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

Mid-term clinical outcomes of the uncemented Robert Mathys pressfit cup

BACKGROUND

The use of uncemented cups during total hip arthroplasty (THA) has gained popularity in recent years. The Robert Mathys (RM) pressfit cup, an uncemented monoblock implant is expected to preserve bone density due to its composition and external surface, while reducing backside wear with its monoblock construction. These factors should lead to a high survival rate of the implant.

AIM

To evaluate the mid-term survival and functional outcome of the RM Pressfit cup in a large study population.

METHODS

Between 2011 and 2020, we included 1324 patients receiving a primary THA using the RM pressfit cup. Final clinical follow-up was performed at 2 years postoperatively with the Dutch arthroplasty register used to assess implant status thereafter. Revision for acetabular failure and reason for revision were reported to evaluate implant survival, while the hip disability and osteoarthritis outcome score (HOOS) scores were used to assess functional outcome.

RESULTS

The mean age at surgery was 64.9 years. The mean follow-up was 4.6 years. Of the 1324 THAs performed, 13 needed cup revisions within 5 years after index THA: 5 due to aseptic loosening, 6 due to infection, 2 due to dislocation and 2 due to other causes. This resulted in a 5-year cup survival of 98.8% (95%CI: 98.1-99.5). Nine of the cup revisions occurred within the first year after index THA. HOOS scores increased significantly in all domains during the first year and levelled out during the second year.

CONCLUSION

In the present study, the RM pressfit cup demonstrated excellent clinical outcomes at mid-term follow-up; however, future studies are needed to assess the long-term outcomes of this acetabular implant.

Early Radiographic and Clinical Outcomes of an Additive-Manufactured Acetabular Component

Background

Additive manufacturing has recently gained popularity and is widely adopted in the orthopaedic industry. However, there is a paucity of literature on the radiographic and clinical outcomes of these relatively novel components. The aim of this study was to assess the 2-year clinical and radiographic outcomes of a specific additive-manufactured acetabular component in primary total hip arthroplasty.

Methods

We performed a retrospective review of 60 patients who underwent primary total hip arthroplasty with the use of the Stryker's TRIDENT II acetabular component. Evaluation of radiographs was performed at 6 weeks, 1 year, and 2 years postoperatively. Radiographs were evaluated for radiolucencies in Charnley and DeLee zones, signs of biologic fixation, and acetabular inclination and anteversion measurements. Patient-reported outcomes and complications were also obtained.

Results

There were no cases of component loosening or changes in component position during follow-up, with an average follow-up time of 1.7 years. A radiolucent line was identified in one patient in zone 1 at 6 weeks; this was absent at 1 year. Radiographic signs of cup biologic fixation were present in 85% of cases by final follow-up. The average inclination was 45.1 (SD = 4.0), and the average anteversion was 26.9 (SD = 5.2). Patient-Reported Outcomes Measurement Information System scores significantly increased at the final follow-up, and there were no complications in this cohort.

Conclusions

This study demonstrated excellent radiographic and clinical outcomes with this novel additive-manufactured acetabular component at early follow-up. Although longer-term follow-up is warranted, this additively manufactured highly porous titanium acetabular component demonstrated excellent biologic fixation and reliable fixation at mid-term follow-up.

The Measurement of the Oxidative Index of Polyethylene Obtained during Revision Hip Arthroplasty and Assessment of Its Variability Depending on the Degree of Osteolysis, Implantation Time, as Well as the Size and Material of the Utilized Head

Background/Objectives: Aseptic loosening is the leading cause of late revision in total hip arthroplasty, primarily due to degenerative oxidation of polyethylene components, leading to wear particle formation and periacetabular osteolysis. This study aimed to analyze the oxidation levels in polyethylene liners and cemented cups retrieved from revision surgeries using Fourier-transform infrared spectroscopy (FTIR) and to explore the correlation between oxidation levels and factors such as head size, head material, fixation method, and implant survival time. Methods: Polyethylene liners and cups were analyzed post-revision surgery to assess oxidation levels, which were then compared to periacetabular bone loss measured by the Paprosky classification. This study evaluated the impact of head size (28 mm vs. 32 mm), head material (ceramic vs. metal), and fixation methods on oxidation. The relationship between the mean oxidation index (OI) and implant survival time was also investigated. Results: There was a significant positive correlation between the mean oxidation index of the polyethylene components and the severity of periacetabular osteolysis according to the Paprosky scale. While the mean OI for samples articulating with ceramic heads was lower than for those with metal heads, and the mean OI for samples with a 32 mm head size was lower than for those with a 28 mm size, these differences were not statistically significant. Furthermore, the fixation method did not affect the oxidation index, and no correlation was found between OI and the survival time of the implants. Conclusions: This study confirms a direct correlation between polyethylene oxidation and periacetabular osteolysis in hip replacements, highlighting the importance of material choice and design in potentially reducing the risk of aseptic loosening. Despite the lack of significant differences in oxidation levels based on head material and size, these factors may still play a role in the long-term outcome of hip arthroplasty, warranting further investigation.

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.

Nexus Evaluation Primary Trident II UNcemented shEll (NEPTUNE)

Aims

The primary aim of this study is to assess the survival of the uncemented hydroxyapatite (HA) coated Trident II acetabular component as part of a hybrid total hip arthroplasty (THA) using a cemented Exeter stem. The secondary aims are to assess the complications, joint-specific function, health-related quality of life, and radiological signs of loosening of the acetabular component.

Methods

A single-centre, prospective cohort study of 125 implants will be undertaken. Patients undergoing hybrid THA at the study centre will be recruited. Inclusion criteria are patients suitable for the use of the uncemented acetabular component, aged 18 to 75 years, willing and able to comply with the study protocol, and provide informed consent. Exclusion criteria includes patients not meeting study inclusion criteria, inadequate bone stock to support fixation of the prosthesis, a BMI > 40 kg/m2, or THA performed for pain relief in those with severely restricted mobility.

Results

Implant survival, complications, functional outcomes and radiological assessment up to ten years following index THA (one, two, five, seven, and ten years) will be performed. Functional assessment will include the Oxford Hip Score, Forgotten Joint Score, 12-Item Short Form Health Survey, EuroQol five-dimension health questionnaire, and pain and patient satisfaction. Radiological assessment with assess for acetabula lucent lines, lysis, and loosening according to DeLee and Charnley zones.

Conclusion

This study is part of a stepwise introduction of a new device to orthopaedic practice, and careful monitoring of implants should be carried out as part of the Beyond Compliance principles. The results of this study will provide functional, radiological, and survival data to either support the ongoing use of the HA acetabulum or highlight potential limitations of this new implant before wide adoption.

Increasing age does not influence hip-specific functional outcome or health-related quality of life following total hip arthroplasty

Aims

The primary aim of our study was to assess the influence of age on hip-specific outcome following total hip arthroplasty (THA). Secondary aims were to assess health-related quality of life (HRQoL) and level of activity according to age.

Methods

A prospective cohort study was conducted. All patients were fitted with an Exeter stem with a 32 mm head on highly cross-linked polyethylene (X3RimFit) cemented acetabulum. Patients were recruited into three age groups: < 65 years, 65 to 74 years, and ≥ 75 years, and assessed preoperatively and at three, 12, 24, and 60 months postoperatively. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), and Hip disability and Osteoarthritis Outcome Score (HOOS), were used to assess hip-specific outcome. EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and 36-Item Short Form Survey (SF-36) scores were used to assess HRQoL. The Lower Extremity Activity Scale (LEAS) and Timed Up and Go (TUG) were used to assess level of activity.

Results

There were no significant (p > 0.05) differences in the WOMAC scores, HSS, HOOS, or EQ-5D-5L at any postoperative timepoint between the age groups. Patients aged ≥ 75 years had significantly lower physical function (p ≤ 0.010) and physical role (p ≤ 0.047) SF-36 scores at 12, 24, and 60 months, but were equal to that expect of an age-matched population. No differences according to age were observed for the other six domains of the SF-36 (p > 0.060). The ≥ 75 years group had a lower LEAS (p < 0.001) and longer TUG test times (p ≤ 0.032) compared to the < 65 years group, but older age groups had significant (p < 0.001) improvement relative to their preoperative baseline measures.

Conclusion

Age did not influence postoperative hip-specific outcome or HRQoL (according to the EQ-5D) following THA. Despite a significant improvement, older patients had lower postoperative activity levels compared to younger patients, but this may be reflective of the overall physical effect of ageing. Cite this article: Bone Jt Open 2022;3(9):692–700.

Analysis of the Risk of Wear on Cemented and Uncemented Polyethylene Liners According to Different Variables in Hip Arthroplasty

Wear debris in total hip arthroplasty is one of the main causes of loosening and failure, and the optimal acetabular fixation for primary total hip arthroplasty is still controversial because there is no significant difference between cemented and uncemented types for long-term clinical and functional outcome. To assess and predict, from a theoretical viewpoint, the risk of wear with two types of polyethylene liners, cemented and uncemented, a simulation using the finite element (FE) method was carried out. The risk of wear was analyzed according to different variables: the polyethylene acetabular component’s position with respect to the center of rotation of the hip; the thickness of the polyethylene insert; the material of the femoral head; and the relationship of the cervical–diaphyseal morphology of the proximal end of the femur to the restoration of the femoral offset. In all 72 simulations studied, a difference was observed in favour of a cemented solution with respect to the risk of wear. With regard to the other variables, the acetabular fixation, the thickness of the polyethylene, and the acetabular component positioning were statistically significant. The highest values for the risk of wear corresponded to a smaller thickness (5.3 mm), and super-lateral positioning at 25 mm reached the highest value of the von Mises stress. According to our results, for the reconstruction of the acetabular side, a cemented insert with a thickness of at least 5 mm should be used at the center of rotation.

Primary Complex Total Hip Arthroplasty in Neglected Anterior Hip Dislocation With Comminuted Pertrochanteric Femur Fracture

Neglected anterior hip dislocation combined with comminuted pertrochanteric ipsilateral fracture of the femur is rare, with few reports in the literature. The present report describes the case of a 7-month-old neglected anterior hip dislocation with a pertrochanteric femoral fracture in a 45-year-old male patient. The patient was treated with total hip arthroplasty with proximal femoral reconstruction. The 2-year follow-up showed good clinical and radiological outcomes with a painless and mobile hip joint. The Harris-Hip score improved from 10 (preoperatively) to 89 (postoperatively) after 2 years. The patient was satisfied with the intervention and showed minimal lurch with ambulation with no leg-length discrepancy. However, long-term results from periodic follow-up are warranted.

Total hip replacement in patient with residual poliomyelitis with neglected femoral neck fracture

A 71-year-old man with residual poliomyelitis was referred to the orthopaedic surgeons with a neglected left femoral neck fracture of the paralytic limb. He had presented at another hospital with left groin pain and inability to weight bear 4 weeks earlier after a fall from standing height, but had delayed treatment due to his insistence on waiting until he returned to his home country.Successful treatment of residual poliomyelitis fractures requires early union as well as early mobilisation and rehabilitation. This patient presented to the orthopaedic surgeons with a challenging case due to the delay in treatment and the fact that the fracture was basicervical which results in an unstable fracture. Surgical expertise was required to decide on the optimum surgical option and a total hip arthroplasty was performed. The patient made a good recovery following physiotherapy as evidenced clinically and radiologically.

Cost effectiveness analyses of total hip arthroplasty for hip osteoarthritis: A PRISMA systematic review

BACKGROUND

Healthcare services are facing economic constraints globally with an increasingly elderly population, and greater burdens of osteoarthritis. Because of the chronic nature of osteoarthritis and the costs associated with surgery, arthroplasty is seen as potentially cost saving. There have been no systematic reviews conducted on cost effectiveness analysis (CEA) studies of total hip arthroplasty (THA) in the management of osteoarthritis. The aim of this systematic review was to evaluate CEAs conducted on THA for osteoarthritis to determine if THA is a cost-effective intervention.

MATERIALS AND METHODS

A systematic review was conducted using five databases to identify all clinical CEAs of THA for osteoarthritis conducted after 1 January 1997. Twenty-eight studies were identified that met the inclusion criteria. The Quality of Health Economic Analysis (QHES) checklist was employed to assess the quality of the studies.

RESULTS

The average QHES score was 86 indicating high quality studies. All studies reviewed concluded that THA was a cost-effective intervention. In younger patients, cementless THA and ceramic on polyethylene implants were found to be most cost effective. Hybrid THA and metal on polyethylene implants had the greatest cost utility in older patients. In patients with acetabular defects, cemented cup with impaction bone grafting was most cost effective, while dual mobility THA was most cost effective in patients with high risk of dislocation.

CONCLUSION

We have shown that THA is a cost-effective treatment for hip osteoarthritis. These findings should be implemented into clinical practice to improve cost utility in health services across the world.