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.

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.

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.

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.

Medium-Term Outcomes of a Forward-Striking Technique to Reduce Fracture Gaps during Long Cephalomedullary Nailing in Subtrochanteric Femoral Fractures.

INTRODUCTION: A residual fracture gap after intramedullary nailing is a known risk factor for delayed union and non-union. This study aimed to report the outcomes of a forward-striking technique to reduce fracture gaps during long cephalomedullary nailing in subtrochanteric femoral fractures (SFFs). METHODS: A retrospective cohort study was conducted on patients with SFFs treated in a single institution between February 2013 and October 2018. A total of 58 patients treated via long cephalomedullary nailing with a forward-striking technique were included. The width of the fracture gap, location of the cephalic screw, tip-apex distance (TAD), and time to bone union were evaluated using intraoperative and postoperative radiographs. Complication rates, including fixation failure, non-union, implant breakage, and infection, were assessed. The mean follow-up duration was 4 (range, 2‒8) years. RESULTS: Of the 58 patients (mean age, 67.9 years), 38 (65.5%) were female. Thirty-two cases (55.2%) were classified as atypical femoral fractures. The mean fracture gap reduced from 5.1 mm to 1.6 mm by forward striking (P<0.001). The reduced fracture gap was significantly greater in atypical SFFs (mean, 4.9 mm vs. 1.7 mm; P<0.001). The lag screw was located in the center-center or center-inferior zones of the femoral head in 54 patients (93.1%). The mean TAD was 14.2 mm and was under 25 mm in 55 patients (94.8%). Bone union was achieved in all cases without reoperation at a mean of 5.4 months. One incident of lag screw breakage was noted at 5 months, but bone union was achieved at 7 months. CONCLUSIONS: The forward-striking technique with a long cephalomedullary nail demonstrated a 100% bone union rate in a consecutive series of 58 SFFs. This technique is effective in reducing the fracture gap as well as placing the cephalic screw into the optimal position. The forward-striking technique was particularly effective in reducing atypical SFFs with a transverse or short oblique configuration.

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.

Effects of disusing closed suction drainage in simultaneous bilateral total hip arthroplasty: A retrospective cohort study.

PURPOSE: Increased blood loss remains a major drawback of simultaneous bilateral total hip arthroplasty (SBTHA). We examined the effects of disusing closed suction drainage (CSD) on postoperative blood loss and transfusion requirement in cementless SBTHA. METHODS: A retrospective cohort study was conducted with a consecutive series of cementless SBTHAs performed by a single surgeon between January 2014 and March 2017. The surgeon routinely used CSD until May 2015 and refrained from CSD in all primary THAs thereafter. This study included SBTHAs with intravenous administration of tranexamic acid (TXA). Postoperative hemoglobin drop, blood loss, transfusion rate, pain scores, complication rates, and implant survivorships were compared between the groups of SBTHA with and without CSD. The minimum follow-up duration was 1 year. RESULTS: Among the 110 patients (220 hips), 46 (92 hips) and 64 (128 hips) underwent SBTHA with and without CSD, respectively. Maximum hemoglobin drop (mean, 4.8 vs. 3.9 g/dL; P = 0.001), calculated blood loss (mean, 1530 vs. 1190 mL; P<0.001), transfusion rate (45.7% vs. 21.9%; P = 0.008), and length of hospital stay (mean, 6.6 vs. 5.8 days; P = 0.004) were significantly lower in patients without CSD. There were no significant differences in postoperative pain scales and wound complication rates. The mean Harris Hip scores at final follow-up (92.5 vs. 92.1; P = 0.775) and implant survivorships with an end-point of any revision at 4 years (98.9% vs. 98.4%; log-rank, P = 0.766) were similar between groups. CONCLUSIONS: Disusing CSD significantly reduced postoperative blood loss and transfusion requirement without increasing postoperative pain and surgical wound complications in cementless SBTHA with concurrent administration of intravenous TXA.

Total Hip Arthroplasty for Secondary Coxarthrosis in Patients with Hereditary Multiple Exostoses: Minimum 5-Year Follow-up Results and Surgical Considerations.

BACKGROUND: Hereditary multiple exostoses (HME) is an autosomal dominant disorder. The lesion in the proximal femoral metaphysis can bring about hip dysplasia and subsequent degenerative arthritis. Due to its rare prevalence, there have been a few case reports of total hip arthroplasty (THA) for osteoarthritis secondary to HME. The aim of this study was to report mid- to long-term outcomes of THA in HME patients and discuss special considerations that should be taken into account during surgery. METHODS: We retrospectively evaluated the clinical and radiological results of THA for osteoarthritis secondary to HME in 11 hips of 9 patients after a minimum follow-up of 5 years (mean, 9.9 years). There were 3 men (3 hips) and 6 women (8 hips), with a mean age of 53.6 years (range, 46.8-58 years) at the index surgery in this study. Harris hip score (HHS) was used for clinical outcome assessment, and radiologically, implant stability, radiolucent lines, liner wear, and any sign of osteolysis or implant loosening were evaluated. Postoperative complications including infection, deep vein thrombosis, and dislocations were also investigated. RESULTS: Cemented stems and cementless cups with the conventional polyethylene liner were used in bilateral hips of a single patient. In the other cases, cementless implants were used with ceramic-on-ceramic bearings. The mean HHS improved from 34.8 preoperatively to 92.5 postoperatively. Polyethylene liner wear and osteolysis were observed in 1 patient with cemented stems. Radiolucent lines were observed in 2 different cases. However, the femoral stems remained stable. There were no surgery-related complications except heterotopic ossification during follow-up. CONCLUSIONS: Despite the several surgical considerations, the mid- to long-term clinical and radiological outcomes of THA in HME patients were satisfactory. The abnormal, wide mediolateral diameter of the proximal metaphysis should be considered in selecting and inserting the stem with adequate anteversion. Leg length discrepancy was also common, so teleradiographs should be obtained before surgery. Intraoperative leg length evaluation might be difficult due to the morphologic changes in the proximal femur after mass excision and individual bone length differences.

Risk factors for osteonecrosis of the femoral head in brain tumor patients receiving corticosteroid after surgery.

PURPOSE: Non-traumatic osteonecrosis of the femoral head (ONFH) is a plausible complication in brain tumor patients. Frequent use of corticosteroid therapy, chemotherapy, and oxidative stress for managing brain tumors may be associated with the development of ONFH. However, there is little knowledge on the prevalence and risk factors of ONFH from brain tumor. This study aimed to investigate the prevalence and risk factors of ONFH in patients with primary brain tumors. METHODS: This retrospective cohort study included data from consecutive patients between December 2005 and August 2016 from a tertiary university hospital in South Korea. A total of 73 cases of ONFH were identified among 10,674 primary brain tumor patients. After excluding subjects (25 out of 73) with missing data, history of alcohol consumption or smoking, history of femoral bone trauma or surgery, comorbidities such as systemic lupus erythematosus (SLE), sickle cell disease, cancer patients other than brain tumor, and previous diagnosis of contralateral ONFH, we performed a 1:2 propensity score-matched, case-control study (ONFH group, 48; control group, 96). Risk factors of ONFH in primary brain tumor were evaluated by univariate and multivariate logistic regression analyses. RESULTS: The prevalence of ONFH in patients with surgical resection of primary brain tumor was 683.9 per 100,000 persons (73 of 10,674). In this cohort, 55 of 74 patients (74.3%) underwent THA for ONFH treatment. We found that diabetes was an independent factor associated with an increased risk of ONFH in primary brain tumor patients (OR = 7.201, 95% CI, 1.349-38.453, p = 0.021). There was a significant difference in univariate analysis, including panhypopituitarism (OR = 4.394, 95% CI, 1.794-11.008, p = 0.002), supratentorial location of brain tumor (OR = 2.616, 95% CI, 1.245-5.499, p = 0.011), and chemotherapy (OR = 2.867, 95% CI, 1.018-8.069, p = 0.046). CONCLUSIONS: This study demonstrated that the prevalence of ONFH after surgical resection of primary brain tumor was 0.68%. Diabetes was an independent risk factor for developing ONFH, whereas corticosteroid dose was not. Routine screening for brain tumor-associated ONFH is not recommended; however, a high index of clinical suspicion in these patients at risk may allow for early intervention and preservation of the joints.

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.

Hip resurfacing arthroplasty for osteonecrosis of the femoral head: Implant-specific outcomes and risk factors for failure.

BACKGROUND: Hip resurfacing arthroplasty (HRA) may be a suitable option for treating osteonecrosis of the femoral head (ONFH). However, concerns regarding the extent of osteonecrosis, amount of defect under the prosthesis, and implant-related complications remain. This study aimed to report implant-specific outcomes and risk factors for failure of HRA in ONFH. METHODS: A total of 202 HRAs (166 patients) performed by a single surgeon were investigated. The stage, size, and location of ONFH were evaluated using preoperative radiographs and magnetic resonance images. Clinical, radiographic results, and serum metal concentrations of articular surface replacement (ASR) and non-ASR devices were compared. Logistic regression analysis was performed to identify the contributors of failures. The mean follow-up duration was 10.6 years. RESULTS: Twenty-six hips (12.9%) were operated with Birmingham Hip Resurfacing (BHR), 99 (49.0%) with ASR, and 77 (38.1%) with Conserve Plus. The mean Harris Hip Score improved from 52.1 to 93.2 at the final follow-up (P < 0.001). Revision-free survivorships of non-ASR and ASR implants were 99.0% and 82.4%, respectively (P < 0.001). In multivariate analysis, the use of ASR prosthesis, greater combined necrotic angle, and smaller head size were associated with revision surgery. A large combined necrotic angle was the only independent risk factor for mechanical failure at the femoral side (P = 0.029). CONCLUSION: HRA for ONFH using BHR and Conserve Plus implants demonstrated favourable clinical outcomes with high revision-free survival rates at 10 years. However, care should be taken for large necrotic lesions that can lead to femoral neck fracture or aseptic femoral loosening. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: This study suggests HRA performed for appropriately selected patients with ONFH can show excellent long-term clinical results. Therefore, HRA should remain as one of the treatment options for ONFH, and further development of HRA implants should be continued.

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.

Outcomes of Total Hip Arthroplasty in Patients with Osteonecrosis of the Femoral Head Following Surgical Treatment of Brain Tumors.

Corticosteroids have been widely used in patients with brain tumors to reduce tumor-associated edema and neurological deficits. This study examined the outcomes of total hip arthroplasty (THA) in patients with osteonecrosis of the femoral head (ONFH) following brain tumor surgery. We identified 34 THAs performed in 26 patients with steroid-induced ONFH among 9254 patients undergoing surgical treatment for primary brain tumors. After propensity score matching with demographics, 68 THAs (52 patients) in ONFH unrelated to brain tumors were selected as the control group. At the time of THA, 54% of brain tumor patients had neurological sequelae and 46% had adrenal insufficiency. After THA, patients with brain tumor required longer hospital stay, reported a lower functional score, and showed a higher rate of heterotopic ossification compared to the control group. However, hip pain score improved significantly after THA in the brain tumor group, and did not differ from that of the control group (P-value = 0.168). Major complication rates were similar (2.9% and 1.5% for the brain tumor and control groups, respectively; P-value = 1.000), and implant survivorships were not different at 7 years (100% and 98.1% for the brain tumor and control groups, respectively; P-value = 0.455). Our findings suggest that THA can be safely performed to reduce hip pain in patients with steroid-induced ONFH after surgical treatment of primary brain tumors.

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.

High survivorship of highly cross-linked polyethylene in revision Total hip Arthroplasty: a minimum 10-year follow-up study.

PURPOSE: Highly cross-linked polyethylene has been introduced to decrease osteolysis secondary to polyethylene wear debris generation. However, few long-term data on revision total hip arthroplasty (THA) using highly cross-linked polyethylene liners are available. The objective of this study was to determine long-term outcomes of a highly cross-linked polyethylene liner in revision THA. MATERIALS & METHODS: We evaluated 63 revision THAs performed in 63 patients using a highly cross-linked polyethylene liner between April 2000 and February 2005. Of these, nine died and four were lost to follow-up. Thus, the final study cohort consisted of 50 patients (50 hips), including 26 males and 24 females with a mean age of 53 years (range, 27-75 years). Mean follow-up was 11 years (range, 10-14 years). RESULTS: The mean Harris hip score improved from 44 points preoperatively to 85 points at the final follow-up. No radiographic evidence of osteolysis was found in any hip. The mean rate of polyethylene liner wear was 0.029 mm/year (range, 0.003 to 0.098 mm/year). A total of 5 hips (10%) required re-revision arthroplasty, including one cup loosening, one recurrent dislocation, and three deep infections. Kaplan-Meier survivorship with an end point of re-revision for any reason was 91.1% and for aseptic cup loosening was 97.9% at 11 years. CONCLUSION: At a minimum of 10 years, the highly cross-linked polyethylene liners showed excellent clinical performance and implant survivorship, and were not associated with osteolysis in our patients with revision THAs.

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.

Modular Stems: Advantages and Current Role in Primary Total Hip Arthroplasty.

Using modular femoral stems in total hip arthroplasty enables surgeons to make fine adjustments to individual joints and offers intraoperative flexibility. The concept of modularity has been developed in numerous shapes, resulting in a vast range of options. Among them, the greatest achievement has been made for prostheses with modular proximal sleeves. The use of these implants has resulted in excellent mid- to long-term results in a number of cases. Although the use of tapered stems with a broaching technique is gaining popularity in straightforward primary surgeries, modular femoral implants are still associated with a number of potential challenges (e.g., developmental dysplasia of the hip, infection sequelae, and skeletal dysplasia). Based on published results, it is advisable to consider it as an option for complicated cases where the proximal femur is severely deformed.

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.