A cementless hip system with a new surface for osseous integration

Biological Safety Evaluation and Surface Modification of Biocompatible Ti-15Zr-4Nb Alloy

We performed biological safety evaluation tests of three Ti–Zr alloys under accelerated extraction condition. We also conducted histopathological analysis of long-term implantation of pure V, Al, Ni, Zr, Nb, and Ta metals as well as Ni–Ti and high-V-containing Ti–15V–3Al–3Sn alloys in rats. The effect of the dental implant (screw) shape on morphometrical parameters was investigated using rabbits. Moreover, we examined the maximum pullout properties of grit-blasted Ti–Zr alloys after their implantation in rabbits. The biological safety evaluation tests of three Ti–Zr alloys (Ti–15Zr–4Nb, Ti–15Zr–4Nb–1Ta, and Ti–15Zr–4Nb–4Ta) showed no adverse (negative) effects of either normal or accelerated extraction. No bone was formed around the pure V and Ni implants. The Al, Zr, Nb, and Ni–Ti implants were surrounded by new bone. The new bone formed around Ti–Ni and high-V-containing Ti alloys tended to be thinner than that formed around Ti–Zr and Ti–6Al–4V alloys. The rate of bone formation on the threaded portion in the Ti–15Zr–4Nb–4Ta dental implant was the same as that on a smooth surface. The maximum pullout loads of the grit- and shot-blasted Ti–Zr alloys increased linearly with implantation period in rabbits. The pullout load of grit-blasted Ti–Zr alloy rods was higher than that of shot-blasted ones. The surface roughness (Ra) and area ratio of residual Al₂O₃ particles of the Ti–15Zr–4Nb alloy surface grit-blasted with Al₂O₃ particles were the same as those of the grit-blasted Alloclassic stem surface. It was clarified that the grit-blasted Ti–15Zr–4Nb alloy could be used for artificial hip joint stems.

Impact of Acetabular Implant Design on Aseptic Failure in Total Hip Arthroplasty

Background

Failure of cementless acetabular osseointegration is rare in total hip arthroplasty. Nevertheless, new fixation surfaces continue to be introduced. Novel implants may lack large diameter, constrained bearings, or dual mobility (DM) bearings to address instability. We compared clinical and radiographic outcomes for acetabular components with differing fixation surfaces and bearing options, focusing on the relationship between fixation surface and osseointegration and the relationship between bearing options and dislocation rate.

Methods

We retrospectively reviewed 463 total hip arthroplasties implanted with 3 different acetabular components between 2012 and 2016. Records were reviewed for demographics, clinical scores, and complications. Radiographs were examined for evidence of acetabular osteointegration. Analysis of variance and chi-square tests were used to compare cohorts.

Results

All cohorts had 100% survivorship free of acetabular fixation failure with no differences in clinical scores. Dislocation occurred in 1.3% of cases (n = 6). Analysis of the “transition” sizes, for which brand determined the maximum bearing diameter, revealed a significantly higher dislocation rate (3/50, 6%) in implants with limited bearing options. All 4 revisions for recurrent dislocation involved well-positioned components that did not accept large diameter, constrained bearings, or DM bearings, resulting in 3 shell revisions to expand bearing options. Femoral revisions were associated with dislocation risk but did not vary between cohorts.

Conclusion

Dislocation was the primary mechanical cause for acetabular revision, while acetabular fixation failure was not encountered. We caution against selecting “new and improved” acetabular components without options for large diameter, constrained bearings, or DM bearings, even when enabling technology makes component positioning reliable.

High Revision Rates of a Cementless Beta-Titanium Alloy Stem with Contamination-Free Roughened Surface in Primary Total Hip Arthroplasty

Optimal osseointegration of cementless total hip arthroplasty is essential for high stability and long-term survival. The purpose of this follow-up study was to evaluate the clinical and radiological outcome, the complications, and survival rates of a beta-titanium alloy stem with a specific grit-blasted-free surface. In 192 patients (mean age of 64.4 years), 202 consecutive primary total hip arthroplasties were performed using a cementless Hipstar^® stem (Stryker, Duisburg, DE). The Harris Hip Score (HHS) was assessed pre-operatively and post-operatively. Radiolucent lines were evaluated and the implant survival rate was calculated using Kaplan-Meier analysis. The mean follow-up was 7.71 years (range of 5.0–14.0 years). Overall, 15 revisions were performed. Early aseptic stem loosening was observed in six cases (2.97%). Radiolucent-lines adjacent to the stem were detected in 73 cases (83.02%), especially (70.46%) in the Gruen zones 1, 7, 8, and 14. The mean postoperative HHS was 92.65 points (range 42–100). The cumulative survival probability of the stem was 94.4% (95% CI 90.3 to 98.5%). Considering aseptic failure as an endpoint, the cumulative survival rate of the stem was 95.3% (95% CI 0.914 to 0.992) at six years of follow-up. Overall, an inferior mid-term implant survival was observed in comparison to well-established cementless stem designs.

Prospective randomized study using EBRA-FCA to compare bone fixation between cementless SL-PLUS Zweymüller versus SL-PLUS MIA femoral implants in primary total hip arthroplasty with clinical assessment at a minimum 5years' follow-up

INTRODUCTION

Sometimes the slightest changes in implant design can lead to failure, even for a validated prosthesis. A minimally invasive cementless model, the SL-PLUS MIA™, in which the lateral shoulder is eliminated, was developed from the Zweymüller SL-PLUS™ implant. After satisfactory in-vitro tests, it required in-vivo assessment to ensure that bone fixation is good. We therefore conducted a prospective randomized study comparing the two versions of the Zweymüller femoral stem, with the aim of (1) comparing bone fixation up to 2 years' follow-up on EBRA-FCA radiography; and (2) assessing any difference in clinical or radiographic performance.

HYPOTHESIS

Primary stability assessed on EBRA-FCA does not significantly differ between the SL-PLUS MIA™ and SL-PLUS™ implants.

PATIENTS AND METHOD

A single-center multi-surgeon prospective randomized study included 80 patients (79 were operated on) between April 2009 and October 2012, with a mean 6 years' follow-up. Radiographic assessment used the EBRA-FCA application up to 2 years' follow-up; clinical assessment, with a minimum 5 years' follow-up, was performed by a single observer, using the Harris and Oxford-12 scores. The two groups, SL-PLUS™ (n=38) and SL-PLUS MIA™ (n=41), were comparable in gender, age, indications, body-mass index and preoperative functional status.

RESULTS

At a minimum 2 years' follow-up, 24 SL-PLUS™ and 27 SL-PLUS MIA™ implants were analyzed on EBRA-FCA. Mean migration was respectively -0.3mm±0.8 [range, -1.6 to 1.3] and -0.5mm±0.7 [range, -2.2 to 0.5] (p=0.21). There was likewise no significant difference in varus tilt. The number of ectopic ossifications did not differ, despite the absence of shoulder: 7 with SL-PLUS™ (23%), and 10 with SL-PLUS MIA™ (32%), without clinical impact. Oxford score improved from 43±6.8 to 19±7 at 5 years' follow-up with SL-PLUS ™ and from 44±8.8 to 20±7.4 with SL-PLUS MIA™: i.e., no significant inter-group difference. Likewise, Harris score at 2 years' follow-up did not differ: 91.6±8.7 and 89.7±10.2, respectively. Implant survival did not differ: SL-PLUS MIA™, 41/41 (100%); SL-PLUS™, 36/38 (94.7%) (p=0.13).

CONCLUSION

There was no significant difference in fixation quality between the SL-PLUS™ and SL-PLUS MIA™ implants. Elimination of the shoulder did not jeopardize primary or secondary fixation, but neither did it reduce the rate of ossification. The modified Zweymüller implant appeared risk-free at 6 years' follow-up.

LEVEL OF EVIDENCE

II, low-power prospective randomized study.

Total hip arthroplasty with accolade/trident through the direct minimally invasive anterior approach without traction table: Learning curve and results after a minimum of 5 years

BACKGROUND

The direct minimally invasive anterior approach (DMIAA) in total hip arthroplasty (THA) is widely accepted. In our department the DMIAA according to Rachbauer together with the Trident cup and Accolade stem was introduced in 2004. The purpose of the study was to demonstrate the five-year results and to analyze the learning curve of a new introduced approach.

PATIENTS AND METHODS

Between July 2004 and May 2006, a consecutive series of 151 THA in 147 patients was retrospectively analyzed. All patients were planned to received a THA with the Accolade/Trident implant system using the DMIAA without traction table. Clinical and radiographic data, complications and survivorship were documented with a follow-up of at least 5 years.

RESULTS

Regarding cup implantation, there were 11 (7.3%) failed intentions to treat due to missing pressfit (8 cases) and acetabular floor perforation (3 cases). No failed intentions to treat occurred during stem implantation. Total implant survival after 5 years follow-up after exclusion of 11 cases with failed intention to treat (N=140) was 96.9% (SD 1.4; CI 94.3-99.6). After exclusion of the failed intentions to treat (N=140, N=4 in the first 20 cases), there was significant (p<0.001) difference between the first 16 implants with a 5 year-survival of 83.2% (SD 8.6; CI 66.4-100) and 95.7% (SD 0.9; CI 93.9-97.5) for the following 124 implants. Radiolucent lines were observed in Gruen zone 1 in 3.3% and in Gruen zone 1 and 2 in 1.1%.

DISCUSSION

THA with Accolade/Trident using the DMIAA without traction table according to Rachbauer temporary exposed patients to a higher risk of implant revisions, which was normalized after the first 20 cases. Results of the learning curve are comparable to other techniques using an orthopaedic traction table. After the typical learning curve, the rate of 5 years implant failure is in accordance with the registry data for non-cemented implants. The Accolade stem showed minimal radiographic signs of radiolucency.

LEVEL OF EVIDENCE

IV, retrospective, consecutive case series.

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.

Radiolucencies surrounding acetabular components with three-dimensional coatings: artifact or real?

Background

Several 2-dimensional and 3-dimensional surfaces are available for cementless acetabular fixation. Plain radiographs are used to assess osseointegration; however, the radiographs are limited by their inability to capture the bone fixation process occurring over the 3-dimensional cup surface. In this cadaveric study, we compared the bone apposition between 2-dimensional and 3-dimensional cups.

Methods

Both types of cups were implanted in 6 cadavers and pelvic radiographs obtained. Each cup was resected from the pelvis with adequate bone around it, and subsequently embedded in a polymer. Six sections of each cup were obtained to examine the metal and bone interface. Photographs and contact radiograph images were obtained for each section, and these were graded to arrive at percent metal-bone contact values for the cups.

Results

On average, <30% of the cups' areas displayed radiolucencies on the pelvic radiographs for both cup types. For the section images and radiographs, there was about 80% aggregate contact between the cups and surrounding bone in both cup types. In the 3-dimensional cups group, some inconsistencies were found between the section photographs and the corresponding radiograph images. The radiolucencies observed on the section radiograph could not always be correlated with metal to bone gap on the section photograph.

Conclusions

Good metal-bone contact (75% + contact area) was observed on both cup types. The inconsistencies found in the 3-dimensional cup group may be because of the interaction of radiographs with the unique porous cup surface resulting in artifactual radiolucencies.

Osteogenic differentiation and proliferation of bone marrow-derived mesenchymal stromal cells on PDLLA + BMP-2-coated titanium alloy surfaces

RhBMP-2 is clinically applied to enhance bone healing and used in combination with titanium fixation implants. The purpose of this in vitro study was to compare the osteogenic differentiation and proliferation of hMSC on native polished versus sandblasted titanium surfaces (TS) and to test their behavior on pure poly-D,L-lactide (PDLLA) coated as well as PDLLA + rhBMP-2 coated TS. Furthermore, the release kinetics of PDLLA + rhBMP-2-coated TS was investigated. Human bone marrow cells were obtained from three different donors (A: male, 16 yrs; B: male, 27 yrs, C: male, 49 yrs) followed by density gradient centrifugation and flow cytometry with defined antigens. The cells were seeded on native polished and sandblasted TS, PDLLA-coated TS and PDLLA + rhBMP-2-coated TS. Osteogenic differentiation (ALP specific activity via ALP and BCA assay) and proliferation (LDH cytotoxicity assay) was examined on day 7 and 14 and release kinetics of rhBMP-2 was investigated on day 3, 7, 10, and 14. We found significant higher ALP specific activity and LDH activity on native polished compared to native sandblasted surfaces. PDLLA led to decreased ALP specific and LDH activity on both surface finishes. Additional rhBMP-2 slightly diminished this effect. RhBMP-2-release from coated TS decreased nearly exponentially with highest concentrations at the beginning of the cultivation period. The results of this in vitro study suggest that native TS stimulate hMSC significantly stronger toward osteogenic differentiation and proliferation than rhBMP-2 + PDLLA-layered TS in the first 14 days of cultivation. The PDLLA-layer seems to inhibit local hMSC differentiation and proliferation.