Posterior pelvic tilt evolution in patients undergoing total hip arthroplasty. A minimum 5-years follow-up clinico-radiological study. / Evolución de la inclinación pélvica a lo largo del tiempo en pacientes intervenidos de prótesis total de cadera. Estudio clínico-radiológico con un seguimiento mínimo de cinco años.

BACKGROUND AND OBJECTIVE: Pelvic tilt influences the relative position between total hip arthroplasty (THA) components. Changes in lumbar spine over time may affect clinical and radiological outcomes of THA during follow-up. We assessed the evolution of pelvic tilt and cup position after THA for a minimum follow-up of five years and the possible appearance of complications. MATERIAL AND METHODS: This retrospective study includes 48 patients operated between 2008 and 2012. Clinical data, complication and radiological analysis included sacro-femoral-pubic and acetabular abduction angles on the anteroposterior pelvic view; and cup anteversion angle on the lateral cross-table hip view according to Woo and Morrey. All assessments were done pre-operatively and at 6 weeks, one, two and five years post-operatively. RESULTS: Mean sacro-femoral-pubic decreased from 60.6∘ preoperatively to 58.8∘ at five years (p > .05), more in females (from 63.3 to 59.3) than males (58.7 to 58.3). Acetabular abduction increased from 47.3 at six-week postoperatively to 48.2 at five years (p > .05) and acetabular anteversion varied from 24.3∘ to 36.1∘ (p < .04). There were four dislocations: one late recurrent dislocation which required cup revision. CONCLUSION: Despite the sacro-femoral-pubic angle tendency to decrease and anteversion tendency to increase after five years, larger studies with longer follow-up are needed to confirm the potential increasing in long term complications.

Mortality as a competition risk factor in the survival analysis of the results of the type of fixation of the total hip prosthesis in octogenarian patients. / Mortalidad como factor de riesgo de competencia en el análisis de supervivencia de los resultados del tipo de fijación de la prótesis total de cadera en pacientes octogenarios.

INTRODUCTION: Total hip replacement (THR) is challenging in octogenarians due to associated comorbidities and controversy regarding fixation type. We ask whether cemented THR is superior to uncemented THR in patients above the age of 80 years. MATERIAL AND METHODS: A total of 382 patients (441 hips) aged 80 years or older who underwent THR between 2004 and 2015 were analysed. A cemented THR was implanted in 196 hips (group 1), an uncemented THR with a grit-blasted stem in 121 (group 2), or with a porous-coated stem in 124 (group 3). Patients in group 1 had a higher mean age, more comorbidities and osteoporotic bone. Survival analysis was calculated using cumulative incidence function to account for the competing risk of death. RESULTS: Medical complications rate was similar. There were 3post-operative fractures: one in group 2 and 2in group 3. Competing risk analysis showed that the cumulative incidence of revision for any cause was 2.3 in group 1, 6.0 in group 2 and 4.1 in group 3 at 10years, and the cumulative incidence of revision for aseptic loosening was 1.2 in group 1, 3.7 in group 2 and 0 in group 3 at the same period. CONCLUSIONS: THR presents an acceptable number of adverse events for octogenarian patients. Despite uncemented fixation was satisfactory, the higher peri-prosthetic fracture rate worsens results in this group.

Outcome of a hemispherical porous-coated acetabular component with a proximally hydroxyapatite-coated anatomical femoral component: an update at 23 to 26 years' follow-up

AIMS: We previously reported the long-term results of the cementless Duraloc-Profile total hip arthroplasty (THA) system in a 12- to 15-year follow-up study. In this paper, we provide an update on the clinical and radiological results of a previously reported cohort of patients at 23 to 26 years´ follow-up. PATIENTS AND METHODS: Of the 99 original patients (111 hips), 73 patients (82 hips) with a mean age of 56.8 years (21 to 70) were available for clinical and radiological study at a minimum follow-up of 23 years. There were 40 female patients (44 hips) and 33 male patients (38 hips). RESULTS: All acetabular and femoral components were well fixed and showed signs of bone ingrowth. Nine acetabular components were revised due to wear-osteolysis-related problems and four due to late dislocation. The probability of not having component revision at 25 years was 83.2% (95% confidence interval (CI) 74.5 to 91.8; number at risk 41). Acetabular osteolysis was observed in ten hips. The mean femoral head penetration was 1.52 mm (sd 0.8) at 15 years and 1.92 mm (sd 1.2) at 25 years. Receiver operating characteristic (ROC) analysis revealed that mean femoral penetration with a value of 0.11 mm/year or more was associated with the appearance of osteolysis. The 25-year Kaplan-Meier survival with different endpoints was 89.9% for acetabular osteolysis (95% CI 83.3 to 96.5), 92.1% for proximal femoral osteolysis (95% CI 86.1 to 98.2), and 75.5% for femoral osteopenia (95% CI 66.5 to 84.5). CONCLUSION: The Duraloc-Profile THA system showed excellent long-term bone fixation. Nevertheless, monitoring is recommended in order to detect wear and late dislocations in this population that was relatively young at the time of surgery. Cite this article: Bone Joint J 2019;101-B:378-385.

The evolution of an uncemented acetabular component in alumina-on-alumina total hip arthroplasty has improved clinical outcome: a prospective, comparative five- to 15-year follow-up study.

AIMS: To determine the effect of a change in design of a cementless ceramic acetabular component in fixation and clinical outcome after total hip arthroplasty PATIENTS AND METHODS: We compared 342 hips (302 patients) operated between 1999 and 2005 with a relatively smooth hydroxyapatite coated acetabular component (group 1), and 337 hips (310 patients) operated between 2006 and 2011 using a similar acetabular component with a macrotexture on the entire outer surface of the component (group 2). The mean age of the patients was 53.5 (14 to 70) in group 1 and 53.0 (15 to 70) in group 2. The mean follow-up was 12.7 years (10 to 17) for group 1 and 7.2 years (4 to 10) for group 2. RESULTS: No hips were revised due to complications related to bearing fracture or to stem loosening. A total of 15 acetabular components were revised for aseptic loosening in group 1 and two in group 2. The survival rate for acetabular component aseptic loosening at eight years was 96.8% (95% confidence interval (CI) 94.8 to 98.7) for group 1 and 99.2% (95% CI 98.0 to 100) for group 2. The risk for aseptic loosening of the acetabular component was higher in group 1 (p = 0.04, Hazard Ratio (HR) 4.99), dysplastic acetabula (p = 0.01, HR 4.12), components outside Lewinnek´s zone (p < 0.001, HR 6.13) and in those with a hip rotation centre distance greater than 5 mm (p = 0.005, HR 4.09). CONCLUSION: Alumina ceramic-on-ceramic THA is an excellent option for young patients. Although newer components appeared to improve fixation, acetabular reconstruction is essential to obtain a satisfactory outcome. Cite this article: Bone Joint J 2017;99-B:749-58.

Clinical outcome following conversion of Girdlestone's resection arthroplasty to total hip replacement: a retrospective matched case-control study.

A total of 31 patients, (20 women, 11 men; mean age 62.5 years old; 23 to 81), who underwent conversion of a Girdlestone resection-arthroplasty (RA) to a total hip replacement (THR) were compared with 93 patients, (60 women, 33 men; mean age 63.4 years old; 20 to 89), who had revision THR surgery for aseptic loosening in a retrospective matched case-control study. Age, gender and the extent of the pre-operative bone defect were similar in all patients. Mean follow-up was 9.3 years (5 to 18). Pre-operative function and range of movement were better in the control group (p = 0.01 and 0.003, respectively) and pre-operative leg length discrepancy (LLD) was greater in the RA group (p < 0.001). The post-operative clinical outcome was similar in both groups except for mean post-operative LLD, which was greater in the study group (p = 0.003). There was a significant interaction effect for LLD in the study group (p < 0.001). A two-way analysis of variance showed that clinical outcome depended on patient age (patients older than 70 years old had worse pre-operative pain, p = 0.017) or bone defect (patients with a large acetabular bone defect had higher LLD, p = 0.006, worse post-operative function p = 0.009 and range of movement, p = 0.005), irrespective of the group. Despite major acetabular and femoral bone defects requiring complex surgical reconstruction techniques, THR after RA shows a clinical outcome similar to those obtained in aseptic revision surgery for hips with similar sized bone defects.

Factors influencing regional variability in the rate of total knee arthroplasty.

BACKGROUND AND PURPOSE: Geographic variations in knee arthroplasty have been detected through international surveys. We aim to investigate in this study the influence of aging index, health budget, and number of orthopedic surgeons in the regional variations of the primary and revision TKA rate in a single European country, Spain. MATERIAL AND METHODS: Inpatient database of knee arthroplasty procedures for years 1997 to 2010 was obtained from the Spanish Ministry of Health, including 393,714 primaries and 37,037 revisions, segregated for each of the 17 regional health services in Spain. Crude and adjusted rates (direct method with total Spanish population per year) were calculated and used as dependent variables. Aging index, regional health budget, and number of orthopedic surgeons per region were used as independent variables in a Kruskal-Wallis test and a negative binomial regression analysis model. RESULTS AND CONCLUSIONS: With a mean crude rate for Spain of 76 primary TKA and 7 revision surgeries per 10(5) population and year, the mean adjusted rate per region oscillated between 702 and 27 primary TKA and 87 and 3 revisions per 10(5). A model was adjusted confirming the influence of aging index, health budget, and number of surgeons, but regional variations remained partly unexplained by these factors.

New polyethylenes in total hip replacement: A ten- to 12-year follow-up study.

Between 1999 and 2001, 90 patients underwent total hip replacement using the same uncemented acetabular and femoral components with a 28 mm metallic femoral head but with prospective randomisation of the acetabular liner to either Durasul highly cross-linked polyethylene or nitrogen-sterilised Sulene polyethylene. We assessed 83 patients at a minimum follow-up of ten years. Linear penetration of the femoral head was estimated at six weeks, six and 12 months and annually thereafter, using the Dorr method, given the non-spherical shape of the acetabular component. There was no loosening of any component; only one hip in the Sulene group showed proximal femoral osteolysis. The mean penetration of the femoral head at six weeks was 0.08 mm (0.02 to 0.15) for the Durasul group and 0.16 mm (0.05 to 0.28) for the Sulene group (p = 0.001). The mean yearly linear penetration was 64.8% lower for the Durasul group at 0.05 mm/year (sd 0.035) for the Sulene group and 0.02 mm/year (sd 0.016) for the Durasul (p < 0.001). Mean linear femoral head penetration at ten years was 61% less in the Durasul than Sulene group. Highly cross-linked polyethylene gives excellent results at ten years.

The extent of the bone defect affects the outcome of femoral reconstruction in revision surgery with impacted bone grafting: a five- to 17-year follow-up study.

We report the results of 79 patients (81 hips) who underwent impaction grafting at revision hip replacement using the Exeter femoral stem. Their mean age was 64 years (31 to 83). According to the Endoklinik classification, 20 hips had a type 2 bone defect, 40 had type 3, and 21 had type 4. The mean follow-up for unrevised stems was 10.4 years (5 to 17). There were 12 re-operations due to intra- and post-operative fractures, infection (one hip) and aseptic loosening (one hip). All re-operations affected type 3 (6 hips) and 4 (6 hips) bone defects. The survival rate for re-operation for any cause was 100% for type 2, 81.2% (95% confidence interval (CI) 67.1 to 95.3) for type 3, and 70.8% (95% CI 51.1 to 90.5) for type 4 defects at 14 years. The survival rate with further revision for aseptic loosening as the end point was 98.6% (95% CI 95.8 to 100). The final clinical score was higher for patients with type 2 bone defects than type 4 regarding pain, function and range of movement. Limp was most frequent in the type 4 group (p < 0.001). The mean subsidence of the stem was 2.3 mm (SD 3.7) for hips with a type 2 defect, 4.3 mm (SD 7.2) for type 3 and 9.6 mm (SD 10.8) for type 4 (p = 0.022). The impacted bone grafting technique has good clinical results in femoral revision. However, major bone defects affect clinical outcome and also result in more operative complications.

Stress-shielding of the proximal femur using an extensively porous-coated femoral component without allograft in revision surgery: a 5- to 17-year follow-up study.

Revision surgery of the hip was performed on 114 hips using an extensively porous-coated femoral component. Of these, 95 hips (94 patients) had a mean follow-up of 10.2 years (5 to 17). No cortical struts were used and the cortical index and the femoral cortical width were measured at different levels. There were two revisions for aseptic loosening. Survivorship at 12 years for all causes of failure was 96.9% (95% confidence interval 93.5 to 100) in the best-case scenario. Fibrous or unstable fixation was associated with major bone defects. The cortical index (p = 0.045) and the lateral cortical thickness (p = 0.008) decreased at the proximal level over time while the medial cortex increased (p = 0.001) at the proximal and distal levels. An increase in the proximal medial cortex was found in patients with an extended transtrochanteric osteotomy (p = 0.026) and in those with components shorter than 25 cm (p = 0.008). The use of the extensively porous-coated femoral component can provide a solution for difficult cases in revision surgery. Radiological bony ingrowth is common. Although without clinical relevance at the end of follow-up, the thickness of the medial femoral cortex often increased while that of the lateral cortex decreased. In cases in which a shorter component was used and in those undertaken using an extended trochanteric osteotomy, there was a greater increase in thickness of the femoral cortex over time.

Outcome of a hemispherical porous-coated acetabular component with a proximally hydroxyapatite-coated anatomical femoral component: a 12- to 15-year follow-up study.

We reviewed 111 hemispherical Duraloc series-500 acetabular components with a minimum follow-up of 12 years. The mean clinical and radiological follow-up was 13.4 years (12 to 15). A Profile hydroxyapatite-coated anatomical femoral component was used in each case. Six patients had a late dislocation, for whom the polyethylene liner was exchanged. Each acetabular component was well fixed and all femoral components showed signs of bone ingrowth. The mean rate of femoral head penetration was 0.10 mm/year (0.021 to 0.481). The probability of not developing femoral cortical hypertrophy and proximal osteopenia by 12 years was 80.2% (95% confidence interval, 72.7 to 87.6) and 77.5% (95% confidence interval, 69.7 to 85.2), respectively. Despite these good clinical results, further follow-up is needed to determine whether these prostheses will loosen with time.

New polyethylenes in total hip replacement: a prospective, comparative clinical study of two types of liner.

Ultra-high-molecular-weight polyethylene sterilised in the absence of air and highly cross-linked polyethylene have been used to avoid osteolysis and loosening in total hip replacement. Our prospective randomised study has assessed the results using two different polyethylenes associated with the same prosthetic design. We assessed 45 Allofit acetabular components with a Sulene-polyethylene liner of conventional polyethylene gamma sterilised with nitrogen and 45 Allofit acetabular components with a Durasul-polyethylene liner sterilised in ethylene oxide, both matched with an Alloclassic stem with a 28 mm modular femoral head. The prostheses were implanted between May 1999 and December 2001. The mean follow-up was for 66.3 months (60 to 92). The linear penetration of the femoral head was estimated at 6 weeks, at 6 and 12 months and annually thereafter from standardised digitised radiographs using image-analysis software. There was no loosening of any prosthetic component. There were no radiolucent lines or osteolysis. The mean rate of penetration calculated from regression analysis during the first five years was 38 microm/year (SD 2) for the Sulene group and 6 microm/year (SD 1) for the Durasul group (p = 0.00002). The rate of penetration of the Durasul group was 15.7% of that of the Sulene group.

Clinical and radiographic results and wear performance in different generations of a cementless porous-coated acetabular cup.

We compared clinical results and wear performance in two different generations of a cementless porous-coated cup, analysing the long-term results of 83 uncemented Harris-Galante I cups (32-mm femoral head) and 93 uncemented Harris-Galante II cups (28-mm femoral head). All polyethylene liners were gamma irradiated in air. Polyethylene linear wear was estimated using a software package. The minimum follow-up was 10 years. Nine Harris-Galante I cups and two Harris-Galante II cups were revised due to aseptic loosening or polyethylene problems. The mean femoral head penetration at 6 weeks after surgery was 0.15 +/- 0.05 mm for the Harris-Galante I cups and 0.12 +/- 0.03 for the Harris-Galante II cups (p < 0.001);but mean wear was 0.13 +/- 0.23 mm per year for the Harris-Galante I cups and 0.11 +/- 0.10 for the Harris-Galante II cups (p = 0.740). Most of the metallic shells in both groups showed stable fixation. The so-called second-generation cups had lower initial polyethylene wear that resulted in less polyethylene wear at the latest the follow-up, but the overall wear rate was similar in both groups despite the different femoral head sizes and the improved locking mechanism.

Long-term results of uncemented acetabular cups with an ACS polyethylene liner. a 14-16-year follow-up study.

We assessed the clinical and radiographic results of 40 porous-coated acetabular cups with an Acetabular Cup System polyethylene liner over a minimum 14-year follow-up. Femoral head penetration was estimated using a software package. Fifteen cups were revised, 11 due to polyethylene liner rupture. All cups but two were radiographically stable, and 11 hips showed acetabular osteolysis. The overall femoral head penetration rate in hips without liner fracture with reference to the early penetration point was 0.1188+/-0.070 mm per year. Polyethylene liner fractures were associated with higher early femoral head penetration (P<0.0001) and a vertical cup position (P=0.0016). The 14-year survival without cup revision for any reason was 63.9%, 71.8% with no ACS polyethylene liner fracture and 65.3% with no acetabular osteolysis. Most cups showed a good clinical outcome in general, but major Acetabular Cup System liner failure and osteolysis were frequent. Patients with the ACS cups still in place should be monitored closely.

The intramedullary elongation nail for femoral lengthening.

We have analysed the results of 24 femoral lengthenings in 23 patients operated on between 1993 and 2000, using a gradual elongation intramedullary nail (Albizzia). Of the 23 patients, 22 had femoral deficiency and one was of short stature. Their mean age was 16.9 years. Technical difficulties encountered during the procedure were mild or moderate in 18 femora and severe in six femora. Distraction was obtained by 15 ratchetings per day (1 mm/day). There were 18 excellent results although in two patients this was achieved after the development of a pseudarthrosis which required further surgery. There were four good and two fair results in which the lengthening obtained was at least 3 cm less than had been projected. The consolidation index was 35.2 days/cm. No patient had associated long-term stiffness of the knee. Femoral lengthening using an elongation nail gives good results and is a comfortable procedure.