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Ko YS, Kang SY, Kim HS, Yoo JJ. Computed Tomography Evaluation of Alumina Ceramic-on-Ceramic Total Hip Arthroplasty With More Than 20 years of Follow-Up: Is a Follow-Up Computed Tomography Scan Necessary? J Arthroplasty 2024:S0883-5403(24)00679-X. [PMID: 38944063 DOI: 10.1016/j.arth.2024.06.058] [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] [Received: 01/08/2024] [Revised: 06/20/2024] [Accepted: 06/24/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Ceramic-on-ceramic (CoC) bearings have been increasingly used in total hip arthroplasty (THA) because of their superior wear resistance and biocompatibility. However, there is a scarcity of reports on the computed tomography (CT) evaluation of CoC bearings with more than 10 years. The aim of this study was to evaluate the long-term CT results of THA using CoC bearings for more than 20 years of follow-up. We hypothesized that there would be no wear, osteolysis, or ceramic fracture. METHODS Between November 1997 and June 2003, 956 hips underwent THA using alumina-on-alumina bearings at a tertiary referral hospital. Among them, 107 hips were assessed, all of which underwent a CT examination more than 20 years after the index surgery. The mean age at the time of surgery was 41 years, and a CT scan was performed at an average of 22.0 years postoperatively (range, 20.0 to 25.1). The CT scans were thoroughly assessed for osteolysis, stem notching, and ceramic component fracture. RESULTS No loosening was observed in the acetabular cup or femoral stem. Stem notching was observed in 3 hips (2.8%). In the CT scan taken after a minimum of 20 years of follow-up, 1 case (0.9%) of osteolysis around the cup and 2 cases (1.9%) of osteolysis around the femoral stem were noted. Suspected chip fractures of the ceramic insert were discovered in 4 cases (3.7%). Despite these findings, the patients remained asymptomatic, and no subsequent surgical intervention was needed after close follow-up. CONCLUSIONS Routine CT examinations for patients who underwent THA using CoC bearings over 20 years ago revealed unexpected findings, such as osteolysis and suspected chip fractures of the ceramic liner. However, routine CT scans may not be universally necessary. The CT evaluation in this cohort should be selectively performed for patients who have relevant clinical symptoms. LEVEL OF EVIDENCE Level III, Therapeutic study.
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Affiliation(s)
- Young-Seung Ko
- Department of Orthopedic Surgery, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea; Department of Orthopaedic Surgery, Hallym university Dong-Tan Sacred Heart Hospital, Hwaseong, South Korea
| | - Sang Yoon Kang
- Department of Orthopedic Surgery, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
| | - Hong Seok Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
| | - Jeong Joon Yoo
- Department of Orthopedic Surgery, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
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Solou K, Panagopoulos A, Tatani I, Megas P. Fracture of femoral neck in modular total hip arthroplasty: a systematic review of the literature. Hip Int 2024; 34:409-420. [PMID: 37932248 DOI: 10.1177/11207000231211253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
BACKGROUND Modular femoral stems have the advantage of anatomic hip reconstruction by restoring the femoral offset thus minimising the bearing surface wear, implant loosening and dislocation. AIM This study aims to investigate the existing literature on modular neck fractures, to identify predisposing factors and guide the decision-making process in the management of these difficult cases. METHODS A systematic literature review was conducted until July 2022. PRISMA guidelines were followed, eligibility criteria were set, and methodology assessment of included studies was conducted based on MINORS criteria, size and primary outcome. Data were extracted and analysed thoroughly. RESULTS 5657 studies were initially screened; the full texts of 124 records were assessed and finally, 32 reports were included. There were 7 clinical studies and 25 case reports. A total of 4825 patients (5204 hips) with a mean age 62.38 years and a mean BMI 29.06 kg/m2 were analysed in the 7 clinical studies. The reported overall weighted revision rate was 0.86%, while the weighted mean modular neck fracture rate was 0.26%. The usual history was sudden experience of hip pain and instability. The average time interval to neck fracture was 4.57 (range 3-4.7) years and a long modular neck was identified in 91.17% of them. Data from case reports showed a mean age and average BMI of 55.85 and 31.63 kg/m2. 82.35% of the patients were male. Necks were fractured after an average time interval of 64.5 ± 8.8 months. CONCLUSIONS The incidence of modular neck fracture is significant. The profile of a male, obese patient with a long modular neck increased risk of neck fracture. Microstructural investigation of the retrieved implants demonstrated a higher incidence of fracture line in the base of the neck junction and at its anterolateral distal part. Surgeons should be aware of this complication while using or revising such protheses.
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Affiliation(s)
| | - Andreas Panagopoulos
- Faculty of Medicine, Patras University, Patra, Greece
- Orthopaedic Department, Patras General University Hospital, Patras, Greece
| | - Irini Tatani
- Faculty of Medicine, Patras University, Patra, Greece
- Orthopaedic Department, Patras General University Hospital, Patras, Greece
| | - Panagiotis Megas
- Faculty of Medicine, Patras University, Patra, Greece
- Orthopaedic Department, Patras General University Hospital, Patras, Greece
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Vercruysse LYG, Milne LP, Harries DTC, de Steiger RN, Wall CJ. Lower Revision Rates and Improved Stability With a Monoblock Ceramic Acetabular Cup. J Arthroplasty 2024; 39:985-990. [PMID: 37871861 DOI: 10.1016/j.arth.2023.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/09/2023] [Accepted: 10/14/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Monoblock ceramic cups are designed to accommodate large-diameter femoral heads. This has the potential to offer the advantages of an increased range of motion and enhanced joint stability. These features could benefit younger and high-demand patients in need of total hip arthroplasty. The aim of this study was to assess the survival rate and the reasons for revision of the DeltaMotion cup. METHODS Data from the AOANJRR were analyzed for all patients who had undergone a primary conventional THA performed between January 1, 2001 and December 31, 2021. Only prostheses with ceramic/ceramic, ceramic/XLPE, metal/XLPE, or CM/XLPE bearing surfaces were included. The primary outcome measure was the cumulative percent revision for all causes. Secondary outcome measures were revision for dislocation/instability, ceramic breakage, or noise. A subanalysis for cup size was also performed. RESULTS There were 486,946 primary conventional THA procedures undertaken for any reason. Of these, 4,033 used the DeltaMotion cup and 482,913 were modular designs. The DeltaMotion cup had the lowest CPR for all diagnoses compared to the modular bearings at all time points, had a significantly lower revision rate for prosthesis dislocation and no revisions for squeaking compared to other modular bearings. There were 175 ceramic breakages recorded in the modular bearing group and 1 ceramic breakage in the DeltaMotion group. CONCLUSIONS The DeltaMotion cup had a low rate of all-cause revision, and for dislocation, ceramic breakage, and noise. Although this cup is no longer manufactured, ongoing follow-up of newer monoblock ceramic cups will determine their suitability for younger and more active patients.
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Affiliation(s)
- Loïc Y G Vercruysse
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Department of Development and Regeneration KU Leuven, Institute for Orthopaedic Research and Training KU Leuven, Leuven, Belgium
| | - Lachlan P Milne
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Dylan T C Harries
- Registry Science, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Richard N de Steiger
- Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, South Australia, Australia; Department of Surgery, Epworth Healthcare, University of Melbourne, Richmond, Victoria, Australia
| | - Christopher J Wall
- Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, South Australia, Australia; Department of Orthopaedics, Toowoomba Hospital, Toowoomba, Queensland, Australia; University of Queensland Rural Clinical School, Toowoomba, Queensland, Australia
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Moon JK, Lee S, Kim CH, Yoon JY, Lee S, Lee KS, Yoon PW. Forte ceramic-on-delta ceramic cementless total hip arthroplasty: an 8- to 15-year follow-up study. Arch Orthop Trauma Surg 2023; 143:5475-5483. [PMID: 36871241 DOI: 10.1007/s00402-023-04793-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/22/2023] [Indexed: 03/06/2023]
Abstract
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.
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Affiliation(s)
- Jun-Ki Moon
- Department of Orthopedic Surgery, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong, Republic of Korea
| | - Seonjeong Lee
- Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, Ulsan University, Asan Medical Center 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Chul-Ho Kim
- Department of Orthopedic Surgery, College of Medicine, Chung-Ang University Hospital, Chung-Ang University, Seoul, Republic of Korea
| | - Jae Youn Yoon
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Ilsan, Republic of Korea
| | - Sunhyung Lee
- Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, Ulsan University, Asan Medical Center 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Kang-Sik Lee
- Biomedical Engineering Research Center, Asan Institute For Life Sciences, Asan Medical Center, Seoul, Republic of Korea
| | - Pil Whan Yoon
- Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, Ulsan University, Asan Medical Center 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
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Li Z, Niu EL, Fu J, Zhou YG, Chai W, Hao LB, Chen JY, Xu C. A Nomogram That Characterizes a Patient's Odds of Developing Squeaking After Fourth-generation Ceramic-on-ceramic THA. Clin Orthop Relat Res 2023; 481:1322-1336. [PMID: 36749832 PMCID: PMC10263255 DOI: 10.1097/corr.0000000000002573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 01/05/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND Although ceramic-on-ceramic (CoC) bearings result in the lowest wear rate of any bearing combination, postoperative squeaking remains worrisome. However, data concerning squeaking in long-term follow-up studies are still lacking, especially for fourth-generation CoC THA. QUESTIONS/PURPOSES (1) After keeping the prosthesis in place for 10 years, what percentage of patients treated with fourth-generation CoC THA implants report squeaking, and are there points in time when squeaking occurs more frequently? (2) What are the characteristics, association with hip function, and factors associated with squeaking? (3) Can we create a nomogram that characterizes a patient's odds of experiencing squeaking based on the factors associated with it? METHODS Between January 2009 and December 2011, 1050 patients received primary THAs at our institution, 97% (1017) of whom received fourth-generation CoC THAs because this was the preferred bearing during this period. Of the 1017 eligible patients, 5% (54) underwent THAs performed by low-volume surgeons, 3% (30) were implanted with cemented prostheses, 2% (22) died, 1% (10) were immobile, 1% (six) underwent revision surgery, and 17% (169) were lost to follow-up before 10 years, leaving 726 patients for analysis here at a mean of 11 ± 1 years. In the study cohort, 64% (464) were male and 36% (262) were female, with a mean age of 44 ± 13 years at primary THA. We extracted data about articular noise from follow-up records in our institutional database and used a newly developed questionnaire to ascertain the percentage of patients who reported squeaking at the latest follow-up interval. Although not validated, the questionnaire was modeled on previous studies on this topic. The longitudinal pattern for squeaking was explored to find timepoints when squeaking occurs more frequently. Based on the questionnaire data, we calculated the percentages of frequent, reproducible, and avoidable squeaking. Hip function was evaluated with the Harris Hip Score and WOMAC score and compared between the squeaking and nonsqueaking groups. Factors associated with squeaking, which were examined in a multivariate analysis, were used to develop a nomogram. RESULTS At 10 years, 16% (116 of 726) of patients reported squeaking. Two squeaking peaks were determined, at 0 to 1 year and 8 to 10 years. Frequent, reproducible, and avoidable squeaking accounted for 42% (36 of 86), 20% (17 of 86), and 41% (35 of 86), respectively. The mean Harris Hip Score (93 ± 4 versus 94 ± 5; p = 0.81) and WOMAC score (16 ± 13 versus 15 ± 13; p = 0.23) did not differ between patients with squeaking and those without. After controlling for potential confounding variables such as etiology and head offset, we found that patients younger than 46 years (odds ratio 2.5 [95% confidence interval 1.5 to 5.0]; p < 0. 001), those who were male (OR 2.0 [95% CI 1.1 to 3.5]; p = 0.04), those having a total flexion and extension arc of less than 50° (OR 2.0 [95% CI 1.2 to 3.3]; p = 0.02), and those with the Corail hip implant (OR 4.1 [95% CI 2.1 to 7.7]; p < 0. 001) were more likely to report squeaking. We created a nomogram that can be used at the point of care that can help clinicians identify patients at a higher risk of experiencing squeaking; this nomogram had good performance (area under the receiver operating characteristic curve of 77%). CONCLUSION As a potential late complication, squeaking after fourth-generation CoC THA is of concern and may be related to increased stripe wear. We recommend that surgeons use this nomogram to assess the odds of squeaking before selecting a bearing, especially in patients at high risk, to facilitate shared decision-making and improve patient satisfaction. Future external validation of the model is still needed to enhance its applicability.Level of Evidence Level III, therapeutic study.
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Affiliation(s)
- Zhuo Li
- School of Medicine, Nankai University, Tianjin, PR China
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
| | - Er-Long Niu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- 305 Hospital of PLA, Beijing, PR China
| | - Jun Fu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, PR China
| | - Yong-Gang Zhou
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, PR China
| | - Wei Chai
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, PR China
| | - Li-Bo Hao
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, PR China
| | - Ji-Ying Chen
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, PR China
| | - Chi Xu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, PR China
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Zajc J, Fokter SK. Bimodular femoral stems in primary total hip arthroplasty. Expert Rev Med Devices 2023; 20:1051-1064. [PMID: 37753590 DOI: 10.1080/17434440.2023.2264177] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/25/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION This review critically examines the efficacy of dual-modular stems in primary total hip arthroplasty. Given the variability and non-comparability of certain femoral stem designs and stem-neck couplings, with some even being withdrawn from the market, this review offers an in-depth analysis of predominant implant performances. AREAS COVERED The paper explores a brief historical summary related to dual-modular stems, including the complications associated with their use, diagnostic tools for evaluation, analysis of both recalled and currently available models, as well as alternative therapeutic options. This information is pertinent for both clinical and research domains. EXPERT OPINION While dual-modular systems were initially touted to offer several advantages, the evidence substantiating these benefits has been ambiguous. Further, these systems introduce the risk of alternative complications. In specific cases involving patients with developmental hip dysplasia and certain proximal femoral deformities requiring complex reconstructions, dual-modular systems might be relevant. Nonetheless, the use of long interchangeable necks in patients with a body mass index above 30 kg/m2 is discouraged, and pairing a long varus-oriented neck with an extra-long femoral head should be avoided in all patients.
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Affiliation(s)
- Jan Zajc
- Clinical Department of Orthopedic Surgery, University Medical Center Maribor, Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Samo K Fokter
- Clinical Department of Orthopedic Surgery, University Medical Center Maribor, Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
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Total ankle arthroplasty with total talar prosthesis for talar osteonecrosis with ankle osteoarthritis: A case report. J Orthop Sci 2021; 26:725-730. [PMID: 30391134 DOI: 10.1016/j.jos.2018.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 01/01/2023]
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Dual Modular Titanium Alloy Femoral Stem Failure Mechanisms and Suggested Clinical Approaches. MATERIALS 2021; 14:ma14113078. [PMID: 34199983 PMCID: PMC8200202 DOI: 10.3390/ma14113078] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/27/2021] [Accepted: 06/02/2021] [Indexed: 12/13/2022]
Abstract
Titanium (Ti) alloys have been proven to be one of the most suitable materials for orthopaedic implants. Dual modular stems have been introduced to primary total hip arthroplasty (THA) to enable better control of the femoral offset, leg length, and hip stability. This systematic review highlights information acquired for dual modular Ti stem complications published in the last 12 years and offers a conclusive discussion of the gathered knowledge. Articles referring to dual modular stem usage, survivorship, and complications in English were searched from 2009 to the present day. A qualitative synthesis of literature was carried out, excluding articles referring solely to other types of junctions or problems with cobalt-chromium alloys in detail. In total, 515 records were identified through database searching and 78 journal articles or conference proceedings were found. The reasons for a modular neck fracture of a Ti alloy are multifactorial. Even though dual modular stems have not shown any clinical benefits for patients and have been associated with worse results regarding durability than monolithic stems, some designs are still marketed worldwide. Orthopaedic surgeons should use Ti6Al4V dual modular stem designs for primary THA in special cases only.
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Lex JR, Welch MD, See A, Edwards TC, Stavropoulos NA, Babis GC. Systematic review of primary total hip arthroplasty using titanium-titanium modular-neck prostheses: the true risk of revision. Hip Int 2021; 31:295-303. [PMID: 32297561 DOI: 10.1177/1120700020916870] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIMS Modular-neck femoral implants are used to enable more variability in femoral neck version, offset and length. It has been reported that these implants carry a higher rate of revision. The aim of this review was to assess the overall and cause-specific revision rate of titanium-titanium alloy modular-neck implants in primary total hip arthroplasty (THA). METHODS A systematic review was conducted following PRISMA guidelines and utilising multiple databases. All results were screened for eligibility. Studies published from 2000 onwards, using a current-generation, titanium-titanium, modular-neck implant were included. Overall and cause-specific revision rates were analysed, comparing to fixed-neck prostheses where applicable. RESULTS 920 studies were screened. After applying exclusion criteria, 23 were assessed in full and 14 included. These consisted of 12 case series and 2 joint registry analyses. 21,841 patients underwent a modular-neck implant with a weighted mean follow-up of 5.7 years, mean age of 62.4 years, and average body mass index (BMI) of 28.4kg/m2. The overall revision rate was 3.95% and 2.98% for modular and fixed-neck prostheses, respectively. For studies with >5 years follow-up the mean revision rate was 3.08%. There was no difference in cause-specific revision rates by implant design. Mean improvement in Harris Hip Score was 41.9. CONCLUSIONS At medium-term, revision rates for titanium-titanium primary modular-neck THA are acceptable. These prostheses are a sensible management option in patients with considerable anatomical hip deformity not amenable to correction with standard fixed-neck implants. Patients of male gender, high BMI and requiring prostheses with a larger neck, offset or head are at higher risk of implant failure.
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Affiliation(s)
- Johnathan R Lex
- Oxford Foundation School, Oxford, UK.,Royal Orthopaedic Hospital, Birmingham, UK
| | - Matthew D Welch
- Oxford Foundation School, Oxford, UK.,Oxford University Clinical Academic Graduate School, Oxford, UK
| | - Abbas See
- Oxford Foundation School, Oxford, UK
| | | | - Nikolaos A Stavropoulos
- 2nd Department of Orthopaedic Surgery, Konstantopouleio General Hospital, National and Kapodistrian University of Athens, Athens Medical School, Athens, Greece.,Department of Orthopaedic Surgery, General Hospital of Karpenissi, Karpenissi, Greece
| | - George C Babis
- 2 Department of Orthopaedic Surgery, Konstantopouleio General Hospital, National and Kapodistrian University of Athens, Athens Medical School, Athens, Greece
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Bilateral neck fracture in bimodular femoral stem after primary total hip arthroplasty: a case report. BMC Musculoskelet Disord 2021; 22:356. [PMID: 33863307 PMCID: PMC8050927 DOI: 10.1186/s12891-021-04210-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 03/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Bi-modular stems were introduced in primary total hip arthroplasty (THA) to enable better control of the femoral offset, leg length, and hip stability. Despite numerous reports on modular femoral neck fractures, some designs are still marketed worldwide. While the risk factors for the sudden failure are multifactorial and mostly known, the timing of this new THA complication is not predictable by any means. Case presentation In this report, the literature regarding one of the most popular bi-modular stems with specific neck-stem coupling (oval Morse taper) is reviewed and illustrated with a case of bilateral modular neck fracture in a patient with idiopathic aseptic necrosis of femoral heads treated with primary bi-modular THA. Because of bilateral modular femoral neck fracture, which occurred 3 years on the left side and 20 years after implantation on the right side, the patient required a total of 6 revisions and 208 days of hospitalized care. Conclusion To our knowledge, this is the first report of bilateral modular neck fracture in a single patient. Even though the same surgeon performed both operations and used the same neck length and orientation, fractures occurred with a 17-year time difference after implantation. This shows that we cannot predict with certainty when a fracture might occur. Orthopaedic surgeons should use bi-modular stem designs for primary THA very cautiously.
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Bahraminasab M, Arab S, Safari M, Talebi A, Kavakebian F, Doostmohammadi N. In vivo performance of Al 2O 3-Ti bone implants in the rat femur. J Orthop Surg Res 2021; 16:79. [PMID: 33482866 PMCID: PMC7821505 DOI: 10.1186/s13018-021-02226-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/11/2021] [Indexed: 11/17/2022] Open
Abstract
Background Alumina-titanium (Al2O3-Ti) biocomposites have been recently developed with improved mechanical properties for use in heavily loaded orthopedic sites. Their biological performance, however, has not been investigated yet. Methods The aim of the present study was to evaluate the in vivo biological interaction of Al2O3-Ti. Spark plasma sintering (SPS) was used to fabricate Al2O3-Ti composites with 25 vol.%, 50 vol.%, and 75 vol.% Ti content. Pure alumina and titanium were also fabricated by the same procedure for comparison. The fabricated composite disks were cut into small bars and implanted into medullary canals of rat femurs. The histological analysis and scanning electron microscopy (SEM) observation were carried out to determine the bone formation ability of these materials and to evaluate the bone-implant interfaces. Results The histological observation showed the formation of osteoblast, osteocytes with lacuna, bone with lamellar structures, and blood vessels indicating that the healing and remodeling of the bone, and vasculature reconstruction occurred after 4 and 8 weeks of implantation. However, superior bone formation and maturation were obtained after 8 weeks. SEM images also showed stronger interfaces at week 8. There were differences between the composites in percentages of bone area (TB%) and the number of osteocytes. The 50Ti composite showed higher TB% at week 4, while 25Ti and 75Ti represented higher TB% at week 8. All the composites showed a higher number of osteocytes compared to 100Ti, particularly 75Ti. Conclusions The fabricated composites have the potential to be used in load-bearing orthopedic applications.
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Affiliation(s)
- Marjan Bahraminasab
- Nervous System Stem Cells Research Center, Semnan University of Medical Sciences, Semnan, Iran. .,Department of Tissue Engineering and Applied Cell Sciences, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran.
| | - Samaneh Arab
- Nervous System Stem Cells Research Center, Semnan University of Medical Sciences, Semnan, Iran.,Department of Tissue Engineering and Applied Cell Sciences, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran
| | - Manouchehr Safari
- Nervous System Stem Cells Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Athar Talebi
- Nervous System Stem Cells Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Fatemeh Kavakebian
- Nervous System Stem Cells Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Nesa Doostmohammadi
- Faculty of Metallurgical and Materials Engineering, Semnan University, Semnan, Iran
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Abstract
Choice of articulating materials, head size and the design of the articulation will become decisive for the long-term performance of a total hip arthroplasty (THA) and especially in terms of risk for dislocation and wear-related problems. Here we account for common alternatives based on available studies and the evidence that can be derived from them.Metal or ceramic femoral heads articulating against a liner or cup made of highly cross-linked polyethylene and ceramic-on-ceramic articulations have about similar risk for complications leading to revision, whereas the performance of metal-on-metal articulations, especially with use of big heads, is inferior. The clinical significance of problems related to ceramic-on-ceramic articulations such as squeaking remains unclear. With use of current technology ceramic fractures are rare.Large femoral heads have the potential to increase the range of hip movement before impingement occurs and are therefore expected to reduce dislocation rates. On the other hand, issues related to bearing wear, corrosion at the taper-trunnion junction and groin pain may arise with larger heads and jeopardize the longevity of THA. Based on current knowledge, 32-mm heads seem to be optimal for metal-on-polyethylene bearings. Patients with ceramic-on-ceramic bearings may benefit from even larger heads such as 36 or 40 mm, but so far there are no long-term reports that confirm the safety of bearings larger than 36 mm.Assessment of lipped liners is difficult because randomized studies are lacking, but retrospective clinical studies and registry data seem to indicate that this liner modification will reduce the rate of dislocation or revision due to dislocation without clear evidence of clinically obvious problems due to neck-liner impingement.The majority of studies support the view that constrained liners and dual mobility cups (DMC) will reduce the risk of revision due to dislocation both in primary and revision THA, the latter gaining increasing popularity in some countries. Both these devices suffer from implant-specific problems, which seem to be more common for the constrained liner designs. The majority of studies of these implants suffer from various methodological problems, not least selection bias, which calls for randomized studies preferably in a multi-centre setting to obtain sufficient power. In the 2020s, the orthopaedic profession should place more effort on such studies, as has already been achieved within other medical specialties, to improve the level of evidence in the choice of articulation when performing one of the most common in-hospital surgical procedures in Europe. Cite this article: EFORT Open Rev 2020;5:763-775. DOI: 10.1302/2058-5241.5.200002.
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Affiliation(s)
- Georgios Tsikandylakis
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Orthopaedics, Gothenburg, Sweden
| | - Soren Overgaard
- The Danish Hip Arthroplasty Register, Aarhus, Denmark
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Luigi Zagra
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Johan Kärrholm
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Orthopaedics, Gothenburg, Sweden
- The Swedish Hip Arthroplasty Register, Gothenburg, Sweden
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Fokter SK, Zajc J, Merc M. Interchangeable neck failures of bi-modular femoral stems in primary total hip arthroplasty cannot be predicted from serum trace element analysis. INTERNATIONAL ORTHOPAEDICS 2020; 45:877-881. [PMID: 32935199 DOI: 10.1007/s00264-020-04812-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Revision of a well-fixed stem due to unexpected modular neck fracture is a catastrophe for the patient and a challenge for the surgeon. This study aimed to test the possibility of predicting interchangeable neck fracture from serum levels of the stem/neck alloy-consisting metals. MATERIALS AND METHODS Nineteen patients at high risk for interchangeable neck fracture were randomly selected out of a cohort of 680 bimodular stems made from Ti6Al4V alloy. Serum levels of titanium, aluminium and vanadium were determined. Nine age- and gender-matched patients were used as controls. RESULTS Mean serum levels of Ti were 6.04 ± 2.52 μg/L, of Al 3.89 ± 1.68 μg/L and of V 0.07 ± 0.04 μg/L in the high-risk group, and 8.22 ± 4.74 μg/L, 4.99 ± 3.98 μg/L and 0.27 ± 0.44 μg/L in the low-risk group, respectively. No statistically significant differences were found between the groups. DISCUSSION Interchangeable neck fracture of bimodular femoral stems cannot be predicted from serum trace element analysis.
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Affiliation(s)
- Samo K Fokter
- Department for Orthopaedic Surgery, University Medical Centre Maribor, 5 Ljubljanska Street, SLO-2000, Maribor, Slovenia.
| | - Jan Zajc
- Faculty of Medicine, University of Maribor, 8 Taborska Street, SLO-2000 Maribor, Slovenia
| | - Matjaž Merc
- Department for Orthopaedic Surgery, University Medical Centre Maribor, 5 Ljubljanska Street, SLO-2000, Maribor, Slovenia
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Baruffaldi F, Mecca R, Stea S, Beraudi A, Bordini B, Amabile M, Sudanese A, Toni A. Squeaking and other noises in patients with ceramic-on-ceramic total hip arthroplasty. Hip Int 2020; 30:438-445. [PMID: 31328560 DOI: 10.1177/1120700019864233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Noise in ceramic-on-ceramic (CoC) total hip arthroplasty (THA) is a potential symptom of abnormal bearing wear. Squeaking and other prosthetic hip noises are multi-factorial phenomena that can be analysed and may provide prognostic information. METHODS 46 patients with noisy CoC bearings were investigated using X-ray, computed tomography and joint fluid analysis, and classified into either high or low risk of ceramic liner fracture groups according to previously published guidelines. Noise events from the bearings of 16 high risk cases which were subsequently revised were compared with 30 patients in the low risk control group who did not undergo revision. Noise events were analysed for their physical characteristics using a standardised protocol and classified as either low frequency and short duration 'clicking' or long duration and high frequency 'squeaking'. RESULTS The peak frequency of squeaking during forward walking was significantly higher for patients in the case group who were revised, compared with the control group. The patient-reported onset of squeaking (46 months postoperatively) was earlier than short-noise emissions (82 months). In the standardised sequence of movements, short-noise always occurred more frequently than squeaking. Small heads (28 mm) were more likely to develop short-noise, while large heads (⩾32 mm) were more likely to develop squeaking. DISCUSSION Noise evaluation may provide additional value for predicting failure of CoC bearings, though some questions should be better investigated in a dedicated prospective trial.
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Affiliation(s)
- Fabio Baruffaldi
- Laboratory of Medical Technology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Rosaria Mecca
- Laboratory of Medical Technology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Susanna Stea
- Laboratory of Medical Technology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alina Beraudi
- Laboratory of Medical Technology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Barbara Bordini
- Laboratory of Medical Technology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marilina Amabile
- Laboratory of Medical Technology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandra Sudanese
- Orthopaedics-Traumatology and Prosthetic Surgery and Revisions of Hip and Knee Replacement, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Aldo Toni
- Orthopaedics-Traumatology and Prosthetic Surgery and Revisions of Hip and Knee Replacement, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Castagnini F, Bordini B, Biondi F, Cosentino M, Stea S, Traina F. Mixed ceramic combinations in primary total hip arthroplasty achieved reassuring mid-to-longterm outcomes. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2020; 31:56. [PMID: 32594253 DOI: 10.1007/s10856-020-06393-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 06/15/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Ceramic-on-ceramic couplings demonstrated to be reliable bearings in primary total hip arthroplasty (THA), with long-term remarkable results. Like-on-like configurations were widely described. On the contrary, mixed material combinations from the same manufacturer, Delta-on-Forte or Forte-on-Delta, were poorly studied. In particular, it is unknown whether mixed ceramic combinations are more at risk of ceramic fractures. Thus, a registry study was conducted to investigate the long-term survival rates and reasons for revision of mixed ceramic combinations. A comparison with Delta-on-Delta couplings was also performed. MATERIALS AND METHODS The regional arthroplasty registry RIPO was enquired about three cohorts of ceramic bearings (head-on-liner: Delta-on-Forte, Forte-on-Delta, Delta-on-Delta). Demographics, survival rates and reasons for revision were evaluated and compared. RESULTS In total, 346 (1.5%) implants had a Delta-on-Forte coupling (mean follow-up: 6.4 years). In total, 1163 (5%) THAs had a Forte-on-Delta articulation (mean follow-up: 8.2 years). Delta-on-Delta surfaces were implanted in 21,874 (93.5%) hips (mean follow-up: 3.9 years). Mixed material combinations were implanted between 2003 and 2007. The survival rates of the three cohorts were similar and were higher than 95% at 10 years. In Forte-on-Delta group, four liners failed (0.3% of the implants), whereas ceramic fractures occurred in 15 cases (0.1%) in Delta-on-Delta couplings (3 heads and 12 liners). Considering ceramic fracture as endpoint, there was no significant difference between the three survival rates. CONCLUSIONS Mixed ceramic bearing configurations from the same manufacturer in primary THA showed mid-to-longterm dependable outcomes, not inferior to the most recent like-on-like ceramic bearings. No additional risks of ceramic fractures were evident. Thus, closer follow-ups are not required.
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Affiliation(s)
- Francesco Castagnini
- Ortopedia-Traumatologia e Chirurgia protesica e dei reimpianti d'anca e di ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, 40136, Italy.
| | - Barbara Bordini
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, Bologna, 40136, Italy
| | - Federico Biondi
- Ortopedia-Traumatologia e Chirurgia protesica e dei reimpianti d'anca e di ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, 40136, Italy
| | - Monica Cosentino
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, Bologna, 40136, Italy
| | - Susanna Stea
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, Bologna, 40136, Italy
| | - Francesco Traina
- Ortopedia-Traumatologia e Chirurgia protesica e dei reimpianti d'anca e di ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, 40136, Italy
- DIBINEM, University of Bologna, Bologna, Italy
- University of Messina, Messina, Italy
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Grupp TM, Baxmann M, Jansson V, Windhagen H, Heller KD, Morlock MM, Knaebel HP. How to proceed with asymptomatic modular dual taper hip stems in the case of acetabular revision. MATERIALS 2020; 13:ma13051098. [PMID: 32121627 PMCID: PMC7084958 DOI: 10.3390/ma13051098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/13/2020] [Accepted: 02/18/2020] [Indexed: 12/15/2022]
Abstract
How to proceed with a clinically asymptomatic modular Metha® Ti alloy stem with dual taper CoCr neck adapter in case of acetabular revision? To systematically answer this question the status of research and appropriate diagnostic methods in context to clinically symptomatic and asymptomatic dual taper stem-neck couplings has been evaluated based on a systematic literature review. A retrieval analysis of thirteen Metha® modular dual taper CoCr/Ti alloy hip stems has been performed and a rational decision making model as basis for a clinical recommendation was developed. From our observations we propose that in cases of acetabular revision, that for patients with a serum cobalt level of > 4 µg/L and a Co/Cr ratio > 3.6, the revision of the modular dual taper stem may be considered. Prior to acetabular revision surgery a systematic diagnostic evaluation should be executed, using specific tests such as serum metal (Co, Cr) ion analysis, plain antero-posterior and lateral radiographs and cross-sectional imaging modalities (Metal Artefact Reduction Sequence Magnetic Resonance Imaging). For an asymptomatic Metha® dual taper Ti alloy/CoCr stem-neck coupling at the stage of acetabular revision careful clinical decision making according to the proposed model should be followed and overreliance on any single examination should be avoided, considering the complete individual differential diagnosis and patient situation.
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Affiliation(s)
- Thomas M. Grupp
- Aesculap AG Research & Development, 78532 Tuttlingen, Germany;
- Department of Orthopaedic Surgery, Physical Medicine & Rehabilitation, Campus Grosshadern Ludwig Maximilians University Munich, 81377 Munich, Germany;
- Correspondence: ; Tel.: +49-7461-95-2667; Fax: +49-7461-95-382667
| | - Marc Baxmann
- Aesculap AG Research & Development, 78532 Tuttlingen, Germany;
| | - Volkmar Jansson
- Department of Orthopaedic Surgery, Physical Medicine & Rehabilitation, Campus Grosshadern Ludwig Maximilians University Munich, 81377 Munich, Germany;
| | - Henning Windhagen
- Department of Orthopaedic Surgery, Hannover Medical School, 30625 Hannover, Germany;
| | - Karl-Dieter Heller
- Department of Orthopaedic Surgery, Herzogin-Elisabeth-Hospital, 38124 Braunschweig, Germany;
| | - Michael M. Morlock
- Institute of Biomechanics, TUHH Hamburg University of Technology, 21073 Hamburg, Germany;
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Castagnini F, Bordini B, Tassinari E, Stea S, Ancarani C, Traina F. Delta-on-Delta Ceramic Bearing Surfaces in Revision Hip Arthroplasty. J Arthroplasty 2019; 34:2065-2071. [PMID: 31160152 DOI: 10.1016/j.arth.2019.04.068] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/24/2019] [Accepted: 04/29/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Fourth-generation ceramic-on-ceramic couplings were developed to improve ceramic toughness and strength. Encouraging outcomes in primary total hip arthroplasty were reported. This coupling was proposed as an attractive option even in the case of revision procedures, particularly in younger patients with a longer life expectancy. However, the pertinent literature is scarce. Thus, a registry study was conducted to investigate the midterm survival rates and reasons for re-revision of the fourth-generation ceramic-on-ceramic bearing surfaces in revision hip arthroplasties. METHODS A total of 327 revision implants (all the components were exchanged) with BIOLOX Delta couplings were investigated using the regional orthopedic registry RIPO. The demographics, the survival rates, and the reasons for re-revision were assessed. Revisions with bearings other than Delta were compared. RESULTS Delta bearings achieved a survival rate of 90.5% at 7 years, with stable results. Twenty-six (8%) re-revisions occurred at a mean follow-up of 4.1 years. And 2.8% of the re-revisions were due to recurrent dislocations; 1.5% of the cases were due to cup aseptic loosening. Septic loosening occurred in 1.6% of the cases. No ceramic fractures were reported. When compared to revisions with bearings other than Delta-on-Delta, Delta coupling cohort achieved similar performances at 5 and 7 years. Lower, nonsignificant rates of aseptic and septic loosening were reported in Delta cohort. CONCLUSION Delta-on-Delta couplings demonstrated to be reliable bearing surfaces in revision settings at a midterm follow-up. Clinical studies and longer follow-ups are required to investigate potential adverse effects, like squeaking and fractures, and confirm these preliminary findings. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Francesco Castagnini
- Ortopedia-Traumatologia e Chirurgia protesica e dei reimpianti d'anca e di ginocchio, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Barbara Bordini
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Enrico Tassinari
- Ortopedia-Traumatologia e Chirurgia protesica e dei reimpianti d'anca e di ginocchio, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Susanna Stea
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cristina Ancarani
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Francesco Traina
- Ortopedia-Traumatologia e Chirurgia protesica e dei reimpianti d'anca e di ginocchio, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Castagnini F, Valente G, Crimi G, Taddei F, Bordini B, Stea S, Toni A. Component positioning and ceramic damage in cementless ceramic-on-ceramic total hip arthroplasty. J Orthop Sci 2019; 24:643-651. [PMID: 30612885 DOI: 10.1016/j.jos.2018.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/21/2018] [Accepted: 12/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND In ceramic-on-ceramic (CoC) total hip arthroplasty (THA), component positioning demonstrated to influence the bearing damage: however the connection between angles and clinical outcomes at long-term follow-ups is currently lacking. Aims of this study were: the computer tomography (CT) assessment of component positioning in CoC THAs; the correlation analysis between positioning and ceramic damage; the identification of safe zones. METHODS 91 consecutive post-operative CT scans including two types of CoC implants, with a mean follow-up of 12 ± 4.4 years, were evaluated. III generation (74.2%) and IV generation (25.8%) CoC surfaces were included. The angle measurements (cup abduction, anteversion, cup tilt, stem antetorsion, sacral slope) were automated using a CT-based software. The combined anteversion was assessed as well as the cup-neck position at -15°, 0°, 45° and 90° of flexion. Ceramic damage was diagnosed using synovial fluid analyses and radiological criteria. RESULTS 63.7% of THAs was inside the cup abduction target 30°-45° and 68.1% was inside the cup anteversion target 5°-25°. 19 patients (20.9%) showed signs of ceramic damage. High cup abduction and high cup-neck 45° minimum angle (which stood for high abduction and extreme combined version) significantly correlated with ceramic damage. No demographical features apart III generation ceramic bearings influenced the results. No safe zones could be detected. CONCLUSIONS In CoC THA, no safe zones can be described. However it is important to avoid cup inclination over 45° and a combination of steep cup and extreme combined version.
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Affiliation(s)
- Francesco Castagnini
- Ortopedia-Traumatologia e Chirurgia Protesica e dei reimpianti d'anca e di ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, 40136, Italy.
| | - Giordano Valente
- Laboratorio di Bio Ingegneria Computazionale, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, Bologna, 40136, Italy
| | - Gianluigi Crimi
- Laboratorio di Bio Ingegneria Computazionale, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, Bologna, 40136, Italy
| | - Fulvia Taddei
- Laboratorio di Bio Ingegneria Computazionale, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, Bologna, 40136, Italy
| | - Barbara Bordini
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, Bologna, 40136, Italy
| | - Susanna Stea
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, Bologna, 40136, Italy
| | - Aldo Toni
- Ortopedia-Traumatologia e Chirurgia Protesica e dei reimpianti d'anca e di ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, 40136, Italy
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Kovač S, Mavčič B, Kotnik M, Levašič V, Sirše M, Fokter SK. What Factors Are Associated With Neck Fracture in One Commonly Used Bimodular THA Design? A Multicenter, Nationwide Study in Slovenia. Clin Orthop Relat Res 2019; 477:1324-1332. [PMID: 31136429 PMCID: PMC6554145 DOI: 10.1097/corr.0000000000000646] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 01/04/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Femoral stems with bimodular (head-neck as well as neck-body) junctions were designed to help surgeons address patients' hip anatomy individually. However, arthroplasty registers have reported higher revision rates in stems with bimodular junctions than in stems with modularity limited to the head-neck trunnion. However, to our knowledge, no epidemiologic study has identified patient-specific risk factors for modular femoral neck fractures, and some stems using these designs still are produced and marketed. QUESTIONS/PURPOSES The purposes of this study were (1) to establish the survival rate free from aseptic loosening of one widely used bimodular THA design; (2) to define the proportion of patients who experienced a fracture of the stem's modular femoral neck; and (3) to determine factors associated with neck fracture. METHODS In this retrospective, nationwide, multicenter study, we reviewed 2767 bimodular Profemur® Z stems from four hospitals in Slovenia with a mean followup of 8 years (range, 3 days to 15 years). Between 2002 and 2015, the four participating hospitals performed 26,132 primary THAs; this implant was used in 2767 of them (11%). The general indications for using this implant were primary osteoarthritis (OA) in 2198 (79%) hips and other indications in 569 (21%) hips. We followed patients from the date of the index operation to the date of death, date of revision, or the end of followup on March 1, 2018. We believe that all revisions would be captured in our sample, except for patients who may have emigrated outside the country, but the proportion of people immigrating to Slovenia is higher than the proportion of those emigrating from it; however, no formal accounting for loss to followup is possible in a study of this design. There were 1438 (52%) stems implanted in female and 1329 (48%) in male patients, respectively. A titanium alloy neck was used in 2489 hips (90%) and a cobalt-chromium neck in 278 (10%) hips. The mean body mass index (BMI) at the time of operation was 29 kg/m (SD ± 5 kg/m). We used Kaplan-Meier analysis to establish survival rates, and we performed a chart review to determine the proportion of patients who experienced femoral neck fractures. A binary logistic regression model that controlled for the potential confounding variables of age, sex, BMI, time since implantation, type of bearing, diagnosis, hospital, neck length, and neck material was used to analyze neck fractures. RESULTS There were 55 (2%) aseptic stem revisions. Survival rate free from aseptic loosening at 12 years was 97% (95% confidence interval [CI] ± 1%). Fracture of the modular neck occurred in 23 patients (0.83%) with a mean BMI of 29 kg/m (SD ± 4 kg/m.) Twenty patients with neck fractures were males and 19 of 23 fractured necks were long. Time since implantation (odds ratio [OR], 0.55; 95% CI 0.46-0.66; p < 0.001), a long neck (OR, 6.77; 95% CI, 2.1-22.2; p = 0.002), a cobalt-chromium alloy neck (OR, 5.7; 95% CI, 1.6-21.1; p = 0.008), younger age (OR, 0.91; 95% CI, 0.86-0.96; p < 0.001), and male sex (OR, 3.98; 95% CI, 1.04-14.55; p = 0.043) were factors associated with neck fracture. CONCLUSIONS The loosening and neck fracture rates of the Profemur® Z stem were lower than in some of previously published series. However, the use of modular femoral necks in primary THA increases the risk for neck fracture, particularly in young male patients with cobalt-chromium long femoral necks. The bimodular stem we analyzed fractured unacceptably often, especially in younger male patients. For most patients, the risks of using this device outweigh the benefits, and several dozen patients had revisions and complications they would not have had if a different stem had been used. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Simon Kovač
- S. Kovač, V. Levašič, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia B. Mavčič, Department of Orthopaedic Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia M. Kotnik, Department of Orthopaedics, Celje General Hospital, Celje, Slovenia M. Sirše, S. K. Fokter, Department of Orthopaedics, University Medical Centre Maribor, Maribor, Slovenia
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Gittings DJ, Dattilo JR, Hardaker W, Sheth NP. Evaluation and Treatment of Femoral Osteolysis Following Total Hip Arthroplasty. JBJS Rev 2019; 5:e9. [PMID: 28806267 DOI: 10.2106/jbjs.rvw.16.00118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Daniel J Gittings
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Papalia R, Di Martino A, Caldaria A, Zampogna B, Denaro V. Outcomes of neck modularity in total hip arthroplasty: an Italian perspective. Musculoskelet Surg 2019; 103:215-220. [PMID: 30673963 DOI: 10.1007/s12306-019-00589-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 01/03/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study is to conduct a systematic review of clinical outcomes and complications of modular neck THA among Italian cohorts. METHODS Only reviewed publications focused on Italian cohort patients in English language were considered for inclusion. Studies were included if they involved patients who underwent total hip replacement surgery with modular necks, and reported aetiology or survival rate or bone stability or clinical scores or complications. RESULTS The studies included in our search reported data on 3714 patients and 3856 hips. Most of the studies were from high-volume surgery centres. The most frequent diagnosis was osteoarthritis that occurred in 2910 cases (75.9%). The average survival rate and average bone stability were 97.20% and 99.37%, respectively. The average HHS improved from 42.1 prior to surgery to 89.52 after surgery. Studies included in our search reported 40 complications. The most frequently reported complication was dislocation (40%). CONCLUSION This review showed excellent survival rate and bone stability and good clinical outcomes in Italian cohort patients treated with modular neck THA, and these clinical results are comparable with international cohort rates. This review suggests that modular implants represent a very satisfying choice when practised by expert orthopaedic joint surgeons.
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Affiliation(s)
- R Papalia
- Department of Orthopaedic and Trauma Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - A Di Martino
- Department of Orthopaedic and Trauma Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo, 200, 00128, Rome, Italy.
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA.
| | - A Caldaria
- Department of Orthopaedic and Trauma Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - B Zampogna
- Department of Orthopaedic and Trauma Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - V Denaro
- Department of Orthopaedic and Trauma Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo, 200, 00128, Rome, Italy
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Solarino G, Piazzolla A, Moretti L, Vicenti G, Moretti B. A minimum 20-year outcome of 100 consecutive alumina-on-alumina arthroplasties performed by a single surgeon. Hip Int 2018; 28:10-14. [PMID: 30755120 DOI: 10.1177/1120700018813218] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND: Ceramic-on-ceramic (CoC) is currently a viable bearing combination in primary total hip arthroplasty (THA) and, due to its mechanical properties, it can be used in young patients requiring a long-lasting implant. The aim of this study is to report the results of a series of CoC THAs at a minimum 20 years follow-up. METHODS: A retrospective study was conducted on the 1st 100 consecutive alumina-on-alumina arthroplasties performed by a single surgeon on 51 females and 40 males with an average age of 60.7 years. The mean preoperative Harris Hip Score was 35. The press-fit cup consisted of a pure titanium core with a titanium alloy mesh. Both the inlay and the head were made of dense polycrystalline surgical-grade alumina. The 32-mm femoral head was anchored on 3 different femoral components. RESULTS: 19 patients with 22 THAs were died or lost, 2 anatomic cementless stems were revised due to sinking, 1 THA was revised for periprosthetic infection. 2 patients sustained a Vancouver B1 periprosthetic femoral fracture. None of the 78 THAs eligible for this study were revised for wear, breakage, noise of the ceramic components. None of the cups, none of the cemented stems, none of the cementless straight stems failed. HHS raised up to a mean value of 95. CONCLUSIONS: The present report demonstrates that CoC coupling offers minimal wear at a long-term follow-up. Further studies are needed to evaluate whether the modern ceramic composites will confirm such excellent results in total hip replacement.
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Affiliation(s)
- Giuseppe Solarino
- Department of Neuroscience and Organs of Sense, Orthopaedic Unit, Faculty of Medicine and Surgery, University of Bari, Italy
| | - Andrea Piazzolla
- Department of Neuroscience and Organs of Sense, Orthopaedic Unit, Faculty of Medicine and Surgery, University of Bari, Italy
| | - Lorenzo Moretti
- Department of Neuroscience and Organs of Sense, Orthopaedic Unit, Faculty of Medicine and Surgery, University of Bari, Italy
| | - Giovanni Vicenti
- Department of Neuroscience and Organs of Sense, Orthopaedic Unit, Faculty of Medicine and Surgery, University of Bari, Italy
| | - Biagio Moretti
- Department of Neuroscience and Organs of Sense, Orthopaedic Unit, Faculty of Medicine and Surgery, University of Bari, Italy
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Lau YJ, Sarmah S, Witt JD. 3 rd generation ceramic-on-ceramic cementless total hip arthroplasty: a minimum 10-year follow-up study. Hip Int 2018; 28:133-138. [PMID: 29890910 DOI: 10.1177/1120700018768617] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION 3rd generation ceramic bearings were introduced in total hip arthroplasty (THA) with the potential to have better mechanical strength and wear properties than their predecessors. At present, there are few studies looking at the long-term results of this latest generation of ceramic bearings. The purpose of our study was to investigate the long-term clinical and radiographic results of 3rd generation ceramic-on-ceramic THA and the incidence of ceramic specific complications such as squeaking and bearing surface fracture. METHODS The database of the senior author (J.D.W.) was reviewed. A total of 126 hip replacements performed in 108 patients (average age 39.6 years) with an average follow-up of 12.1 years (10-16 years) was identified. Clinical notes and plain radiographs were reviewed. To measure function, patients were contacted and an Oxford Hip Questionnaire was completed. Patients were also directly questioned about the presence of squeaking or any other sounds from the hip. Radiographs were evaluated for signs of wear, osteolysis, loosening and heterotopic ossification. The abduction angle of the acetabular component was measured. RESULTS The average Oxford Hip Score was 39.8 out of 48. Survivorship at 10 years was 94.6% (95% CI) with revision for any cause as the endpoint. There was 1 femoral head fracture, no osteolysis, no squeaking and no detectable wear. CONCLUSIONS The good clinical and radiographic results for this series of patients are similar to other recent long-term studies looking at 3rd generation ceramic-on-ceramic THA. The results compare favourably with other bearing surfaces. The lack of osteolysis associated with this articulation is encouraging and may also make it a good choice for younger patients requiring total hip replacement.
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Hannouche D, Zingg M, Miozzari H, Nizard R, Lübbeke A. Third-generation pure alumina and alumina matrix composites in total hip arthroplasty: What is the evidence? EFORT Open Rev 2018; 3:7-14. [PMID: 29657840 PMCID: PMC5890134 DOI: 10.1302/2058-5241.3.170034] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Wear, corrosion and periprosthetic osteolysis are important causes of failure in joint arthroplasty, especially in young patients. Ceramic bearings, developed 40 years ago, are an increasingly popular choice in hip arthroplasty. New manufacturing procedures have increased the strength and reliability of ceramic materials and reduced the risk of complications. In recent decades, ceramics made of pure alumina have continuously improved, resulting in a surgical-grade material that fulfills clinical requirements. Despite the track record of safety and long-term results, third-generation pure alumina ceramics are being replaced in clinical practice by alumina matrix composites, which are composed of alumina and zirconium. In this review, the characteristics of both materials are discussed, and the long-term results with third-generation alumina-on-alumina bearings and the associated complications are compared with those of other available ceramics.
Cite this article: EFORT Open Rev 2018;3:7-14. DOI: 10.1302/2058-5241.3.170034
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Affiliation(s)
- Didier Hannouche
- Department of Orthopaedic Surgery and Traumatology, Geneva University Hospital, Switzerland
| | - Matthieu Zingg
- Department of Orthopaedic Surgery and Traumatology, Geneva University Hospital, Switzerland
| | - Hermes Miozzari
- Department of Orthopaedic Surgery and Traumatology, Geneva University Hospital, Switzerland
| | - Remy Nizard
- Department of Orthopaedic Surgery, AP-HP, Hôpital Lariboisière, Paris University, Paris, France
| | - Anne Lübbeke
- Department of Orthopaedic Surgery and Traumatology, Geneva University Hospital, Switzerland
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Collet T, Atanasiu JP, de Cussac JB, Oufroukhi K, Bothorel H, Saffarini M, Badatcheff F. Midterm outcomes of titanium modular femoral necks in total hip arthroplasty. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:395. [PMID: 29152495 DOI: 10.21037/atm.2017.07.36] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background Modular femoral necks present surgical and biomechanical advantages in total hip arthroplasty (THA), but their benefits remain controversial due to risks of corrosion and fracture at the additional junction. This study aimed to report 10-year survival and clinical outcomes of a titanium femoral stem with a titanium modular neck in consecutive series. Methods The authors reviewed the records of 97 patients (99 THAs) using uncemented modular stem and ceramic-on-ceramic acetabular components. Patients were evaluated at minimum follow-up of 5 years using the Harris Hip Score (HHS) and Postel Merle-D'Aubigné score (PMA). Survival was calculated using the Kaplan-Meier (KM) method with any reoperation or revision as endpoint. Results From the original cohort, 14 patients died, 6 were lost to follow-up, and 5 had revision operations with exchange of the femoral stem. The KM survival at 10 years was 94.2% (CI, 86.5-97.5). Clinical assessment was performed on 67 of the 72 patients (69 of the 74 hips) presently living with their original THA components. At mean follow-up of 9.4±1.0 years (median, 10; range, 5-11), the HHS was 93.6±8.2 and the PMA score 17.0±1.6. The X-rays revealed no signs of adverse reactions or bone loss. Conclusions The uncemented titanium hip stem with modular titanium neck provided a satisfactory 10-year survival and clinical outcomes. Neck modularity enabled restoration of patient-specific femoral offset and limb length thanks to five possible neck configurations, though greater follow up is required to confirm the long-term benefits and safety of this design concept.
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Affiliation(s)
- Thurial Collet
- Polyclinique de l'Europe, Unité de chirurgie orthopédique réparatrice et sportive, St Nazaire, France
| | - Jean-Pierre Atanasiu
- Chirurgie Orthopédique et Traumatologique, Polyclinique de Poitiers, Poitiers Cedex, France
| | - Jean-Baptiste de Cussac
- Polyclinique de l'Europe, Unité de chirurgie orthopédique réparatrice et sportive, St Nazaire, France
| | - Kamal Oufroukhi
- Clinique Chirurgicale de la Loire, Rue des Rolletières, Saumur, France
| | | | - Mo Saffarini
- Medical Technology, ReSurg SA, Nyon, Switzerland
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Lau YJ, Sarmah S, Witt JD. 3rd generation ceramic-on-ceramic cementless total hip arthroplasty: a minimum 10-year follow-up study. Hip Int 2017:0. [PMID: 28777383 DOI: 10.5301/hipint.5000541] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION 3rd generation ceramic bearings were introduced in total hip arthroplasty (THA) with the potential to have better mechanical strength and wear properties than their predecessors. At present, there are few studies looking at the long-term results of this latest generation of ceramic bearings.The purpose of our study was to investigate the long-term clinical and radiographic results of 3rd generation ceramic-on-ceramic THA and the incidence of ceramic specific complications such as squeaking and bearing surface fracture. METHODS The database of the senior author (J.D.W.) was reviewed. A total of 126 hip replacements performed in 108 patients (average age 39.6 years) with an average follow-up of 12.1 years (10-16 years) was identified. Clinical notes and plain radiographs were reviewed. To measure function, patients were contacted and an Oxford Hip Questionnaire was completed. Patients were also directly questioned about the presence of squeaking or any other sounds from the hip. Radiographs were evaluated for signs of wear, osteolysis, loosening and heterotopic ossification. The abduction angle of the acetabular component was measured. RESULTS The average Oxford Hip Score was 39.8 out of 48. Survivorship at 10 years was 94.6% (95% CI) with revision for any cause as the endpoint. There was 1 femoral head fracture, no osteolysis, no squeaking and no detectable wear. CONCLUSIONS The good clinical and radiographic results for this series of patients are similar to other recent long-term studies looking at 3rd generation ceramic-on-ceramic THA. The results compare favourably with other bearing surfaces. The lack of osteolysis associated with this articulation is encouraging and may also make it a good choice for younger patients requiring total hip replacement.
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Kim CH, Choi YH, Jeong MY, Chang JS, Yoon PW. Cobalt Intoxication Heart Failure after Revision Total Hip Replacement for Ceramic Head Fracture: A Case Report. Hip Pelvis 2016; 28:259-263. [PMID: 28097117 PMCID: PMC5240314 DOI: 10.5371/hp.2016.28.4.259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 11/10/2016] [Accepted: 11/20/2016] [Indexed: 11/24/2022] Open
Abstract
In 1960s, toxic heart failure due to cobalt poisoning was firstly reported from Canadian industrial worker. Following development of bearing materials in hip arthroplasties, using cobalt-chrome alloy in bearing surface, there were rarely reported of systemic affect toxic cobaltism include toxic heart failure due to articulation wear in Western countries. It could be happened more easily by third body wear from ceramic particle especially revision total hip replacement (THR) surgery using cobalt-chrome alloy following ceramic articulation breakage which index surgery performed by ceramic on ceramic bearing. In Korea, due to many surgeons prefer ceramic on ceramic bearing in THR compared to Western countries, it might be more important issue within a time. However in our knowledge, there was no previous report about cobalt poisoning heart failure in Korea. It is still very rare and hard to diagnose cobalt intoxication heart failure after THR, so we report a case of fatal heart failure caused by cobalt intoxication after revision THR in 53-year old man who successfully underwent re-revision THR.
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Affiliation(s)
- Chul-Ho Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hyun Choi
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi Yeon Jeong
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Suk Chang
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Pil Whan Yoon
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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