Survival and reasons for revision of the uncemented Symax hip stem: A Dutch Arthroplasty Register study.

AIMS: Previous studies have already shown early proximal ingrowth, fast osseous integration, and a stable fit of the uncemented Symax hip stem, with excellent clinical and radiographic performance. Aims were to evaluate cumulative revision rates and reasons for revision of the Symax hip stem using Dutch Arthroplasty Register (LROI) data and to assess possible associations between patient characteristics and revision rate of the Symax hip stem. PATIENTS AND METHODS: All total hip arthroplasties with the uncemented Symax hip stem registered in the LROI between 2007 and 2017 were included (n = 5,013). Kaplan-Meier survival analysis was performed to assess the cumulative 1, 5 and 7-year revision percentages. Cox proportional hazard regression analysis was performed to assess the association between patient and procedural characteristics, and revision arthroplasty of the stem. RESULTS: Cumulative 1, 5, and 7-year revision rates (with 95% confidence interval (CI)) for revision of any component were 1.5% (CI 1.2%-1.8%), 3.2% (CI 2.7%-3.7%), and 3.8% (CI 3.1%-4.4%) respectively. Cumulative 1, 5, and 7-year stem revision rates of the Symax hip stem were 0.9% (CI 0.6%-1.1%), 1.5% (CI 1.1%-1.9%), and 1.7% (CI 1.3%-2.1%) respectively. Periprosthetic fractures (n = 35) and loosening of the stem (n = 30) were the most common reasons for revision of the stem. Revision of the stem was associated with acute fracture as primary diagnosis (Hazard Ratio (HR) 2.4 (CI 1.3-4.3)), or history of a previous surgery to the affected hip (HR 2.7 (CI 1.4-5.2)). CONCLUSION: This population-based registry study shows revision rates for the Symax hip stem comparable to those for best performing uncemented total hip arthroplasties in the Netherlands. Primary diagnosis of an acute fracture, and history of previous surgery on the affected hip, were significantly associated risk factors for revision of the Symax hip stem, and we discourage the use of the Symax hip stem in these patients.

Early stabilization of the uncemented Symax hip stem in a 2-year RSA study.

Background and purpose - The uncemented Symax hip stem has shown early proximal ingrowth as result of the BONIT-hydroxyapatite (HA) coating and the distal DOTIZE surface treatment. We evaluated 2-year postoperative radiostereometric analysis (RSA) migration of the Symax hip stem in THA patients. We also investigated the correlation between migration at 4 weeks and clinical outcomes after 2 years.Patients and methods - Patients in a 2-year clinical follow-up single-centre RSA randomized controlled trial were randomized to 2 different cup designs. All 45 patients received a Symax hip stem. RSA migration patterns of the Symax hip stem is presented here as a single cohort. RSA examinations were performed postoperatively, but before weight-bearing, and subsequently after 1, 3, 6, 12, and 24 months. Clinical outcomes and radiographic evaluations were assessed 3, 6, 12, and 24 months postoperatively.Results - During the first 4 weeks, the Symax hip stem subsided, rotated into retroversion, and translated posteriorly, after which the migration ceased and the prosthesis stabilized. All clinical outcomes improved from preoperatively to 2 years. There was no clinically or statistically significant correlation between subsidence and retroversion at 4 weeks and clinical outcomes after 2 years.Interpretation - RSA evaluation of the uncemented Symax hip stem confirms that the design principles and coating properties lead to early stabilization of the stem, as early as 4 weeks postoperatively. There was no correlation between subsidence and retroversion at 4 weeks and clinical outcomes after 2 years. Based on the predictive potential of the RSA technique, we anticipate excellent long-term survival of this hip stem.

2-stage revision of 120 deep infected hip and knee prostheses using gentamicin-PMMA beads.

Background and purpose - A 2-stage revision is the most common treatment for late deep prosthesis-related infections and in all cases of septic loosening. However, there is no consensus about the optimal interval between the 2 stages. Patients and methods - We retrospectively studied 120 deep infections of total hip (n = 95) and knee (n = 25) prostheses that had occurred over a period of 25 years. The mean follow-up time was 5 (2-20) years. All infections had been treated with extraction, 1 or more debridements with systemic antibiotics, and implantation of gentamicin-PMMA beads. There had been different time intervals between extraction and reimplantation: median 14 (11-47) days for short-term treatment with uninterrupted hospital stay, and 7 (3-22) months for long-term treatment with temporary discharge. We analyzed the outcome regarding resolution of the infection and clinical results. Results - 88% (105/120) of the infections healed, with no difference in healing rate between short- and long-term treatment. 82 prostheses were reimplanted. In the most recent decade, we treated patients more often with a long-term treatment but reduced the length of time between the extraction and the reimplantation. More reimplantations were performed in long-term treatments than in short-term treatments, despite more having difficult-to-treat infections with worse soft-tissue condition. Interpretation - Patient, wound, and infection considerations resulted in an individualized treatment with different intervals between stages. The 2-stage revision treatment in combination with local gentamicin-PMMA beads gave good results even with difficult prosthesis infections and gentamicin-resistant bacteria.

Randomized comparison between the cemented Scientific Hip Prosthesis and Omnifit: 2-year DEXA and minimum 10-year clinical follow-up.

Radiostereometry (RSA) of the cemented Scientific Hip Prosthesis (SHP) reported excessive migration and predicted high failure rates. In a prospective randomized clinical trial we compared minimum 10 years results of the SHP (n=38) with the Omnifit-stem (n=37). Two-year bone remodelling, compared with dual energy x-ray absorptiometry and assessed in regions of interest A-D based on the 7 Gruen zones, showed better periprosthetic bone preservation around the SHP in all but one regions (P<.05). At 10 years Harris Hip Score was better for the SHP (P=.0001) but Oxford Hip Score was the same (P=.79). There were no revisions in either group, but radiographic loosening was definite in 1 SHP and 1 Omnifit. Based on earlier RSA studies, the rough surface finish of the SHP was expected to cause cement abrasion, osteolysis and inferior survival. However our clinical and remodelling results could not confirm these expectations, suggesting that the link of early migration and mid-term clinical results is not sufficiently clear for the SHP.

Randomised trial comparing bone remodelling around two uncemented stems using modified Gruen zones.

For assessment of bone remodelling around total hip arthroplasty using dual-emission X-ray absorptiometry (DEXA), a variety of different systems to identify regions of interest (ROI) have been used, making comparisons between stem designs difficult. The Gruen zones are now widely used for this purpose. We present the results of a randomised clinical trial comparing 2 uncemented stem designs with proximal coating, using a modification of the Gruen zones to allow improved representation of the effect of the implant on bone mineral density (BMD) over time. DEXA-data were used in a randomised trial with 2 years follow up, comparing the uncemented Symax(TM) (n=25) and Omnifit(®) (n=24) stems. The effect on BMD was determined using the 'standard' adapted Gruen zones, and a modification which studied an equal length and position for zones 1 and 7 around both stems, assuring that the same regions in terms of cancellous and cortical bone were compared. The 'modified' regions of interest give lower BMD values around the Omnifit(®) than using the 'standard' Gruen zones (3.6 % in zone 7, p<0.05). The difference with the Symax(TM) BMD values, which had been concealed using the standard Gruen zones, became statistically significant in favour of the Symax(TM) implant. This adaptation can detect a statistically significant difference in bone preservation in zone 7 between stems that would otherwise not have been revealed. We recommend the use of 'modified' Gruen zones for more valid comparison of remodelling caused by different implant designs.