Over ten-year follow-up results of a prospective and consecutive series of primary total hip arthroplasty with an original cementless total hip prosthesis.

PURPOSE: High survival rates up to ten  years have been reported for non-cemented hip replacements. Publications beyond ten years have more diverse conclusions. To study the long-term survival of uncemented total hip replacement (THR), we examined a series of 125 THR, all with a minimum follow-up of ten  years. METHODS: This is a prospective study of 203 patients operated for coxarthrosis between 2007 and 2011, by six senior surgeons. The original ellipsoidal stem and the impacted acetabulum were systematically cementless; the acetabulum had either a fixed ceramic or polyethylene insert, or a dual-mobility insert. At the date of the follow-up check, 44 patients were deceased and 34 patients were lost to follow-up. This left 125 complete files for our study. RESULTS: They were a revision of the cup in four cases and a revision of the femoral stem in three cases (3.4%). The Kaplan-Meier cumulative survival rate of the THR, by considering revision for any reason as endpoint, at ten  years (120 months) is estimated at 96.6% (CI 92.7-98.7). Radiologically, on 86 analyses (68.8%) at ten  years and more reported, no significant evolution of the appearance of the cancellous bone around the acetabular cup was noted, nor any ossification. Some periprosthetic osteogenesis reactions were noted around the 1/3 distal but no periprosthetic edging. CONCLUSION: In this minimum ten-year follow-up study, a cementless THR with a straight ellipsoidal cementless stem and a press-fit cup provides excellent implant survival and high patient satisfaction. (Clinically felt minimal difference.).

The risk analysis of perioperative complications of cementless hip arthroplasty in octogenarians.

INTRODUCTION: Hip arthroplasty is exposed to demographic change as patients age. Analysis of risk factors for surgical treatment decisions in the group of ≥ 80-year-old patients is crucial. Healthcare systems in developed countries are being tested medically and financially by the ageing population. Therefore, this study analysed the perioperative complications of cementless primary hip arthroplasty in octogenarians and compared them with patients aged ≤ 60 years. METHODS: A retrospective data analysis of the year 2017 was done in a maximum care hospital of General Orthopaedic Surgery. Patients aged ≥ 80 years or ≤ 60 years with primary cementless hip arthroplasty were included. The outcome of interest was surgery-related and systemic complications, the development of haemoglobin and the incidence of blood transfusion after cementless primary hip arthroplasty in octogenarians during the hospitalisation and the follow-up treatment. Chi-square tests and Fischer's exact test were used for nominal variables. The two-factorial variance analysis-mixed model was used for Hb analyses and the Welch test for group comparison for metric parameters. RESULTS: There was a significantly increased incidence of systemic complications during hospitalisation in the ≥ 80-year-old patients (phi 0.26; Std. Ri - 0.8 (A), 2.2 (B); p = 0.007), as well as a significantly increased rate of blood transfusions (phi 0.403; Std. Ri - 1.3 (A), 3.2 (B); p = < 0.001). No clustered pre-existing conditions in the ≥ 80-year-old patients pointed out a significant association with the incidence of systemic complications. Surgery-related complications showed no significant difference during hospitalisation and follow-up treatment. CONCLUSION: The study reveals that primary cementless hip prosthesis implantation is a safe procedure without increased incidence of surgery-related complications. Increased attention should be paid to interdisciplinary preoperative optimisation (adjustment of blood pressure, blood transfusions, if necessary, safe exclusion of urinary tract infections) and postoperative care of octogenarians (tight laboratory examinations, geriatric co-attendance).

Low-Molecular-Weight Heparins (LMWH) and Synthetic Factor X Inhibitors Can Impair the Osseointegration Process of a Titanium Implant in an Interventional Animal Study.

Background and objectives: Cementless total hip arthroplasty is a common surgical procedure and perioperative thromboprophylaxis is used to prevent deep vein thrombosis or pulmonary embolism. Osseointegration is important for long-term implant survival, and there is no research on the effect of different thromboprophylaxis agents on the process of osseointegration. Materials and Methods: Seventy rats were allocated as follows: Group I (control group), Group II (enoxaparin), Group III (nadroparin), and Group IV (fondaparinux). Ovariectomy was performed on all subjects, followed by the introduction of an intramedullary titanium implant into the femur. Thromboprophylaxis was administered accordingly to each treatment group for 35 days postoperatively. Results: Group I had statistically significantly lower anti-Xa levels compared to treatment groups. Micro-CT analysis showed that nadroparin had lower values compared to control in bone volume (0.12 vs. 0.21, p = 0.01) and percent bone volume (1.46 vs. 1.93, p = 0.047). The pull-out test showed statistically significant differences between the control group (8.81 N) compared to enoxaparin, nadroparin, and fondaparinux groups (4.53 N, 4 N and 4.07 N, respectively). Nadroparin had a lower histological cortical bone tissue and a higher width of fibrous tissue (27.49 µm and 86.9 µm) at the peri-implant area, compared to control (43.2 µm and 39.2 µm), enoxaparin (39.6 µm and 24 µm), and fondaparinux (36.2 µm and 32.7 µm). Conclusions: Short-term administration of enoxaparin, nadroparin, and fondaparinux can reduce the osseointegration of titanium implants, with nadroparin having the most negative effect. These results show that enoxaparin and fondaparinux are preferred to be administered due to a lesser negative impact on the initial implant fixation.

History of bone acoustic in fracture diagnosis: crepitus in antiquity; bone percussion with Auenbrugger; bone auscultation with Laennec and Lisfranc; monitoring cementless hip arthroplasty fixation with acoustic and sensor.

PURPOSE: The problems posed by trauma, fractures, and dislocations have not changed in human history. The traumas of prehistoric persons were similar to those observed by Imhotep, Hippocrates, and Galen or, more recently, by Ambroise Paré, Watson Jones, and Böhler. And the current road traumas are probably no more severe than those caused by mammoths, the construction of the pyramids, or middle age wars. Diagnostic methods have evolved, and the advent of radiography has revolutionized the diagnosis of traumatology. Before discovering radiography, another physical phenomenon made it possible to help in the diagnosis of fractures. This physical phenomenon is acoustic. METHODS: Curiously, no history of acoustics in fracture diagnosis has been published so far. This article proposes briefly reviewing the history and evolution of acoustics in orthopaedic surgery from antiquity to the present day. RESULTS: Before the invention of radiography by Conrad Roentgen in 1895, the surgeons described crepitus as the most critical sign of fractures in antiquity. Surgeons remarked during the eighteenth and nineteenth century that bone was a good sound-conductor. Physicians improved first the diagnosis of fractures by using percussion established by Auenbrugger in 1755. The principle of chest mediate auscultation with a stethoscope was described by Laennec in 1818. Lisfranc used the stethoscope to amplify the crepitus sound of fractures. Surgeons also developed association of percussion and auscultation with a stethoscope to diagnose and reduce fracture. Recently, acoustic emission technology has seen a recent increase in applications to prevent femur fractures during cementless fixation. CONCLUSION: The acoustic properties of bones were known to a prehistoric person who knew how to make flutes from animal or human bones. Surgeons used them for the diagnosis of fractures before radiography. Acoustic properties of bones currently remain a subject of research for the prevention of fractures.

To withhold or to implement bisphosphonate after cementless hip arthroplasty: a dilemma in elderly hip fracture patients.

BACKGROUND: Prior studies reported ambivalent effects of bisphosphonates on the fixation of cementless stem in hip arthroplasty patients. To set up the postoperative guide of bisphosphonate use after cementless hip arthroplasty, we investigated whether zoledronate has beneficial or negative effects in the stem migration and walking ability after cementless hemi-arthroplasty in elderly patients, who were operated due to femoral neck fracture. METHODS: We compared 59 patients (zoledronate group), who received zoledronate after cementless hemi-arthroplasty, and 66 patients (control group), who did not receive that agent. We evaluated stem subsidence, cortical porosis around the stem, and walking ability with the use of Koval's categories at 2-year follow-up. RESULTS: No patient had more than 2 mm of stem subsidence in both groups. One patient in the control group had cortical porosis around the stem, but none in the zoledronate group. There were no significant differences in the postoperative Koval scores (p = 0.769) and in the proportion of walking recovery to pre-fracture status (p = 0.695) between the two groups. CONCLUSION: We did not find neither beneficial nor negative effect of this agent in terms of stem fixation and walking ability. Zoledronate can be used after cementless hemi-arthroplasty to manage the osteoporosis in elderly patients.

Hip Arthroplasty Using the Bencox® Hip System: An Evaluation of a Consecutive Series of One Thousand Cases.

PURPOSE: This is a report on the outcomes associated with a consecutive series of 1,000 cementless hip arthroplasties utilizing the Bencox® hip stem-the first Korean-developed hip prosthesis. MATERIALS AND METHODS: A consecutive series of 1,000 hip arthroplasties using the Bencox® hip stem were analyzed, starting from its initial release (September 2006) until June 2014. Patients in this consecutive series underwent surgery for fractures (n=552), arthritis (n=155), avascular necrosis (n=209), and revisions (n=84). Of these 1,000 cases, patients with a minimum follow-up of at least 1 year (n=616) were retrospectively analyzed for radiographic and clinical outcomes (i.e., Harris hip score). The stability of the prosthesis was evaluated by examining subsidence. RESULTS: During the follow-up period (mean follow-up period of 54.8 months), there were 2 cases requiring revision of the femoral stem-both were caused by periprosthetic fractures and neither involved stem loosening. The mean Harris hip score during follow-up was 95.5. Bone ongrowth occurred in 95% of patients; no cases of subsidence or aseptic loosening of the stem were detected, and no cases of postoperative complications such as ceramic breakage were observed. CONCLUSION: Clinical and radiographic evaluations of hip arthroplasty using the Bencox® hip stem revealed excellent outcomes with an average of 54.8 month follow-up in a consecutive series of 1,000 cases.

Accuracy of Digital Tomosynthesis With Metal Artifact Reduction for Detecting Osteointegration in Cementless Hip Arthroplasty.

BACKGROUND: Cementless hip arthroplasty is increasingly gaining popularity worldwide. Radiologic identification of osteointegration is key to confirming biologic fixation. We conducted the study reported here to determine the sensitivity and specificity of digital tomosynthesis with metal artifact reduction (TMAR), radiography, and conventional computed tomography in detecting osteointegration in cementless hip arthroplasty. METHODS: We prospectively included data for 24 patients who underwent revision hip arthroplasty in our hospital, with 13 femoral and 14 acetabular cementless components retrieved that contained solid evidence of biologic fixation. All patients underwent 3 examinations before surgery, and evidence of osteointegration on retrieved prostheses was used as the reference standard. Seven orthopedic surgeons evaluated these images independently using uniform criteria. RESULTS: On the femoral side, the sensitivity and specificity of detecting osteointegration were 73.8% ± 4.6% and 94.3% ± 1.5%, respectively, for TMAR; 50.4% ± 5.3% and 87.8% ± 2.1%, respectively, for radiography; and 36.4% ± 5.1% and 90.9% ± 1.9%, respectively, for CT. On the cup side, the corresponding values were 60.2% ± 8.3% and 86.4% ± 5.7%, respectively, for TMAR; 45.9% ± 8.5% and 66.4% ± 7.8%, respectively, for radiography; and 45.1% ± 8.5% and 73.5% ± 7.3%, respectively, by computed tomography. CONCLUSION: TMAR significantly improved the accuracy osteointegration detection in cementless hip arthroplasty (P < .017).

Current methods of preventing aseptic loosening and improving osseointegration of titanium implants in cementless total hip arthroplasty: a review.

Hip osteoarthritis is the most common joint disorder, and is represented by a degenerative process, resulting in pain and functional impairment. If conservative treatment for hip osteoarthritis fails, the only remaining option is hip arthroplasty. Despite good survival of implants, loosening of components is the most common complication. This leads to revision surgeries, which are technically demanding, expensive, and result in a low satisfaction rate. Uncemented hip replacements require proper osseointegration for increased survival. Physical characteristics of implants include biocompatibility, Young's modulus of elasticity, strength, and corrosion resistance, and each influence fixation of implants. Moreover, implant surface treatments, pore size, pore density, and femoral stem design should be appropriately selected. Patients' optimization of obesity, osteoporosis, cardiovascular disease, psychotic disorders, and smoking cessation are associated with a higher survival of implants. Surgical factors, such as approach, drilling and rasping, acetabular bone coverage, acetabular cup positioning, and implant size, also affect survival of implants. Avoiding drugs, which may impair osseointegration of implants, and having an appropriate rehabilitation protocol are important. Future directions include anabolic and anti-catabolic bone-acting drugs to enhance osseointegration of implants. Comprehensive knowledge of the factors mentioned above is important for preventing aseptic loosening, with important socioeconomic consequences.

Hip Arthroplasty Using the Bencox® Hip System: An Evaluation of a Consecutive Series of One Thousand Cases / 대한고관절학회지

PURPOSE: This is a report on the outcomes associated with a consecutive series of 1,000 cementless hip arthroplasties utilizing the Bencox® hip stem–the first Korean-developed hip prosthesis. MATERIALS AND METHODS: A consecutive series of 1,000 hip arthroplasties using the Bencox® hip stem were analyzed, starting from its initial release (September 2006) until June 2014. Patients in this consecutive series underwent surgery for fractures (n=552), arthritis (n=155), avascular necrosis (n=209), and revisions (n=84). Of these 1,000 cases, patients with a minimum follow-up of at least 1 year (n=616) were retrospectively analyzed for radiographic and clinical outcomes (i.e., Harris hip score). The stability of the prosthesis was evaluated by examining subsidence. RESULTS: During the follow-up period (mean follow-up period of 54.8 months), there were 2 cases requiring revision of the femoral stem–both were caused by periprosthetic fractures and neither involved stem loosening. The mean Harris hip score during follow-up was 95.5. Bone ongrowth occurred in 95% of patients; no cases of subsidence or aseptic loosening of the stem were detected, and no cases of postoperative complications such as ceramic breakage were observed. CONCLUSION: Clinical and radiographic evaluations of hip arthroplasty using the Bencox® hip stem revealed excellent outcomes with an average of 54.8 month follow-up in a consecutive series of 1,000 cases.

Intraoperative Proximal Femoral Fracture in Primary Cementless Total Hip Arthroplasty.

Intraoperative proximal femoral fracture is a complication of primary cementless total hip arthroplasty (THA) at rates of 2.95-27.8%. A retrospective review of 2423 consecutive primary cementless THA cases identified 102 hips (96 patients) with fracture. Multivariate analysis compared fracture incidences between implants, Accolade (Stryker Orthopaedics) and Tri-Lock (DePuy Orthopaedics, Inc.), and evaluated potential risk factors using a randomized control group of 1150 cases without fracture. The fracture incidence was 4.4% (102/2423), 3.7% (36/1019) using Accolade and 4.9% using Tri-Lock (66/1404) (P=0.18). Female gender (OR=1.96; 95% CI 1.19-3.23; P=0.008) and smaller stem size (OR=1.64; 95% CI 1.04-2.63; P=0.03) predicted increased odds of fracture. No revisions of the femoral component were required in the fracture cohort.

Outcomes of Surgical Treatment of Periprosthetic Femoral Fractures in Cementless Hip Arthroplasty.

PURPOSE: We aimed to evaluate the results of surgical treatment of periprosthetic femoral fractures in cementless total hip arthroplasty (THA). MATERIALS AND METHODS: From June 2002 to May 2012, 40 patients who could be followed-up for more than 1 year after surgery were enrolled in this study. The mean duration of follow-up was 28.5 months (range, 15-97 months) and the average age at the time of surgery was 71.5 years (range, 38-89 years). The fracture types were determined by using the Vancouver classification. Among intraoperative fractures, there were type A in 3 hips, type B2 in 2 hips and type B3 in one. Among postoperative fractures, type AG was present in 5 hips, type AL in 2 hips, type B1 in 15 hips, type B2 in 6 hips, type B3 in 3 hips, and type C in 3 hips. Evaluation of the results was based on bony union, stability of the prosthesis, postoperative complications, and Harris hip score at the final follow-up. RESULTS: Bony union was achieved in all but one case and the average time for bony union was 21 weeks. The mean Harris hip score was 86 at the final follow-up. Clinical results were above good in 34 of 40 hips (85.0%). Stem loosening occurred in one patient with a type B1 fracture treated with open reduction and plate fixation. Nonunion was observed in 1 patient with an AG type fracture. CONCLUSION: Open reduction and fixation using a plate with a screw and cerclage wiring provided good results for periprosthetic fractures in patients who had a stable femoral stem without bone defects. Revision surgery with a cementless long stem should be considered in patients with an unstable stem or suspected stability in B1 type of THA using a proximal fixation type.

Outcomes of Surgical Treatment of Periprosthetic Femoral Fractures in Cementless Hip Arthroplasty / 대한고관절학회지

PURPOSE: We aimed to evaluate the results of surgical treatment of periprosthetic femoral fractures in cementless total hip arthroplasty (THA). MATERIALS AND METHODS: From June 2002 to May 2012, 40 patients who could be followed-up for more than 1 year after surgery were enrolled in this study. The mean duration of follow-up was 28.5 months (range, 15-97 months) and the average age at the time of surgery was 71.5 years (range, 38-89 years). The fracture types were determined by using the Vancouver classification. Among intraoperative fractures, there were type A in 3 hips, type B2 in 2 hips and type B3 in one. Among postoperative fractures, type AG was present in 5 hips, type AL in 2 hips, type B1 in 15 hips, type B2 in 6 hips, type B3 in 3 hips, and type C in 3 hips. Evaluation of the results was based on bony union, stability of the prosthesis, postoperative complications, and Harris hip score at the final follow-up. RESULTS: Bony union was achieved in all but one case and the average time for bony union was 21 weeks. The mean Harris hip score was 86 at the final follow-up. Clinical results were above good in 34 of 40 hips (85.0%). Stem loosening occurred in one patient with a type B1 fracture treated with open reduction and plate fixation. Nonunion was observed in 1 patient with an AG type fracture. CONCLUSION: Open reduction and fixation using a plate with a screw and cerclage wiring provided good results for periprosthetic fractures in patients who had a stable femoral stem without bone defects. Revision surgery with a cementless long stem should be considered in patients with an unstable stem or suspected stability in B1 type of THA using a proximal fixation type.

Improving peri-prosthetic bone adaptation around cementless hip stems: a clinical and finite element study.

This study assessed whether the Symax™ implant, a modification of the Omnifit(®) stem (in terms of shape, proximal coating and distal surface treatment), would yield improved bone remodelling in a clinical DEXA study, and if these results could be predicted in a finite element (FE) simulation study. In a randomized clinical trial, 2 year DEXA measurements between the uncemented Symax™ and Omnifit(®) stem (both n=25) showed bone mineral density (BMD) loss in Gruen zone 7 of 14% and 20%, respectively (p<0.05). In contrast, the FE models predicted a 28% (Symax™) and 26% (Omnifit(®)) bone loss. When the distal treatment to the Symax™ was not modelled in the simulation, bone loss of 35% was predicted, suggesting the benefit of this surface treatment for proximal bone maintenance. The theoretical concept for enhanced proximal bone loading by the Symax™, and the predicted remodelling pattern were confirmed by DEXA-results, but there was no quantitative match between clinical and FE findings. This was due to a simulation based on incomplete assumptions concerning the yet unknown biological and mechanical effects of the new coating and surface treatment. Study listed under ClinicalTrials.gov with number NCT01695213.

Radiological Analysis of the Tapered Femoral Stem after Cementless Hip Arthroplasty: Minimum 5 years follow-up / 대한정형외과학회잡지

PURPOSE: We reviewed radiological mid-term results of cementless hip replacement using Mallory-Head tapered titanium femoral stem. MATERIALS AND METHODS: Forty six patients, 50 hips were followed for more than 5 years. Mean age was 56 years, and mean follow-up period was 6.8 years. Radiologically changes in alignment, subsidence and wear rate were measured. Radiolucent line, endosteal spot weld and osteolysis were also assessed according to Gruen zones. RESULTS: All stems showed stable fixation, and radiolucent lines were observed in noncoated zones of 13 cases (26%) . Osteolysis was observed around the proximal stem in 16 cases (32%) , but it did not progress distally. CONCLUSION: With minimum follow-up of 5 years, the tapered titanium femoral stem showed good radiological results, however osteolysis needs more long-term follow-up.

Cementless Hip Arthroplasty in Patients with Avascular Necrosis of the Femoral Head: Long term results in AML / 대한정형외과학회잡지

PURPOSE: We reviewed the clinical and radiological outcomes of total hip arthroplasty and bipolar hemiarthroplasty for avascular necrosis of the femoral head. MATERIALS AND METHODS: From January 1986 to December 1989, 24 cases were treated with total hip arthroplasty and 27 cases with bipolar hemiarthroplasty for avascular necrosis of the femoral head. Clinical outcomes were assessed using Harris Hip Score. Serial radiographs of the hip were used to assess stability of the femoral component, change of the acetabular cup angle, osteolysis of acetabulum or femur, wear of polyliner and erosion of the acetabular cartilage. RESULTS: The average Harris Hip Score was 93.1 in bipolar hemiarthroplasty group and 86.8 in total hip arthroplasty group at last follow up. Femoral osteolysis was observed in 17 patients of 24 total hip arthroplasties and in 14 patients of 27 bipolar hemiarthroplasties. Acetabular osteolysis was observed in 8 cases of 24 total hip arthroplasties. Revision was undertaken 8 cases (33.3%) in the total hip arthroplasty group and 6 cases (22.2%) in the bipolar hemiarthroplasty group. The main causes of revision were wear of polyliner and severe osteolysis in the total hip arthroplasty group and erosion of the acetabular cartilage in the bipolar arthroplasty group. CONCLUSION: The main cause of failure after total hip arthroplasty for avascular necrosis of the femoral head was using a 32 mm femoral head and a polyliner less than 8mm thickness.