Causes for revision of dual-mobility and standard primary total hip arthroplasty : Matched case-control study based on a prospective multicenter study of two thousand and forty four implants.

INTRODUCTION: The causes for revision of primary total hip arthroplasty (THA) are various and quite well known. The developing use of dual-mobility THA (DM-THA) seems a relevant option to decrease the risk of instability. Due to lack of long-term follow-up, this innovative retentive concept is suspected to increase the risk of polyethylene (PE) wear. the aim of the study was to analyse the causes for DM-THA revision and assess whether or not its occurrence is different from that of fixed-standard (FS) THA , particularly for aseptic loosening or wear and/or osteolysis. MATERIALS AND METHODS: The SoFCOT group conducted an observational prospective multicentre study from 1 January 2010 to 31 December 2011. Inclusion criteria comprised an exhaustive collection of 2044 first-revision THAs with 251 DM-THAs and 1793 FS-THAs. After excluding complications linked to patient factors (infection and periprosthetic fractures), we performed a matched case-control study (matching ratio 1:1) comparing two groups of 133 THAs. RESULTS: Revisions for aseptic loosening or osteolysis/wear were as frequent in DM-THA (58.7 %) as in FS-THA (57.1 %) (p 0.32); 7.5 % of DM-THA were revised for dislocation versus 19.5 % of FS-THA (p 0.007). DISCUSSION: Revision for osteolysis/wear and aseptic loosening were as frequent in DM-THA as in FS-THA; revision for dislocation was less frequent in DM-THA. This confirms the efficiency of the DM concept regarding the risk of dislocation. Causes for revision were different between groups, and revisions for dislocation were less frequent in DM-THA. Only prospective comparative studies could provide reliable information that may support broader use of the DM concept.

Cementless Total Hip Arthroplasty With Metasul Bearings Provides Good Results in Active Young Patients: A Concise Followup.

BACKGROUND: A primary concern of younger, more active patients who have undergone total hip arthroplasty (THA) is the longevity of the implant. Cementless fixation and hard-on-hard bearings are recognized as options to enhance THA durability. Earlier, we published a series of 83 cementless primary THAs using 28-mm metal-on-metal (MoM) bearings in patients aged 50 years or younger; here we provide concise followup on that same group after an additional 8-year survey period. QUESTIONS/PURPOSES: (1) What is the long-term survivorship of cementless primary THA using 28-mm MoM bearings in patients aged 50 years or younger? (2) What are the clinical and radiographic results of cementless THA in this active patient population? (3) Can any of the observed implant failures or adverse events be attributed to the metallic nature of the bearing couple? METHODS: We retrospectively reviewed 83 cementless THAs performed in three institutions over a decade (1995-2004) in 68 patients with 28-mm MoM articulation. All patients (15 bilateral) had a median age of 42 years (range, 24-50 years) at the time of the index procedure and 56 of them (82% [70 hips]) had activity level graded Devane 4 or 5 before significant hip pain. A 28-mm Metasul™ articulation was used with an Alloclassic-SL™ cementless stem in all cases paired with three different cementless titanium acetabular components (one threaded and two press-fit cups) from the same manufacturer. Survivorship analysis was calculated according to Dobbs life table, patient clinical results were evaluated with use of the Postel-Merle d'Aubigné scoring system, radiographic analysis was performed by independent observers, and cobalt level was determined in whole blood. RESULTS: The 15-year survivorship (33 hips at risk) for revision for any reasons (four hips) and for aseptic loosening (one hip) was 96% (95% confidence interval [CI], 81%-99%) and 99% (95% CI, 85%-99.9%), respectively. The median Merle d'Aubigné-Postel score remained stable at 17 points (range, 10-18). Thus far, we have not observed pseudotumors or other adverse reactions to metallic debris. Eight hips have undergone reoperation: trochanteric suture removal (one), psoas tendon impingement (two), and five revisions for periprosthetic fracture (one), late infection (two), acetabular osteolysis (one, as a result of polyethylene backside wear), and one hydroxyapatite-coated cup for aseptic loosening. None of the complications, failures, or revisions observed so far could directly be related to the metallic nature of the 28-mm Metasul bearings used in this selected group of patients. CONCLUSIONS: The current survey at 13-year median followup has not yet indicated any long-term deleterious effects related to dissemination of metallic ions. Two senior authors continue to use 28- or 32-mm Metasul™ bearings with cementless THA components in young and active patient populations. Longer followup with a more sophisticated imaging study is necessary to confirm this so far positive report. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Do the Reasons for Ceramic-on-ceramic Revisions Differ From Other Bearings in Total Hip Arthroplasty?

BACKGROUND: Despite widespread use of ceramic-on-ceramic (CoC) in total hip arthroplasty (THA) during the past 10 years, little is known about why revisions are performed in hips with this bearing or the time elapsed before revision. QUESTIONS/PURPOSES: The purposes of this study were: (1) Do the reasons for first revision differ between CoC bearings and other bearing couples? (2) Does the time to revision differ between CoC and other bearing couples? (3) Are there unique reasons for revisions of CoC bearings? METHODS: All members of the Société Française de Chirurgie Orthopédique et Traumatologique (SoFCOT) who performed ≥ 30 revisions per year were invited to participate in this multicenter, prospective, observational study. Our data represent 12% of the revision procedures performed in France. A total of 2107 first revisions of THA (from January 2010 to December 2011) were done in 2107 patients (1201 females [57%] and 906 males [43%]; median age, 73 years; age range, 17-104 years) at the time of surgery after a median of 11 years (range, 0 day-42 years) after the primary THA. There were 238 of 2107 (11%) CoC, 148 of 2107 (7%) metal-on-metal (MoM), and 1721 of 2017 (82%) metal-on-polyethylene (MoP) bearings. RESULTS: The reasons for reoperation differed according to the bearing component: (1) for the MoP reference bearing (odds ratio [OR]; 95% confidence interval), cup loosening occurred in 698 of 1721 hips (41%), periprosthetic fracture in 220 of 1721 hips (13%), and osteolysis in 213 of 1721 hips (12%); (2) for CoC, cup loosening occurred in 41 of 238 hips (17%) (OR, 0.31 [0.22-0.43; p < 0.001), infection in 39 of 238 hips (16%) (OR, 1.63 [1.12-2.37]; p = 0.01), and dislocation in 23 of 238 hips (10%) (OR, 0.9 [0.57-1.42]; p = 0.9); (3) for MoM, cup loosening occurred in 28 of 148 hips (19%) (OR, 0.34 [0.22-0.52]; p < 0.001), adverse reaction to metallic debris in 26 of 148 hips (18%) (OR, 18.12 [9.84-33.4]; p < 0.001), and infection in 16 of 148 hips (11%) (OR, 1 [0.59-1.73]; p = 0.9). In comparison with MoP, osteolysis was rarely the reason for revision in CoC (four of 238 hips [2%]; OR, 0.12 [0.05-0.33]; p < 0.001), but this bearing was frequently revised because of iliopsoas irritation (18 of 238 hips [8%]; OR, 4.9 [2.7-9]; p < 0.001). The time elapsed before revision differed between bearings: median of 3 years (range, 3 days to 28 years) for CoC and 4 years (range, 14 days to 37 years) for MoM versus a median 13 years (range, 0 day to 42 years) for MoP (p < 0.001). Thirty-seven of the 238 revisions (16%) were directly related to ceramic use (ceramic breakage [n = 23], squeaking [n = 6], impingement [n = 7], incorrect ceramic insert insertion [n = 1]). No factors were identified that contributed to breakage of the 12 bulk ceramic components (eight heads, four inserts, four of 12 Delta ceramic). No factors were associated with squeaking, iliopsoas irritation, or impingement, but component orientation was not assessed. CONCLUSIONS: The reasons and time to first revision differed between CoC and other bearings. CoC THAs are revised earlier and are sensitive to mechanical problems such as impingement, squeaking, and ceramic rupture that did not disappear with introduction of Delta ceramics and large-diameter (≥ 36 mm) bearings. CoC was rarely revised for osteolysis, but a high rate of iliopsoas irritation requires further investigation. LEVEL OF EVIDENCE: Level III, therapeutic study.

What does the SOFCOT-RENACOT 2024 hip prosthesis register tell us?

INTRODUCTION: The French Society of Orthopedic and Traumatology Surgery (SOFCOT) multicenter register of hip prostheses (HP) has been collecting data from nearly 100 centers in France since 2006. After 18 years of collection, this analysis was carried out to deduce the main conclusions. HYPOTHESIS: Despite its low representativeness (3%), this register provides instructive information on the evolution of hip arthroplasty techniques and implants in France. MATERIAL AND METHODS: As of the 31st of December 2023, 58,314 primary HP were recorded, mainly for primary osteoarthritis (44,535 hips, 76.4%), followed by femoral neck fractures (4,880, 8.4%). The mean age was 71 years (SD, 11.6) with 57% (33,305) women. In total, 73% of the implants were uncemented and 170 brand names were listed. Over the same period, 5,853 first reoperations were recorded. Social security number matching identified 777 revisions of an already registered primary HP. The revision index for 100 components observed per year (RCOY) allows the performance of implants to be compared (alert threshold if >1.3). RESULTS: The causes of these 777 early first revisions at a short mean follow-up (MF) of 1.4 years were: dislocation (191/777, 24.6%), peri-prosthetic fracture (175, 22.5%), aseptic loosening (103, 13.3%) and acute infection (101, 13%). The RCOY for all primary HP was 0.25 at 5.4 years of MF. This index: (i) Depended on the type of implant: 0.23 for HP with dual-mobility cups (DMC) at 4.7 years of MF; 0.25 for HP with short femoral stems at 4.4 years; and 0 for resurfacing after only 2.5 years (due to the creation of a specific mandatory register, since 2015, which put an end to the voluntary inclusion of resurfacing in this general register). (ii) Depended on the method of fixation: 0.21 for completely cemented HP at 7.8 years of MF and 0.29 at 4.9 years for completely uncemented HP. (iii) Based on the friction torque: 0.12 for conventional metal-metal HP at 9.7 years of MF and 0.29 at 5.1 years for alumina-alumina HP. (iv) Finally, 3 arthroplasties with 3 uncemented stems had an RCOY > 1.3. DISCUSSION: Although the RCOY of HP with conventional cemented femoral stems is only 0.16 at 6.6 years of MF, while that of HP with conventional uncemented stems is 0.29 at 4.9 years, the trend towards uncemented femoral fixation has continued to intensify. Resurfacing gives good results following careful selection of implants but with a short MF of 2.5 years. Conventional metal-metal bearings continue to give excellent results at almost 10 years of MF. The 10-year survival of HP with short femoral stems is favorable compared to that of HP with conventional stems. There is no significant difference between the survival of HP with conventional versus highly cross-linked polyethylene liner. CONCLUSION: Despite its low representativeness, this register provides information on the techniques and implants used in France. The addition of clinical monitoring and PROM within the new SOFCOT-RENACOT registry as well as re-certification obligations should help promote its development. LEVEL OF EVIDENCE: III; prospective comparative study.

Reasons for malpractice claims after primary total hip arthroplasty in France: Insurance data from 240 claims from 2014 to 2017.

INTRODUCTION: Total hip arthroplasty (THA) is one of the most frequent orthopedic surgery procedures, and orthopedic surgeons are among the most frequently accused of malpractice by their patients. Identifying the main reasons for malpractice claims after THA is a prior condition to reducing their frequency. The quality of the preoperative risk information given to the patient by the surgeon is crucial for these purposes. Data specific to THA are sparse in France, and we therefore conducted a retrospective study (1) to determine whether the outcome of medico-legal expert appraisal correlated with the quality and traceability of preoperative information, and (2) to identify the most frequent grounds for complaint after primary THA. HYPOTHESIS: The quality of patient information partly determines expert appraisal. MATERIAL AND METHOD: A retrospective study was conducted based on data from the Branchet medical professional insurance agency for malpractice claims following THA over the period 2014-2017, with 240 complete files, for 125 women and 115 men. Data comprised: type of procedure, main grounds of complaint (complications), positive or negative expert appraisal, quality of preoperative patient information, amounts of compensation accorded and fees paid, and the practitioner's liability. We assessed correlations between information quality and liability. RESULTS: Surgical site infection and neurologic deficit were the two main grounds for malpractice claims. In the 240 files, cases for 106 operations (44.2%) were submitted to arbitration, 95 (39.6%) were brought to court, and 39 (16.2%) were settled out of court. The practitioner was held at least partly liable in 40 files (16.7%). Information to the patient was deemed imperfect or poor for 119 files (49.6%) and good in 121 (50.4%). Mean compensation was €30,940 (range, €0 to €198,100). In 27 of the 40 cases of liability (67.5%), the information to the patient was deemed imperfect or poor. Twenty-six of the 40 cases (65%) were settled out of court. In case of poor information, there was a significant risk for the practitioner to be held liable: 7.5 vs. 25% (p=0.003). DISCUSSION: The present study listed the main complications underlying malpractice claims after THA: infection, neurologic complications, and limb-length discrepancy. This should enable practitioners to improve patient information so as to reduce the rate of malpractice claims or at least decrease the practitioner's liability, as the study found a correlation between information quality and expert appraisal. LEVEL OF EVIDENCE: IV; retrospective study.

What are the causes for failures of primary hip arthroplasties in France?

BACKGROUND: There are no large database cohorts describing the causes for failure of primary THAs in France. Because implants and causes for revision vary between national registers, it is important to obtain data from all countries. QUESTIONS/PURPOSES: We therefore determined (1) the mechanisms of failure of primary THAs, (2) their order of appearance with time, (3) the types of surgical techniques and implant designs used to perform revision THAs, and (4) 90-day complications after revision THA in France. METHODS: We prospectively collected data on all 2107 first-time revision THAs from 30 tertiary centers from January 1, 2010, to December 31, 2011. A dual-mobility liner had been used in 251 hips. Mean time from primary procedure to revision THA was 11.2 years (range, 1 day to 42 years). Mean age at revision was 70 years (range, 17-104 years). RESULTS: The causes for revision were mechanical loosening (42%), periprosthetic fracture (12%), infection (11%), wear/osteolysis (11%), dislocation (10%), surgical technique error (6%), and implant fracture (3%). The most common type of revision procedure was all-component revision (49%). A dual-mobility liner was used in 1184 hips (62%). The 90-day dislocation rate was less than 4%, and mortality rate was 1.6%. CONCLUSIONS: Contrary to other reported data, we found dislocation was not the main cause for failure of primary THAs but was still the more frequent early complication after revision. These findings might be related to the use of dual-mobility sockets in more than 10% of primary THAs and more than 60% of revision THAs.

Bone cement implantation syndrome in hip arthroplasty: Frequency, severity and prevention.

INTRODUCTION: Cemented femoral implants incur a serious risk of potentially fatal accidents in case of bone cement implantation syndrome (BCIS). As French data are sparse regarding this issue, Orthorisq, the official accreditation body for orthopedic surgeons, conducted an inter-professional survey: 1) to assess the frequency of BCIS, 2) to analyze risk factors related to the patient and to professional practices, and 3) to set out guidelines to reduce frequency and/or severity. HYPOTHESIS: French data on BCIS are underestimated and need updating to ease communication between colleagues. MATERIAL AND METHOD: In 2019, Orthorisq ran a survey of its members' practices and a "mirror" survey of anesthesiologists. In the decade from 2009 to 2018, the 775 respondent orthopedic surgeons, both occasional and systematic "cementers", reported their experience with a declared annual rate of 80,112 arthroplasties, including 63,799 (79.6%) in scheduled surgery. Some of the survey questions concerned cementing technique. With the help of the French College of Anesthesia and Intensive Care Medicine, 305 anesthesiologists responded to the mirror survey. RESULTS: The 776 orthopedic surgeons reported 1896 cementing accidents with 387 deaths during the study decade. Accidents were 6-fold more frequent in traumatology than in scheduled orthopedic surgery (0.71% versus 0.12%) and, more importantly, were more serious: mortality was 10-fold higher (0.17% versus 0.017% [p<0.001]). Certain "tricks and tips" intended to improve cementing quality, such as a dedicated system and especially a plug, significantly increased the risk of BCIS (p<0.001). Over the same period, the 305 anesthesiologists had been involved in 490 cementing accidents; 88 (29%) had been faced by at least 1 death, most often in emergency settings (60/28). While 753 surgeons (96%) reported warning the anesthetists and 571 (74%) waited for agreement before cementing, only 109 (36%) and 124 (41%) anesthetists reported being systematically alerted to cementing and implant reduction, respectively. The rate of serious accidents was 0.19% and mortality was 0.05%, for a cumulative probability of 0.24% per year. Extrapolated to the data of the ATIH Technical Agency of Hospitalization Information and subtracting arthroplasties by "never-cementers", these figures indicate 311 accidents with 65 deaths in femoral BCIS for 2018. DISCUSSION: In scheduled surgery, BCIS was exceptional, but the rate in traumatology was much higher. Certain techniques intended to improve femoral cementing quality actually increased the risk of BCIS; in high-risk patients, especially in traumatology, non-cemented femoral implants or else a 1st-generation cementing technique should therefore be preferred. Prevention of BCIS and/or reduction of severity require identification of at-risk patients and good communication between surgeons and anesthesiologists, especially at the various steps of the checklist. LEVEL OF EVIDENCE: IV; case series.

Is dual mobility associated with an increased risk of revision for infection? Matched cohort of 231 cases of dual-mobility cups and 231 fixed cups.

INTRODUCTION: We used a matched cohort of 231 cases of revision of primary dual-mobility cups (DMC) total hip arthroplasty (THA) and 231 cases of fixed cups (FC) THA, to determine whether (i) revision for infection was more frequent when using DMC-THA than FC-THA; (ii) Causes for revision were significantly different. METHODS: The French Society of Orthopaedics and Traumatology carried out a prospective multicentre study from 2010 to 2011. The inclusion criterion was an exhaustive collection of 1st revision THA (at least 1 component revised, re-revision excluded). 2,044 1st revision cases were prospectively collected; 251 (13.5%) were revision of DMC-THA and 1,793 were revision of FC-THA (87.7%). We defined a matching process (1:1) between the 2 cohorts. 231 DMC-THAs were eligible for comparison with 231 FC-THAs. RESULTS: 47 (20.3%) FC-THAs were revised for infection and 54 (23.3%) DMC-THAs. There was no statistical difference (p = 0.43). 41 (17.7%) FC-THAs were revised for dislocation, compared to 11 (4.7%) DMC-THAs (p<0.001). DISCUSSION: The main finding of our study was that DMC was not associated with an increased risk of revision for infection compared to standard THA. THA revision for infection was not correlated to the type of cup used. It is mandatory to report on comparable types of patients when comparing outcomes. For similar patient profiles (i) DMC-THAs were not revised more often for infection than FC-THA (ii) FC-THAs were revised 4 times more for dislocation than DMC-THA.

THA using metal-on-metal articulation in active patients younger than 50 years.

UNLABELLED: The main concern of patients with longer life expectancies and of patients who are younger and more active is the longevity of their total hip arthroplasty. We retrospectively reviewed 83 cementless total hip arthroplasties in 73 patients implanted with metal-on-metal articulation. All patients were younger than 50 years old (average age, 41 years) at the time of the index procedure, and 80% of the patients had an activity level graded 4 or 5 when measured with the system of Devane et al. A 28-mm Metasul articulation was used with three different cementless titanium acetabular components. At the most recent followup (average, 7.3 years), the average Merle d'Aubigné-Postel score improved from a preoperative 11.1 points to 17.4 points. We observed no radiographic evidence of component loosening. Ten acetabular components had lucency limited to one zone. The 10-year survivorship with the end point of revision (ie, exchange of at least one prosthetic or bearing component) was 100% (95% confidence interval, 90%-100%). Metasul bearings with cementless acetabular components remain promising in this high-risk younger patient population. However, additional followup strategies are recommended to determine any possible long-term deleterious effects associated with the dissemination of metallic ions. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Metal-on-metal bearings in cementless primary total hip arthroplasty.

One hundred cementless titanium primary total hip arthroplasties with 28 mm Metasul bearings were prospectively studied (osteoarthritis in 76% of hips, mean age 59.6 years). Ninety-eight were reviewed after a 6-year average follow-up (range, 17-126 months) with clinical results graded excellent and good in 97%. One femoral component was revised for aseptic loosening at 7.8 years. Postoperative cobalt level was higher than the upper "normal" value (5 microg/L in whole blood) for 16 cases. No significant relationship could be established between cobalt concentration increase and any demographic or surgical data, including activity level, except anteversion of the cup >25 degrees. In this early experience, impingement due to a head sleeve has been the main cause of dislocation and failure, and systemic cobalt survey appeared to be a good indicator of metal-on-metal bearing mechanical behavior.