Dislocation and survival rate of dual mobility cups in revision total hip arthroplasty in patients with high risk of instability.

PURPOSE: Instability remains as an unsolved complication after revision total hip arthroplasty (rTHA). Dual mobility (DM) cups have decreased dislocation rate in rTHA; however, there are few clinical studies that evaluate the risk of dislocation after rTHA in patients with high risk of instability. METHODS: Between 2007 and 2019, 95 consecutive rTHA using a DM cup, in 93 patients with instability risk factors were retrospectively reviewed. Instability risk factors were defined as follows: deficient abductor mechanism (22.1%), previous dislocation (68.4%), Paprosky 3 acetabular bone defect (21.1%), neuromuscular disease (4.2%), lumbar spine arthrodesis (6.3%), and more than one previous surgery (33.6%). Mean follow-up was 4.3 ± 2.4 years. Clinical and radiographic parameters were reported. DM cup survival was determined using a Kaplan-Meier analysis with re-revision for any cause as the end-point. Surgical complications and re-dislocation rate was recorded. RESULTS: Seven DM cups were re-revised; three due to aseptic loosening, three due to peri-prosthetic joint infection (PJI), and one due to instability. At seven years follow-up, the survival rate of the DM cup using re-revision for any reason as the end-point was 82.4% (95% confidence interval, 66.4-98.4%). There were 12 (12.6%) complications: two (2.1%) dislocations, six (6.3%) PJI, four (4.2%) peri-prosthetic fractures. CONCLUSION: Our findings suggest DM cups are effective reducing dislocation rate in rTHA in patients with a high risk of instability, without increasing early aseptic loosening and with a low rate of dislocation. Nevertheless, longer follow-up is needed to confirm implant stability and dislocation rates in the long term.

Outcome measures and survivorship following total hip arthroplasty in adolescent population.

BACKGROUND: The most frequent indication for total hip arthroplasty (THA) in adolescent patients has been juvenile idiopathic arthritis (JIA). However, in recent years, other causes have become more prevalent. QUESTIONS/PURPOSES: (1) What is the survivorship following THA across the diagnostic spectrum in adolescent population? (2) How are quality of life results affected by systemic medical conditions? METHODS: We retrospectively reviewed all consecutive THA in patients under 21 years of age, performed at our Institution between 1993 and 2018. There were 34 prostheses implanted in 26 patients with a mean age of 18.4 years (range 11 to 21). The most frequent diagnosis was JIA (14 hips), followed by avascular necrosis (10 hips). Patient reported outcomes were assessed using Harris and Oxford Hip Scores (HHS and OHS), Visual Analogue Scale (VAS) and EuroQol-5D. Survivorship for revision and aseptic loosening was determined with Kaplan Meier analysis. RESULTS: At final follow-up, the overall survival rate was of 89.3% at 12-year follow-up. Three acetabular components underwent revision surgery for aseptic loosening. Clinical HHS significantly improved from 37.5 to 90.6 points (p < 0.001). Mean OHH was 37.4 points, with a final VAS of 1.64 points. Mean 5Q-5D was 0.704 with an interquartile range of 0.4 to 1.0. JIA patients displayed worse pre-operative HHS scores, and at final follow-up had worse HHS, OHS, VAS and EQ-5D scores compared to the rest of the patients. Complications included three intra-operative femoral fractures, one sciatic nerve palsy and one adductor contracture. CONCLUSION: THA in adolescent patients provides improved functional outcomes with acceptable revision rates at mid-term follow-up.

Long-Term Outcomes of a Titanium-Encased Ceramic Liner Total Hip Arthroplasty (15 to 21Year Results).

BACKGROUND: Historically, aseptic loosening and osteolysis were responsible for most of the revisions among young and more active patients. Ceramic-on-ceramic bearings reduced wear but presented mechanical issues such ceramic fracture or liner chipping during insertion. To prevent this from happening a titanium-encased alumina liner was developed. The aim of this study is to address long-term results of this specific ceramic design. METHODS: All patients received an uncemented acetabular component with ceramic-on-ceramic bearing (94 hips in 77 patients). Patients were prospectively followed over 15 years. Clinical evaluation included the Harris Hip Score and Visual Analog Scale pain scale. Radiographic analysis included integration, osteolysis, and ceramic-related mechanical issues, such as malseating of the insert. RESULTS: The studied acetabular design survivorship was 98.9% at a mean follow-up of 17.2 years. One arthroplasty was revised secondary to infection but no cup had loosened or migrated during the study. Only 1 cup showed complete radiolucent lines. There was no fracture of any ceramic component in the study group. Malseating was present in 12 acetabular components (12.8%). No osteolysis was observed with over 15 years of follow-up. CONCLUSION: In conclusion, this acetabular component demonstrates a favorable clinical and radiological outcome with over 15 years of follow-up. Osteolysis was not observed and incomplete seating of the titanium-sleeved ceramic liner did not lead to mechanical problems.

Open reduction and navigated Iliosacral screws for vertically unstable pelvic fractures.

AIMS: To evaluate clinical and radiological results of vertically unstable pelvic fractures managed by open reduction and navigated iliosacral screws. PATIENTS AND METHODS: The study included eleven patients with complex posterior ring fractures with vertical instability admitted to our hospital and managed with CT navigated iliosacral screws. There were 7 type C1, 2 C2 and 2 C3, according to Tile classification. Three patients presented a spino-pelvic dissociation and four a vertical sacral fracture affecting the foramina (Denis 2). Vertical displacement, pelvic deformity and asymmetry were measured. Tornetta and Matta criteria were used to assess the quality of pelvic reduction. RESULTS: An excellent reduction was achieved in 9 fractures and a good reduction in two. Asymmetry index improved from 13.18 to 2.72. Deformity index improved from 0.049 to 0.010. Only two patients with a Denis 2 fracture showed secondary displacement during follow-up. Four patients presented neurological complications due to their initial injuries. Seven patients were able to resume their previous activities. CONCLUSION: CT navigated IS screws provide enough stability after an anatomic reduction of the fracture. There was no complication related to screw insertion and adequate screw positioning was achieved in all the cases.

Do trabecular metal cups achieve better results when compared to hemispherical porous titanium cups in acetabular revision surgery?

BACKGROUND: Trabecular metal (TM) cups were introduced in order to achieve better ingrowth and stability of the cup in acetabular revision surgery. As their use has evolved over time, we have queried whether TM cups would improve results in terms of the rate of aseptic loosening when compared to historical uncemented porous titanium cups used in revision surgery for acetabular bone loss in Hospital La Paz (Madrid, Spain). METHODS: We retrospectively reviewed 197 acetabular revisions performed between 1991 and 2015. Titanium cups were used in 81 cases and TM cups in 116. The mean follow-up was 8.1 years (range 1-15); 12.0 ± 7.8 for titanium group and 5.4 ± 3.1 for TM group. The most common reason for revision was aseptic loosening. A Kaplan-Meier analysis was used to determine the survival of the cup, with radiological failure and re-revision due to aseptic loosening as the endpoints. Cox multivariate regression analyses were performed to assess different risk factors for failure. RESULTS: 1 TM cup and 1 titanium cup were re-revised due to aseptic loosening (p = 0.61). Radiological cup loosening was observed in 4 TM cups and 2 titanium cups (p = 1.0). At 6 years, the probability of not having radiological cup loosening was 97.4% (95% CI, 93.9-100) for the titanium cups and 95.1% for the TM cups (95% CI, 90.1-99.9) (p = 0.59). Another 5 cups were re-revised due to dislocation. Hips with a greater Paprosky defect showed a higher risk of loosening (p < 0.05, hazard risk (HR) 3.04; 95% CI, 0.97-9.54). CONCLUSIONS: This study shows there was no significant difference in re-revision due to aseptic loosening or radiological loosening between titanium and TM cups in revision surgery for acetabular bone loss. Both types of cups demonstrate excellent results with a low failure rate and minimal complications.

Comparison of an Uncemented Tapered Stem Design in Cobalt-Chrome vs Titanium at 15-Year Follow-Up.

BACKGROUND: Cobalt-chromium (Co-Cr) and titanium (Ti) have been the most popular materials employed for cementless implants. The purpose of this study was to compare clinical and radiological results of a single stem design with both alloys at long-term follow-up. METHODS: Two hundred consecutive uncemented stems implanted in 171 patients (100 Co-Cr and 100 Ti implants) between 1999 and 2002 were studied. Mean age of the patients was 60.9 years (range, 20-84). Clinical results were evaluated using the Harris hip score. The presence of thigh pain was also analyzed. Stem fixation was graded according to Engh criteria. Radiolucent lines, osteolysis, and stem subsidence were also analyzed. RESULTS: At 15-year follow-up, no stems had been revised. Both groups showed similar clinical results with mean Harris hip score of 93.4 (Co-Cr) vs 93.9 (Ti). There was no difference in the rate of thigh pain (11 vs 8.3, respectively, P = .507). Radiolucent lines were more frequent in the Co-Cr group (63.6% vs 35.6%, P < .001). CONCLUSION: Ti stems showed better osteointegration than Co-Cr stems, with a significantly lower incidence of radiolucent lines. However, this did not affect the clinical results or the appearance of thigh pain.

Better survival of total knee replacement in patients older than 70 years: a prospective study with 8 to 12 years follow-up.

BACKGROUND: Modern knee designs have popularized its use in younger patients due to its better performance. There remains uncertainty whether higher demands of these patients can affect implant survivorship. PURPOSE: To assess whether modern knee designs have provided similar results in patients younger than 70 years versus older patients. METHODS: We included 203 consecutive patients (236 knees) who underwent knee replacement for osteoarthritis with a mean follow-up of 11.4 years (range: 8.8 to 12). The mean age was 70 years (range: 31 to 85). Knee replacements were stratified into two groups: 109 were younger than 70 years and 127 were older than 70 years (70 years of age is the mandatory retirement age). RESULTS: There were no significant pre-operative differences between groups with regards to knee alignment, alpha or beta angles, knee score or function score. Fourteen implants were radiographically loose at last follow up visit. Groups were matched in terms of demographic data. We found that patients older than 70 years had significantly better mean survivorship at 12 years. (97% vs. 88%; P=0.010). Patients under 70 years presented with a higher rate of polyethylene wear which was further associated with radiolucent lines in the femur and tibia as well as the presence of osteolysis. There was also an association between migration and presence of osteolysis. CONCLUSIONS: Patients over 70 years old undergoing cemented total knee replacement for osteoarthritis showed better implant survivorship versus patients under 70 years old.

Reconstruction of the rotation center of the hip after oblong cups in revision total hip arthroplasty.

BACKGROUND: The preoperative bone defect and the reconstruction of the center of rotation of the hip are critical in acetabular revision surgery. Uncemented oblong cups are employed in order to manage these issues. We analyzed the clinical results and rates of revision of two different uncemented oblong cups, the reconstruction of the center of rotation of the hip, as well as the rate of radiological loosening and possible risk factors. MATERIALS AND METHODS: Forty-five patients (46 hips) underwent acetabular revision surgery using two different uncemented oblong cups. We assessed the clinical results and the survival rate for revision and aseptic loosening. Intraoperative bone loss was classified according to Paprosky, and acetabular reconstruction was assessed according to Ranawat. The mean follow-up was 7.2 years (range 4-11 years). RESULTS: There were four re-revisions (three due to aseptic loosening); the survival rate for re-revision due to aseptic loosening was 60.1 % at seven years. The mean distance between the center of the femoral head prosthesis and the approximate center of the femoral head improved from 21.5 to 10.2 mm. Thirteen cups showed radiological loosening; the survival rate for radiological loosening at seven years was 40.54 %. A smaller postoperative horizontal distance was correlated with cup loosening. CONCLUSIONS: Although optimal acetabular reconstruction can be achieved by using oblong uncemented cups in revision hip surgery, the clinical and radiological results are not encouraging. Excessive medialization of the cup may increase the rate of loosening.

Peroperative fractures in uncemented total hip arthroplasty: results with a single design of stem implant.

The incidence of intraoperative femoral fractures with a single design of stem implant, the Meridian (Stryker-Howmedica, Rutherford, N.J.), has been assessed in a study of 117 implants in patients treated consecutively between 1996 and 2001. The aim of the study was to evaluate the risk factors for suffering an intraoperative fracture and to determine, based on a short-term follow-up, if there were radiographic signs of early loosening. The following variables were analysed: demographic factors of the patient, morphology of the femur, intraoperative factors and postoperative radiographic factors. The radiographic stability of the implant and the presence of early signs of loosening were evaluated 2 years after surgery. The incidence of femoral fractures was 11% (13 cases in 117 implants), which is higher that reported in earlier published studies, and there was an increased number of fractures when the proximal filling of the femoral canal was higher. Although there was no statistically significant relation between the variables studied and the appearance of an intraoperative fracture, we conclude that the appearance of a femoral intraoperative fracture did not affect the radiographic stability of the implant during the short-term follow-up of our study cohort.