Comparative Outcomes and Failure Rates of Total Femur Replacement in Oncologic and Nononcologic Indications: A Systematic Review and Meta-analysis.

BACKGROUND: Total femur replacement (TFR) has become increasingly significant as a salvage procedure for both oncologic reconstruction and complex nononcologic conditions such as revision arthroplasty. Despite its effectiveness in limb salvage, TFR is associated with high complication and failure rates, which vary depending on the underlying indication. METHODS: This systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of MEDLINE, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases was conducted, focusing on studies that reported outcomes of TFR in oncologic and nononcologic cases. Primary outcomes included failure mode and rates according to the Henderson classification, functional outcomes scores, and mobility status. Data were analyzed using random-effects models and generalized linear mixed models. RESULTS: A total of 35 studies involving 1,002 patients were included. The majority of TFRs were performed for oncologic reasons (63.7%). The mean Musculoskeletal Tumor Society (MSTS) score was 66%, with a limb salvage rate of 89%. The meta-analysis revealed a combined failure rate of 34%. For type 4 failures (infection), nononcologic patients exhibited a significantly higher rate at 18% (95% confidence interval [CI], 12%-26%, I2 = 46%, p < 0.01) compared with 8% in oncologic patients (95% CI, 6%-12%, I2 = 0%). Regarding combined types 1 to 4 failures, oncologic patients had a rate of 20% (95% CI, 25%-52%, I2 = 60%), whereas nononcologic patients faced a higher rate of 37% (95% CI, 12%-26%, I2 = 63%) (p < 0.05), indicating a significant difference. There were no significant differences in the MSTS score. In addition, there were no notable differences when comparing failure modes 1, 2, and 3 independently. Mobility analysis showed that approximately 70% of patients required walking aids after surgery. CONCLUSION: TFR offers a valuable limb salvage option in both oncologic and nononcologic scenarios, despite its high failure rates. Although functional outcomes were similar between groups, the higher failure rate in nononcologic cases and the poor overall quality of evidence warrant further comprehensive assessments into predictors of outcomes to optimize results. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Total hip arthroplasty with monobloc press-fit acetabular components and large-diameter bearings for atypical acetabula is safe: a consecutive case series of 125 hips with mean follow-up of 9 years.

BACKGROUND: Large-diameter head (LDH) total hip arthroplasty (THA) with a monobloc acetabular component improves hip stability. However, obtaining initial press-fit stability is quite challenging in atypical acetabula. The purpose of this study was to assess primary and secondary fixation of monobloc cups in atypical acetabula. METHODS: In this consecutive case series, the local arthroplasty database was used to retrospectively identify patients with secondary osteoarthritis who underwent primary hip replacement with press-fit only LDH monobloc acetabular components between 2005 and 2018 and who had a minimum of 2 years of follow-up. Radiographic evaluation was performed at last follow-up, and patient-reported outcome measures (PROMs) were assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Forgotten Joint Score (FJS), and the Patient's Joint Perception (PJP) question. RESULTS: One hundred and six LDH THAs and 19 hip resurfacings were included in the study. Preoperative diagnoses included hip dysplasia (36.8%), Legg-Calve-Perthes disease (32.0%), osteoarthritis with acetabular deficiency (17.6%), periacetabular osteotomy (8.0%), arthrodesis (4.0%), and osteopetrosis (1.6%). After a mean follow-up of 9.2 years, no aseptic loosening of the acetabular component was recorded nor observed on radiologic review. There were 13 (10.4%) revisions unrelated to the acetabular component fixation. The mean WOMAC and FJS scores were 9.2 and 80.9, respectively. In response to the PJP question, 49.4% of the patients perceived their hip as natural, 19.1% as an artificial joint with no restriction, 31.5% as an artificial joint with restriction, and none as a non-functional joint. CONCLUSION: Primary press-fit fixation of monobloc acetabular components with LDH implanted in atypical acetabula led to secondary fixation in all cases with low revision and complication rates and great functional outcomes. With careful surgical technique and experience, systematic use of supplemental screw fixation is not essential in THA with atypical acetabula.

Midterm results of titanium conical Wagner stem with challenging femoral anatomy: Survivorship and unique bone remodeling.

BACKGROUND: Complex anatomy of the proximal femur makes total hip arthroplasty (THA) more challenging. Short, straight, fluted and conical titanium stem like the Wagner Cone can be helpful to address small femoral canal, increased femoral neck version, important leg length discrepancy or proximal femoral deformity. The outcome in these patients is less assured and associated with high rate of complications. Therefore, we did a retrospective study aiming to answer: 1) can the Wagner Cone stem provide acceptable mid- to long-term implant survivorship; 2) help minimizing perioperative adverse events; 3) produce favorable clinical outcome measured by WOMAC score; and 4) be associated with a favorable radiographic femoral bone remodeling at the last follow-up? HYPOTHESIS: Wagner Cone stem is an advantageous solution for the distorted proximal femur in complex THA. PATIENTS AND METHOD: Our cohort was derived from the patient registries where medical records of 88 patients (103 hips) who underwent primary THA using the Wagner prosthesis were retrospectively reviewed. Then, data was analyzed for patients' demographics and surgical data, and comparing preoperative, immediate postoperative and last follow-up data. Eleven patients (12 hips) were excluded (7 hips followed up less than 2 years or lost to follow-up, 3 hips that had the Wagner stem for revision and 2 Wagner stems inserted for periprosthetic fracture). This left 77 patients (91 hips) with Wagner cone stems implanted for more than 2 years between March 2003 and February 2017 by 7 surgeons in 3 academic hospitals. Implant revision, reoperations, WOMAC score and radiographic analyses were recorded at last follow-up. RESULTS: After a mean follow-up of 7.8 (range, 2.0-16.2) years, Wagner stem survivorship was 98.9% (95% CI: 94 to 100%) with one (1.1%) stem revision for failure of osteointegration. Five (5.5%) acetabular revisions, one for aseptic loosening, 2 for adverse reaction to metal debris and 2 for infection. One (1.1%) sciatic neuropathy and 4 (4.4%) intraoperative fractures were encountered. The mean WOMAC score was 90.5±11.4 (59-100). Radiographic analysis showed clear signs of stem osseointegration and hypertrophic bone remodeling in 82 cases (92.1%). CONCLUSIONS: Used in complex cases with proximal distorted femurs, the Wagner Cone stem demonstrated a low complication rate, a high-rate consistent adaptive bone remodeling, excellent clinical results, and midterm survival. It is a safe, reliable and advantageous option in complex primary THA. However, the contribution of the underlying cause of the secondary osteoarthritis on the long-term survival of the stem remains to be demonstrated. LEVEL OF EVIDENCE: IV; retrospective study.

Personalized alignment™ for total knee arthroplasty using the ROSA® Knee and Persona® knee systems: Surgical technique.

Total knee arthroplasty (TKA) procedures are expected to increase up to 565% in the United States over the next 3 decades. TKAs were traditionally performed with neutral mechanical alignments that provided equal medial and lateral gaps in extension and flexion to reduce implant wear but were less successful at restoring native knee function and associated with high patient dissatisfaction. Kinematic alignment (KA) restores native anatomy and minimizes soft tissue release; however, KAs that recreate severe deformities and/or biomechanically inferior alignments result in significant increases in implant stress and risk of aseptic loosening. Restricted kinematic alignment (rKA) recreates pre-arthritic anatomy within a range of acceptable alignment boundaries, and improved patient clinical scores and faster recoveries have been reported with rKA techniques. Personalized Alignment™ is an evolution of rKA that relies heavily upon robotic assistance to reliably recreate patient anatomy, native soft tissue laxity, and accurate component placement to improve patients' clinical outcomes. The purpose of this surgical technique report is to describe the Personalized Alignment TKA method using the ROSA® Knee System and Persona® The Personalized Knee® implants. Herein we provide specific procedures for pre-operative planning, anatomical landmarking and evaluation, intra-operative planning and adjustment of resections and cuts, cut validation and soft tissue evaluation with robotic-assisted personalized TKA.

Despite higher revision rate, MoM large-head THA offers better clinical scores than HR: 14-year results from a randomized controlled trial involving 48 patients.

BACKGROUND: The high failure rates of metal on metal (MoM) large diameter head total hip arthroplasty (LDH THA) and hip resurfacing (HR) prevented their long-term comparisons with regards to clinical outcome. Such knowledge would be important as ceramic LDH bearing is now available. With long-term follow-up, we investigated the difference in 1) patient-reported outcome measures (PROMs); 2) revision and adverse events rates, and 3) metal ion levels between MoM LDH THA and HR. METHODS: Forty-eight patients were randomized for LDH THA (24) or HR (24) with the same MoM articulation. At a mean follow-up of 14 years, we compared between groups different PROMs, the number of revisions and adverse events, whole blood Cobalt (Co) and Chromium (Cr) ion levels, and radiographic signs of implant dysfunction. RESULTS: LDH THA (all cases: revised and well-functioning) had significantly better WOMAC (94 versus 85, p = 0.04), and more frequently reported having no limitation (p = 0.04). LDH THA revision rate was 20.8% (5/24) versus 8.3% (2/24) for HR (p = 0.4). Mean Co and Cr ion levels were higher in LDH THA compared to the HR (Co: 3.8 µg/L vs 1.7 µg/L; p = 0.04 and Cr: 1.9 µg/L vs 1.4 µg/L, p = 0.1). On radiographic analyses, 2 LDH THAs showed signs of adverse reaction to metal debris, whereas 1 loose femoral HR component was documented. CONCLUSION: In the long-term, MoM LDH THA had a high trunnion related revision rate but nonetheless showed better PROMs compared to HR. Provided with a well-functioning modular junction, non-MoM LDH THA would offer an appealing option. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT04516239 ), August 18, 2020. Retrospectively registered.

Ceramic-on-ceramic total hip arthroplasty is superior to metal-on-conventional polyethylene at 20-year follow-up: A randomised clinical trial.

BACKGROUND: Metal-on-conventional polyethylene (MoPc) bearing wear-related biological reactions in total hip arthroplasty (THA) continue to raise concerns among young, active patients. Ceramic-on-ceramic (CoC) bearings may offer improved outcomes in this patient population. QUESTIONS/PURPOSES: The aim of this study was to determine if, more than 20years postoperatively, there is a difference between MoPc and CoC THA in terms of (1) survivorship, (2) related complications, (3) radiographic signs of wear, and (4) functional scores. HYPOTHESIS: CoC bearing THAs have superior clinical results compared to MoPc THAs. PATIENTS AND METHODS: A total of 140 hips in 116 patients with a mean age of 42years were randomised to receive CoC or MoPc THA between 1996 and 2001. Sixty-nine hips in 58 patients received MoP and 71 hips in 68 patients received CoC. Revision rate, WOMAC score, and radiological signs of osteolysis and loosening were compared at last follow-up. RESULTS: After a mean follow-up of 21years (19-23), 40 patients (48 THAs; 34%) had died and 6 patients (6 THAs; 4%) were lost to follow-up. Aseptic revision rate was significantly higher in the MoPc group (17/69; 24.6%) versus CoC (2/71; 2.8%; p<0.001). Kaplan-Meier survivorship estimator with revision for aseptic reasons was 73.6% (95% CI: 63.3-84.9%) for MoPc and 96.9% (95% CI: 92.8-100%) for CoC (p<0.001). On radiographic evaluation, 13% (3/23) MoPc were considered loose versus no CoC, and 61% (14/23) MoPc versus 6% (2/33) CoC showed osteolytic signs (p<0.001). CoC had better mean WOMAC scores than MoPc (11.0 vs. 19.4; p=0.048). No ceramic fracture was observed. CONCLUSION: In this RCT, CoC bearings provided excellent results and were safer than MoPc bearings at more than 20-year follow-up. The long-term in vivo behaviour of CoC bearing makes it a great THA option for middle-aged patients and should be compared to newer polyethylene bearings. LEVEL OF EVIDENCE: I.

Hip Resurfacing Compared with 28-mm Metal-on-Metal Total Hip Replacement: A Randomized Study with 15 Years of Follow-up.

BACKGROUND: Bone stock conservation, hip anatomy preservation, and greater stability are among the promoted advantages of hip resurfacing (HR). However, the disappointing failure of some implants nearly led to its abandonment. The aim of this study was to compare clinical scores and revision and complication rates after HR with those after total hip arthroplasty (THA). METHODS: Two hundred and three hips were randomized to 28-mm metal-on-metal (MoM) THA (99 hips) or to HR (104 hips). Main outcome measures compared between groups were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, the revision rate, and the complication rates. The radiographic findings were also assessed. RESULTS: After a mean follow-up of 15 years (range, 14 to 16 years), 9 (4.4%) of the 203 patients were lost to follow-up and 15 (7.4%) had died. The Kaplan-Meier survivorship, with revision for any reason as the end point, was 89.2% (95% confidence interval [CI], 82.3% to 96.1%) for HR and 94.2% (95% CI, 89.3% to 99.1%) for THA (p = 0.292). The reasons for revision included infection (3 patients), recurrent dislocation (1 patient), and adverse reaction to metal debris (ARMD) (1 patient) in the THA group and ARMD (2 patients) and femoral head loosening (7 patients) in the HR group. With aseptic revision as the end point, the Kaplan-Meier survivorship was significantly higher in the THA group (97.4% versus 89.2%; p = 0.033). No dislocation occurred in the HR group compared with 4 in the THA group (p = 0.058). Both groups achieved a similar mean WOMAC score (10.7 in the HR group and 8.8 in the THA group; p = 0.749), Forgotten Joint Score (87.1 and 85.3, respectively; p = 0.410), University of California Los Angeles (UCLA) activity score (6.3 and 6.4, respectively; p = 0.189), and overall joint perception (p = 0.251). CONCLUSIONS: The specific HR and MoM 28-mm THA implants used in this study showed good long-term survival and function. The overall rates of complications and revisions were similar in both groups but were of different types. As it provides better femoral bone preservation and biomechanical reconstruction, HR may continue to have a role in selected patients when performed by experienced surgeons and using validated implants. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.