Cementless total hip arthroplasty with alumina bearings in patients younger than fifty with femoral head osteonecrosis

Updating Osteonecrosis of the Femoral Head

Osteonecrosis of the femoral head (ONFH), a condition characterized by the presence of a necrotic bone lesion in the femoral head, is caused by a disruption in the blood supply. Its occurrence is more common in young and middle-aged adults and it is the main reason for performance of total hip arthroplasty in this age group. Its incidence is increasing along with increased use of glucocorticoids for management of adjuvant therapy for treatment of leukemia as well as organ transplantation and other myelogenous diseases. Current information on etiology and pathogenesis, as well as natural history, stage system, and treatments is provided in this review. A description of the Association Research Circulation Osseous (ARCO) criteria for classification of glucocorticoids- and alcohol-associated ONFH, 2019 ARCO staging system, and 2021 ARCO classification using computed tomography for the early stages of ONFH is also provided.

Forte ceramic-on-delta ceramic cementless total hip arthroplasty: an 8- to 15-year follow-up study

INTRODUCTION

Forte ceramic head on delta ceramic liner articulation showed satisfactory midterm results without ceramic-related complication. We aimed to investigate the clinical and radiological outcomes of cementless total hip arthroplasty (THA) with forte ceramic head on delta ceramic liner articulation.

MATERIALS AND METHODS

Overall, 107 patients (57 men, 50 women; 138 hips) who underwent cementless THA with forte ceramic head on delta ceramic liner articulation were enrolled. The mean follow-up duration was 11.6 years. For the clinical assessments, Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), presence of thigh pain, and presence of squeaking were evaluated. Radiographs were assessed to search for osteolysis, stem subsidence, loosening of implants. Kaplan-Meier survival curves were evaluated.

RESULTS

The mean HHS and WOMAC improved from 57.1 and 28.1 preoperatively to 81.4 and 13.1 at the final follow-up, respectively. Nine revisions (6.5%) were performed; 5 hips for stem loosening, 1 hip for ceramic liner fracture, 2 hips for periprosthetic fracture, and 1 hip for progressive osteolysis around cup and stem. Thirty-two patients (37 hips) complained squeaking, in which 4 cases (2.9%) were identified as ceramic-related noises. After a mean follow-up period of 11.6 years, 91% (95% CI 87.8-94.2) were free from revision of both femoral and acetabular components due to any reason.

CONCLUSIONS

Cementless THA with forte ceramic-on-delta ceramic articulation showed acceptable clinical and radiological results. Serial surveillance of these patients should be performed due to the possibility of cerami- related complications such as squeaking, osteolysis, and ceramic liner fracture.

Total Hip Arthroplasty via direct anterior approach for osteonecrosis; comparison with primary hip osteoarthritis in a mid term follow up

Background

To determine the mid-term outcomes of conventional cementless Total Hip Arthroplasty (THA) in patients with avascular necrosis (AVN) of the femoral head and compare to patients with primary hip osteoarthritis (OA).

Method

A total of 330 consecutive primary THA procedures (AVN and OA) performed between 2010 and 2013 by a single surgeon and in a single center using the direct anterior approach (DAA) were included. Assessments including SF-36, WOMAC, and Harris Hip Scores (HHS) were retrieved from patients before the surgery and at the latest follow-up. Clinical and functional outcomes were compared between the AVN and OA groups.

Results

A total of 294 consecutive THA (AVN = 107, OA = 187) with 104.4 ± 6.2 months follow-up were analyzed, which AVN patients were significantly younger (32.0 vs. 59.6 y/o). Corticosteroid 34 (31.8%), idiopathic AVN 31 (29.0%) and use of unapproved weight gain supplements (UWGS) 23 (21.5%) were the main reasons for AVN. Despite that preoperative scores were comparable (P > 0.05), the HHS, SF-36, and WOMAC scores are significantly higher in the AVN group after THA surgery (P < 0.05). Moreover, flexion and abduction ROM were significantly higher in the AVN group (P < 0.05). Regarding each complication, no significant difference was observed between groups. In the whole sample, there were 5 (1.7%) revisions due to loosening of acetabular components, all the OA group (P > 0.05).

Conclusion

Conventional cementless THA with highly cross-linked polyethylene provides satisfactory mid-term results in patients with AVN with a low rate of postoperative complications. Compared to primary OA patients, this group reaches superior postoperative scores.

Сomparative analysis of large diameter bearing ceramic monoblock acetabular components

Introduction

The goal of total hip arthroplasty (THA) is to provide ease to patients with persistent and exhausting pain. Durability is the main challenge associated with any tribological pair, with the aim of minimizing wear and thus avoiding problems with aseptic loosening of components and osteolysis. When polyethylene inserts are used in young patients, we should always consider their disadvantages, e.g., increased wear of the interacting components. Proper selection of friction pairs allows prolonged implant life. Ceramic-on-ceramic (CoC) friction pairs should provide long-term wear of the friction components.

Objectives

To evaluate the mid-term results of using the monoblock Maxera Cup (Zimmer Biomet) acetabular system in cementless THA.

Methods

We operated on 151 patients using the monoblock Maxera Cup (Zimmer Biomet) acetabular system. The mean follow-up duration was 6 years (73.8 ± 11.7 months). Fifty-seven women and 94 men aged 19-64 years were surgically treated. All 170 THA cases in 151 patients were divided into 3 groups according to the diameters of the CoC friction pairs used (40, 44, and 48 mm). As a control group, we have taken 50 patients who received 50 THA using a standard 36 mm CoC friction pair. The achieved functional results were evaluated using the HHS scale, WOMAC scale, and SF36 scale. We also evaluated the mean duration of surgical intervention and blood loss.

Results

When assessing long-term results, the average HHS significantly increased from 34.10 (before surgery) to 87.50 (postoperation) points in the 1st group, from 46.24 to 96.5 points in the 2nd group, and from 38.70 to 92.10 points in the 3rd group. From preoperative examination to 1 year after surgery, there was a 2.4-fold improvement in the functional results in group 1 and 1,8 and 2.9 -fold improvement in groups 2 and 3, indicating excellent treatment results. Inconsistent creaking in the implanted joint was noted in only 2.6% of cases in which a CoC friction pair with a diameter of 44 mm was used. We did not observe any complications associated with aseptic or septic loosening of the components either clinically or radiologically during the 7-year follow-up period after surgery in the entire patient population.

Conclusions

1Use of the CoC monoblock allowed us to expect an increase in the life cycle of the implant and provided good joint function and perception by the patient.2Monoblock cups provided good joint function and perception by the patient.3Acoustic effects, in the form of minor creaking, did not affect the functional results.

Third-Generation Ceramic-on-Ceramic Total Hip Arthroplasty in Patients with Osteonecrosis of the Femoral Head: A 10- to 16-year Follow-up Study

BACKGROUND

Long-term follow-up results of ceramic-on-ceramic (COC) total hip arthroplasty (THA), specifically, in patients with osteonecrosis of the femoral head (ONFH) are unknown. We evaluated (1) clinical results and radiological outcomes, (2) ceramic-related complications: noise and ceramic fracture, (3) osteolysis, and (4) survivorship after alumina COC THA in ONFH patients with longer than 10-year follow-up.

METHODS

From May 2003 to June 2009, 325 ONFH patients (403 hips) underwent primary THAs at our department. Among them, 231 patients (293 THAs) were followed for 10 to 16 (mean, 12.9) years. There were 148 men and 83 women, their mean age at the time of THA was 47.2 years, and their mean body index was 24.0 kg/m2. The postoperative CT scans were done in 160 hips.

RESULTS

Grinding sensation or squeak was noted in 6.8% (20/293), ceramic head fracture occurred in 2.4% (7/293) and acetabular osteolysis developed in 0.7% (2/293). All 7 ceramic fractures occurred in 28-mm short-neck heads. There was no detectable wear or prosthetic loosening, and the 16-year survivorship was 96.0% (95% confidence interval; 93.8% to 98.2%). The mean Harris hip score was 91.7 (range, 84 to 100) points at the final follow-up.

CONCLUSIONS

The 10- to 16-year results of alumina COC THAs were encouraging with an excellent survivorship. However, ceramic fracture and noise still remain matters of concern. We recommend not to use 28-mm short-neck ceramic head to avoid ceramic head fractures.

LEVEL OF EVIDENCE

III.

Survival and complications of total hip arthroplasty using third-generation dual-mobility cups with non-cross-linked polyethylene liners in patients younger than 55years

BACKGROUND

In younger patients, total hip prostheses are subjected to wide motion ranges and wear-inducing forces. Dual-mobility cups (DMCs) are effective in decreasing the risk of dislocation. However, wear and osteolysis have been reported with first-generation DMCs. These complications have not been assessed in younger patients managed with third-generation DMCs associated with a lower risk of intra-prosthetic dislocation (IPD). We therefore designed a retrospective study of patients younger than 55years at THA with third-generation DMCs. Our objectives were to evaluate (1) the complication rate, and (2) the survival rate.

HYPOTHESIS

The rate of complications of THA with third-generation DMCs in patients younger than 55years of age is comparable to that in the general population of THA patients.

MATERIAL AND METHODS

This retrospective study included 79 consecutive patients (91 hips) who had total hip arthroplasty (THA) between 2007 and 2012. We included all patients younger than 55years who underwent primary THA with a third-generation DMC and a liner made of non-cross-linked polyethylene. The patients were evaluated clinically and radiologically.

RESULTS

Mean follow-up was 9.8years (range: 2-13years). At last follow-up, no patient had experienced prosthetic dislocation or IPD. Aseptic and septic cup loosening each occurred in 1 patient. In all, 7 (7.7%) patients required revision surgery with exchange of at least one component (cup loosening, n=2; neck fracture with a short stem fixed to the neck, n=1; peri-prosthetic femoral fracture, n=1; infection, n=1; and femoral-stem loosening, n=2). Peri-acetabular osteolysis developed in 2 (2.2%) hips. Cup survival to aseptic loosening was 98.9% (95% confidence interval, 97%-100%) and survival to revision for any reason except infection was 95.6% (95% confidence interval, 82%-100%).

DISCUSSION

In patients younger than 55years, third-generation DMCs were associated with absence of prosthetic dislocation, absence of IPD, and a low revision rate for cup loosening, in the medium term. These implants therefore constitute a viable treatment option in younger patients requiring THA.

LEVEL OF EVIDENCE

IV, retrospective study.

Fracture of a 40-mm BIOLOX Delta Femoral Head

Ceramic bearing surfaces have gained popularity in total hip arthroplasty as a result of the favorable mechanical properties and low wear rates. Despite the recognition as an attractive articulation, problems such as ceramic head fracture persist. Smaller heads and higher body mass indices are touted as risk factors for ceramic head fracture and are often associated with antecedent trauma. We present a case report of an 83-year-old male with a body mass index of 26.7 kg/m² who suffered a fracture of a 40-mm ceramic femoral head. This occurred atraumatically 5 years from his index surgery. This patient underwent revision total hip arthroplasty which included debridement of ceramic debris and alteration of the bearing surface with femoral head and polyethylene liner exchange.

Osteonecrosis of the Femoral Head: an Updated Review of ARCO on Pathogenesis, Staging and Treatment

Non-traumatic osteonecrosis of the femoral head (ONFH) usually affects adults younger than 50 years and frequently leads to femoral head collapse and subsequent arthritis of the hip. It is becoming more prevalent along with increasing use of corticosteroids for the adjuvant therapy of leukemia and other myelogenous diseases as well as management of organ transplantation. This review updated knowledge on the pathogenesis, classification criteria, staging system, and treatment of ONFH.

The reasons for ceramic-on-ceramic revisions between the third- and fourth-generation bearings in total hip arthroplasty from multicentric registry data

This study aimed to evaluate (1) the overall reasons for first revision in CoC THAs; (2) whether the reasons for revision differ between third-generation and fourth-generation CoC THAs; and (3) the specific factors associated with bearing-related problems as the reason for revision. We retrospectively reviewed 2045 patients (2194 hips) who underwent first revision THA between 2004 and 2013, among which 146 hips with CoC bearings underwent revision. There were 92 hips with third-generation ceramic bearings and 54 hips with fourth-generation ceramic bearings. The major reasons for CoC THA revisions were ceramic fracture and loosening of the cup or stem. When ceramic fracture, squeaking, incorrect ceramic insertion, and unexplained pain were defined as directly related or potentially related to ceramic use, 28.8% (42/146) of CoC revisions were associated with bearing-related problems. Among the third-generation ceramic bearings, revision was performed in 41.3% (38/92) of cases owing to bearing-related problems whereas revisions were performed for only 7.4% (4/54) of cases with fourth-generation ceramic bearings owing to bearing-related problems (p < 0.001). Younger age, lower American Society of Anesthesiologists (ASA) grade, and preoperative diagnosis of osteonecrosis were factors related to CoC THA revisions due to bearing-related problems.

Japanese Orthopaedic Association 2019 Guidelines for osteonecrosis of the femoral head

PURPOSE

The Clinical Practice Guidelines for Osteonecrosis of the Femoral Head (ONFH) 2019 Edition, written by the working group for ONFH guidelines of the Japanese Investigation Committee (JIC) for ONFH under the auspices of the Japanese Ministry of Health, Labour, and Welfare and endorsed by the Japanese Orthopaedic Association, were published in Japanese in October 2019. The objective of this guideline is to provide a support tool for decision-making between doctors and patients.

METHODS

Procedures for developing this guideline were based on the Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014, which proposed an appropriate method for preparing clinical guidelines in Japan.

RESULTS

This clinical practice guideline consists of 7 chapters: epidemiology; pathology; diagnosis; conservative therapy; surgical treatment: bone transplantation/cell therapy; surgical treatment: osteotomy; and surgical treatment: hip replacement. Twelve background questions and 13 clinical questions were determined to define the basic features of the disease and to be addressed when deciding treatment in daily practice, respectively.

CONCLUSIONS

The clinical practice guidelines for the ONFH 2019 edition will be useful for physicians, investigators, and medical staff in clinical practice, as well as for patients, during the decision-making process when defining how to treat ONFH.

Stem cell therapy for osteonecrosis of femoral head: Opportunities and challenges

Osteonecrosis of the femoral head (ONFH) is a progressive disease with a complex etiology and unclear pathogenesis, resulting in severe hip pain and dysfunction mainly observed in young patients. Although total hip arthroplasty (THA) is the most effective treatment for patients with ONFH in the terminal stage, the results of THA in young patients or active populations are often not favorable, with some complications related to the prosthesis. With the development of biotechnology, an increasing number of studies pay attention to use of stem cells for the treatment of ONFH. Stem cells are characterized by the ability to self-renew and differentiate into multiple cell types, including differentiation into osteoblasts and endothelial cells to mediate bone repair and angiogenesis. Furthermore, stem cells can offer growth factors to promote blood supply in the necrotic regions by paracrine effects. Therefore, stem cell therapy has become one of the hip-preserving alternatives for ONFH. This review summarized the current trends in stem cell therapy for ONFH, from clinical applications to related basic research, and showed that an increasing number of studies have confirmed the effectiveness of stem cell therapy in ONFH. However, many unsolved problems and challenges in practical applications of stem cell therapy still exist, such as patient selection, standardized procedures, safety assessment, and the fate of transplanted cells in the body. Additional studies are required to find ideal cell sources, appropriate transplantation methods, and the optimal number of cells for transplantation.

•

Diversities in repair processes present a challenge in the targeted treatment of ONFH.

•

Osteogenesis and angiogenesis are the primary mechanisms of MSCs treatment in ONFH.

•

Systematic safety assessment and cell tracing are necessary for stem cell therapy.

•

Optimal numbers and methods of cell transplantation need to be further confirmed.

Short to mid-term outcome of total hip arthroplasty with cementless implants in patients younger than 25 years old

BACKGROUND

Total hip arthroplasty (THA) was once reserved for old patients with hip arthritis but has become more common in very young patients (≤25 years old) diagnosed with various joint disease that were not relieved with conservative treatment. The purpose of this study was to evaluate short to mid-term outcome of THA in patients younger than 25 years old.

METHOD

This retrospective study included 45 patients younger than 25 years (mean age 21.8 ± 2.14 years) who underwent THA. The surgical indications, implant selection, leg length discrepancy, medication history, radiographic outcome, survival and clinical results including the modified Harris hip score (mHHS) and SF-36 score were assessed.

RESULT

The mean follow-up period recorded for patients was 7.82 years (range 5-12 years). The most common diagnosis was avascular necrosis (37.7%) followed by ankylosing spondylitis (24.4%), developmental dysplasia of the hip (17.7%) and rheumatoid arthritis (8.8%). The preoperative leg length discrepancy (LLD), which ranged from 0.5-7 cm significantly improved after surgery ranging from 0-1 cm. The mean preoperative mHHS was 32.44 ± 18.90 compared with the postoperative score of 94.54 ± 5.81 (p < 0.001). The preoperative p-value of SF-36 was lower compared to the postoperative value in all subgroups of SF-36 (p < 0.001). At the latest follow-up there were no radiological signs of loosening and all the implants were classified as well-integrated.

CONCLUSION

At present total hip arthroplasty is considered to be safe and a good solution for young patients below 25 years suffering from end-stage joint disease; however, longer follow-up is required to evaluate the long-term function and outcome of the prosthesis in order to restore the normal lifestyle of the patients.

Highly Cross-Linked Polyethylene in Cementless Total Hip Arthroplasty in Patients with Previous Acetabular Fractures: A Minimum 5-Year Follow-Up Study

BACKGROUND

Outcomes of THA after acetabular fracture are generally less favorable than those of the nontraumatic arthritis due to a higher rate of cup loosening and osteolysis. We, therefore, investigated whether highly cross-linked polyethylene liners positively impact outcomes of THA in patients with posttraumatic osteoarthritis after acetabular fracture.

METHODS

We retrospectively evaluated 39 patients with previous acetabular fracture who underwent THA using highly cross-linked polyethylene liner after a mean 8.5 year follow-up. All procedures were performed at a single institution by a single surgeon using the same type of THA implants. Wear measurements were performed using a computer-assisted PolyWare software. Osteolysis was evaluated with use of radiography and computed tomography.

RESULTS

The mean preoperative Harris hip score was 44.4 points, which improved to 93.1 points at final follow-up. Neither femoral nor acetabular components displayed mechanical loosening and no components had been revised. Radiographs and CT scans did not demonstrate osteolysis. The mean linear wear was 0.043 mm/y (range 0-0.098 mm/y). With the data available, univariate regression analysis suggests that age, gender, weight, initial fracture type, the duration of follow-up, activity level, liner thickness, acetabular cup inclination, and the necessity of bone graft had no influence on liner penetration.

CONCLUSION

While the long-term effects of the polyethylene particles from highly cross-linked polyethylene remain unknown, implant survivorship and wear data in this study are promising for this high-risk population. Our encouraging results support the continued use of this type of polyethylene in patients after acetabular fractures.

LEVEL OF EVIDENCE

Level IV Therapeutic study.

Incidence of Ceramic Fracture in Contemporary Ceramic-on-Ceramic Total Hip Arthroplasty: A Meta-analysis of Proportions

BACKGROUND

We performed a proportion meta-analysis of currently available data to determine the prevalence of ceramic fracture for each generation.

METHODS

A total of 10,571 total hip arthroplasties from 45 studies were included. Proportion meta-analysis with a random-effects model was performed to estimate the prevalence of ceramic fracture. To determine whether the ceramic fractures have a fatigue nature and a risk or latent period for the development, postoperative time lapse, patient age, and body mass index were related with ceramic fracture by metaregression analysis.

RESULTS

As of postoperative 2.0 to 18.8 years, the rate of ceramic fracture was 0.5% (95% CI, 0.3%-0.8%) in the forte group and 0.2% (95% CI, 0.1%-0.4%) in the delta group (P = .059). The ceramic fracture rate for each component was 0.2% (95% CI, 0.1%-0.3%) for the forte head, 0.1% (95% CI, 0.0%-0.2%) for the delta head (P = .210), 0.2% (95% CI, 0.1%-0.3%) for the forte liner, and 0.2% (95% CI, 0.1%-0.4%) for the delta liner (P = .305). The rate of ceramic fracture per 1000 patient-years was 0.9 (95% CI, 0.5-0.13) in the forte group and 0.5 (95% CI, 0.2-0.8) in the delta group (P = .072). In metaregression analysis, no significant associations were found between prevalence of ceramic fracture and postoperative time lapse, patient age, or body mass index.

CONCLUSIONS

The rate of ceramic fracture was 0.9/1000 patient-year in the forte group and 0.5/1000 patient-year in the delta group. The results of this study provide baseline data for further studies validating ceramic bearings.

LEVEL OF EVIDENCE

Level I, meta-analysis.

Highly Cross-Linked Polyethylene in Total Hip Arthroplasty in Patients Younger Than 50 Years With Osteonecrosis of the Femoral Head: A Minimum of 10 Years of Follow-Up

BACKGROUND

Polyethylene wear and subsequent periprosthetic osteolysis remain a major concern of total hip arthroplasty (THA) failure in young, active patients with osteonecrosis of the femoral head (ONFH). The literature is lacking regarding the long-term performance of highly cross-linked polyethylene (HXLPE) in these patients. The purpose of this study is to evaluate long-term results for cementless THA using metal-on-HXLPE bearing couplings in patients younger than 50 years with ONFH.

METHODS

We retrospectively evaluated the clinical and radiographic results of a consecutive series of 85 THAs (in 67 patients) performed with HXLPE liners (Durasul) in patients younger than 50 years who had ONFH. All procedures were performed at a single institution by a single surgeon using the same type of implants. The minimum duration of follow-up was 10 years (mean, 13.5 years; range, 10-17.3 years). Wear was measured using computer software. Osteolysis was evaluated with the use of radiography and computed tomography.

RESULTS

The mean Harris hip score was 49.3 points (range, 26-68 points) before surgery, which improved to 93.6 points (range, 87-98 points) after surgery. Neither femoral nor acetabular components displayed mechanical loosening, and no components had been revised by the final follow-up evaluation. Radiographs and computed tomography scans did not demonstrate osteolysis. The mean liner wear was 0.037 mm/y (range, 0-0.099 mm/y). With the data available, univariate regression analysis did not demonstrate that age, sex, weight, activity level, underlying cause of osteonecrosis, liner thickness, or cup inclination had any influence on liner penetration.

CONCLUSION

Although the long-term effects of HXLPE particles remain unknown, the implant survivorship rate and wear rate in our study are promising and support the continued use of metal-on-HXLPE bearing couplings in these high-risk patients because they do not produce any of the issues associated with hard-on-hard couplings.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Which Osteotomy for Osteonecrosis of the Femoral Head and Which Patient for the Osteotomy?

Transtrochanteric curved varus osteotomy (TCVO) and transtrochanteric rotational osteotomy (TRO) are joint-preserving procedures for osteonecrosis of the femoral head. The purpose of this review is to provide up-to-date guidelines for the osteotomies. One retrospective comparison revealed that TCVO has shorter operation time, less bleeding, lower incidence of osteophyte formation, and lower rate of secondary collapse. To obtain successful results of the osteotomy, the patient should be younger than 40 years and should have a body mass index of less than 24 kg/m². The osteotomy should be performed in early stages of femoral head osteonecrosis before marked collapse of the femoral head. The patient should have a medium-size lesion and an enough viable bone to restore the intact articular surface and subchondral bone in the weight-bearing area.

Bone-preserving total hip arthroplasty in avascular necrosis of the hip-a matched-pairs analysis

PURPOSE

Short-stem hip arthroplasty has the potential advantage of femoral bone stock preservation, especially in view of the expected revisions in the often relatively young patients. Despite short-stem hip prosthesis are increasingly used for total hip arthroplasty, there are no sufficient mid- and long-term results especially for patients with avascular femoral head osteonecrosis. The present study investigates mid-term functional results as well as the revision rate following implantation of a short-stem prosthesis.

METHODS

In the period 06/2005 until 12/2013, a total of 351 short-stem hip prostheses were implanted. The study included 331 complete data sets. A retrospective analysis was performed using the Oxford Hip Score. All revisions were registered.

RESULTS

In a total of 331 prostheses, the Oxford Hip Score was "excellent" in 66.2%, "good" in 12.7%, "fair" in 13.0%, and "poor" in 8.2% with a mean follow-up of 57.4 months (SD ± 29.8; range 24-115). In 26 cases, aseptic osteonecrosis of the hip was the indication (7.9%). The Oxford Hip Score was "excellent" in 66.7%, "good" in 0.0%, "fair" in 20.8%, and "poor" in 12.5%. The cumulated five year survival rate was 96.7%.

CONCLUSION

In mid-term observation, the Metha® short-stem prosthesis shows no disadvantage in functional outcome and in survival time compared to a standard hip stem. Providing a correct indication, the Metha® short stem is a valuable option in total hip arthroplasty for younger patients with avascular osteonecrosis of the femoral head. Evaluation has shown no significant differences between aseptic osteonecrosis and other indications.

Total Hip Arthroplasty in Patients With Avascular Necrosis After Hematopoietic Stem Cell Transplantation

The immunosuppressive regimens required for hematopoietic stem cell transplantation predispose recipients to complications, including avascular necrosis. Cancer-related comorbidities, immunosuppression, and poor bone quality theoretically increase the risk for perioperative medical complications, infection, and implant-related complications in total joint arthroplasty. This study reviewed 20 primary total hip arthroplasties for avascular necrosis in 14 patients. Outcomes were assessed at routine clinical visits and Harris hip scores were calculated. Follow-up radiographs were evaluated for component malposition, loosening, polyethylene wear, and osteolysis. Average follow-up was 44.5 months for all patients. Postoperative clinical follow-up revealed good to excellent outcomes, with significant improvement in functional outcome scores. There were no periprosthetic infections or revisions for aseptic loosening. There was 1 dislocation on postoperative day 40, which was treated successfully with a closed reduction. Two patients with a prior history of venous thromboembolism developed a pulmonary embolus on postoperative day 13 and 77, respectively. Four patients died several months to years after arthroplasty of complications unrelated to the surgical procedure. Total hip arthroplasty can both be safely performed and greatly improve quality of life in recipients of hematopoietic stem cell transplantation who develop avascular necrosis. However, prolonged venous thromboembolism prophylaxis should be carefully considered in this high-risk patient population. [Orthopedics. 2018; 41(2):e257-e261.].

An evidence-based guide to the treatment of osteonecrosis of the femoral head

Non-traumatic osteonecrosis of the femoral head is a potentially devastating condition, the prevalence of which is increasing. Many joint-preserving forms of treatment, both medical and surgical, have been developed in an attempt to slow or reverse its progression, as it usually affects young patients. However, it is important to evaluate the best evidence that is available for the many forms of treatment considering the variation in the demographics of the patients, the methodology and the outcomes in the studies that have been published, so that it can be used effectively. The purpose of this review, therefore, was to provide an up-to-date, evidence-based guide to the management, both non-operative and operative, of non-traumatic osteonecrosis of the femoral head. Cite this article: Bone Joint J 2017;99-B:1267-79.

Mid-term results of the BIOLOX delta ceramic-on-ceramic total hip arthroplasty

Aims

We conducted a prospective study of a delta ceramic total hip arthroplasty (THA) to determine the rate of ceramic fracture, to characterise post-operative noise, and to evaluate the mid-term results and survivorship.

Patients and Methods

Between March 2009 and March 2011, 274 patients (310 hips) underwent cementless THA using a delta ceramic femoral head and liner. At each follow-up, clinical and radiological outcomes were recorded. A Kaplan-Meier analysis was undertaken to estimate survival.

Results

Four patients (four hips) died and 18 patients (20 hips) were lost to follow-up within five years. The remaining 252 patients (286 hips) were followed for a mean of 66.5 months (60 to 84). There were 144 men (166 hips) and 108 women (120 hips) with a mean age of 49.7 years (16 to 83) at surgery. The mean pre-operative Harris Hip Score of 47.1 points improved to 93.8 points at final follow-up. Six patients reported squeaking in seven hips; however, none were audible. Radiolucent lines involving Gruen zones one and/or seven were seen in 52 hips (18.2%). No hip had detectable wear, focal osteolysis or signs of loosening. One hip was revised because of fracture of the ceramic liner, which occurred due to an undetected malseating of the ceramic liner at the time of surgery. One hip was revised for a periprosthetic fracture of the femur, and one hip was treated for periprosthetic joint infection. The six-year survivorship with re-operation for any reason as the endpoint was 99.0% (95% confidence interval 97.8% to 100%).

Discussion

The rate of delta ceramic fracture was 0.3% (one of 286). While ceramic head fracture was dominant in previous ceramic-on-ceramic THA, fracture of the delta ceramic liner due to malseating is a concern. Cite this article: Bone Joint J 2017;99-B:741–8.

Outcomes after total hip arthroplasty in young patients with osteonecrosis of the hip

BACKGROUND

Osteonecrosis of the hip is a clinical, radiographic, and pathologic entity that commonly affects young patients. This study evaluates long-term implant survival and patient-reported outcomes after primary total hip arthroplasty (THA) in patients with osteonecrosis aged 35 or younger.

METHODS

A retrospective study with prospective follow-up was conducted at a major academic medical center. Chart review was performed to identify young THA patients with osteonecrosis, and follow-up surveys were conducted to determine implant survival and patient-reported outcomes. Kaplan-Meier survival analysis was performed to evaluate implant survival, and the hip disability and osteoarthritis outcome score (HOOS) was used to describe patient-reported outcomes.

RESULTS

The study included 135 patients (204 THAs) with a mean time to follow-up of 14 years. In this group, 10-year implant survival was 86% and 20-year implant survival was 66%. Implant survival was longer in male patients (p = 0.02) and patients that were over the age of 25 at the time of surgery (p = 0.03). The mean HOOS scores at follow-up were 87 for pain, symptoms, and ADLs, and 77 for sports. All HOOS measures were lower in patients that underwent a revision THA, and HOOS-Pain and HOOS-Sport scores were lower in patients that were over the age of 25 at the time of surgery (p<0.05).

CONCLUSIONS

Young patients with osteonecrosis have good implant survival and long-term outcomes after THA. Patient factors and implant characteristics should be considered when predicting implant survival and outcomes after THA in young patients with osteonecrosis.

Hip Squeaking after Ceramic-on-ceramic Total Hip Arthroplasty

Objective:

The present study aimed to review the characteristics and influencing factors of squeaking after ceramic-on-ceramic (CoC) total hip arthroplasty (THA) and to analyze the possible mechanisms of the audible noise.

Data Sources:

The data analyzed in this review were based on articles from PubMed and Web of Science.

Study Selection:

The articles selected for review were original articles and reviews found based on the following search terms: “total hip arthroplasty”, “ceramic-on-ceramic”, “hip squeaking”, and “hip noise.”

Results:

The mechanism of the squeaking remains unknown. The possible explanations included stripe wear, edge loading, a third body, fracture of the ceramic liner, and resonance of the prosthesis components. Squeaking occurrence is influenced by patient, surgical, and implant factors.

Conclusions:

Most studies indicated that squeaking after CoC THA was the consequence of increasing wear or impingement, caused by prosthesis design, patient characteristics, or surgical factors. However, as conflicts exist among different articles, the major reasons for the squeaking remain to be identified.

Metal on Metal or Ceramic on Ceramic for Cementless Total Hip Arthroplasty: A Meta-Analysis

BACKGROUND

Hard bearings, metal on metal (MOM) and ceramic on ceramic (COC), have been developed to overcome polyethylene wear-related osteolysis, but comparisons between these 2 hard bearings are limited. We performed a meta-analysis to determine revision rates for (1) any reason, (2) aseptic loosening, (3) periprosthetic joint infection (PJI), and (4) recurrent dislocation between MOM and COC bearings in cementless total hip arthroplasty.

METHODS

This analysis included 3 studies comparing COC and MOM bearings and 56 studies reporting outcomes of MOM or COC bearings. We conducted a comparison meta-analysis (with a fixed-effects model) on the 3 comparative studies and a proportional meta-analysis on the data from the 59 articles to determine a consensus.

RESULTS

In the comparison meta-analysis, MOM showed higher revision rate than COC for any reason (odds ratio = 2.39, P = .046) and PJI (odds ratio = 6.21, P = .015). In the proportion meta-analysis, the MOM group showed significantly higher revision rate than COC group for any reason, aseptic loosening, and PJI.

CONCLUSION

MOM bearings were associated with a higher risk of revision for any reason and PJI than COC bearings after cementless total hip arthroplasty.

Hip resurfacing for osteonecrosis

Aims

Hip resurfacing arthroplasty (HRA) is an alternative to conventional total hip arthroplasty for patients with osteonecrosis (ON) of the femoral head. Our aim was to report the long-term outcome of HRA, which is not currently known.

Patients and Methods

Long-term survivorship, clinical scores and radiographic results for 82 patients (99 hips) treated with HRA for ON over a period of 18 years were reviewed retrospectively. The mean age of the 67 men and 15 women at the time of surgery was 40.8 years (14 to 64). Patients were resurfaced regardless of the size of the osteonecrotic lesion.

Results

The mean clinical follow-up was 10.8 years (2 to 18). The mean University of California, Los Angeles hip scores at the last follow-up were 9.3, 9.4, 9.2 and 6.8 for pain, walking, function and activity, respectively. A total of six hips underwent revision surgery, four for loosening of the femoral component and two for loosening of the acetabular component. Using any revision as an end point, the 15-year Kaplan-Meier survivorship was 90.3%. There were no wear-related failures. There were no femoral failures among the hips reconstructed with a cemented metaphyseal stem. A total of five hips showed narrowing of the femoral neck; all stabilised and remain asymptomatic, 21 showed signs of femoral neck impingement.

Conclusion

To our knowledge, this is the first report of a series of HRA performed for ON with 15-year survivorship. Our data confirm that patients with advanced stages of ON of the femoral head are excellent candidates for HRA. Cite this article: Bone Joint J 2016;98-B:901–9.

Hip arthroplasty for treatment of advanced osteonecrosis: comprehensive review of implant options, outcomes and complications

Surgical treatment for late stage (post-collapse) osteonecrosis of the femoral head is controversial. In these situations, the outcome of joint preservation procedures is poor. There are several arthroplasty options for late-stage disease. The clinical outcomes of hemiarthroplasty and hemiresurfacing are unpredictable because of progressive acetabular cartilage degeneration. Total hip resurfacing may be associated with further vascular insult to the femoral head and early failure of the implant. Total hip replacement with metal-on-conventional polyethylene bearing surfaces has been the gold standard, but implant survivorship is limited in young active patients due to wear and osteolysis. Newer alternative bearing surfaces may have improved wear characteristics, but their durability must be confirmed in longer-term studies.

Does osteonecrosis of the femoral head increase surgical and medical complication rates after total hip arthroplasty? A comprehensive analysis in the United States

Total hip arthroplasty (THA) is a definitive option for end-stage osteonecrosis of the femoral head (ONFH). Historically, higher revision rates were observed in this population compared to THA for osteoarthritis (OA). This study provides a comprehensive evaluation of postoperative medical and surgical complications comparing THA in ONFH and OA at 90 days, 1 year, and 2 years after surgery. The PearlDiver database identified 45,002 OA and 8,429 ONFH patients who underwent THA. Mechanical complications (prosthetic loosening and osteolysis, implant failure), dislocation, renal and respiratory complications were significantly increased in the ONFH group within 2 years after THA. Pulmonary embolism rates where increased in younger ONFH patients within 2 years after THA. This data helps clinicians in the postoperative risk assessment of patients with ONFH.

Ceramic-on-ceramic THA Implants in Patients Younger Than 20 Years

BACKGROUND

Poor survival of THA implants in very young patients has been attributed to use of cemented implants, wear of conventional polyethylene, and the presence of morphologic deformities in the proximal femur or in the acetabulum. Few studies have reported the long-term results of ceramic-on-ceramic implants in THAs in patients younger than 20 years.

QUESTION/PURPOSES

We determined: (1) the proportion of patients who experienced complications related to the ceramic bearing (squeaking, fracture); (2) the survivorship free from loosening and free from revision for any reason; (3) whether patients with osteonecrosis had inferior survivorship compared with patients whose surgical indication was all other diagnoses including sequelae of pediatric hip disorders (developmental dysplasia of the hip, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis); and (4) clinical function.

METHODS

Between 1979 and 2013, we performed 113 primary THAs in 91 patients younger than 20 years at the time of surgery. Of those, 105 THAs (83 patients) were done with ceramic-on-ceramic bearings (91% of the 91 patients); during that period, a ceramic-on-ceramic bearing couple was indicated in all patients younger than 20 years. In eight patients (eight hips), a cemented polyethylene cup was implanted because the diameter of the acetabulum was smaller than the smallest available ceramic cup (46 mm), or because adequate fixation of a ceramic press-fit cup could not be achieved despite careful reaming of the acetabulum. The most common diagnosis indicating THA was avascular necrosis of the femoral head (56.2%; 59 hips). Thirty-five patients (40 hips) had undergone previous operations before the replacement. Three patients (4%; four hips) died from unrelated causes, nine patients (11%; 13 hips) were lost to followup, and four patients (five hips) had a followup greater than 8.5 years but have not been seen in the last 5 years. Patients were assessed clinically (using the Merle d'Aubigne-Postel score, Hip disability and Osteoarthritis Outcome score (HOOS), and the SF-12(®) Health Survey, and radiographically for signs of radiolucencies, subsidence, or osteolysis on plain films. The mean followup was 8.8 ± 6.1 years (range, 2-34.4 years).

RESULTS

Five patients experienced transient noise generation, defined as a snap in four patients and squeaking in one. Seventeen hips underwent revision surgery-16 for aseptic loosening and one for septic loosening. The implant survival rate at 10 years with aseptic loosening as the endpoint was 90.3% (95% CI, 82.4%-98.9%). No hip had acetabular or femoral osteolysis. Survivorship in patients with osteonecrosis did not differ from survivorship in patients with other diagnoses. The Merle d'Aubigne-Postel score increased from 10.1 ± 4.0 to 17.6 ± 1.1 (p < 0.01); the mean HOOS score was 79.3 ± 13.8 (range, 50.6-100); the mean SF-12(®) physical and mental component scores were 48.1 ± 7.9 (range, 21.4-57.6), and 47.4 ± 12.2 (range, 24.5-99.4), respectively.

CONCLUSIONS

We found that patient-reported outcomes scores improved in most patients undergoing THA in this very young study group. Underlying diagnosis did not affect long-term survivorship. However, the revision-free survival rate at 10 years is lower than published estimates in older patients, and with 11% of patients lost to followup, our estimates may represent a best-case scenario. Therefore, we believe THA should be performed as a last resort in this population.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Do alumina matrix composite bearings decrease hip noises and bearing fractures at a minimum of 5 years after THA?

BACKGROUND

Ceramic-on-ceramic bearing couples are theoretically attractive in total hip arthroplasty (THA) because of low wear, but concerns regarding ceramic fracture and squeaking have arisen. Improved material properties of newer alumina matrix composite (AMC) materials, known as Delta ceramics, may reduce these risks. In addition, the use of thinner liners and larger femoral heads may be helpful clinically to lower the rate of dislocation. However, limited short-term clinical results are available and intermediate-term effects are unclear.

QUESTIONS/PURPOSES

(1) What is the frequency of bearing-related complications (dissociation, fracture, and noise) with ceramic-on-ceramic AMC bearings in cementless THA? (2) What other complications arose in patients treated with these bearings? (3) What are the Harris hip scores (HHS) and survivorship free from reoperation and revision at a minimum of 5 years after cementless THA performed with AMC bearings?

METHODS

Over a 9-month period in 2009, one surgeon performed 125 THAs, of which 100 (80% of the total) were performed with cementless, AMC bearings. During the period in question, the exclusion criteria for this implant were primary THAs with severe acetabular or femoral bone defect and revision THAs. Of these, 94 hips (95%) in 91 patients were available for analysis at a minimum of 5 years (range, 5-6 years), because five patients (six hips) had died. Mean age at the time of arthroplasty was 55 ± 14 years. Prostheses with an identical design and Biolox(®) Delta ceramics were used in all patients. Noise was classified into squeaking, clicking, grinding, and popping. Ceramic fracture, dislocation, and any other complications associated with the use of AMC ceramics were also investigated. Clinical evaluation included the modified HHS preoperatively and at each followup. Survivorship free from reoperation and revision was calculated using the Kaplan-Meier method.

RESULTS

Of 91 patients, four developed bearing-related complications, including one with liner dissociation despite initial square seating and three with clicking. No patients had ceramic fractures. A single event of perioperative dislocation occurred in one patient and postoperative periprosthetic fracture occurred in two hips. Mean HHS improved from 56 to 93 points at the final followup (p < 0.001). Survivorship at 5 years free from reoperation and revision was 96.8% and 97.9%, respectively.

CONCLUSIONS

Improved material properties combined with the possible use of larger diameter heads make AMC ceramics a promising alternative bearing option with seemingly comparable clinical outcomes reported by others with conventional ceramic bearings. Despite these encouraging results, however, meticulous technical precautions such as square seating and proper impaction in particular should be taken during liner insertion, because we did observe one liner dissociation and several patients with hip noises.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A Ten-Year Update

➤ Although multiple theories have been proposed, no one pathophysiologic mechanism has been identified as the etiology for the development of osteonecrosis of the femoral head. However, the basic mechanism involves impaired circulation to a specific area that ultimately becomes necrotic.➤ A variety of nonoperative treatment regimens have been evaluated for the treatment of precollapse disease, with varying success. Prospective, multicenter, randomized trials are needed to evaluate the efficacy of these regimens in altering the natural history of the disease.➤ Joint-preserving procedures are indicated in the treatment of precollapse disease, with several studies showing successful outcomes at mid-term and long-term follow-up.➤ Studies of total joint arthroplasty, once femoral head collapse is present, have described excellent outcomes at greater than ten years of follow-up, which is a major advance and has led to a paradigm shift in treating these patients.➤ The results of hemiresurfacing and total resurfacing arthroplasty have been suboptimal, and these procedures have restricted indications in patients with osteonecrosis of the femoral head.

Outcomes of total hip arthroplasty in patients with osteonecrosis of the femoral head-a current review

The purpose of this review was to analyze (1) patient-reported outcomes and implant survivorship of osteonecrosis (ON) patients following total hip arthroplasty (THA), (2) if prior hip-preserving procedures influence these outcomes, (3) if resurfacing procedures alter outcomes; and (4) how these outcomes may have been impacted by the choice of different bearing surfaces. Today, with implant innovations such as cementless constructs, ceramic bearing surfaces, and highly cross-linked polyethylene, ON patients derive great benefit and have high survivorship following THA. Most studies have shown that previous hip-preserving procedures do not have a deleterious effect on outcomes. Literature on the use of ceramic and highly cross-linked polyethylene bearing surfaces have shown that these implant designs are useful in younger and more active patients. Future research should evaluate the long-term outcomes and survivorship of these new THA constructs.

Total hip arthroplasty in the treatment of osteonecrosis of the femoral head: then and now

The objective of this review is to summarize and analyze the survivorship and the reported results of the use of total hip arthroplasty (THA) in patients with osteonecrosis of the femoral head. In the past, THA was thought to have poor survivorship and poor clinical and radiological results in patients with this diagnosis. However, more recent reports have suggested an improvement in the survivorship, radiological results, and outcomes of THAs when performed for this condition. Surgeons have incorporated THA into their practice patterns to the point that an increasing percentage of patients with this particular diagnosis are currently being treated with it. When collapse and/or arthrosis of the necrotic femoral head are present, THA seems to be the most reliable and proven option for its treatment.

Comparison between 28 mm and 32 mm ceramic-on-ceramic bearings in total hip replacement

Large femoral heads have become popular in total hip replacement (THR) as a method of reducing the risk of dislocation. However, if large heads are used in ceramic-on-ceramic THR, the liner must be thinner, which may increase the risk of fracture. To compare the rates of ceramic fracture and dislocation between 28 mm and 32 mm ceramic heads, 120 hips in 109 patients (51 men and 58 women, mean age 49.2 years) were randomised to THR with either a 28 mm or a 32 mm ceramic articulation. A total of 57/60 hips assigned to the 28 mm group and 55/60 hips assigned to the 32 mm group were followed for at least five years. No ceramic component fractures occured in any patient in either group. There was one dislocation in the 32 mm group and none in the 28 mm group (p = 0.464). No hip had detectable wear, focal osteolysis or prosthetic loosening. In our small study the 32 mm ceramic articulation appeared to be safe in terms of ceramic liner fracture.

Cite this article: Bone Joint J 2014;96-B:1459–63.

Meta-analysis of the Incidence and Risk Factors for Squeaking after Primary Ceramic-on-ceramic Total Hip Arthroplasty in Asian Patients

Purpose

The purpose of this study was to assess the squeaking incidence and risk factors after primary ceramic-on-ceramic total hip arthroplasty (THA) in Asian patients using meta-analysis.

Materials and Methods

We performed a meta-analysis of published data on the squeaking incidence and risk factors from 2000 to 2013. Eight studies in Asians were analyzed for both squeaking incidence and risk factors and 25 studies in Western patients were analyzed for squeaking incidence. The data collected were: patient factors, surgical factors and implantation factors.

Results

The overall incidence of hip squeaking was 2.7% in Asians and 3.1% in Westerners. This difference was not statistically significant. The only significant risk factor was an increase in the acetabular cup abduction angle. Of the factors, the cup abduction angle was the only significant risk factor for the occurrence rate of squeaking, and the occurrence rate tended to increase with increasing angle.

Conclusion

The incidence of squeaking in Asians after primary ceramic-on-ceramic THA is 2.7% and is similar to that in Westerners. The increased cup abduction angle is associated with squeaking; therefore, surgeons should be careful not to implant the cup at a too steep abduction angle.

An estimation of the incidence of squeaking and revision surgery for squeaking in ceramic-on-ceramic total hip replacement: a meta-analysis and report from the Australian Orthopaedic Association National Joint Registry

Squeaking arising from a ceramic-on-ceramic (CoC) total hip replacement (THR) may cause patient concern and in some cases causes patients to seek revision surgery. We performed a meta-analysis to determine the incidence of squeaking and the incidence of revision surgery for squeaking. A total of 43 studies including 16,828 CoC THR that reported squeaking, or revision for squeaking, were entered into the analysis. The incidence of squeaking was 4.2% and the incidence of revision for squeaking was 0.2%. The incidence of squeaking in patients receiving the Accolade femoral stem was 8.3%, and the incidence of revision for squeaking in these patients was 1.3%.

Hip osteonecrosis: does prior hip surgery alter outcomes compared to an initial primary total hip arthroplasty?

The purpose of this study was to assess the clinical and radiographic outcomes of total hip arthroplasty (THA) in patients who had osteonecrosis to see if prior hip preserving surgery affected outcomes. Implant survivorship, Harris hip scores, and radiographic outcomes were compared between 87 patients (92 hips) who had undergone prior hip preserving procedures and 105 patients (121 hips) who had only undergone THA. Patients were also sub-stratified into low- and high-risk groups for osteonecrosis. At a mean follow-up of 75 months, there were no significant differences in survivorship, clinical, and radiographic outcomes among the cohorts. Higher revision rates were associated with patients who were in the high-risk group. The authors believe that hip joint preserving procedures may not adversely affect the outcomes of later THA in patients with osteonecrosis.

Osteonecrosis of the femoral head

Symptomatic hip osteonecrosis is a disabling condition with a poorly understood aetiology and pathogenesis. Numerous treatment options for hip osteonecrosis are described, which include non-operative management and joint preserving procedures, as well as total hip replacement (THR). Non-operative or joint preserving treatment may improve outcomes when an early diagnosis is made before the lesion has become too large or there is radiographic evidence of femoral head collapse. The presence of a crescent sign, femoral head flattening, and acetabular involvement indicate a more advanced-stage disease in which joint preserving options are less effective than THR. Since many patients present after disease progression, primary THR is often the only reliable treatment option available. Prior to the 1990s, outcomes of THR for osteonecrosis were poor. However, according to recent reports and systemic reviews, it is encouraging that with the introduction of newer ceramic and/or highly cross-linked polyethylene bearings as well as highly-porous fixation interfaces, THR appears to be a reliable option in the management of end-stage arthritis following hip osteonecrosis in this historically difficult to treat patient population.

Cite this article: Bone Joint J 2013;95-B, Supple A:46–50.

Ceramic-on-ceramic total hip arthroplasty: minimum of six-year follow-up study

Background

This study examines the clinical and radiologic results of ceramic-on-ceramic total hip arthroplasties with regard to wear, osteolysis, and fracture of the ceramic after a minimum follow-up of six years.

Methods

We evaluated the results of a consecutive series of 148 primary ceramic-on-ceramic total hip arthroplasties that had been performed between May 2001 and October 2005 in 142 patients. The mean age was 57.2 years (range, 23 to 81 years). The mean follow-up period was 7.8 years (range, 6.1 to 10.1 years). Preoperative diagnosis was avascular necrosis in 77 hips (52%), degenerative arthritis in 36 hips (24.3%), femur neck fracture in 18 hips (12.2%), rheumatoid arthritis in 15 hips (10.1%), and septic hip sequelae in 2 hips (1.4%). Clinical results were evaluated with the Harris hip score, and the presence of postoperative groin or thigh pain. Radiologic analysis was done with special attention in terms of wear, periprosthetic osteolysis, and ceramic failures.

Results

The mean Harris hip score improved from 58.3 (range, 10 to 73) to 92.5 (range, 79 to 100) on the latest follow-up evaluation. At final follow-up, groin pain was found in 4 hips (2.7%), and thigh pain was found in 6 hips (4.1%). Radiologically, all femoral stems demonstrated stable fixations without loosening. Radiolucent lines were observed around the stem in 25 hips (16.9%), and around the cup in 4 hips (2.7%). Endosteal new bone formation was observed around the stem in 95 hips (64.2%) and around the cup in 88 hips (59.5%). No osteolysis was observed around the stem and cup. There were 2 hips (1.4%) of inclination changes of acetabular cup, 2 hips (1.4%) of hip dislocation, 1 hip (0.7%) of ceramic head fracture, and 1 hip (0.7%) of squeaking. The Kaplan-Meier survival rate of the prostheses was 98.1% at postoperative 7.8 years.

Conclusions

The ceramic-on-ceramic total hip arthroplasty produced excellent clinical results and implant survival rates with no detectable osteolysis on a minimum six-year follow-up study. The ceramic-on-ceramic couplings could be a reasonable option of primary total hip arthroplasty for variable indications.

Cementless modular total hip arthroplasty in patients younger than fifty with femoral head osteonecrosis: minimum fifteen-year follow-up

This study aimed to report the outcome of total hip arthroplasty (THA) with a modular femoral component in patients younger than fifty years with osteonecrosis of femoral head. Sixty-four osteonecrotic hips in fifty-five patients were available for clinical and radiographic analyses at minimum follow-up of fifteen-years. The mean Harris hip score improved from 36 points preoperatively to 92.7 points at final follow-up. Sixty-two (95.3%) hips demonstrated stable bone ingrowth. No hips showed loosening or required revision for aseptic loosening. Survivorship with an end point of stem revision for any reason was 93.8% and for aseptic loosening was 100% at 16.8years. We believe that cementless THA with a modular stem is a promising procedure for young and active patients with osteonecrosis of the femoral head.

Highly cross-linked polyethylene in total hip arthroplasty for osteonecrosis of the femoral head: a minimum 5-year follow-up study

We evaluated 162 hips with osteonecrosis of the femoral head that had undergone THA using highly cross-linked polyethylene liner after a minimum follow-up of 5 years. Neither femoral nor acetabular components displayed radiographic evidence of mechanical loosening or osteolysis, and no components had been revised at the latest follow-up. The mean rate of linear liner wear was 0.038 mm/year. Univariate regression analysis did not demonstrate that age, gender, weight, activity level or cup inclination had any influence on penetration. While the long term effects of altered mechanical properties of highly cross-linked PE remain unknown, the clinical and radiographic results at a minimum of 5 years are promising for this high-risk population.

Metasul vs Cerasul bearings: a prospective, randomized study at 9 years

The aims of our study were to compare metal-on-metal (Metasul) and ceramic-on-ceramic (Cerasul) bearings and to evaluate the clinical and radiographic results of these 2 different hard-on-hard bearings. We conducted a prospective, randomized study on a series of 250 cementless primary total hip arthroplasties. The prostheses were similar in all aspects except for the bearing surfaces: 50% of Metasul bearing and 50% of Cerasul bearing. All the patients were evaluated both clinically and radiographically. No patient was lost to follow-up. Clinical outcomes in both groups were similar. Considering aseptic loosening as the end point for failure, the 9-year survival rate was 100% for Cerasul and 98.4% for Metasul. Neither bearing outperformed the other both radiographically and clinically. The overall 9-year survival rate was 99.2% and 97.6% in the Cerasul and Metasul groups, respectively.

Alumina-on-alumina THA performed in patients younger than 30 years: a 10-year minimum followup study

BACKGROUND

THA in patients younger than 30 years presents challenges because of uncertainties regarding the long-term survivorship of prostheses. Alumina-on-alumina bearings, which exhibit little long-term wear, may be a reasonable option but the long-term survivorship is unknown.

QUESTIONS/PURPOSES

We determined (1) the survival rate of alumina-on-alumina bearings in patients younger than 30 years after a 10-year followup, (2) the incidence of audible hip clicking and squeaking, (3) radiographic evidence of osteolysis, and (4) the effects on pregnancy, childbirth, and career choice.

METHODS

We retrospectively reviewed 62 patients who had 75 THAs with alumina-on-alumina bearings followed more than 10 years (average, 11.5; range, 10-13.5 years). Mean patient age at the time of surgery was 24 years (range, 18-30 years). All operations were performed using the same cementless implant at a single center. We determined survival, presence of osteolysis, and function (Harris hip score, WOMAC).

RESULTS

The 10-year survival rate of alumina-on-alumina bearings in THAs, with revision for any reason as the end point, was 98.9%. Audible hip clicking and squeaking were identified in 10 hips and two hips, respectively. No osteolysis was detected. None of the 11 patients who became pregnant had been affected by their THA during pregnancy or childbirth. Seven of the 14 patients who were unemployed at the time of index surgery stated that their THA affected their job choice.

CONCLUSIONS

We found a high 10-year survival of cementless alumina-on-alumina bearings in THAs in patients younger than 30 years. Lifetime events such as job choice, pregnancy, and childbirth should be considered when choosing THA for patients younger than 30 years.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Ceramic-on-ceramic total hip arthroplasty: incidence and risk factors of bearing surface-related noises in 125 patients

The ceramic-on-ceramic bearing surface has high wear resistance and good biocompatibility in total hip arthroplasty (THA). However, the postoperative noise problem has been an important issue. The purpose of this retrospective study was to determine the incidence and risk factors of bearing surface-related noises in patients with third-generation ceramic-on-ceramic THAs. One hundred twenty-five patients (143 hips) with ceramic-on-ceramic THAs were included in the study and followed to obtain noise and functional results. Patient factors, including sex, age, height, weight, body mass index, diagnosis, and postoperative range of motion, and surgical factors, including cup inclination, ceramic head size and length, and size of cup related to noises, were recorded. Mean follow-up was 4.2 years (range, 2-10 years). Mean Harris Hip Score was 94 points (range, 68-100 points) at latest follow-up. One (0.8%) patient had radiological evidence of osteolysis, and 4 (3.2%) patients had hip dislocation. No hip sustained a fracture of the ceramic component. Eight (6.4%) patients developed noise at their hips, including clicking in 4, grinding in 2, and snapping in 2. No patient developed squeaking hips or underwent revision surgery because of noisy hips. Younger patients (P=.01), a diagnosis of osteonecrosis (P=.014), a 28-mm ceramic head (P=.042), and a higher hip range of motion postoperatively (P=.001) were related to noise in ceramic-on-ceramic THAs. The study showed third-generation ceramic-on-ceramic THAs had a low incidence of noise problems. However, long-term follow-up is necessary to determine the clinical relevance.

Glucocorticoid-induced avascular bone necrosis: diagnosis and management

Glucocorticoid use is one of the most important causes of avascular bone necrosis (AVN). The pathogenesis of glucocorticoid-induced AVN is not fully understood but postulated mechanisms include fat hypertrophy, fat emboli and intravascular coagulation that cause impedance of blood supply to the bones. Data regarding the relationship between AVN and dosage, route of administration and treatment duration of glucocorticoids are conflicting, with some studies demonstrating the cumulative dose of glucocorticoid being the most important determining factor. Early recognition of this complication is essential as the prognosis is affected by the stage of the disease. Currently, there is no consensus on whether universal screening of asymptomatic AVN should be performed for long-term glucocorticoid users. A high index of suspicion should be exhibited for bone and joint pain at typical sites. Magnetic resonance imaging (MRI) or bone scintigraphy is more sensitive than plain radiograph for diagnosing early-stage AVN. Conservative management of AVN includes rest and reduction of weight bearing. Minimization of glucocorticoid dose or a complete withdrawal of the drug should be considered if the underlying conditions allow. The efficacy of bisphosphonates in reducing the rate of collapse of femoral head in AVN is controversial. Surgical therapy of AVN includes core decompression, osteotomy, bone grafting and joint replacement. Recent advances in the treatment of AVN include the use of tantalum rod and the development of more wear resistant bearing surface in hip arthroplasty.

Ceramic-on-ceramic bearings in hip arthroplasty: state of the art and the future

This systematic review of the literature summarises the clinical experience with ceramic-on-ceramic hip bearings over the past 40 years and discusses the concerns that exist in relation to the bearing combination. Loosening, fracture, liner chipping on insertion, liner canting and dissociation, edge-loading and squeaking have all been reported, and the relationship between these issues and implant design and surgical technique is investigated. New design concepts are introduced and analysed with respect to previous clinical experience.

Outcomes of total hip replacement in patients with slipped capital femoral epiphysis

BACKGROUND

Total hip replacement has been advocated for the treatment of degenerative hip diseases secondary to slipped capital femoral epiphysis; nonetheless, outcomes of this procedure have not been well established. We reviewed the outcomes of modern total hip replacements in patients who suffered from slipped capital femoral epiphysis.

METHODS

A retrospective study was carried out on 32 total hip replacements performed on 28 patients who suffered from slipped capital femoral epiphysis from August 1994 to January 2007. The average age at the time of surgery was 45 years. Clinical evaluation was performed using the Harris Hip Score, radiographic assessment measuring cup and stem orientation, the extent of osteolysis around the implant, and leg length discrepancy. The average follow-up was 98 months (range 25-204 months).

RESULTS

Two total hip replacements failed, one for stem aseptic loosening and the other for modular neck failure. The cumulative survival rate at 9 years was 92.8 %. If the end point was revision for implant loosening, the survival rate improved to 96.8 % at 9 years. The only complication recorded was an intraoperative fracture of the lesser trochanter immediately treated with cerclage wire. At the latest follow-up, the Harris Hip Score averaged 86 (range 70-97). Leg length discrepancies greater than 1 cm were present in 18 cases before surgery, and in only 6 cases after surgery.

DISCUSSION

We recommend total hip replacement for patients who suffer from slipped capital femoral epiphysis because of the satisfactory survival, low complication rate, and the possibility of restoring leg length.

Cementless acetabular fixation in patients 50 years and younger at 10 to 18 years of follow-up

The purpose of the study was to evaluate the 10- to 18-year follow-up of cementless acetabular fixation in patients 50 years and younger. We retrospectively reviewed a consecutive group of 118 patients (144 hips) in whom primary total hip arthroplasty had been performed by 2 surgeons using a cementless acetabular component. Two (1.4%) cementless acetabular components were revised because of aseptic loosening. Twenty-four hips (16.7%) were revised for any mechanical failure of the acetabular component mostly related to acetabular liner wear and osteolysis. The average linear wear rate was 0.19 mm per year, which was higher than our previous reports with cemented acetabular fixation. The fiber mesh ingrowth surface of the cementless acetabular component in this study was superior to cemented acetabular components in terms of fixation. However, the high rates of wear and osteolysis have led to poor overall acetabular component construct survivorship.

Third-generation ceramic-on-ceramic total hip arthroplasty in patients younger than 30 years with osteonecrosis of femoral head

The purpose of this study was to evaluate the functional and radiographic results of patients younger than 30 years who underwent cementless third-generation ceramic-on-ceramic total hip arthroplasty for osteonecrosis of the femoral head. Forty-one patients (56 hips) with a minimum follow-up of 6 years were included. In all cases, third-generation ceramic-on-ceramic articulation was used. Average Harris Hip Scores improved from 52.9 preoperatively to 98.2, and Western Ontario and McMaster Universities Osteoarthritis Index score, from 95.2 to 25.2. Thirty-nine patients returned to their normal occupations. No aseptic loosening or osteolysis was observed. Total hip arthroplasty performed using third-generation ceramic-on-ceramic bearings for osteonecrosis of femoral head was found to provide satisfactory clinical and radiologic results, especially in active, young patients.

Bearing surface considerations for total hip arthroplasty in young patients

Bearing selection for total hip arthroplasty in young patients is important because of the likely long service life of the implant. Careful consideration of the next operation is recommended when choosing components. No prospective, randomized studies exist that document the clear superiority of any bearing couple in young, active patients. Modern metals, ceramics, and polyethylenes all hold promise. Further long-term data on modern bearings are needed to determine the clinical performance of these bearings. This article summarizes the available data on various bearing couples in patients aged younger than 50 years.

Squeaking after third-generation ceramic-on-ceramic total hip arthroplasty

We retrospectively reviewed records of 1002 patients who underwent a third-generation ceramic-on-ceramic total hip arthroplasty. Fifteen patients complained of squeaking, at any time after their arthroplasty. Of these 15 patients, 14 were evaluated clinically and radiologically. These 14 patients were found to have significantly higher mean body mass index of 25.8 kg/m(2) as compared with all the other patients who did not complain of squeaking (mean, 23.7 kg/m(2)) (P = .022). The acetabular opening angle was significantly lower (mean, 34°) than a matched control group (mean, 38°) (P = .016). Limb length shortening of more than 5 mm was observed in 12 (85.7%) of the 14 patients as compared with only 4 (28.6%) of 14 patients in the matched control group. Flexion and sitting cross legged were identified as the movements, which most commonly (11/12) resulted in squeaking. The incidence of squeaking was found to be low (1.5%), and we identified high body mass index, decreased acetabular opening angle, and limb length shortening as factors associated with squeaking.

Eleven- to 14-year follow-up results of cementless total hip arthroplasty using a third-generation alumina ceramic-on-ceramic bearing

To analyze long-term survivorship of cementless total hip arthroplasties (THAs) with the third-generation alumina ceramic-on-ceramic bearing, 100 consecutive THAs between 1996 and 1998 were reviewed. One cup and 2 stems were revised due to aseptic loosening. Another cup showed chipping of the acetabular liner at 8 years and required cup revision. The remaining hips showed stable bone ingrowth fixation with no osteolysis at the final follow-up. The 14-year survivorship as the end point of revision was 97.9% for the cup, 97.8% for the stem, and 95.7% for the overall implants, respectively. We conclude that cementless THA with the third-generation ceramic-on-ceramic hip bearing provided an excellent survivorship and eliminated periprosthetic osteolysis for 11 to 14 years.