Mean 23-Year Outcomes of Total Hip Arthroplasty Using a Modular Femoral Stem With Metaphyseal Fixation Sleeve.

BACKGROUND: Although the modular sleeve concept for femoral implants has several advantages, studies reporting on greater than 20-year outcomes are limited. This study aimed to report the mean 23-year results of total hip arthroplasty (THA) using a modular stem with metaphyseal fixation sleeve. METHODS: This study reviewed primary THAs performed using a modular stem between October 1994 and April 1998. Of the 272 hips (221 patients) identified, 220 hips (177 patients) satisfying the minimum 20-year follow-up were included. The Harris Hip Score was used for clinical evaluation. Final hip radiographs were analyzed to evaluate the implant stability and the extent of femoral osteolysis. The mean follow-up duration was 23 years (range, 20 to 28). RESULTS: The mean Harris Hip Score improved from 38 points (range, 26 to 67) preoperatively to 90 points (range, 71 to 100) at the final follow-up (P < .001). Femoral osteolysis was observed in 146 hips (67.1%), but 145 were located proximal to the osseo-integrated sleeve. Overall, 4 femoral revisions were performed; 2 for chronic infection, one for aseptic loosening, and one for periprosthetic femoral fracture. Of the 19 (8.6%) periprosthetic femoral fractures, the most common type was Vancouver AG (13 hips). One (0.5%) asymptomatic distal stem fracture occurred, while no complications were identified at the stem-sleeve junction. Implant survivorship free of any femoral revision was 98.3% at 23 years. CONCLUSIONS: A THA using a modular stem with metaphyseal fixation sleeve demonstrated 98.3% stem survivorship with excellent clinical outcomes at a mean follow-up of 23 years in non-obese patients.

Bearing-Related Complications of Total Hip Arthroplasty Using Fourth-Generation Ceramic-On-Ceramic Articulations: Does Articular Noise Increase Over Time?

BACKGROUND: We previously reported the mean 6-year outcomes of total hip arthroplasty (THA) using fourth-generation ceramic-on-ceramic (CoC) articulations. With extended observations, this study aimed to report the mean 12-year outcomes focusing on bearing-related complications of CoC THA. METHODS: We reviewed primary CoC THAs performed between May 2009 and April 2012 at a single institution. Of the 831 hips (739 patients), 716 hips (635 patients) that satisfied a minimum 10-year follow-up were included. The mean age at operation was 54 years (range, 16 to 83). The occurrence of bearing-specific complications, including ceramic fractures and noise generation, was evaluated. The mean follow-up duration was 12 years (range, 10 to 14). RESULTS: A total of 2 (0.3%) ceramic liner fractures occurred, as previously reported. No additional ceramic fractures were observed during the extended follow-up period. However, the cumulative incidence of audible noise increased from 6.4 (48 of 749) to 8.2% (59 of 716). Of the 59 hips with noise, 26 (44.1%) developed noise within 1 year, whereas 13 (22.0%) presented with noise more than 5 years after THA. The noise was described as clicking in 35 hips (4.9%) and as squeaking in 24 hips (3.4%). No revision surgeries were performed for noise, except in 2 cases of concomitant liner fractures. The implant survivorship free of any revision was 98.1% at 12 years. CONCLUSIONS: No additional ceramic fractures were identified in this extension study at a minimum follow-up of 10 years. However, the prevalence of articular noise has increased from 6.4 to 8.2% since the previous report. Possible late-onset noise should be considered when performing CoC THA in younger patients.

Long-Term Outcomes of Cementing Highly Cross-Linked Polyethylene Liners Into Well-Fixed Acetabular Shells in Revision Total Hip Arthroplasty.

BACKGROUND: Cementing a new liner into a secure, well-positioned metallic shell can be a less-invasive strategy in revision total hip arthroplasty (THA). This study aimed to report the mean 14-year outcomes of cementing highly cross-linked polyethylene (XLPE) liners into well-fixed acetabular shells in revision THAs. METHODS: This study reviewed a single-surgeon series of cementing XLPE liners into well-fixed acetabular components. Of the 52 hips (51 patients) evaluated, 48 hips (47 patients) that satisfied a minimum follow-up of 10 years were included. The Harris Hip score was used for clinical evaluation. Final hip radiographs were used to determine the extent of acetabular osteolysis and stability of the components. The mean age at index operation was 53 years (range, 32 to 72). The mean follow-up duration was 14 years (range, 10 to 18). RESULTS: The mean Harris Hip score improved from 58 points (range, 23-81) preoperatively to 91 points (range, 45-100) at the final evaluation (P < .001). A total of 3 acetabular rerevisions were performed, all for aseptic loosening of the outer shell. One postoperative dislocation occurred, but it was successfully treated with a closed reduction. Final radiographs showed a significant reduction in acetabular osteolysis (P < .001). Implant survivorship free from any rerevision was 93.3% (95% confidence interval, 85.9-100%) at 14 years. CONCLUSION: Cementing an XLPE liner into a well-fixed acetabular shell in revision THA demonstrated excellent clinical and radiographic outcomes at a mean of 14 years postoperatively. This technique could be a safe and durable option in the absence of XLPE liners compatible with preimplanted shells.

Incidence and Risk Factors of Iliopsoas Tendinopathy After Total Hip Arthroplasty: A Radiographic Analysis of 1,602 Hips.

BACKGROUND: Iliopsoas tendinopathy (IPT) can cause persistent groin pain and lead to dissatisfaction after total hip arthroplasty (THA). This study aimed to report the characteristics, incidences, risk factors, and treatment outcomes of IPT after THA. METHODS: We reviewed primary THAs performed at a single institution between January 2012 and May 2018. Clinical and radiographic analyses were performed on 1,602 THAs (1,370 patients). Patient characteristics, component sizes, inclination and anteversion angles, and antero-inferior cup prominence (≥8 millimeters (mm)), were compared between the groups with and without IPT. Changes in teardrop to lesser trochanter distance were measured to estimate changes in leg length and horizontal offset caused by THA. Logistic regression models were used to identify the risk factors for IPT. IPT was identified in 53 hips (3.3%). RESULTS: Patients with IPT had greater leg lengthening (12.3 versus 9.3 mm; P = .001) and higher prevalence of antero-inferior cup prominence (5.7 versus 0.4%; P = .002). There was no significant difference in inclination, anteversion, and horizontal offset change between the two groups. In multivariate analyses, greater leg lengthening, prominent acetabular cup, women, and higher body mass index were associated with IPT. All patients reported improvement in groin pain after arthroscopic tenotomy, while 35.7% with nonoperative management reported improvement (P < .001). CONCLUSIONS: Symptomatic IPT occurred in 53 (3.3%) of the 1,602 primary THAs. Our findings suggest that leg lengthening as well as prominent acetabular cup in THAs can be associated with the development of IPT. Arthroscopic tenotomy was effective in relieving groin pain caused by IPT.

Rectangular Taper Stem Designs Are Associated With a Higher Risk for Periprosthstic Femoral Fractures After Cementless Total Hip Arthroplasty.

BACKGROUND: Periprosthetic femoral fractures (PFFs) remain a major concern following cementless total hip arthroplasty (THA). This study aimed to evaluate the association between different types of cementless tapered stems and the risk of postoperative PFF. METHODS: A retrospective review of primary THAs performed at a single center from January 2011 to December 2018 included 3,315 hips (2,326 patients). Cementless stems were classified according to their design. The incidence of PFF was compared between flat taper porous-coated stems (type A), rectangular taper grit-blasted stems (type B1), and quadrangular taper hydroxyapatite-coated stems (type B2). Multivariate regression analyses were performed to identify independent factors related to PFF. The mean follow-up duration was 61 months (range, 12 to 139). Overall, 45 (1.4%) postoperative PFFs occurred. RESULTS: The incidence of PFF was significantly higher in type B1 stems than in type A and type B2 stems (1.8 versus 0.7 versus 0.7%; P = .022). Additionally, more surgical treatments (1.7 versus 0.5 versus 0.7%; P = .013) and femoral revisions (1.2 versus 0.2 versus 0%; P = .004) were required for PFF in type B1 stems. After controlling for confounding variables, older age, diagnosis of hip fracture, and use of type B1 stems were significant factors associated with PFF. CONCLUSION: Type B1 rectangular taper stems were found to have higher risks for postoperative PFF and PFF requiring surgical management than type A and type B2 stems in THA. Femoral stem geometry should be considered when planning for cementless THA in elderly patients who have compromised bone quality.

The Effect of Teriparatide Treatment on the Risk of Fragility Fractures in Postmenopausal Women with Osteoporosis: Results from the Asian and Latin America Fracture Observational Study (ALAFOS).

The Asian and Latin America Fracture Observational Study (ALAFOS) is a prospective, observational, single-arm study conducted in 20 countries across Asia, Latin America and the Middle East. ALAFOS evaluated new clinical vertebral and non-vertebral fragility fractures in relation to time on teriparatide, in postmenopausal women with osteoporosis in real-life clinical practice. Clinical fragility fractures, back pain, and health-related quality of life (HRQoL) were recorded in 6-month intervals for ≤ 24 months during teriparatide treatment and up to 12-months post-treatment. Data were analysed with piecewise exponential regression with inverse probability weighting for time to event outcomes and mixed-model repeated measures for back pain and HRQoL. 3054 postmenopausal women started teriparatide and attended ≥ one follow-up visit (mean [SD] age 72.5 [10.4] years). The median (95% CI) time to treatment discontinuation was 22.0 months (21.2, 22.8). During the treatment period, 111 patients (3.6%) sustained 126 clinical fractures (2.98 fractures/100 patient-years). Rates of new clinical fragility fractures were significantly decreased during the > 6-12, > 12-18, and > 18-24-month periods, as compared with the first 6 months of treatment (hazard ratio [HR] 0.57; 95% CI 0.37, 0.88; p = 0.012; HR 0.35; 95% CI 0.19, 0.62; p < 0.001; HR 0.43; 95% CI 0.23, 0.83; p = 0.011; respectively). Patients also reported an improvement in back pain and HRQoL (p < 0.001). These results provide data on the real-world effectiveness of teriparatide in the ALAFOS regions and are consistent with other studies showing reduction of fractures after 6 months of teriparatide treatment. These results should be interpreted in the context of the noncontrolled design of this observational study.

Long-Term Outcomes of Revision Total Hip Arthroplasty Using a Tapered and Fluted Modular Stem: A Mean Follow-Up of 16 Years.

BACKGROUND: Tapered modular stems are increasingly used in revision total hip arthroplasty (THA) with deficient femoral bone stock. This study aimed to report the long-term outcomes of revision THA using a tapered and fluted modular stem. METHODS: Between December 1998 and February 2006, 113 revision THAs (110 patients) were performed with a tapered and fluted modular stem at a single institution. Hip radiographs were used to identify stem subsidence, stability, and femoral radiolucency. Final outcomes were assessed in 72 hips (70 patients), with a minimum follow-up of 10 years. RESULTS: The mean follow-up duration was 16 years (range, 10-23). At the final evaluation, the Harris Hip Score improved from a mean of 41 points (range, 10-72) preoperatively to 83 points (range, 56-100) (P < .001). Six femoral re-revisions were performed for the following reasons: 1 aseptic loosening, 2 stem fractures, and 3 infections. One stem fracture occurred at the modular junction after 14 years, and the other at a more distal location after 15 years. Stem subsidence was >5 mm in 6 hips (9.1%), but secondary stability was achieved in all stems. Osseointegration was observed in 63 (95.5%) hips. Stem survivorship was 91.1% with an end point of any re-revision and 94.6% for aseptic re-revision. CONCLUSION: A tapered and fluted modular stem demonstrated excellent implant survivorship with reliable bony fixation at a mean follow-up of 16 years. This type of stem can be a durable option for revision THA in patients who have femoral defects.

Outcomes of revision total hip arthroplasty using the modular dual mobility acetabular system to treat recurrent dislocation.

BACKGROUND: Recurrent dislocation is a difficult complication after total hip arthroplasty (THA). This study aimed to report the clinical and radiographic outcomes of revision THA using the modular dual mobility (MDM) acetabular system to treat recurrent dislocation. METHODS: Between March 2015 and February 2019, 34 revision THAs were performed using the MDM system for treating recurrent dislocation in a single institution. Of these, 32 revision THAs (32 patients) that satisfied a minimum follow-up of one year (mean, 4 years) were included in this study. Patient-reported outcomes, complication rates, and radiographic results were evaluated. RESULTS: Seventeen patients (53.1%) had lumbar degenerative kyphosis, and six (18.8%) had surgically fused lumbar spines during the index operation. All acetabular components were revised, whereas femoral stems were retained in 29 patients (90.6%). No redislocation or intraprosthetic dislocation was noted after revision. One additional revision was required for acetabular loosening with periprosthetic joint infection. No additional revision was performed for aseptic loosening. A partial radiolucent line was found in two hips (6.3%) confined to one acetabular zone. CONCLUSIONS: Revision THA using the MDM system was effective in treating recurrent dislocation in a group of patients with a high prevalence of lumbar spinal pathology. During a mean follow-up of 4 years, one additional revision THA was performed for septic loosening and none for aseptic loosening.

Outcomes of Cerclage Cabling for Intraoperative Calcar Cracks in Cementless Total Hip Arthroplasty Using Broach-Only, Tapered Wedge Stems.

BACKGROUND: Intraoperative femoral fractures are well-known but often overlooked complications in total hip arthroplasty (THA). We examined outcomes of cerclage cabling for intraoperative calcar cracks in THA with cementless tapered wedge stems. METHODS: In total, 4928 primary THAs were performed using broach-only, tapered wedge stems between January 2007 and November 2017 in a single institution. Of these, we identified 71 intraoperative calcar cracks (69 patients) managed by 2-mm cerclage cables. Clinical outcomes, amount of stem subsidence, and implant survivorship of the calcar crack group (68 THAs) were compared with those of the matched control group (68 THAs) without intraoperative fractures. Multivariate analysis was performed to identify potential risk factors for stem subsidence >3 mm. RESULTS: The mean stem subsidence was greater in the calcar crack group (2.0 vs 1.2 mm, P = .021), whereas revision-free survivorships of THA were similar between groups at 6 years (98.5% vs 98.4%; log-rank, P = .987). In the calcar crack group, a Dorr type C femur and the absence of cabling proximal to the lesser trochanter (LT) were identified as independent risk factors for stem subsidence >3 mm. For the subgroup with 42 calcar cracks managed by a single cable applied proximal to the LT, revision-free survivorship of THA was 100% at 6 years. There was no complete radiolucency to indicate aseptic stem loosening in either group. CONCLUSION: The application of a single cable proximal to the LT of the femur for intraoperative calcar cracks demonstrated 100% revision-free survivorship with lower stem subsidence in THA with tapered wedge stems.

Total Hip Arthroplasty With Subtrochanteric Shortening Osteotomy in Patients With High Hip Dislocation Secondary to Childhood Septic Arthritis: A Matched Comparative Study With Crowe IV Developmental Dysplasia.

BACKGROUND: Total hip arthroplasty (THA) with subtrochanteric shortening osteotomy (SSO) is performed to manage hips with high dislocations. We compared outcomes of THA with SSO in patients with high hip dislocation resulting from childhood septic arthritis and Crowe IV developmental dysplasia of the hip (DDH). METHODS: We reviewed 60 THAs with SSO performed between May 1996 and December 2013. Thirty-one cases were classified as sequelae of childhood infection and 29 as DDH. Twenty-five hips were selected for each group after the propensity score was matched with preoperative demographics and leg length discrepancy (LLD). Clinical scores, complication and reoperation rates, radiographic results, and survivorships were compared. The mean duration of follow-up was 12.3 (range 5-22) years. RESULTS: The average correction in LLD was 2.5 cm for childhood infection and 3.6 cm for DDH (P = .002). The infection group received more transfusions (mean 3.3 vs 2.0 units, P = .002), required more time for union of osteotomy site (mean 6.8 vs 5.2 months, P = .042), and reported lower Harris Hip Score (mean 85.1 vs 91.3, P = .017). Reoperations were performed in 11 (44%) previously infected hips and 3 (12%) DDHs (P = .012). Kaplan-Meier survivorship with an endpoint of revision for any reason was lower in the infection group (83.6%) than in the DDH group (100%) at 10 years (log rank, P = .040). CONCLUSION: THA with SSO in high hip dislocation secondary to childhood septic arthritis demonstrated less favorable clinical outcomes with increased risks of complication, compared with those performed in Crowe IV DDH with similar degree of chronic dislocation.

Surgical outcomes of simple distal femur fractures in elderly patients treated with the minimally invasive plate osteosynthesis technique: can percutaneous cerclage wiring reduce the fracture healing time?

INTRODUCTION: Achieving adequate reduction is difficult when performing minimally invasive plate osteosynthesis (MIPO) in elderly patients with simple distal femur fracture. This study aimed to evaluate the elderly patients who had undergone percutaneous wiring-assisted reduction with MIPO for simple distal femur fractures to determine the effect of this technique on reduction quality and fracture union. MATERIALS AND METHODS: Between January 2009 and September 2017, 56 patients (56 femurs) with displaced simple distal femur fractures treated with MIPO at three trauma centers were finally enrolled. The MIPO technique with percutaneous cerclage wire reduction was performed in 25 patients (Group A). Among them, 12 patients had a simple spiral metaphyseal fracture (Group A*). In comparison, MIPO without percutaneous cerclage wire reduction was performed in 31 patients (Group B). Among them, seven patients had a simple spiral metaphyseal fracture (Group B*). Medical records containing surgical records were retrospectively reviewed to investigate demographic data, comorbidities, complications, operative time, and fluoroscopic time. Radiographs were evaluated for assessing the quality of the reduction and fracture union. RESULTS: The mean fracture union time of Group A* was 21.7 weeks, which was significantly shorter than that of Group B* (28.6 weeks). The mean coronal and sagittal angulation in Group A* was 0.6° and 0.7°, respectively, which were significantly lesser than those in Group B* (2.4° and 3.2°, respectively). Mean translation in Group A* was 1.43 mm, which was significantly shorter than that in Group B* (3.81 mm). Nonunion occurred in two patients in Group B. CONCLUSION: Surgical treatment of simple spiral distal femur fractures with percutaneous cerclage wiring-assisted reduction and the MIPO technique in elderly patients resulted in better reduction and faster union time. Therefore, this technique could be a good solution if used in accordance with the indication.

The prevalence, risk factors and prognostic implications of dysphagia in elderly patients undergoing hip fracture surgery in Korea.

BACKGROUND: Dysphagia is prevalent in geriatric patients, such as elderly hip fracture patients, and is associated with a poor prognosis. This study investigated (1) the prevalence of dysphagia based on clinical screening and a video-fluoroscopic swallowing study (VFSS), (2) the risk factors of dysphagia, and (3) the prognostic implications of dysphagia in elderly patients (≥ 65 years) undergoing hip fracture surgery. METHODS: In this retrospective study, data from 393 female and 153 male patients ≥65 years of age who underwent surgery for a hip fracture between 2015 and 2018 were analysed. Patients who were considered at high risk of dysphagia after screening underwent a VFSS. To identify risk factors of dysphagia, demographic factors, the American Society of Anesthesiologists classification, past medical history, known risk factors of dysphagia, and factors associated with surgery were analysed using a binary logistic regression model. Odds ratios (ORs) of dysphagia for having poor prognosis including postoperative pneumonia, intensive care unit (ICU) admission, and death within 6 months after surgery were obtained by logistic regression. The association of postoperative pneumonia with poor prognosis was also analysed. RESULTS: Dysphagia was seen in 5.3% of hip fracture patients. In multivariate regression analysis, a serum albumin level < 3.5 g/dL was identified as a risk factor for dysphagia (OR [95%CI] = 3.13 [1.40, 7.01]). Dysphagia was identified as a risk factor for postoperative pneumonia in regression analysis after adjustment (OR [95%CI] = 3.12 [1.05, 9.27]). Postoperative pneumonia was significantly associated with ICU admission (OR [95% CI] = 4.56 [1.85, 11.28]) and death within 6 months after surgery (OR [95% CI] = 2.56 [1.03, 6.33]). CONCLUSIONS: Dysphagia in elderly hip fracture surgery patients was associated with postoperative pneumonia, a risk factor for poor outcomes including ICU admission and death within 6 months after surgery. A serum albumin level < 3.5 g/dL was identified as a risk factor for dysphagia. Therefore, diagnostic testing should be performed to detect dysphagia, especially in patients with a low serum albumin level. Finally, particular care should be taken to prevent postoperative complications in patients with dysphagia.

A Minimum of 15-Year Results of Cementless Total Hip Arthroplasty Using a 28-mm Metal-On-Metal Articulation.

BACKGROUND: We previously reported unexpected early failures of total hip arthroplasty (THA) utilizing a 28-mm Ultima metal-on-metal (MoM) articulation. However, long-term results of small-diameter MoM THAs still remain unclear. The purpose of this study was to evaluate the clinical and radiographic outcomes of the previously reported cohort at a minimum follow-up of 15 years. METHODS: The original cohort consisted of 171 primary THAs (167 patients) using a 28-mm MoM articulation performed between April 2000 and March 2002. Of these, 130 hips (126 patients) were reviewed at an average follow-up of 17.1 (range, 15-18) years. Clinical score, complications, presence of osteolytic lesion, serum metal ion concentrations, and implant survivorships were evaluated. RESULTS: The mean Harris Hip Score improved from 44.9 points preoperatively to 90.5 points at the latest follow-up. During the entire period since the original surgery, a total of 5 revisions (3.8%) were associated with adverse reaction to metal debris (ARMD). The last revision surgery for symptomatic ARMD was performed at 6 years postoperatively. The implant survivorships with an end point of revision for aseptic failure and for any reason were 95.4% and 93.8%, respectively. Radiographic osteolytic lesions were detected in 27 hips (20.8%). The average serum metal concentration was 2.50 (range, 0.12-9.86) µg/L for cobalt and 2.81 (range, 0.82-12.3) µg/L for chromium. CONCLUSIONS: THA using a 28-mm MoM articulation showed favorable long-term outcomes with a relatively high revision-free survival rate. There was no significant symptomatic ARMD after the last acetabular revision performed at 6 years postoperatively.

Femoral Stem Survivorship in Dorr Type A Femurs After Total Hip Arthroplasty Using a Cementless Tapered Wedge Stem: A Matched Comparative Study With Type B Femurs.

BACKGROUND: There is a lack of understanding on relationship between the femoral geometry and outcomes of total hip arthroplasty (THA). We investigated clinical and radiographic outcomes of THA using a cementless tapered wedge stem in patients with Dorr type A proximal femoral morphology and compared with those of type B femurs at a minimum follow-up of 5 years. METHODS: We analyzed 1089 hips (876 patients) that underwent THA using an identical cementless tapered wedge stem. We divided all femurs into 3 types (Dorr type A, B, and C). Type A and B femurs were statistically matched with age, gender, body mass index, and diagnosis by using propensity score matching. Clinical, radiographic results, and stem survivorship were compared between the matched 2 groups. RESULTS: A total of 611 femurs (56%) were classified as type A, 427 (39%) as type B, and 51 (5%) as type C. More radiolucent lines around femoral stems were found in type A femurs (7.8%) than in type B femurs (2.5%) (P < .001). Patients with radiolucency showed worse Harris Hip Score (86.2 points) compared with those without radiolucency (93.0 points) (P < .001). The stem survivorship of type A femur (97.8%) was lower than that of type B femur (99.5%) (P = .041). The reasons for femoral revision in type A femurs were periprosthetic fracture (67%), aseptic loosening (22%), and deep infection (11%). CONCLUSIONS: This study showed a higher rate of complications after THAs using a cementless tapered wedge stem in Dorr type A femurs than those performed in type B femurs.

Clinical Outcomes and Bearing-Specific Complications Following Fourth-Generation Alumina Ceramic-on-Ceramic Total Hip Arthroplasty: A Single-Surgeon Series of 749 Hips at a Minimum of 5-Year Follow-Up.

BACKGROUND: The purpose of this study is to evaluate the minimum 5-year outcomes and bearing-specific complications in a single surgeon series of fourth-generation alumina ceramic-on-ceramic total hip arthroplasties (THAs). METHODS: We retrospectively analyzed 667 patients (749 hips) who underwent primary THAs by a single surgeon using fourth-generation alumina ceramic bearings. There were 315 men and 352 women with a mean age of 54.2 years. The surgeon used cementless prostheses with an identical design and BIOLOX Delta ceramics in all hips, using a 36-mm head in 472 hips (63%) and a 32-mm head in 227. The mean follow-up duration was 6.5 years (range, 5 to 8 years). RESULTS: The mean Harris hip score improved from 45.6 points preoperatively to 91.3 points at final follow-up. All but 1 acetabular cup and all femoral stems were well fixed. No radiographic evidence of osteolysis was identified at final follow-up. There were 2 (0.3%) ceramic liner fractures and no ceramic head fractures. A total of 48 hips (6.4%) exhibited audible noise (29 clickings and 19 squeakings), but no patient required revision. Other complications were 1 dislocation, 1 deep infection, 3 iliopsoas tendonitis, and 6 periprosthetic femoral fractures. Kaplan-Meier survivorship for revision for any reason was 98.6% (95% confidence interval, 97.7-99.5) at 6.5 years. CONCLUSION: Delta ceramic-on-ceramic THAs had a high rate of survivorship without radiographic evidence of osteolysis at 6.5-year follow-up. However, we found 0.3% ceramic liner fractures and 6.4% audible noises associated with the use of Delta ceramics.

Periprosthetic femoral fracture as cause of early revision after short stem hip arthroplasty-a multicentric analysis.

BACKGROUND: The objective of this study was to analyze the prevalence and causes of early re-operation after hip replacement surgery using short bone-preserving stems in a large multicentre series. Specifically, we evaluated the clinical features of periprosthetic fractures occurring around short stems. METHODS: A total of 897 patients (1089 hips) who underwent primary total hip arthroplasty or bipolar hemiarthroplasty from January 2011 to February 2015 using short bone-preserving femoral stems were recruited. Mean patient age was 57.4 years (range, 18-97 years), with a male ratio of 49.7% (541/1089). Re-operation for any reason within two years was used as an endpoint. The incidence and clinical characteristics of the periprosthetic femoral fractures were also recorded. Mean follow-up period was 5.1 years (range, 2-7.9 years). RESULTS: Early re-operation for any reason was identified in 16 (1.5%) of 1089 hips. The main reason for re-operation was periprosthetic femoral fracture, which accounted for eight (50%) of the 16 re-operations. The overall incidence of periprosthetic femoral fracture at two years was 1.1% (12/1089). According to the Vancouver classification, two fractures were AG type and the other ten were B1 type. Advanced age, higher American Society of Anesthesiologist grade, femur morphology of Dorr type C, and the use of a calcar-loading stem increased the risk for periprosthetic femoral fracture. CONCLUSION: Periprosthetic femoral fracture was the major reason for re-operation after hip replacement surgery using short bone-preserving stems accounting for 50% (8/16) of re-operations two years post-operatively, but did not seem to deteriorate survivorship of implanted prostheses.

High union rates of locking compression plating with cortical strut allograft for type B1 periprosthetic femoral fractures.

PURPOSE: Unified classification system (UCS) type B1 periprosthetic femoral fractures are associated with many complications, and management decisions continue to be controversial. The purpose of this study was to evaluate outcomes of UCS type B1 periprosthetic femoral fractures treated by locking compression plating with strut allograft augmentation. MATERIALS AND METHODS: We retrospectively reviewed 17 consecutive UCS type B1 periprosthetic femoral fractures treated by open reduction and internal fixation using a lateral locking compression plate supplemented with an anterior cortical strut allograft. There was one man and 16 women with an average age of 74 years (range, 57-92 years). All had a cementless hip arthroplasty, and eight of the arthroplasties were revisions. RESULTS: The mean duration of follow-up was 28 months (range, 12-74 months). All 17 fractures healed successfully at a mean of 20 weeks (range, 12-30 weeks). The mean post-operative Harris hip score was 86 points (range, 77-95 points). No mechanical complications such as failure of plate or screws and malalignment were noted. According to the graft-remodeling classification of Emerson et al., a partial bridging was observed in nine and a complete bridging in eight. Two patients required a removal of the plate due to irritation of the iliotibial band. No femoral stem loosening or deep infection was observed. CONCLUSION: Our findings indicate that open reduction and internal fixation of UCS type B1 periprosthetic femoral fractures using a lateral locking compression plate supplemented with anterior cortical strut allograft provides adequate mechanical stability of fracture fixation and enhances the fracture healing.

Primary ceramic-on-ceramic total hip arthroplasty using a 32-mm ceramic head with a titanium-alloy sleeve.

BACKGROUND: Modern ceramic-on-ceramic bearings have become attractive alternatives to conventional polyethylene in total hip arthroplasty (THA) as a result of their low wear and minimal particle production. However, 28-mm heads in ceramic-on-ceramic bearing couples have been associated with ceramic fracture. To address these issues, 32-mm and larger ceramic heads with a titanium-alloy sleeve have been introduced, although limited data are available on their durability and clinical outcomes. QUESTIONS/PURPOSES: We determined (1) the survivorship of the primary ceramic-on-ceramic THA using a 32-mm ceramic head with a titanium-alloy sleeve at a minimum followup of 5 years; (2) Harris hip scores; (3) the incidence of ceramic fracture and noisy hip; and (4) the proportion of hips showing radiographic evidence of osteolysis. METHODS: From November 2005 to August 2009, we performed 301 ceramic-on-ceramic THAs using a 32-mm ceramic head with a titanium-alloy sleeve in 270 patients. Of these, 12 patients (12 hips [4%]) died from problems unrelated to surgery and 13 patients (15 hips [5%]) were lost during followup before a minimum of 5 years had been reached, leaving 245 patients who had 274 THAs with a minimum followup of 5 years (mean, 6.5 years; range, 5-9 years) in this retrospective analysis. During the study period, 30% (301 of 997 hips) were performed with this articulation based on the operating surgeon's discretion. The mean patient age at the time of surgery was 55 years (range, 16-82 years). All operations were performed at a single center. All of the ceramic implants were hot isostatic-pressed, laser-marked, proof-tested third-generation alumina. We determined the implant survival, Harris hip scores, incidence of ceramic fracture or noisy hips (based on a questionnaire), and presence of osteolysis. RESULTS: The survival rate of ceramic-on-ceramic bearings in primary THA using a 32-mm ceramic head with a titanium-alloy sleeve was 98% (95% confidence interval, 96%-100%) at 9 years. The Harris hip score improved from a mean of 47 points preoperatively to 93 points at last followup. One ceramic head fractured at 6 years postoperatively. No ceramic liners fractured. Audible hip clicking and squeaking were identified in four hips and one hip, respectively. Osteolysis was detected in three hips, but none had symptoms. CONCLUSIONS: Primary ceramic-on-ceramic THA using a 32-mm ceramic head with a titanium-alloy sleeve has a survivorship of 98% at 9-year followup. Nevertheless, surgeons should be aware of the potential risks of ceramic fracture, noise, and osteolysis associated with the use of a ceramic head with a titanium-alloy sleeve. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Outcomes of total hip arthroplasty in patients with primary immune thrombocytopenia.

BACKGROUND: Immune thrombocytopenia (ITP) is an immune-mediated acquired disease that is characterized by a decrease in the platelet count and an increased risk of bleeding. There is little information in the literature about the results of major joint replacement surgery in patients with ITP. The aim of this study was to report on the results of total hip arthroplasty (THA) in patients with primary ITP. METHODS: We retrospectively identified 15 THAs performed in 11 patients with primary ITP. The study group was matched (1:2) to a non-ITP control group of 30 THAs in 22 patients. According to the perioperative hematologic evaluation, blood management interventions were performed. All procedures were performed by a single surgeon and all patients received cementless components with ceramic-on-ceramic bearing. Mean duration of follow-up was 7.1 years (range, 2-13). RESULTS: No significant differences were found between the two groups with regard to mean operative time, intraoperative blood loss, amount of closed suction drainage, length of hospital stay, and readmission rate. However, the proportion of patients requiring transfusion of packed red blood cells and/or platelet concentrate was higher in the ITP group when compared to the non-ITP group. Mean Harris hip score improved from 49.5 points preoperatively to 93.4 points at the final follow-up and no hips were revised for loosening or osteolysis in the ITP group. No significant differences were found between the two groups with respect to mean postoperative Harris hip scores and complication rates. CONCLUSIONS: Our study showed encouraging clinical and radiographic results of THA in patients with ITP without increased risk of adverse events compared to those in patients without ITP. On the basis of these findings, we suggest that modern cementless THA might be a viable treatment for achieving functional improvement in patients with ITP and end-stage hip disease.

High incidence of stem loosening in association with periprosthetic femur fractures in previously well-fixed cementless grit-blasted tapered-wedge stems.

PURPOSE: Periprosthetic femur fracture is a potentially worrisome phenomenon for cementless stem fixation. The aim of this study was to document the incidence of stem loosening following periprosthetic femur fracture in previously well-fixed cementless grit-blasted tapered-wedge stems. METHODS: We identified 36 periprosthetic femur fractures of either Vancouver B1 or B2 following hip arthroplasties using cementless grit-blasted tapered-wedge titanium stems at three participating institutions (GB group). The control group consisted of 21 periprosthetic femur fractures of either Vancouver B1 or B2 following hip arthroplasties using cementless proximal porous-coated stems at the same institutions during the same period of study (PC group). All femoral stems had been in a well-fixed state before occurrence of fracture. All patients were treated surgically and femoral stem stability was assessed using preoperative radiographs and confirmed by intraoperative scrutinization. RESULTS: Seven (19.4%) of 36 fractures were Vancouver B1 and 29 (80.6%) were Vancouver B2 in the GB group, whereas 18 (85.7%) of 21 fractures were Vancouver B1 and 3 (14.3%) were Vancouver B2 in the PC group (P < 0.0001). The odds ratio for stem loosening was 24.86 (95% CI, 5.69-108.63) in the GB group versus the PC group. CONCLUSIONS: Hip arthroplasty using cementless grit-blasted tapered-wedge titanium stems showed higher incidence of stem loosening in association with periprosthetic femur fracture than hip arthroplasty conducted using proximal porous-coated stems. A high index of suspicion of stem loosening might be necessary in periprosthetic femur fracture following hip arthroplasty using this type of stems.