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Herzberg R, Tracey OC, Tahvilian S, Baksh N, Zikria B, Naziri Q. Incidence of heterotopic ossification following total hip arthroplasty by approach: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2089-2098. [PMID: 38536499 DOI: 10.1007/s00590-024-03896-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/28/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Heterotopic ossification (HO) formation has been increasingly recognized as a complication of major orthopedic surgeries, particularly total hip arthroplasty (THA). Though, the overall incidence of HO following THA has been well-documented, it is often not reported by severity or by surgical approach. QUESTIONS/PURPOSES (1) What are the demographics of patients with HO? (2) What is the severity of HO following THA using the Brooker classification? (3) What is the incidence and class of HO following different THA approaches (anterior, posterior, posterolateral, anterolateral, superior, lateral, trans-gluteal)? (4) What are the number and training level of surgeons who performed each procedure? METHODS The PubMed, Embase, and Web of Science databases were queried, and PRISMA guidelines were followed. Qualitative and quantitative analyses were performed using Microsoft Excel. RESULTS We isolated 26 studies evaluating 6512 total hip arthroplasties (THA). The mean HO percentage overall was 28.8%, mostly Class I (54.2%) or Class II (29.6%). The highest percentage of HO was associated with the modified direct lateral (57.2%) and the traditional lateral (34.6%) approaches. The lowest HO percentages were identified following posterolateral (12.8%) and direct superior approaches (1%). Most studies reported a singular senior surgeon operating within the same approach for all patients. CONCLUSIONS The traditional lateral and modified direct lateral approaches to THA resulted in the highest percentage of HO postoperatively. However, most ossification cases were not clinically significant and did not strongly affect overall patient morbidity. Further studies are warranted to identify an association between severity of ossification and different arthroplasty approaches.
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Affiliation(s)
- Rex Herzberg
- Department of Orthopedic Surgery and Rehabilitation Medicine, Downstate Medical Center, State University of New York (SUNY), Downstate Health Sciences University, 450 Clarkson Avenue, MSC 30, Brooklyn, NY, 11203, USA
| | - Olivia C Tracey
- Department of Orthopedic Surgery and Rehabilitation Medicine, Downstate Medical Center, State University of New York (SUNY), Downstate Health Sciences University, 450 Clarkson Avenue, MSC 30, Brooklyn, NY, 11203, USA
| | - Shahriar Tahvilian
- Touro College of Osteopathic Medicine, 230 W 125th St 3rd Floor, New York, NY, 10027, USA
| | - Nayeem Baksh
- Department of Orthopedic Surgery and Rehabilitation Medicine, Downstate Medical Center, State University of New York (SUNY), Downstate Health Sciences University, 450 Clarkson Avenue, MSC 30, Brooklyn, NY, 11203, USA
| | - Bashir Zikria
- Department of Orthopedic Surgery, Johns Hopkins Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Qais Naziri
- Department of Orthopedic Surgery and Rehabilitation Medicine, Downstate Medical Center, State University of New York (SUNY), Downstate Health Sciences University, 450 Clarkson Avenue, MSC 30, Brooklyn, NY, 11203, USA.
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Marqués López F, Pares Alfonso I, Donaire Hoyas D, Ruiz Morales G, Tey Pons M, Lizano Díez X, León García A. Total Hip Replacement with a Fully Hydroxyapatite-Coated Shortened Stem: Five- to Thirteen-Year Follow-Up Results. J Clin Med 2024; 13:2657. [PMID: 38731186 PMCID: PMC11084338 DOI: 10.3390/jcm13092657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 04/26/2024] [Accepted: 04/28/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Shortened femoral stems aim to mimic the biomechanical performance of traditional stems while preserving more bone and minimizing soft tissue damage. Our objective is to assess the outcomes of patients treated with a shortened stem (Furlong Evolution, JRI Orthopaedics, Sheffield, UK) to analyze the implant's efficacy and survivorship. Methods: This retrospective observational study included all patients aged 18 to 70 undergoing uncemented shortened stem total hip replacement at Hospital del Mar between 2010 and 2018. Hip function and pain were assessed with the Merle d'Aubigné-Postel scale and visual analog scale, respectively. A radiographic analysis measured stem and cup orientation, leg length discrepancy, stem subsidence, and radiolucencies around the cup. Perioperative complications, prosthetic failures, and reoperations were documented. Results: A total of 109 patients (74 male, 35 female) of a mean age of 51.8 ± 8.8 years were included. The average follow-up was 91 ± 17.4 months. Radiographically, 71 (65.1%) of the stems had been inserted at the appropriate angulation (±3°), and 102 (93.6%) of the cups had been placed in the Lewinnek safety zone. Leg length discrepancy was observed in 19 (17.4%) cases. The mean Merle d'Aubigné-Postel score improved from 13.1 ± 1.39 preoperatively to 17.8 ± 0.49 at 6 months postoperatively (p < 0.001). Merle d'Aubigné-Postel subscales also reflected a statistically significant improvement (p < 0.001). The mean pain score 12 months postoperatively was 0.52 ± 1.22, with 95.4% of patients declaring themselves satisfied or highly satisfied. The expected 13-year survival according to a Kaplan-Meier analysis was 100% in the absence of infection and 91.3% if revision for any cause is taken as a survival endpoint. Conclusions: The shortened stem under analysis provides excellent functional results and long-term survival rates.
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Affiliation(s)
- Fernando Marqués López
- Parc de Salut Mar, 08003 Barcelona, Spain; (I.P.A.); (G.R.M.); (M.T.P.); (X.L.D.); (A.L.G.)
| | - Ivet Pares Alfonso
- Parc de Salut Mar, 08003 Barcelona, Spain; (I.P.A.); (G.R.M.); (M.T.P.); (X.L.D.); (A.L.G.)
| | | | - Gregorio Ruiz Morales
- Parc de Salut Mar, 08003 Barcelona, Spain; (I.P.A.); (G.R.M.); (M.T.P.); (X.L.D.); (A.L.G.)
| | - Marc Tey Pons
- Parc de Salut Mar, 08003 Barcelona, Spain; (I.P.A.); (G.R.M.); (M.T.P.); (X.L.D.); (A.L.G.)
| | - Xavier Lizano Díez
- Parc de Salut Mar, 08003 Barcelona, Spain; (I.P.A.); (G.R.M.); (M.T.P.); (X.L.D.); (A.L.G.)
| | - Alfonso León García
- Parc de Salut Mar, 08003 Barcelona, Spain; (I.P.A.); (G.R.M.); (M.T.P.); (X.L.D.); (A.L.G.)
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Upadhyay PK, Shah N, Kumar V, Mirza SB. Hydroxyapatite ceramic-coated femoral components in younger patients followed up for 27 to 32 years. Bone Jt Open 2024; 5:286-293. [PMID: 38591124 PMCID: PMC11002557 DOI: 10.1302/2633-1462.54.bjo-2023-0136.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Abstract
Aims This study reports the results of 38 total hip arthroplasties (THAs) in 33 patients aged less than 50 years, using the JRI Furlong hydroxyapatite ceramic (HAC)-coated femoral component. Methods We describe the survival, radiological, and functional outcomes of 33 patients (38 THAs) at a mean follow-up of 27 years (25 to 32) between 1988 and 2018. Results Of the surviving 30 patients (34 THAs), there were four periprosthetic fractures: one underwent femoral revision after 21 years, two had surgical fixation as the stem was deemed stable, and one was treated nonoperatively due to the patient's comorbidities. The periprosthetic fracture patients showed radiological evidence of change in bone stock around the femoral stem, which may have contributed to the fractures; this was reflected in change of the canal flare index at the proximal femur. Two patients (two hips) were lost to follow-up. Using aseptic loosening as the endpoint, 16 patients (18 hips; 48%) needed acetabular revision. None of the femoral components were revised for aseptic loosening, demonstrating 100% survival. The estimate of the cumulative proportion surviving for revisions due to any cause was 0.97 (standard error 0.03). Conclusion In young patients with high demands, the Furlong HAC-coated femoral component gives excellent long-term results.
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Affiliation(s)
- Piyush K. Upadhyay
- Cumberland Infirmary, North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK
- School of Engineering University of Warwick, Coventry, UK
| | - Nirav Shah
- University Hospitals Sussex NHS Foundation Trust, West Sussex, UK
| | - Vishal Kumar
- Manchester University NHS Foundation Trust (MFT), Manchester, UK
| | - Saqeb B. Mirza
- Trauma and Orthopaedics, University Hospital Wales, Cardiff, UK
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Gómez-Vallejo J, Roces-García J, Moreta J, Donaire-Hoyas D, Gayoso Ó, Marqués-López F, Albareda J. Biomechanical Behavior of an Hydroxyapatite-Coated Traditional Hip Stem and a Short One of Similar Design: Comparative Study Using Finite Element Analysis. Arthroplast Today 2021; 7:167-176. [PMID: 33553545 PMCID: PMC7856394 DOI: 10.1016/j.artd.2020.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 11/23/2022] Open
Abstract
Background The objective is to compare, by the means of finite elements analysis, the biomechanical behavior of a conventional stem of proven performance with a short stem based on the same fixation principles. Methods A 3D femur was modeled from CT scan data, and real bone density measures were incorporated into it. Load stresses were applied to that bone in 3 different scenarios: without prosthesis, with the conventional stem, and with the short stem. Different bone loading patterns were compared by Gruen’s zones both visually and statistically using Welch’s test. Results The implantation of a stem generates a certain degree of stress shielding in the surrounding bone, but the pattern of the change is very similar in the compared stem models. Although there is statistical significance (P < 0.01) in the mean stress variation in most of the Gruen’s zones, the magnitude of the difference is always under 2 MPa (range: 0.01 – 1.74 MPa). Conclusions The bone loading patterns of the traditional stem and the short stem are very similar. Although there is no evidence of a link between biomechanics and clinical outcomes, our results may suggest that theoretical advantages of short stems can be exploited without the fear of altering bone loading patterns.
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Affiliation(s)
- Jesús Gómez-Vallejo
- Department of Orthopaedic Surgery, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Jorge Roces-García
- Department of Construction and Manufacturing Engineering, University of Oviedo, Oviedo, Spain
| | - Jesús Moreta
- Group of Lower Limb Reconstructive Surgery, Biocruces Bizkaia Health Research Institute, Osakidetza. Department of Orthopaedic Surgery and Traumatology, Hospital Galdakao-Usansolo, Bizkaia, Spain
| | | | - Óscar Gayoso
- Department of Orthopaedic Surgery, Hospital San Rafael, La Coruña, Spain
| | | | - Jorge Albareda
- Department of Orthopaedic Surgery, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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Keeling P, Howell JR, Kassam AAM, Sathu A, Timperley AJ, Hubble MJW, Wilson MJ, Whitehouse SL. Long-Term Survival of the Cemented Exeter Universal Stem in Patients 50 Years and Younger: An Update on 130 Hips. J Arthroplasty 2020; 35:1042-1047. [PMID: 31882346 DOI: 10.1016/j.arth.2019.11.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 11/04/2019] [Accepted: 11/07/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is variable evidence regarding survivorship beyond 20 years of total hip arthroplasties in young patients. We report the long-term results of the Exeter cemented hip system in patients ≤50 years at minimum of 20 years. METHODS Clinical and radiological outcomes of 130 consecutive total hip arthroplasties in 107 patients aged 50 years or younger at primary operation were reviewed; 77% had a diagnosis other than osteoarthritis. All patients were followed at 5-year intervals, no patients were lost to follow-up, and the status of every implant is known. RESULTS Mean age at surgery was 41.8 (17-50) years. Mean follow-up was 22.0 (20.0-26.1) years. There were 79 hips surviving, 14 hips (11 patients) deceased, and 37 hips revised. Reasons for revision: 29 hips for aseptic cup loosening (26 stems revised using cement-in-cement, three left in-situ); three stems for femoral osteolysis, two related to acetabular polyethylene wear (14.1 and 17.0 years), one with Gaucher's disease (21.1 years); one broken stem (12.9 years); one cup for instability (4.3 years-stem revised using cement-in-cement); and two hips with infection (8.5 and 23.8 years). There were no cases of aseptic loosening of the Exeter stem. There were no radiologically loose stems although eight patients had radiological evidence of loosening of the cemented cup. Survivorship at 22 years was 74.9% for revision for all causes and 96.3% for revision of the stem for aseptic loosening or lysis. CONCLUSION The Exeter cemented stem has excellent survivorship at minimum 20 years in young patients. Acetabular component survivorship was less favorable, but the advent of highly cross-linked polyethylene may improve this in the long term.
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Affiliation(s)
- Parnell Keeling
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Jonathan R Howell
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Al-Amin M Kassam
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Anubhav Sathu
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - A John Timperley
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK; College of Engineering, Maths and Physical Science, University of Exeter, Exeter, Devon, UK
| | - Matthew J W Hubble
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Matthew J Wilson
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Sarah L Whitehouse
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia
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Primary Total Hip Arthroplasty in Patients Less Than 50 Years of Age at a Mean of 16 Years: Highly Crosslinked Polyethylene Significantly Reduces the Risk of Revision. J Arthroplasty 2019; 34:S238-S241. [PMID: 30935803 DOI: 10.1016/j.arth.2019.02.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/11/2019] [Accepted: 02/14/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to evaluate clinical and radiographic outcomes of patients less than 50 years of age undergoing primary total hip arthroplasty (THA) at a minimum of 10 years. METHODS Three hundred nine consecutive THAs performed on 273 patients were reviewed. At a minimum of 10 years, 13 were deceased and 23 were lost to follow-up leaving 273 THAs in 237 patients who were followed for a mean of 16 years (range 10-19.9). The cohort consisted of 116 females (49%) and 121 males (51%), with a mean age of 42.3 years at the time of surgery (range 19-49). The majority of preoperative diagnoses included osteoarthritis in 149 (63%) and avascular necrosis in 55 (23%). Two hundred sixteen had highly crosslinked polyethylene (HXLPE) and 57 had non-HXLPE acetabular liners. The femoral stems were cementless in 98% (266/273) and the acetabular components were cementless in all cases. Femoral head composition was cobalt-chromium in all cases and the majority of sizes in the non-HXLPE cohort were 28 mm (52/57; 91%), while the HXLPE group primarily consisted of 28 mm (141/216; 65%) and 32 mm (74/216; 34%) heads. Analysis involved Kaplan-Meier survivorship with a log-rank test for equivalence, Fisher's exact test for pairwise comparisons, and a paired t-test for Harris Hip Score, with alpha = 0.05 being statistically significant. RESULTS There were 6 revisions for wear in the non-HXLPE group (10.5%) compared to none in the HXLPE group (P < .001). Similarly, survivorship with revision for any reason as the endpoint at 16 years was significantly higher at 93.0% in the XLPE group (95% confidence interval 88.7-95.7) compared to 85.7% (95% confidence interval 73.5-92.6) in the non-HXLPE group (P = .023). Additional revisions in the HXLPE group included 6 for instability (2.8%), 5 secondary to infection (2.4%), and 3 stem failures (1.4%). Non-wear-related revisions in the non-HXLPE group included 5 due to instability (8.8%) and 3 due to stem failures (5.3%). The mean Harris Hip Scores for the entire cohort improved from a mean of 46.2 points preoperatively to 89.8 points at most recent follow-up (P < .001). CONCLUSION The use of HXLPE has led to a significant reduction in the risk of failure in patients <50 years old, with over 93% survivorship at 16 years. Instability and infection, however, remain substantial causes of failure. LEVEL OF EVIDENCE Therapeutic Level III.
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Erivan R, Villatte G, Brientini JM, Kreider D, Descamps S, Boisgard S. 7-year results of primary total hip arthroplasty with the uncemented Avenir stem. Hip Int 2019; 29:418-423. [PMID: 30415580 DOI: 10.1177/1120700018810211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIMS The aim of the present study was to evaluate the 7-year functional outcome and radiographic results of primary total hip arthroplasties (THAs) performed with the uncemented Avenir stem. PATIENTS AND METHODS Between January 2006 and October 2008, 100 consecutive primary hips in 92 patients were enrolled at 2 centres. The mean age at operation was 58.5 years (27-87 years). Mini-incision (50%) and standard approaches (50%) were used to implant 22 standard and 78 lateralised stems. RESULTS The 7-year Kaplan-Meier survival rate was 98.9% (95% CI, 92.9-99.8) with stem revision for any reason as endpoint. No stem related complications occurred. 1 stem revision was due to deep infection at 51 months post-op. We had 4 acetabular revisions. The mean Harris Hip Score (HHS) at 7 years follow-up was 93.1 points (60-100). Radiographic analysis showed 2 patients had non-progressive radiolucent lines and no patient had any signs of stem subsidence or loosening. CONCLUSION The 7-year implant survival and the functional outcomes for THA performed with the study device are excellent and were in line with those documented for comparable contemporary uncemented fully HA-coated stems. Longer term follow-up of this consecutive series needs to be performed.
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Affiliation(s)
- Roger Erivan
- 1 Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, ICCF, Clermont-Ferrand, France
| | - Guillaume Villatte
- 1 Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, ICCF, Clermont-Ferrand, France
| | | | | | - Stéphane Descamps
- 1 Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, ICCF, Clermont-Ferrand, France
| | - Stéphane Boisgard
- 1 Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, ICCF, Clermont-Ferrand, France
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Haddad FS. Established dogma should be challenged. Bone Joint J 2017; 99-B:1409-1410. [PMID: 29092976 DOI: 10.1302/0301-620x.99b11.bjj-2017-1189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 09/28/2017] [Indexed: 11/05/2022]
Affiliation(s)
- F S Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK
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9
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Haddad FS. Common Hip Arthroplasty Problems-Useful Alternative Solutions From "Across the Pond". J Arthroplasty 2017; 32:S45-S46. [PMID: 28427737 DOI: 10.1016/j.arth.2017.02.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 02/27/2017] [Indexed: 02/01/2023] Open
Affiliation(s)
- Fares S Haddad
- Institute of Sport, Exercise & Health, University College Hospital, London, United Kingdom
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Affiliation(s)
- Fares S Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK
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Elmengaard B, Baas J, Jakobsen T, Kold S, Jensen TB, Bechtold JE, Soballe K. Do Bone Graft and Cracking of the Sclerotic Cavity Improve Fixation of Titanium and Hydroxyapatite-coated Revision Implants in an Animal Model? Clin Orthop Relat Res 2017; 475:442-451. [PMID: 27554268 PMCID: PMC5213936 DOI: 10.1007/s11999-016-5022-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND We previously introduced a manual surgical technique that makes small perforations (cracks) through the sclerotic bone shell that typically forms during the process of aseptic loosening ("crack" revision technique). Perforating just the shell (without violating the proximal cortex) can maintain overall bone continuity while allowing marrow and vascular elements to access the implant surface. Because many revisions require bone graft to fill defects, we wanted to determine if bone graft could further increase implant fixation beyond what we have experimentally shown with the crack technique alone. Also, because both titanium (Ti6Al4V) and hydroxyapatite (HA) implant surfaces are used in revisions, we also wanted to determine their relative effectiveness in this model. QUESTIONS/PURPOSES We hypothesized that both (1) allografted plasma-sprayed Ti6Al4V; and (2) allografted plasma-sprayed HA-coated implants inserted with a crack revision technique have better fixation compared with a noncrack revision technique in each case. METHODS Under approval from our Institutional Animal Care and Use Committee, a female canine animal model was used to evaluate the uncemented revision technique (crack, noncrack) using paired contralateral implants while implant surface (Ti6Al4V, HA) was qualitatively compared between the two (unpaired) series. All groups received bone allograft tightly packed around the implant. This revision model includes a cylindrical implant pistoning 500 μm in a 0.75-mm gap, with polyethylene particles, for 8 weeks. This engenders a bone and tissue response representative of the metaphyseal cancellous region of an aseptically loosened component. At 8 weeks, the original implants were revised and followed for an additional 4 weeks. Mechanical fixation was assessed by load, stiffness, and energy to failure when loaded in axial pushout. Histomorphometry was used to determine the amount and location of bone and fibrous tissue in the grafted gap. RESULTS The grafted crack revision improved mechanical shear strength, stiffness, and energy to failure (for Ti6Al4V 27- to 69-fold increase and HA twofold increases). The histomorphometric analysis demonstrated primarily fibrous membrane ongrowth and in the gap for the allografted Ti6Al4V noncrack revisions. For allografted HA noncrack revisions, bone ongrowth at the implant surface was observed, but fibrous tissue also was present in the inner gap. Although both Ti6Al4V and HA surfaces showed improved fixation with grafted crack revision, and Ti6Al4V achieved the highest percent gain, HA demonstrated the strongest overall fixation. CONCLUSIONS The results of this study suggest that novel osteoconductive or osteoinductive coatings and bone graft substitutes or tissue-engineered constructs may further improve bone-implant fixation with the crack revision technique but require evaluation in a rigorous model such as presented here. CLINICAL RELEVANCE This experimental study provides data on which to base clinical trials aimed to improve fixation of revision implants. Given the multifactorial nature of complex human revisions, such a protocoled clinical study is required to determine the clinical applicability of this approach.
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Affiliation(s)
- Brian Elmengaard
- Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Joergen Baas
- Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Jakobsen
- Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Soren Kold
- Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas B Jensen
- Department of Plastic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Joan E Bechtold
- Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark.
- Department of Orthopaedic Surgery, Minneapolis Medical Research Foundation, University of Minnesota, Minneapolis, MN, USA.
- Orthopaedic Biomechanics Laboratory, Minneapolis Medical Research Foundation, Life Sciences Building, Suite 118, 700 South 10th Avenue, Minneapolis, MN, 55415, USA.
| | - Kjeld Soballe
- Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
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Bechtold JE, Swider P, Goreham-Voss C, Soballe K. Experimental and Numerical Models of Complex Clinical Scenarios; Strategies to Improve Relevance and Reproducibility of Joint Replacement Research. J Biomech Eng 2016; 138:021008. [PMID: 26720312 DOI: 10.1115/1.4032368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Indexed: 12/26/2022]
Abstract
This research review aims to focus attention on the effect of specific surgical and host factors on implant fixation, and the importance of accounting for them in experimental and numerical models. These factors affect (a) eventual clinical applicability and (b) reproducibility of findings across research groups. Proper function and longevity for orthopedic joint replacement implants relies on secure fixation to the surrounding bone. Technology and surgical technique has improved over the last 50 years, and robust ingrowth and decades of implant survival is now routinely achieved for healthy patients and first-time (primary) implantation. Second-time (revision) implantation presents with bone loss with interfacial bone gaps in areas vital for secure mechanical fixation. Patients with medical comorbidities such as infection, smoking, congestive heart failure, kidney disease, and diabetes have a diminished healing response, poorer implant fixation, and greater revision risk. It is these more difficult clinical scenarios that require research to evaluate more advanced treatment approaches. Such treatments can include osteogenic or antimicrobial implant coatings, allo- or autogenous cellular or tissue-based approaches, local and systemic drug delivery, surgical approaches. Regarding implant-related approaches, most experimental and numerical models do not generally impose conditions that represent mechanical instability at the implant interface, or recalcitrant healing. Many treatments will work well in forgiving settings, but fail in complex human settings with disease, bone loss, or previous surgery. Ethical considerations mandate that we justify and limit the number of animals tested, which restricts experimental permutations of treatments. Numerical models provide flexibility to evaluate multiple parameters and combinations, but generally need to employ simplifying assumptions. The objectives of this paper are to (a) to highlight the importance of mechanical, material, and surgical features to influence implant-bone healing, using a selection of results from two decades of coordinated experimental and numerical work and (b) discuss limitations of such models and the implications for research reproducibility. Focusing model conditions toward the clinical scenario to be studied, and limiting conclusions to the conditions of a particular model can increase clinical relevance and research reproducibility.
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Haddad FS. Debate is healthy: more data are needed. Bone Joint J 2016; 98-B:865-6. [PMID: 27365462 DOI: 10.1302/0301-620x.98b7.38073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 06/06/2016] [Indexed: 11/05/2022]
Affiliation(s)
- F S Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK
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14
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Affiliation(s)
- F S Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK
| | - L Zagra
- Istituto Ortopedico Galeazzi IRCCS, Via R. Galeazzi 4, 20161, Milan, Italy
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