High early failure rate after cementless hip replacement in the octogenarian

Durability of Primary Total Hip Arthroplasty With Cementless Stems Without a Collar in Elderly Patients Age 75 Years and Over

BACKGROUND

Cementless femoral fixation in total hip arthroplasty (THA) has increased in prevalence worldwide. However, cementless fixation in elderly patients is controversial due to the risks of periprosthetic fracture and aseptic loosening. This study evaluated outcomes in patients undergoing primary THA utilizing a cementless stem without a collar, comparing those less than 75 years to those older than 75 years.

METHODS

Between 2011 and 2021, there were 2,605 cementless THAs performed by 4 surgeons utilizing a highly porous metal fixation surface without a collar and consistent clinical protocols. There were 469 patients who had an age ≥ 75 years. Revision rates, intraoperative fractures, and 90-day mortality were compared between cohorts. In the ≥ 75 year age group, there were more women, more American Society of Anesthesiologists physical status classification III or IV, a lower body mass index, and more kidney disease, osteoporosis, and thyroid disease (P ≤ .002).

RESULTS

All-cause revision rates trended lower for the ≥75 year age group compared to < 75 year (1.9 versus 3.5%, P = .082) at 20-months of follow-up. Moreover, there was no difference in all-cause femoral component revisions comparing ≥ 75 to < 75 year age groups (1.5 versus 2.2%, P = .375), with only 3 of 10 femoral revisions due to aseptic loosening being in the ≥ 75 year age group. Intraoperative fracture (0.2 versus 0.5%, P = .701) and 90-day mortality (0.2 versus 0.1%, P = .460) did not differ between ≥ 75 and < 75 year age groups.

CONCLUSIONS

Older patients had comparable revision rates compared to younger patients using cementless femoral fixation without a collar. Furthermore, there was no difference in 90-day mortality or intraoperative fracture rates. Study findings provide evidence for the safety and durability of cementless THA using collarless femoral stems in elderly patients ≥ 75 years of age.

LEVEL OF EVIDENCE

III.

A comparison of cemented femoral fixation via anterior versus posterior approach total hip arthroplasty: an analysis of 60,739 total hip arthroplasties

BACKGROUND

Anterior approach total hip arthroplasty (THA) decreases the rate of dislocation but increases femoral-sided complications in the way of periprosthetic fractures and component loosening. A cemented prosthesis may reduce femoral-sided complications and improve the risk:benefit profile of anterior approach THA.

METHODS

Data from the Australian National Joint Replacement Registry were analysed for patients undergoing primary THA via the anterior or posterior approach using a cemented polished femoral stem from January 2015 to December 2021. The primary outcome measure was the cumulative percent revision (CPR) for all causes and CPR for femoral component loosening and fracture. The CPR for the primary outcome measures were compared between the anterior and posterior approach and adjusted for age, sex, ASA score, BMI and femoral head size.

RESULTS

The study included 60,739 THAs with cemented stems (10,742 anterior, 49,997 posterior). The rate of revision of the anterior versus the posterior approach did not significantly differ (HR 0.87 (95% CI, 0.74-1.03), p = 0.100). Anterior approach THA had a significantly higher rate of revision for femoral component loosening (HR 5.06 [95% CI, 3.08-8.30], p < 0.001); and a decreased rate of revision for infection (HR 0.59 [95% CI, 0.43-0.81], p = 0.001) and dislocation/instability (HR 0-3 months 0.48 [95% CI, 0.27-0.83], p = 0.008; HR >3 months 0.30 [95% CI, 0.15-0.61], p < 0.001). There was no difference in the rate of revision surgery for fracture between the 2 approaches (HR 1.01 [95% CI, 0.71-1.43]), p = 0.975).

CONCLUSIONS

There is no significant difference in overall revision rates with cemented femoral fixation performed with an anterior or posterior approach. Cemented fixation performed with the anterior approach partly mitigates femoral complications with no difference in the revision rate for fracture but an increased rate of femoral component loosening.

Osteoporotic Patients Undergoing Total Hip Arthroplasty Have a Similar 5-Year Cumulative Incidence Rate of Periprosthetic Fracture Regardless of Cemented Versus Cementless Femoral Stem Fixation

BACKGROUND

In osteoporotic patients, surgeons may utilize cemented femoral fixation to minimize risk of fracture. The purpose of this study was to compare 5-year implant survivability in patients who have osteoporosis who underwent elective total hip arthroplasty (THA) with cementless versus cemented fixation.

METHODS

A retrospective analysis of patients who have osteoporosis undergoing THA with either cemented or cementless femoral fixation was conducted using a national administrative claims database. Of the 18,431 identified THA patients who have osteoporosis, 15,867 (86.1%) underwent cementless fixation. The primary outcome was a comparison of the 5-year cumulative incidences of aseptic revision, mechanical loosening, and periprosthetic fracture (PPF). Kaplan-Meier and Multivariable Cox Proportional Hazard Ratio analyses were used, controlling for femoral fixation method, age, sex, a comorbidity scale, use of osteoporosis medication, and important comorbidity.

RESULTS

There was no difference in aseptic revision (Hazard's Ratio (HR): 1.13; 95% Confidence Interval (CI): 0.79 to 1.62; P value: .500) and PPF (HR: 0.96; 95% CI: 0.64 to 1.44; P value: .858) within 5 years of THA between fixation cohorts. However, patients who had cemented fixation were more likely to suffer mechanical loosening with 5 years post-THA (HR: 1.79; 95% CI: 1.17 to 2.71; P-value: .007).

CONCLUSIONS

We found a similar 5-year rate of PPF when comparing patients who underwent cementless versus cemented femoral fixation for elective THA regardless of preoperative diagnosis of osteoporosis. While existing registry data support the use of cemented fixation in elderly patients, a more thorough understanding of the interplay between age, osteoporosis, and implant design is needed to delineate in whom cemented fixation is most warranted for PPF prevention.

Active osseointegration in an ex vivo porcine bone model

Achieving osseointegration is a fundamental requirement for many orthopaedic, oral, and craniofacial implants. Osseointegration typically takes three to 6 months, during which time implants are at risk of loosening. The aim of this study was to investigate whether osseointegration could be actively enhanced by delivering controllable electromechanical stimuli to the periprosthetic bone. First, the osteoconductivity of the implant surface was confirmed using an in vitro culture with murine preosteoblasts. The effects of active treatment on osseointegration were then investigated in a 21-day ex vivo model with freshly harvested cancellous bone cylinders (n = 24; Ø10 mm × 5 mm) from distal porcine femora, with comparisons to specimens treated by a distant ultrasound source and static controls. Cell viability, proliferation and distribution was evident throughout culture. Superior ongrowth of tissue onto the titanium discs during culture was observed in the actively stimulated specimens, with evidence of ten-times increased mineralisation after 7 and 14 days of culture (p < 0.05) and 2.5 times increased expression of osteopontin (p < 0.005), an adhesive protein, at 21 days. Moreover, histological analyses revealed increased bone remodelling at the implant-bone interface in the actively stimulated specimens compared to the passive controls. Active osseointegration is an exciting new approach for accelerating bone growth into and around implants.

A Radiographic Evaluation of Uncemented Total Hip Replacements and the Role of Uncemented Implants in the Management of Hip Osteoarthritis in the Elderly Population

Introduction The idea of an uncemented, fully coated hydroxyapatite (HA) stem was introduced almost 40 years ago, aiming to achieve a solid biological fixation by preserving natural bone activity. While many studies underline the longevity of uncemented total hip replacement (THR), NHS England's Best Practice Tariff (BPT) recommends using cemented implants in patients over the age of 69, with financial penalties when this policy is not met. At the same time, the 'paradox' of increased use of uncemented implants worldwide has been well described, with many surgeons using them regardless of the age group of the patient. Materials and methods This study focuses on the radiographic evaluation of the uncemented Pinnacle/Corail total hip replacement construct in 123 patients of all age groups who underwent an elective procedure, with a minimum radiographic follow-up of two years. Implant information (collared or non-collared stem), femur type (Dorr classification), age, gender, and revision rate were collected and radiographic analysis of the femoral stem and acetabular component was performed for the immediate post-operative, six-month, one- to two-year follow-up radiograph of all patients. We conducted a statistical analysis, dividing the patients into two groups based on age: those above or below 69 years old. Results There was no statistically significant difference in rates of radiographic lucency after two years with regard to the femoral component. Both collared and non-collared stems seem to perform equally well, with no significant difference detected. However, a statistically significant difference in rates of radiographic lucency of the acetabular cup was noted between the two age groups (p=0.018), with higher rates detected in the under-69-year-old age group. Conclusion This study demonstrates that, radiographically, the uncemented Pinnacle/Corail construct performs equally well in all age groups. In our cohort of patients, the age of the patient did not predict the osseointegration of the implant in the short-term follow-up.

Cementless tapered wedge stems in patients undergoing primary total hip arthroplasty with Dorr C bone-are complication risks increased?

Background

The use of cementless femoral stems in patients undergoing primary total hip arthroplasty (THA) with Dorr C bone remains controversial for fear of fracture or subsidence. Purpose of this multicenter study was to compare clinical outcomes and complications of THA using a tapered femoral prosthesis in patients with Dorr C bone versus Dorr A/B bone.

Methods

A total of 1,030 patients underwent primary THA with a tapered wedge femoral stem at a minimum one year follow up. Forty-eight patients with Dorr C bone (mean age 68.7 years) were compared with a matched cohort of patients with Dorr A/B bone (mean age 69.9 years). Mean follow-up was approximately 4 years in both cohorts. There were no differences in sex, age, body mass index (BMI), Harris Hip Score (HHS), complications, and radiographic outcomes including subsidence and aseptic loosening were evaluated.

Results

Postoperative HHSs were a mean of 82 points in the Dorr C cohort compared to 84 points in the Door A/B cohort (P=0.2653). There was no significant difference in complication or revision rates for any reason (P=0.23). Mean subsidence for the Dorr C and Dorr A/B was 1.4 and 1.2 mm, respectively (P=0.5164), and there was no aseptic loosening of the femoral component found in either group.

Conclusions

Current generation tapered wedge cementless femoral stems provide stable fixation for patients with Dorr C bone quality without increased complications with respect to fracture or subsidence and can be considered an alternative to cemented stems in patients with compromised bone quality.

High grade femoral stem subsidence in uncemented hip hemiarthroplasty - A radiographic analysis and an early prediction while treating femoral neck fractures

PURPOSE

Femoral component subsidence is a known risk factor affecting almost all hip replacements using a collarless, cement-less stems. High grade subsidence >5mm is functionally limiting to the patient. Early analysis and prediction of this complication on the immediate post-operative radiographs will help surgeons to opt for alternative solutions to mitigate this complication.

METHODS

A retrospective study including 116 patients, who underwent cement-less bipolar hemi-arthroplasties treated from 2020-2022 were included in the study. Body Mass Index (BMI) and pre-operative American Society Anesthesiologist (ASA) score was retrieved from the medical records. Post operative radiographs on postoperative day two, at four weeks and at eight weeks were evaluated. Dorr's score, initial subsidence ratio (ISR) , stem angulation, proximal stem-canal fit (PSCF) ratio, distal stem-canal fit (DSCF) ratio, medial flare modifier (MFM) were recorded.

RESULTS

A total of 18 patients showed subsidence over 5mm on radiographs evaluated at four weeks. The mean high-grade stem subsidence was 13.5mm +/- 2.67. Evaluating their respective postoperative day two radiographs- ISR was >1 in 16 out of 18 patients (89%), PSCF ratio <0.75 in 83% and DSCF ratio <0.5 in 78% patients. All these patients had a neutral/negative MFM. BMI >25 (p<0.05) and ASA >3 (p<0.001) correlated with a higher degree of stem subsidence.

CONCLUSION

A lower BMI and ASA score accompanied by a positive MFM were protective factors against femoral stem subsidence. A higher ISR along with a PSCF ratio <0.75 and DSCF ratio <0.5, were highly predictive of stem subsidence over 5 mm.

Total Hip Arthroplasty in fracture neck of femur: A review of the literature

Fracture Neck of Femur (FnF) is a major cause of loss of independence, morbidity and mortality in a vulnerable group of elderly patients; as well as a substantial economic burden on healthcare systems across the world. An increasingly ageing population has resulted in a rise in incidence and prevalence of FnF. Over 76,000 patients were admitted with FnF in the United Kingdom in 2018, with the resulting health and social costs estimated to be in excess of £2 billion. It is therefore important that the outcomes of all management options be evaluated to ensure constant improvement as well as allocation of resources as appropriate. It is widely agreed that patients presenting with displaced intracapsular FnF injuries are managed operatively; with options including internal fixation, hemiarthroplasty or Total Hip Arthroplasty (THA). The volume of THA performed for FnF has significantly increased in recent years. However, compliance with national guidelines on FnF patient selection for THA has been shown to be inconsistent. The aim of this study was to review current literature with regards to the use of THA in management of FnF patients. The literature describes managing FnF in ambulant and independent patients by THA with dual-mobility acetabular cup and cemented femoral component via the anterolateral approach. There is scope for further research in assessing the outcomes of different prosthetic femoral head sizes and choice of bearing surfaces (tribiology) used for THA as well as cementation of the acetabular cup component specifically in FnF patients.

Higher risk of 2-year cup revision of ceramic-on-ceramic versus ceramic-on-polyethylene bearing: analysis of 33,454 primary press-fit total hip arthroplasties registered in the Dutch Arthroplasty Register (LROI)

BACKGROUND AND PURPOSE

The influence of bearing on short-term revision in press-fit total hip arthroplasty (THA) remains under-reported. The aim of this study was to describe 2-year cup revision rates of ceramic-on-ceramic (CoC) and ceramic-on-polyethylene (CoPE).

PATIENTS AND METHODS

Primary press-fit THAs with one of the three most used cups available with both CoC or CoPE bearing recorded in the Dutch Arthroplasty Register (LROI) were included (2007-2019). Primary outcome was 2-year cup revision for all reasons. Secondary outcomes were: reasons for revision, incidence of different revision procedures and use of both bearings over time.

RESULTS

2-year Kaplan-Meier cup revision rate in 33,454 THAs (12,535 CoC; 20,919 CoPE) showed a higher rate in CoC (0.67% [95% CI, 0.54-0.81]) compared to CoPE (0.44% [95% CI, 0.34-0.54]) (p = 0.004). Correction for confounders (age, gender, cup type, head size) resulted in a hazard ratio (HR) of 0.64 [95%CI, 0.48-0.87] (p = 0.019). Reasons for cup revision differed only by more cup revision due to loosening in CoC (26.2% vs.1 3.2%) (p = 0.030). For aseptic loosening a revision rate of 0.153% [95% CI, 0.075-0.231] was seen in CoC and 0.058% [95%CI 0.019-0.097] in CoPE (p = 0.007). Correction for head size resulted in a HR of 0.475 [95% CI, 0.197-1.141] (p = 0.096). Incidence of different revision procedures did not differ between bearings. Over time the use of CoPE has increased and CoC decreased.

CONCLUSIONS

A higher 2-year cup revision rate in press-fit THA was observed in CoC compared to CoPE. Cup loosening was the only significantly different reason for revision and seen more often in CoC and mostly aseptic. Future randomised controlled trials need to confirm causality, since the early cup revision data provided has the potential to be useful when choosing the bearing in press-fit THA, when combined with other factors like bone quality and patient and implant characteristics.

A lower canal fill rate and unreestablished vertical femoral offset may increase the risk of the postoperative periprosthetic fractures after cementless bipolar hemiarthroplasty for femoral neck fractures in elderly patients

BACKGROUND

Periprosthetic fractures (PPFs) is one of the major causes of failure of hip arthroplasty with cementless stem; however, studies on the incidence and risk factors of PPFs after cementless hemiarthroplasty for femoral neck fractures (FNFs) are lacking.

METHODS

This retrospective study included patients who underwent cementless bipolar hemiarthroplasty for displaced intracapsular FNFs. The demographic data were reviewed, Dorr classification was used to describe morphology of the femur, radiological parameters were measured including stem-shaft angle, canal fill ratio (CFR), canal flare index (CFI), morphologic cortical index (MCI), canal calcar ratio (CCR), and vertical and horizontal femoral offset.

RESULTS

The sample comprised 10 men and 46 women (affected hip: left, 38; right, 18). The mean patient age was 82.82±10.61 (range, 69-93) years, and the mean hemiarthroplasty to PPFs time was 26.28±14.04 (range, 6.54-47.77) months. Seven (12.28%) patients had PPFs. A significant relationship was found between the incidence of PPF and CFR (p = 0.012), patients had a significantly smaller femoral stem CFR (0.76%±0.11%) than controls (0.85%±0.09%). The PPFs group had a significant shorter and unreestablished vertical femoral offset (p = 0.048).

CONCLUSIONS

A smaller femoral stem CFR associated with a potentially unacceptably high PPFs risk in uncemented hemiarthroplasty for displaced FNFs may result from mismatched prosthesis and bone dimensions in the elderly population, especially when accompanied by a poorly reestablished vertical femoral offset. With increasing evidence of the benefits of cemented fixation, a cemented stem for the treatment of displaced intracapsular FNFs is recommended for such a elderly frail population.

Prediction model for an early revision for dislocation after primary total hip arthroplasty

Dislocation is one of the most common complications after primary total hip arthroplasty (THA). Several patient-related risk factors for dislocation have been reported in the previous literature, but only few prediction models for dislocation have been made. Our aim was to build a prediction model for an early (within the first 2 years) revision for dislocation after primary THA using two different statistical methods. The study data constituted of 37 pre- or perioperative variables and postoperative follow-up data of 16 454 primary THAs performed at our institution in 2008-2021. Model I was a traditional logistic regression model and Model II was based on the elastic net method that utilizes machine learning. The models' overall performance was measured using the pseudo R2 values. The discrimination of the models was measured using C-index in Model I and Area Under the Curve (AUC) in Model II. Calibration curves were made for both models. At 2 years postoperatively, 95 hips (0.6% prevalence) had been revised for dislocation. The pseudo R2 values were 0.04 in Model I and 0.02 in Model II indicating low predictive capability in both models. The C-index in Model I was 0.67 and the AUC in Model II was 0.73 indicating modest discrimination. The prediction of an early revision for dislocation after primary THA is difficult even in a large cohort of patients with detailed data available because of the reasonably low prevalence and multifactorial nature of dislocation. Therefore, the risk of dislocation should be kept in mind in every primary THA, whether the patient has predisposing factors for dislocation or not. Further, when conducting a prediction model, sophisticated methods that utilize machine learning may not necessarily offer significant advantage over traditional statistical methods in clinical setup.

Electrochemically applied hydroxyapatite on the cementless porous surface of Bi-Metric stems reduces early migration and has a lasting effect : an efficacy trial of a randomized five-year follow-up radiostereometric study

AIMS

BoneMaster is a thin electrochemically applied hydroxyapatite (HA) coating for orthopaedic implants that is quickly resorbed during osseointegration. Early stabilization is a surrogacy marker of good survival of femoral stems. The hypothesis of this study was that a BoneMaster coating yields a fast early and lasting fixation of stems.

METHODS

A total of 53 patients were randomized to be treated using Bi-Metric cementless femoral stems with either only a porous titanium plasma-sprayed coating (P group) or a porous titanium plasma-sprayed coating with an additional BoneMaster coating (PBM group). The patients were examined with radiostereometry until five years after surgery.

RESULTS

At three months, the mean total translation (TT) was 0.95 mm (95% confidence interval (CI) 0.68 to 1.22) in the P group and 0.57 mm (95% CI 0.31 to 0.83) in the PBM group (p = 0.047). From two to five years, the TT increased by a mean of 0.14 mm (95% CI 0.03 to 0.25) more in the P group than in the PBM group (p = 0.021). In osteopenic patients (n = 20), the mean TT after three months was 1.61 mm (95% CI 1.03 to 2.20) in the P group and 0.73 mm (95% CI 0.25 to 1.21) in the PBM group (p = 0.023). After 60 months, the mean TT in osteopenic patients was 1.87 mm (95% CI 1.24 to 2.50) in the P group and 0.82 mm (95% CI 0.30 to 1.33) in the PBM group (p = 0.011).

CONCLUSION

There was less early and midterm migration of cementless stems with BoneMaster coating compared with those with only a porous titanium plasma-sprayed coating. Although a BoneMaster coating seems to be important for stem fixation, especially in osteopenic patients, further research is warranted. Cite this article: Bone Joint J 2022;104-B(6):647-656.

Tapered wedge stems decrease early postoperative subsidence following cementless total hip arthroplasty in Dorr type C femurs compared to fit-and-fill stems

Background

To compare the degree of stem subsidence between two different femoral component designs and to determine the risk factors associated with stem subsidence after cementless total hip arthroplasty (THA) in Dorr type C femurs.

Methods

We retrospectively reviewed 104 consecutive hips in 100 patients with Dorr type C proximal femoral morphology who underwent primary cementless THA using a fit-and-fill stem or a tapered wedge femoral stem at our institution between January 2012 and June 2021. A fit-and-fill stem was used in 55 hips and a tapered wedge stem was used in 49 hips. Radiologically, the distance between the apex of the major trochanter and the stem shoulder were measured at three different time points (immediately [0W], one week [1W], and six weeks [6W] after surgery) and the degrees of stem subsidence were assessed by comparing the distance between 0 and 1W, 1W and 6W, and 0W and 6W, respectively.

Results

The mean degree of stem subsidence (0W vs. 1W) was 0.24 mm (standard deviation [SD] 0.36) in the fit-and-fill stem group, and 0.23 mm (SD 0.41) in the tapered wedge stem group. There was no significant difference between the two groups (P = 0.4862). However, the mean degrees of subsidence were significantly higher in the fit-and-fill stem group (1W vs. 6W, 0.38 mm [SD 0.68]; 0W vs. 6W, 0.65 mm [SD 0.87]) than in the tapered wedge stem group (1W vs. 6W, 0.16 mm [SD 0.32]; 0W vs. 6W, 0.24 mm [SD 0.38]) (P < 0.05 for both). In addition, the rates of > 3 mm subsidence (in which instability can be observed) were 18.2% (10 of 55 hips) and 2.0% (1 of 49 hips), respectively. There was also a significant difference between the two stems (P = 0.0091). Multivariate analysis demonstrated that fit-and-fill stem was a risk factor for > 3 mm subsidence after THA in Dorr type C femurs (P = 0.0050).

Conclusion

Our findings suggest that the tapered wedge stem is more suitable for Dorr type C femurs than the fit-and-fill stem to avoid early postoperative subsidence in cementless THA.

Cementless hydroxyapatite-coated stem with dual mobility and posterior approach in over-80 year-old patients with osteoarthritis: Rates of dislocation and periprosthetic fracture at a mean 8 years' follow-up

BACKGROUND

Straight cementless stems are common in primary total hip arthroplasty (THA) in the elderly, but controversial due to higher risk of loosening and periprosthetic fracture (PPF). Apart from registries, results for the Corail implant and dual mobility (DM) in over-80 years-old are not known, notably in case of systematic association to a DM cup. We therefore performed a retrospective analysis of Corail implants in patients aged≥80years at implantation for osteoarthritis of the hip, assessing 1) PPF rate and survival for cementless straight stems associated to DM cups, 2) complications, and dislocation in particular, and 3) clinical scores.

HYPOTHESIS

PPF and dislocation rates are low in THA with cementless straight stem associated to DM cup in patients aged≥80years.

PATIENTS METHODS

A retrospective study was conducted in our department for the period July 2007 to December 2012. Inclusion criteria were age≥80years, with primary THA for osteoarthritis. Exclusion criteria were revision procedure and femoral neck fracture. One hundred and twenty-eight consecutive THAs were included, in 120 patients, with a minimum 5years' follow-up. Clinical results were assessed on Harris Hip Score (HHS) and Oxford Hip Score (OHS). Data were collected for PPF or dislocation and other complications.

RESULTS

At a mean 8±1 years' follow-up (range, 5-10 years), 66 patients (55%, for 68 hips) were alive, 48 (40%, for 54 hips) had died, and 6 (5%, for 6 hips) were lost to follow-up. Median age at surgery was 83years (range, 80-93years). Mean OHS at last follow-up was 41±6 (range, 21-48) and HHS 83±14 (range, 23-100) with mean gain of 32 points (95% CI, [28-36]; p<0.001)). There were 2 cases (1.6%) of PPF, at 2 and 65months, and no dislocations or cases of aseptic loosening. There were 2 cases (1.6%) of intraoperative calcar fracture, treated by wire cerclage with immediate complete weight-bearing, without further complications. With death as a competing risk, cumulative 10-year incidence of femoral stem revision was 1.6% [95% CI: 0.4-6.5], and cumulative incidence of all-cause revision was 4.1% [95% CI: 1.7-9.7].

DISCUSSION

In an over-80 year-old population, primary THA with straight cementless stem and 2nd generation dual mobility cup was an effective option with low risk of PPF or dislocation after a minimum 5-year of follow-up.

LEVEL OF EVIDENCE

IV; retrospective study.

Comparable mortality but higher revision rate after uncemented compared with cemented total hip arthroplasties in patients 80 years and older: report of 43,053 cases of the Dutch Arthroplasty Register

Background and purpose - Mortality and revision risks are important issues during shared decision-making for total hip arthroplasty (THA) especially in elderly patients. We examined mortality and revision rates as well as associated patient and prosthesis factors in primary THA for osteoarthritis (OA) in patients ≥ 80 years in the Netherlands. Patients and methods - We included all primary THAs for OA in patients ≥ 80 years in the period 2007-2019. Patient mortality and prosthesis revision rates were calculated using Kaplan-Meier survival analyses. Risk factors for patient mortality and prosthesis revision were analyzed using multivariable Cox regression analysis adjusted for age, sex, ASA class, fixation method, head size, and approach. Results - Mortality was 0.2% at 7 days, 0.4% at 30 days, 2.7% at 1 year, and 20% at 5 years. Mortality was higher in males and higher ASA class, but did not differ between fixation methods. The 1-year revision rate was 1.6% (95% CI 1.5-1.7) and 2.6% (CI 2.5-2.7) after 5 years. Multivariable Cox regression analysis showed a higher risk of revision for uncemented (hazard ratio [HR] 1.6; CI 1.4-1.8) and reverse hybrid THAs (HR 2.9; CI 2.1-3.8) compared with cemented THAs. Periprosthetic fracture was the most frequently registered reason for revision in uncemented THAs. Interpretation - Mortality is comparable but revision rate is higher after uncemented compared with cemented THA in patients 80 years and older, indicating that cemented THA might be a safer option in this patient group.

SuperPath approach is a recommendable option in frail patients with femoral neck fractures: a case-control study

INTRODUCTION

The treatment of intracapsular femoral neck fractures (FNFs) in the elderly is usually based on hip replacement, both total hip arthroplasty (THA) and hemiarthroplasty (HA). Recently, several tissue-sparing approaches for hip arthroplasty had been described with promising results in terms of hospitalization length, blood loss and dislocation rate. The aim of the present study was to compare the blood loss and the transfusion rate in a cohort of patients with FNF treated using an HA through both the SuperPath (SP) and the traditional posterolateral (PL) approaches.

MATERIALS AND METHODS

We retrospectively collected data from patients affected by FNFs between January 2018 and February 2020. All patients with intracapsular FNF treated with a single HA implant (Profemur L, MicroPort Orthopedics Inc., USA) via PL or SP approaches were included. Exclusion criteria were pathological fractures, polytrauma and preoperatively transfused patients.

RESULTS

Thirty-five patients were included and analysed in the present study. 17 patients were classified in the SP group, and 18 in the PL one. The rate of antithrombotic therapy was higher in the SP group compared with the PL group [10 (58, 82%) vs 4 (22, 2%)]. While the two groups did not differ in terms of preoperative haemoglobin (Hb), 48 h postoperative Hb and Hb reduction, a significative difference was observed in terms of blood transfusion rate (1 SP vs 9 PL, p = 0.0072).

CONCLUSIONS

The SuperPath approach in patients with FNF under antithrombotic therapy assures lower transfusion rate, potentially reducing complication rates and improving patients' outcomes.

Periprosthetic Femoral Fracture Is a Leading Cause of Early Revision With Taper-Slip Stems in Primary Total Hip Arthroplasty: An Analysis of 2765 Total Hip Arthroplasties From a High-Volume Hospital

BACKGROUND

In 2016, the CPT stem replaced the Exeter stem as the main cemented stem at our institution. We assessed the prevalence of revision for periprosthetic femoral fracture (PFF) in patients operated on with either CPT or Exeter stem and compared the risk for revision between these stems.

METHODS

Primary total hip arthroplasties either performed in 2012-2015 with Exeter stem (n = 1443) or in 2017-2018 with CPT stem (n = 1322) were included. The prevalence of revision for PFF was compared. The Kaplan-Meier estimated survivorships were calculated for the 2 stem designs. The risk for revision was analyzed using the Cox proportional hazard regression model.

RESULTS

At 2 years, PFF was the most common reason for revision in the study population (1.3% prevalence, comprising 35% of all revisions). Moreover, 1.6% (95% confidence interval [CI] 1.0-2.4) of the CPT and 1.0% (95% CI 0.6-1.6) of the Exeter stems had been revised due to PFF. The 3-year Kaplan-Meier probability estimates for all-cause revision were 4.8% for the CPT (95% CI 3.6-6.0) and 3.3% for the Exeter stem (95% CI 2.3-4.3). The hazard ratio for revision due to any reason was 1.1 (95% CI 0.3-3.8) during the first 2 weeks, and 1.8 (95% CI 1.2-2.7, P = .006) from 2 weeks onwards for the CPT compared with the Exeter stem.

CONCLUSION

The considerable number of PFF revisions with taper-slip stems, especially with CPT stems, is a matter of concern. Alternative cemented stems should be considered in patients at high risk for PFF.

Uncemented femoral stem design might have an impact on postoperative periprosthetic femur fracture pattern. A Comparison between flat-wedge and dual-wedge stems

INTRODUCTION

Type I, flat-wedge and type II, dual-wedge stems are currently two common stem types used in primary, uncemented hip arthroplasty. The prevalence of periprosthetic femur fracture is higher in type I stems, possibly because of the different shapes and areas of bone contact. We aimed to compare the fracture pattern, stem stability during the fracture and type of subsequent procedures in periprosthetic femur fractures between type I and II stems.

MATERIALS AND METHODS

This was a retrospective, cross-sectional study conducted in a single tertiary referral hospital of Taipei, Taiwan. We included primary hip arthroplasty procedures using type I or type II stems complicated with postoperative periprosthetic femur fractures. We recorded the age, sex, ASA grade, index procedure, institution of where the index procedure was performed, trauma mechanism, time from index procedure to fracture, procedure for periprosthetic fracture and radiographic parameters including Dorr type, Vancouver classification, stem stability, fracture pattern, type and brand of the stems for analysis.

RESULTS

We included 132 patients who had undergone surgery for periprosthetic femur fracture for type I (N = 46) or type II (N = 86) stems. The mean age was 74.5 years and 52.3% of the patients were female. Type I stems were associated with a higher proportion of a complex fracture pattern (52.2% vs. 8.2%), femoral stem loosening (78.2% vs. 60.4%) and a higher rate of revision stem procedures (69.6% vs. 50.0%) compared with type II stems. Using multivariate analysis, type I stem was the only factor for a complex fracture pattern in the overall population (aOR: 23.60, 95% CI: 6.54-85.16), hemiarthroplasty (aOR: 160.50, 95% CI: 9.77-2635.95) and total hip arthroplasty (aOR: 14.17, 95% CI: 2.92-68.79) subgroups.

CONCLUSION

We observed a difference in fracture patterns between type I and type II stems. Type I stems appear to be an independent risk factor for a complex fracture pattern in patients who had undergone primary hip arthroplasty.

Competing Risks Methods Are Recommended for Estimating the Cumulative Incidence of Revision Arthroplasty for Health Care Planning Purposes

Cumulative incidence of revision provides a measure of the failure rate of joint replacements and can be used to project demand for revisions. The most commonly applied survival analysis method (Kaplan-Meier [KM]) does not account for competing risks (eg, death). The authors compared the cumulative incidence function (CIF), a competing risks method, with the KM method through application to population-based cohorts. They measured time to revision, death, or censoring for unilateral total hip arthroplasty (THA; n=12,496) and total knee arthroplasty (TKA; n=19,172) cohorts in administrative databases in Alberta and TKAs (n=80,177) in the Swedish Knee Arthroplasty Register. The authors compared relative differences between the KM and CIF. They fitted Cox, Fine and Gray, and Royston and Parmar regression models and compared coefficients, standard errors, and P values. On sensitivity analysis, the authors included staged bilateral operations. Kaplan-Meier estimates exceeded the CIF at each time point. The magnitude of overestimation increased with follow-up time and was greatest for the Swedish cohort. At 5 years, relative differences between KM and CIF estimates for the Alberta THA and TKA and Swedish TKA cohorts were 1.8%, 2.3%, and 3.8%, respectively. These differences increased to 3.1%, 5.8%, and 8.2%, respectively, at 9 years, reaching 39.1% at 20 years (Swedish cohort). On sensitivity analysis (including staged bilateral operations), the Fine and Gray subdistribution hazard ratio differed from the Cox and Royston and Parmar hazard ratios. When the frequency of competing risks is high, competing risks methods are recommended to obtain accurate cumulative incidence estimates for informing health care planning and decision making. [Orthopedics. 2021;44(4):e549-e555.].

Reduction of Periprosthetic Proximal Femur Fracture in Direct Anterior Total Hip According to Stem Design

The direct anterior approach (DAA) is gaining popularity in primary total hip arthroplasty (THA). Although DAA has demonstrated many advantages over other surgical approaches, periprosthetic femur fractures (PPFF) rates continue to be higher. Femoral stem designs that allow for easier insertion via a DAA may contribute to the higher rates of fracture seen in this approach. Certain stem designs and fixation methods may reduce the risk of PPFF via a DAA in primary THA.

Midterm Survivorship of an Uncemented Hydroxyapatite-Coated Titanium Femoral Component and Clinically Meaningful Outcomes in Patients Older Than 75 Years

Purpose: It remains controversial whether cementless femoral components are safe in elderly patients. The aim of this study was (1) to determine the stem survival rate in patients >75 years of age who were treated with an uncemented femoral component and (2) to report clinically significant results on a mid-term follow-up. Methods: 107 total hip arthroplasties (THA) were retrospectively evaluated in 97 patients over 75 years of age (mean age 78 years, range 75–87) treated with an uncemented femoral stem. The minimum follow-up was five years (mean 6.4 years, range 5–8). Stem survival rates, clinically meaningful outcomes, and incidence of complications were evaluated. Results: Kaplan-Meier survival analysis, with the endpoint revision for any reason, showed a 6.4-year survival rate of 98% (95% CI, 95–99%; 63 hips at risk). The survival rates were comparable for male and female patients (log-rank test, p = 0.58). The modified Harris Hip Score (mHHS) improved from 42.2 (12 to 85) points to 81.1 (22 to 97) points (p < 0.0001). Mid-term minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were 25, 84, and 70, respectively. Conclusion: An uncemented stem is a viable option in patients over 75 years with good clinical outcomes and survivorship. Periprosthetic fractures were not a relevant failure mechanism with the stem used.

Mortality as a competition risk factor in the survival analysis of the results of the type of fixation of the total hip prosthesis in octogenarian patients

INTRODUCTION

Total hip replacement (THR) is challenging in octogenarians due to associated comorbidities and controversy regarding fixation type. We ask whether cemented THR is superior to uncemented THR in patients above the age of 80 years.

MATERIAL AND METHODS

A total of 382 patients (441 hips) aged 80 years or older who underwent THR between 2004 and 2015 were analysed. A cemented THR was implanted in 196 hips (group 1), an uncemented THR with a grit-blasted stem in 121 (group 2), or with a porous-coated stem in 124 (group 3). Patients in group 1 had a higher mean age, more comorbidities and osteoporotic bone. Survival analysis was calculated using cumulative incidence function to account for the competing risk of death.

RESULTS

Medical complications rate was similar. There were 3post-operative fractures: one in group 2 and 2in group 3. Competing risk analysis showed that the cumulative incidence of revision for any cause was 2.3 in group 1, 6.0 in group 2 and 4.1 in group 3 at 10years, and the cumulative incidence of revision for aseptic loosening was 1.2 in group 1, 3.7 in group 2 and 0 in group 3 at the same period.

CONCLUSIONS

THR presents an acceptable number of adverse events for octogenarian patients. Despite uncemented fixation was satisfactory, the higher peri-prosthetic fracture rate worsens results in this group.

The Lawrence D. Dorr Surgical Techniques & Technologies Award: Aseptic Reoperations Within One Year of Primary Total Hip Arthroplasty Markedly Increase the Risk of Later Periprosthetic Joint Infection

BACKGROUND

Despite the success of primary total hip arthroplasties (THAs), some patients will require an aseptic reoperation within 1 year of the index THA. The goal of this study is to evaluate the risk of subsequent periprosthetic joint infection (PJI) in patients undergoing an aseptic reoperation within 1 year of a primary THA.

METHODS

A retrospective review utilizing our institutional joint registry identified 211 primary THAs requiring aseptic reoperation within 1 year following index arthroplasty. A control group of 15,357 primary THAs not requiring reoperation within 1 year was identified. Patients were divided into groups based on time from primary THA to reoperation: (1) within 90 days (n = 112 THAs; 40% for dislocation, 34% for periprosthetic fracture) or (2) 91-365 days (n = 99 THAs; 37% for dislocation, 29% for periprosthetic fracture). Mean follow-up was 7 years.

RESULTS

Patients undergoing an aseptic reoperation within 90 days had a PJI rate of 4.8% at 2 years, while the 91-365 day group had a PJI rate of 3.2% at 2 years. The control group had a PJI rate of 0.2% at 2 years. Employing a multivariate analysis, reoperation within 90 days of index arthroplasty had an elevated risk of PJI (hazard ratio 8, P < .001) as did a reoperation between 91 and 365 days (hazard ratio 13, P < .001).

CONCLUSION

Aseptic reoperations within 1 year following primary THA resulted in an 8- to 13-fold increased risk of subsequent PJI. The risk was similar whether the aseptic reoperation was early (within 90 days) or later (91-365 days).

LEVEL OF EVIDENCE

Level III (Prognostic).

Does Femoral Morphology Predict the Risk of Periprosthetic Fracture After Cementless Total Hip Arthroplasty?

BACKGROUND

Periprosthetic femur fracture remains a leading mode of early failure following cementless total hip arthroplasty (THA). The purpose of this study is to determine if a specific femoral morphology is associated with an increased risk of acute, periprosthetic fracture after cementless THA.

METHODS

An institutional arthroplasty registry was used to identify 32 primary, cementless THAs revised for acute, postoperative periprosthetic fracture ("fracture" cohort) within 3 months of the index procedure. Patients were matched 1:2 to 64 THAs without fracture ("control" cohort) for age, body mass index, gender, and stem design. Preoperative radiographic measurements performed on anteroposterior pelvis and femur radiographs included the neck-shaft angle, endosteal width at 4 locations, and external cortical diameter at 2 locations. These measurements were used to calculate the morphological cortical index, canal flare index, canal calcar ratio, and canal bone ratio. Postoperative measurements included canal fill and stem alignment. Statistical analyses included clustered regressions, Fisher's exact test, and Student's t-test.

RESULTS

The mean endosteal width at 10 cm distal to the lesser trochanter was greater in fracture patients, although not statistically significant (P = .1). However, this resulted in differences in the canal flare index (P = .03), canal calcar ratio (P = .03), and canal bone ratio (P = .03) between the 2 cohorts. These ratios indicate decreased meta-diaphyseal taper in fracture patients. Preoperative femoral neck-shaft angle was more varus in fracture patients (P = .04).

CONCLUSION

Patients sustaining an acute, periprosthetic fracture with cementless femoral fixation after THA had thinner distal cortices and a decreased meta-diaphyseal taper.

Cementing of the hip arthroplasty stem increases load-to-failure force: a cadaveric study

Background and purpose - To date, there is not a single clinical or mechanical study directly comparing a cemented and a cementless version of the same stem. We investigated the load-to-failure force of a cementless and a cemented version of a double tapered stem. Material and methods - 10 femurs from 5 human cadaveric specimens, mean age 74 years (68-79) were extracted. Bone mineral density (BMD) was measured using peripheral quantitative computed tomography. None of the specimens had a compromised quality (average T value 0.0, -1.0 to 1.4). Each specimen from a pair randomly received a cemented or a cementless version of the same stem. A material testing machine was used for lateral load-to-failure test of up to a maximal load of 5.0 kN. Results - Average load-to-failure of the cemented stem was 2.8 kN (2.3-3.2) and 2.2 kN (1.8-2.8) for the cementless stem (p = 0.002). The cemented version of the stem sustained a higher load than its cementless counterpart in all cases. Failure force was not statistically significantly correlated to BMD (p = 0.07). Interpretation - Implanting a cemented version of the stem increases the load-to-failure force by 25%.

To cement or not to cement acetabular cups in total hip arthroplasty: a systematic review and re-evaluation

INTRODUCTION

Total Hip Arthroplasty (THA) in the treatment of primary osteoarthritis of the hip has evolved to a very safe and cost-effective intervention with revision rates below 5% after 10 years. To this day, however, controversy remains on whether or not to cement the acetabular cup.

METHODS

A comprehensive PubMed search of the English literature for studies published between 2007 and 2018 was performed. Studies comparing the clinical (revision rate, functionality), radiological (wear) or economic (cost) differences between cemented (cemented stem with cemented cup) and hybrid (cemented stem with uncemented cup) prostheses for primary osteoarthritis of the hip were identified as eligible.

RESULTS

A total of 1032 studies were identified whereof twelve were included for qualitative synthesis. All studies concerning the risk of revision were based on registry data, covering a total of 365,693 cups. Cemented prostheses had a similar or lower risk of revision compared to hybrid prostheses in every study, but performed slightly worse on functionality and quality of life. While cemented prostheses were the cheapest option, hybrids were the most cost-effective.

DISCUSSION

The widespread preference for cementless fixation of the acetabulum cannot be explained by a superior survival of cementless or hybrid models. Irrespective of age, cemented fixation of the acetabulum remains the gold standard to which other techniques should be compared.

Subsidence of Hydroxyapatite-Coated Femoral Stem in Dorr Type C Proximal Femoral Morphology

BACKGROUND

Good bone quality and proper proximal femoral morphology are thought to be necessary for tapered design, cementless femoral stems to resist subsidence. Using tapered, cementless stem for patients with stovepipe morphology or Dorr type C is controversial. The purpose of this study is to analyze (1) subsidence of the fully hydroxyapatite (HA)-coated, tapered, cementless stem in different morphology according to Dorr classification, (2) subsidence of the stem related to radiographic canal-fill ratio.

METHODS

The digitized radiographs of 311 consecutive cementless primary total hip arthroplasty with fully HA-coated, tapered stem were retrospectively reviewed. Subsidence and the canal-fill ratio at 4 locations were evaluated postoperatively after a minimum of 2 years of follow-up. The threshold of subsidence >3 mm was considered as a clinically significant migration.

RESULTS

A multivariate regression analysis of subsidence across Dorr type, controlling for age, gender, and intraoperative calcar fracture, demonstrated 0.40 mm (P = .28) and 0.18 mm (P = .51) greater subsidence in Dorr type C and B when compared to Dorr type A. Age, gender, and calcar fracture had no influence on subsidence, whereas greater canal-fill ratio at 2 cm below lesser trochanter resulted in significantly less subsidence (P = .02). Additionally, all variables did not affect the risk of having subsidence >3 mm.

CONCLUSION

The proximal femoral morphology has no statistically significant effect on the subsidence of fully HA-coated stem. Therefore, this stem type might be a viable option for Dorr type C. Increasing the canal-fill ratio at metadiaphyseal junction may ensure the stability of the stem.

ASA class is associated with early revision and reoperation after total hip arthroplasty: an analysis of the Geneva and Swedish Hip Arthroplasty Registries

Background and purpose - Data from several joint replacement registries suggest that the rate of early revision surgery after primary total hip arthroplasty (THA) is increasing. The ASA class, now widely recorded in arthroplasty registries, may predict early revision. We investigated the influence of ASA class on the risk of revision and other reoperation within 3 months and within 5 years of primary THA. Patients and methods - We used data from the Geneva and Swedish Hip Arthroplasty Registries, on primary elective THAs performed in 1996-2016 and 2008-2016, respectively. 5,319 and 122,241 THAs were included, respectively. Outcomes were all-cause revision and other reoperations evaluated using Kaplan-Meier survival and Cox regression analyses. Results - Within 3 months after surgery, higher ASA class was associated with greater risk of revision and other reoperation. 3-month cumulative incidences of revision by ASA class I, II, and III-IV respectively, were 0.6%, 0.7%, and 2.3% in Geneva and 0.5%, 0.8%, and 1.6% in Sweden. 3-month cumulative incidences of other reoperation were 0.4%, 0.7%, and 0.9% in Geneva and 0.2%, 0.4%, and 0.7% in Sweden. Adjusted hazard ratios (ASA III-IV vs. I) for revision within 3 months were 2.7 (95% CI 1.2-5.9) in Geneva and 3.3 (CI 2.6-4.0) in Sweden. Interpretation - Assessment of ASA class of patients prior to THA will facilitate risk stratification. Targeted risk-reduction strategies may be appropriate during the very early postoperative period for patients identified as at higher risk. Systematically recording ASA class in arthroplasty registries will permit risk adjustment and facilitate comparison of revision rates internationally.

Dental Implant Quality Register-A possible tool to further improve implant treatment and outcome

The Board of EAO (European Association for Osseointegration) has discussed an initiative to explore the conditions to establish a Dental Implant Register. It was suggested to bring this issue to the EAO Consensus Conference 2018 for a discussion and to possibly propose relevant and manageable parameters. This article presents some select examples from quality registers in the medical field. Based on the experience of established registers, essentially in the medical field, factors considered to be of importance, if and when establishing a Dental Implant Register are introduced and discussed.

Fourteen-year experience with short cemented stems in total hip replacement

PURPOSE

The age of the population requiring total hip replacement (THR) is increasing and this may lead to a return of cemented stems. Advantages of a short cemented femoral device include preservation of metaphyseal bone, easier insertion, and easier cement removal in case of revision. The purpose of this study is to describe the rationale and assess midterm results of unique innovative short cemented double-tapered polished stem applied with contemporary cementing techniques.

METHODS

Our experience with this short cemented stem includes two different groups of elderly patients. Group 1 (prototype version of the short stem) from January 2005 to January 2008 counts 43 THR. Group 2 (final commercial version of the short stem) from January 2013 to January 2015 counts 54 THR. The average age in groups 1 and 2 was 79 and 75 respectively. Patients underwent clinical follow-up with the Harris Hip Score (HHS) and completed radiographic evaluation.

RESULTS

Thirty-one patients of group 1 had died for reasons unrelated to their THR. The surviving 9 hips have a follow-up of 11.2 years. In group 2, eight  patients died for reasons unrelated to their THR. Follow-up for the surviving 40 patients is 4.6 years. HHS improved in both groups. In 34/43 hips of group 1 and in 41/54 of group 2 we observed a Barrack grade A cement mantle. Survival with revision of the stem for aseptic loosening as the endpoint was 100%.

CONCLUSIONS

This study confirms the effectiveness of a short, polished, collarless, tapered cemented stem implanted with contemporary cementing techniques which appears as successful as the standard sized components.

Discrepancy and contradiction regarding fixation of hip stems with or without cement: survey among 765 hip arthroplasty specialists

INTRODUCTION

The growing use of cementless stems is associated with an increase in implant-related complications. This global survey study investigates which parameters orthopaedic surgeons currently consider for either cemented or cementless stem fixation in primary total hip arthroplasty (THA).

METHODS

A survey regarding current practice patterns was distributed among hip arthroplasty specialists. Key questions concerned: (i) frequency of using cemented/cementless stems; (ii) frequency of using parameters which influence a choice between both; (iii) usage of specific cut-off values for parameters.

RESULTS

507 (out of 765) respondents, having at least 5 years' experience and performing at least 50 cases a year, were selected for analysis. Respondents using both fixation techniques ( n = 413; 81%) use a cementless stem in 69% and a cemented stem in 31%. The choice is most frequently based on: (i) patient age; (ii) cortical thickness; (iii) femoral canal shape; (iv) bone mineral density; and (v) stem fit on preoperative templating. 57% using both fixation techniques do not use a specific cut-off value for age. 92% of the respondents that do use a cut-off value for age use exclusively cemented stems in patients being ⩾72.7 years (median 75; range 50-90 years). Considerable discrepancy and even contradictory responses were present regarding the other parameters and the use of specific cut-off values.

CONCLUSIONS

Current practice patterns regarding stem fixation in primary THA vary substantially among orthopaedic surgeons. Evidence-based guidelines are needed to define which parameters and threshold values support the best individual choice for hip stem fixation.

Clinical Performance of Ultra-Short Anatomic Cementless Versus Fourth-Generation Cemented Femoral Stems for Hip Replacement in Octogenarians

The aim of this study was to determine how ultra-short anatomic cementless vs cemented femoral stems affect the survival of primary total hip arthroplasties in octogenarians. Specifically, the authors investigated whether ultra-short anatomic cementless and cemented femoral components would have similar (1) functional results, (2) radiographic results, (3) revision and survival rates, and (4) complication rates in octogenarians. The authors evaluated 93 consecutive octogenarians (98 hips) in the ultra-short stem group (mean age, 86.5±5.3 years) and 78 consecutive octogenarians (92 hips) in the cemented stem group (mean age, 85.7±5.8 years). The average follow-up was 8.1 years (range, 5-12 years) in the ultra-short anatomic cementless stem group and 7.8 years (range, 5-11 years) in the cemented stem group. Mean preoperative (39 vs 37 points) and postoperative (81 vs 83 points) Harris hip scores were similar in the 2 groups (P=.131 and .128, respectively). The incidence of thigh pain was 0% in both groups. At final follow-up, mean Western Ontario and McMaster Universities Osteoarthritis Index scores (18 vs 14 points) and University of California, Los Angeles activity scores (4.3 vs 4.5 points) were similar in the 2 groups. The revision rate was 3% (3 hips) in the ultra-short stem group and 3% (3 hips) in the cemented stem group. Survivorship of the femoral stem was 97.3% at 8.1 years in the ultra-short stem group and 97.9% at 7.8 years in the cemented stem group (P=.136). Ultra-short anatomic cementless and cemented stems obtained rigid fixation in octogenarians. However, the incidence of undisplaced periprosthetic calcar fracture intraoperatively was significantly higher (P=.003) in the cemented stem group. [Orthopedics. 2018; 41(4):e470-e478.].

The effect of bearing type on the outcome of total hip arthroplasty

Background and purpose - Alternative bearing surfaces such as ceramics and highly crosslinked polyethylene (HXLPE) were developed in order to further improve implant performance of total hip arthroplasties (THAs). Whether these alternative bearing surfaces result in increased longevity is subject to debate. Patients and methods - Using the Dutch Arthroplasty Register (LROI), we identified all patients with a primary, non-metal-on-metal THA implanted in the Netherlands in the period 2007-2016 (n = 209,912). Cumulative incidence of revision was calculated to determine differences in survivorship of THAs according to bearing type: metal-on-polyethylene (MoPE), metal-on-HXLPE (MoHXLPE), ceramic-on-polyethylene (CoPE), ceramic-on-HXLPE (CoHXLPE), ceramic-on-ceramic (CoC), and oxidized-zirconium-on-(HXL)polyethylene (Ox(HXL)PE). Multivariable Cox proportional hazard regression ratios (HRs) were used for comparisons. Results - After adjustment for confounders, CoHXLPE, CoC, and Ox(HXL)PE resulted in a statistically significantly lower risk of revision compared with MoPE after 9 years follow-up (HR =0.8-0.9 respectively, compared with HR =1.0). For small (22-28 mm) femoral head THAs, lower revision rates were found for CoPE and CoHXLPE (HR =0.9). In the 36 mm femoral head subgroup, CoC-bearing THAs had a lower HR compared with MoHXLPE (HR =0.7 versus 1.0). Crude revision rates in young patients (< 60 years) for CoHXLPE, CoC, and Ox(HXL)PE (HR =0.7) were lower than MoPE (HR =1.0). However, after adjustment for case mix and confounders these differences were not statistically significant. Interpretation - We found a mid-term lower risk of revision for CoHXLPE, CoC, and Ox(HXL)PE bearings compared with traditional MoPE-bearing surfaces.

Ultra-Short Versus Conventional Uncemented Stems for Hip Replacement in Octogenarians

The aim of this study was to determine how an ultra-short anatomic uncemented stem vs a diaphyseal filling five-eighths porous coated uncemented femoral stem (conventional stem) affects the survival of primary total hip arthroplasties in octogenarians. The current study consisted of 52 patients (55 hips) in the ultra-short stem group (mean age, 85.5±5.3 years) and 61 patients (72 hips) in the diaphyseal (conventional) stem group (mean age, 84.1±4.8 years). The predominant diagnosis was osteoarthritis, followed by osteonecrosis of the femoral head, in both groups. Average follow-up was 6.1 years (range, 5-8 years) in the ultra-short stem group and 6.3 years (range, 5-9 years) in the conventional stem group. Pre- (41 vs 39 points) and postoperative (85 vs 86 points) Harris hip scores were similar between groups (P=.131 and .129, respectively). The incidence of thigh pain was 0% (0 of 52 patients) in the ultra-short stem group and 15% (9 of 61 patients) in the conventional stem group. The revision rate was 1.8% (1 hip) in the ultra-short stem group and 1.4% (1 hip) in the conventional stem group. Survivorship of the femoral stem was 98.2% in the ultra-short stem group at 6.1 years and 98.6% in the conventional stem group at 6.3 years. Ultra-short anatomic and diaphyseal filling uncemented stems obtained osseointegration in all hips. However, the prevalence of thigh pain and periprosthetic fracture were significantly higher in the patients with a conventional stem than in those with an ultra-short stem. [Orthopedics. 2018; 41(1):28-34.].

Cementless Total Hip Arthroplasty in Octogenarians

BACKGROUND

Although several studies indicate excellent results for cementless implants, controversy persists regarding its use in elderly patients. We determined to evaluate the outcome on patients aged over 80 years who were treated with cementless total hip arthroplasty for primary osteoarthritis of the hip.

METHODS

We assessed the data of 162 consecutive total hip arthroplasties in octogenarian patients (mean age 83 years, range 80-96 years). A control group was created, consisting of 342 patients aged younger than 80 years (mean age 65 years, range 37-79 years). The median follow-up of the cohort was 128.4 months (range 6-211).

RESULTS

Competing risk analyses revealed a cumulative implant survival of 98.1% at 5 and 10 years in the study group compared to 99.1% and 98.4% in the control group, taking system exchange as the end point. No differences in regard to system exchange could be detected between the groups. A significantly worsened complication-free survival rate was evident in the octogenarian group. Osteoporosis was the most powerful risk factor that proved to have a significant negative impact on development of complications.

CONCLUSION

Uncemented total hip arthroplasty is a viable option for the elderly patient. In this population sector, an excellent rate of implant survival can be expected. However, a significant increase of total complications in the octogenarian group could be detected, and was mainly caused by an elevated number of early postoperative complications. Osteoporosis turned out to be a strong risk factor in regard to complication-free survival. Surgeons should therefore be aware of this.

Advances in hip arthroplasty surgery: what is justified?

Total hip arthroplasty (THA) surgery has shown dramatic changes in terms of increased number of procedures and of technical development in recent years. It has been described as “the operation of the 20^th century” for the excellent results, the high satisfaction of the patients and the improvement of the quality of life.

A lot of variations have been introduced over the last few decades in THA especially in terms of indications (both in younger and older patients), techniques and devices (approaches, tissue preservation, biomaterials and industrial finishing), per-operative management (blood loss and pain control) and post-operative protocols (the so called “fast track” surgery). Looking at all these advances the emerging question is: have all of them been justified both in terms of improvement of the results for the patients and of the cost/benefit ratio from an economical point of view?

The purpose of this paper is to critically analyse the advantages and the disadvantages of the theoretically proposed “advances in hip arthroplasty” and attempt to understand which are justified of such “advances” nowadays, based on the international and the European perspective with a focus on the author’s personal clinical experience.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.170008. Originally published online at www.efortopenreviews.org

Risk factors for post-operative periprosthetic fractures following primary total hip arthroplasty with a proximally coated double-tapered cementless femoral component

AIMS

The aim of this study was to identify patient- and surgery-related risk factors for sustaining an early periprosthetic fracture following primary total hip arthroplasty (THA) performed using a double-tapered cementless femoral component (Bi-Metric femoral stem; Biomet Inc., Warsaw, Indiana).

PATIENTS AND METHODS

A total of 1598 consecutive hips, in 1441 patients receiving primary THA between January 2010 and June 2015, were retrospectively identified. Level of pre-operative osteoarthritis, femoral Dorr type and cortical index were recorded. Varus/valgus placement of the stem and canal fill ratio were recorded post-operatively. Periprosthetic fractures were identified and classified according to the Vancouver classification. Regression analysis was performed to identify risk factors for early periprosthetic fracture.

RESULTS

The mean follow-up was 713 days (1 to 2058). A total of 48 periprosthetic fractures (3.0%) were identified during the follow-up and median time until fracture was 16 days, (interquartile range 10 to 31.5). Patients with femoral Dorr type C had a 5.2 times increased risk of post-operative periprosthetic fracture compared with type B, while female patients had a near significant two times increased risk over time for post-operative fracture.

CONCLUSION

Dorr type C is an independent risk factor for early periprosthetic fracture, following THA using a double tapered cementless stem such as the Bi-Metric. Surgeons should take bone morphology into consideration when planning for primary THA and consider using cemented femoral components in female patients with poor bone quality. Cite this article: Bone Joint J 2017;99-B:451-7.

Perioperative Periprosthetic Fractures Associated With Primary Total Hip Arthroplasty

BACKGROUND

Periprosthetic fracture (PPF) is a rare but devastating complication of primary total hip arthroplasty (THA). While PPF is associated with increased morbidity and mortality, early revision rate, and poor patient outcome, there is a paucity of data on patient and hospital-dependent risk factors. Using a large administrative database, we investigated epidemiology and the risk factors associated with perioperative PPF after primary THA.

METHODS

We performed a retrospective review of the National Inpatient Sample records from 2006 to 2011 and identified 1062 PPFs of 1,187,969 patients using International Classification of Diseases, Ninth Revision code for PPF (996.44). We then analyzed sociodemographic characteristics, comorbidities, and hospital characteristics of our study population.

RESULTS

The overall incidence of PPF in National Inpatient Sample database was 0.089% (8.9 per 10,000 THAs). Patient-dependent risk factors were: female (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.67-2.22), low household income (OR 1.4, 95% CI 1.18-1.65), Medicaid (OR 1.89, 95% CI 1.39-2.57), and uninsured (OR 2.74, 95% CI 1.63-4.61). Patients with malnutrition and hemiparesis/hemiplegia were associated 10-fold and 6-fold risk of PPF. Nonteaching hospitals (OR 1.15, 95% CI 1.01-1.32), hospitals in northeast (OR 1.29, 95% CI 1.04-1.59), and rural hospitals (OR 1.27, 95% CI 1.06-1.53) had higher incidence of PPF.

CONCLUSION

Our study demonstrates that the incidence of PPF was low in our study population, and greater awareness is needed when performing primary THAs in patients with risk factors identified in our study to prevent PPF.

The Relative Merits of Cemented and Uncemented Prostheses in Total Hip Arthroplasty

The results of modern cemented and uncemented total hip arthroplasties are outstanding and both systems have their advantages and disadvantages. This paper aims to examine the designs of different types of prostheses, some history behind their development and the reported results. Particular emphasis is placed on cemented stem design and the details of cementing technique.

Cementless Tapered Femoral Stems for Total Hip Arthroplasty in Octogenarians

BACKGROUND

The use of cementless femoral components has become the standard in younger patients due to increased implant survivorship and decreased loosening. However, it remains controversial whether these femoral stems can provide comparable results in elderly patients. Therefore, our purpose was to compare the (1) incidence of revisions; (2) clinical outcomes; (3) incidence of postoperative blood transfusions; and (4) differences in complications between the 2 cohorts.

METHODS

Seventy-four consecutive patients (78 hips) aged 80 years or older, who underwent primary total hip arthroplasty using a cementless, tapered, femoral stem were retrospectively compared with a matched cohort of 76 patients (78 hips) who were less than 80 years. Mean age was 83 years (range, 80-91 years) vs 59 years (range, 17-79 years) for the matched group. Minimum follow-up was 2 years. Revision rates, clinical outcomes using the Harris Hip Score, incidences of complications, and postoperative transfusion rates were evaluated.

RESULTS

In the octogenarian cohort, the aseptic survivorship was 99%, compared with 95% in the matched group. There were 2 aseptic loosenings (2.6%): 1 femoral implant loosening (1.3%) and 1 acetabular loosening, but only 1 revision was performed, as one of the patients declined revision surgery. In the matched cohort, there were 6 revisions (7.7%). There were no significant differences in revision rates between the 2 cohorts, and no significant differences in final Harris Hip Score scores. The incidence of blood transfusion in the study group was 42% vs 19% in control group (P < .01).

CONCLUSION

The use of cementless, tapered, femoral stems yielded excellent results in the octogenarian group, although adequate patient preoperative optimization is necessary given the significantly higher transfusion incidence.

Still no single gold standard for using cementless femoral stems routinely in total hip arthroplasty

Background

There is now a clear trend with increased usage of cementless femoral stems for all ages and most patients. As the number of total hip arthroplasties (THAs) performed annually continues to increase with expanding indications for THA and demands for improved quality of life, so will the prevalence of THA in the elderly and aging populations. This is worrisome as the risk of complications with cementless femoral stems increases in elderly patients and those with poor bone quality. The purpose of this study is to analyze the available data from comparative studies to determine whether cementless femoral stems are overused and whether cemented stems warrant increased consideration.

Methods

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searches were performed to find original studies comparing cementless and cemented femoral stems; large population registry studies and reports were also included.

Results

This systematic review documents that older patients with cementless fixation increase the risk of revision, there is no clear fixation advantage in midaged patients, and younger patients fare better with cementless fixation. Complications after THA create burdens on the health care system and on patients.

Conclusions

Using evidence-based data should be better guidance in selecting the most reliable implants for THA. Although cementless femoral fixation for THA has evolved to the “new standard,” it has not been proven to be the “gold standard” for all patients.

Surgical treatments for osteoarthritis

There are two main surgical treatments for osteoarthritis: conservative treatments, where the damaged cartilage is left in place, and radical treatments, where the cartilage is replaced by an artificial endoprosthesis; this latter procedure is termed joint arthroplasty. These treatments are only offered to symptomatic patients. Arthrodesis is yet another surgical intervention in cases of osteoarthritis. It will sacrifice the joint's articular function and is performed on small osteoarthritic joints, such as wrists and ankles, for instance. Osteoarthritis symptoms are usually the consequence of an imbalance between the load applied to a joint and the surface available to support that load. Therefore, conservative treatments will either tend to decrease the load exerted on the joint, such as in a tibial valgus osteotomy for instance, or to improve the articular surface supporting that load. Sometimes, both can be provided at the same time; the peri-acetabular osteotomy for hip dysplasia is an example of such a procedure. Conservative treatments are usually offered to young patients in order to delay, if not avoid, the need for a joint prosthesis. They are usually performed before osteoarthritis appears or at an early stage. Joint arthroplasties have overwhelmingly excellent functional results and today's research is directed towards providing rapid recovery, very long-term stability, and the assurance of a good functionality in extreme conditions. However, complications with joint arthroplasties can be serious with little, if any, reasonable salvage solution. Therefore, these procedures are offered to patients who have failed adequate medical treatment measures.

The Morphology of the Proximal Femoral Canal Continues to Change in the Very Elderly: Implications for Total Hip Arthroplasty

A shape mismatch between cementless stems and the femoral canal of very elderly patients could partly explain the inferior performance of cementless compared to cemented stems in this age group. Influences of age and gender on canal morphology were investigated by measuring coronal/sagittal dimensions on CT-scans of subjects ≥80 years old (n = 117) and subjects < 80 years old (n = 51). Absolute canal dimensions like width were larger in octogenarians than in younger subjects. These differences were larger in the sagittal plane than in the coronal plane (P < 0.001). Canal flaring changed asymmetrically with increased medial and less lateral flaring in octogenarians. Age-related changes were mainly observed in females and should be taken into consideration for implant design, selection and implantation in octogenarians.