin in 4%. Revision of the acetabulum with a cementless porous-coated hemispherical fiber-metal component is superior to the results reported for acetabular revisions with cement at similar followup.

Primary noncemented total hip arthroplasty in patients with ankylosing spondylitis. Clinical and radiographic results at an average follow-up period of 6 years.

Twenty consecutive primary noncemented total hip arthroplasties performed on 12 men with ankylosing spondylitis were available to be studied clinically and radiographically at an average follow-up period of 75 months (range, 27-121 months). The average patient age at the time of surgery was 35 years (range, 23-53 years). Harris hip scores averaged 48.4 before surgery and 89.1 at the most recent follow-up examination. Significant improvements in pain, function, and range of motion were observed following total hip arthroplasty. No hip has required a surgical revision or reoperation. Heterotopic ossification was observed in 6 of 14 hips (43%) in the ankylosing spondylitis patients who had not had any perioperative prophylaxis for heterotopic bone formation. By contrast, 43 of 49 hips (88%) demonstrated heterotopic bone formation in a well-defined control group of 45 men with other diagnoses undergoing the same procedure by the same group of surgeons at the same institution. During the same period using the same implants. A thorough review of the literature and data from the institution does not support the notion that ankylosing spondylitis patients are necessarily predisposed to form heterotopic ossification. The use of routine perioperative prophylaxis for heterotopic ossification may not be warranted in all patients with ankylosing spondylitis undergoing routine primary noncemented total hip arthroplasty.

Total hip replacement with insertion of an acetabular component without cement and a femoral component with cement. Four to seven-year results.

One hundred and fifty-three so-called hybrid total hip replacements were performed in 142 patients from 1985 to 1987 at Rush-Presbyterian-St. Lukes Medical Center. A hemispherical porous-coated acetabular component was inserted without cement and was fixed with screws, and a femoral stem was inserted with the use of so-called third-generation cementing techniques. The average age of the patients at the time of the operation was sixty-seven years (range, thirty-nine to eighty-five years). The average preoperative Harris hip score was 46 points (range, 9 to 73 points). One hundred and eleven patients (120 hips) were available for clinical review; 100 of these patients (109 hips) had a complete set of radiographs available. The average Harris hip score was 86 points (range, 29 to 100 points) at the time of follow-up (average duration, sixty-two months; range, forty-eight to eighty-five months). There was progressive migration of one cup (1 per cent); another cup migrated one centimeter in the first two years after the operation, with no additional migration evident after that time. The remaining acetabular components were stable. Two femoral components (2 per cent) were determined to be definitely loose. The remaining femoral components were stable. This population of patients had a good result after so-called hybrid total hip replacement with insertion of a porous-coated acetabular component without cement and a femoral component with cement for the reconstruction of a painful hip.