Mid-term outcomes of a stemless ceramic head anatomic total shoulder replacement

Background In an anatomic shoulder replacement (aTSR) good results have been reported with the use of a stemless humeral prosthesis. In vitro a ceramic articulation with polyethylene has been shown to produce less polyethylene wear particles than with metal. This study aims to evaluate clinical and radiographic results of a stemless aTSR with a ceramic head articulating with a polyethylene glenoid component, with mid-term follow-up. Methods All patients (n = 92) in this prospective study had an aTSR utilizing a stemless humeral component with a ceramic head and a cemented double pegged cemented polyethylene glenoid component for glenohumeral osteoarthritis. Pre- and postoperative clinical evaluations at 2 years were performed using the ASES score, Constant score, SPADI score, DASH score, VAS pain score, patient satisfaction and range of motion. There was a 5-year evaluation of SPADI, ASES, pain, and satisfaction, plus radiographic assessment of glenoid component radiolucent lines and humeral osteolysis. Results Seventy-four cases (68.1 ± 7.1 years) had a five-year follow-up and demonstrated active elevation improvement from 91.3° preoperatively to 151.1° (p < 0.001). Further improvement was identified with the ASES from 41.6 to 94.3, the SPADI from 62.9 to 4.3, VAS pain from 5.6 to 0.4 (0–10), and satisfaction levels were at 96%. Sixty-two cases had no glenoid radiolucent lines with a maximum Lazarus score of 2 in one patient. Constant scores, available up to 2 years, improved significantly from 30.3 to 77.9 (p < 0.001). There was one case that required revision for glenoid loosening. Conclusions Overall, the 5-year results of this ceramic head prosthesis demonstrated good radiographic and clinical outcomes. Trial registration ACTRN12613001183774. Registered: 29 October 2013 - Retrospectively registered. Australian New Zealand Clinical Trials Registry (ANZCTR).

Radiolucent lines do not affect the longevity of highly cross-linked polyethylene cemented components in total hip arthroplasty

Aims We aimed to evaluate the long-term outcome of highly cross-linked polyethylene (HXLPE) cemented acetabular components and assess whether any radiolucent lines (RLLs) which arose were progressive. Methods We retrospectively reviewed 170 patients who underwent 187 total hip arthroplasties at two hospitals with a minimum follow-up of ten years. All interventions were performed using the same combination of HXLPE cemented acetabular components with femoral stems made of titanium alloy. Kaplan-Meier survival analysis was performed for the primary endpoint of acetabular component revision surgery for any reason and secondary endpoint of the appearance of RLLs. RLLs that had appeared once were observed over time. We statistically assessed potential relationships between RLLs and a number of factors, including the technique of femoral head autografting and the Japanese Orthopaedic Association score. Results The mean follow-up period was 13.0 years (10.0 to 16.3). Femoral head autografting was performed on 135 hips (72.2%). One acetabular component was retrieved because of deep infection. No revision was performed for the aseptic acetabular loosening. The Kaplan-Meier survival curve for the primary and secondary endpoints were 98.2% (95% confidence interval (CI) 88.6% to 99.8%) and 79.3% (95% CI 72.8% to 84.6%), respectively. RLLs were detected in 38 hips (21.2%), at a mean of 1.7 years (1 month to 6 years) postoperatively. None of the RLLs were progressive, and the presence of RLLs did not show a significant association with the survival and clinical score. RLLs were more frequently observed in hips without femoral head autografts than in those with autografts. Conclusion The use of HXLPE cemented acetabular components in total hip arthroplasty demonstrated excellent clinical outcomes after ten years, and no RLLs were progressive, and their presence did not affect the outcome. Femoral head autografting did not negatively impact the acetabular component survival or the appearance of RLLs. Cite this article: Bone Joint J 2021;103-B(10):1604–1610.

Total hip arthroplasty with ultra-short uncemented stem in patients with osteonecrosis of the femoral head: mid-term results

Background: Mid-term results (clinical and radiographic) of ultra-short anatomical cementless stem total hip arthroplasty (THA) in patients with osteonecrosis of the femoral head (ONFH) has not often been presented. The aim of this study is to evaluate THA using the Proxima stem in patients with ONFH in the mid-term. Methods: The study consists of 73 patients (97 THAs) with a Proxima stem implanted between 2006 and 2015. The mean age of patients was 47.4 years, with a mean follow-up 105.2 months. The clinical results include preoperative and postoperative Harris Hip Scores (HHSs). Radiological follow-up reports on stem migration, bony trabecular development and radiolucent lines. The complications and revisions were registered. Kaplan-Meier survival analysis was performed to determine the implant survival. Results: The average HHS improved significantly from 40.3 preoperatively to 98.0 at the final evaluation ( p ˂ 0.0001). Stem migration (subsidence and “varisation”) was observed in 11 hips (in 9 of them up to 6th postoperative month without any further progression, in 2 with progressive migration and radiological loosening). Bony trabecular development was detected in modified Gruen zones (1,2,4,6,7 for Proxima stem): in zone 1 (0%), 2 (67.0%), 4 (64.9%), 6 (64.9%), 7 (0%). Radiolucent lines were observed in 1 cup and 6 stems (2 were loose, 4 with fibrous stable fixation). Complications were found in 5 hips (5.1%): squeezing hip once, repeated dislocation in 1, 1 early deep infection, and 2 loose stems. 2 hips (2.1%) were revised (dislocation, infection). The implant survival was 98.9% and 97.9% clinically and radiologically, respectively. Conclusions: Observations in the mid-term show that the clinical and radiological results of the Proxima stem in patients with ONFH are promising. The stem design preserves the proximal femoral bone stock. The bony trabecular appearance confirms physiological proximal femoral load transmission.

Design and rationale of the ATtune Knee Outcome Study (ATKOS): multicenter prospective evaluation of a novel uncemented rotating platform knee system

Background Total Knee Arthroplasty (TKA) remains the gold standard for treatment of debilitating symptoms of knee osteoarthritis (OA). Even though providing satisfactory results for the majority of patients, some studies report dissatisfaction after TKA to be as high as 20%. Among other things, pain catastrophising and self-efficacy are thought to compromise results of TKA. Implant manufacturers keep improving upon their designs in an attempt to improve functional outcomes. One of these novel knee systems is the Attune. To our knowledge, there are no clinical follow-up studies reporting results of the uncemented version. The main objective of this multicentre prospective observational study is to evaluate revision rate, complications, radiographic outcomes (i.e. alignment and radiolucent lines) and patient reported outcomes of the uncemented Attune mobile bearing TKA. Secondary objectives are (1) to assess physical function, return to sport and return to work after TKA and (2) to evaluate the long-term effect of preoperative psychological factors on satisfaction after TKA. Methods All patients presenting in the participating centres with knee pathology warranting joint replacement therapy will be considered for inclusion, an absolute indication for cemented fixation is the only exclusion criterium. Evaluation of clinical and radiographic performance (e.g. radiolucent lines) is done at 6 weeks, 6 months, 1 year, 5 years and 10 years after surgery using validated patient reported outcome measures. Cumulative revision rates are calculated after 5 and 10 years using Kaplan–Meier methods. Physical function is assessed with performance based measurements before and 1 year after surgery. Return to sports is assessed using the Tegner and University of California Los Angeles (UCLA) activity rating scale before and 1 year after surgery. Return to work is evaluated by inviting patients of working age to complete a short questionnaire 1 year after surgery. Psychologic factors are assessed using questionnaires for pain catastrophising, pain self-efficacy and mental health before, 5 years and 10 years after surgery. Preoperative psychologic scores are correlated to functional outcomes. Discussion The current study aims to report the clinical performance of a novel implant and can help provide insight in factors that play a role in satisfaction after TKA. Trial registration ClinicalTrials.gov identifier: NCT04247672 (January 30, 2020)

Total hip arthroplasty using highly cross-linked polyethylene in patients aged 50 years and younger

Aims Highly cross-linked polyethylene (HXLPE) has greatly improved the durability of total hip arthroplasty (THA) in young patients because of its improved wear characteristics. Few studies have followed this population into the second decade, and therefore the purpose of this investigation was to evaluate the clinical outcome for THA patients 50 years of age and younger at a minimum of 15 years postoperatively. The second purpose was to evaluate the radiological findings secondary to wear or mechanical failure of the implant. Methods Between October 1999 and December 2005, 105 THAs were performed in 95 patients (53 female, 42 male) aged 50 years and younger (mean 42 years (20 to 50)). There were 87 patients (96 hips) that were followed for a minimum of 15 years (mean 17.3 years (15 to 21)) for analysis. Posterior approach was used with cementless fixation with a median head size of 28 mm. HXLPE was the acetabular bearing for all hips. Radiographs were evaluated for polyethylene wear, radiolucent lines, and osteolysis. Results Clinical outcomes showed significant improvement of mean Harris Hip Scores from 52.8 (SD 13.5) preoperatively to 94.8 (SD 7.6) postoperatively. One hip was revised for recurrent instability, and there were no infections. No hips were revised for mechanical loosening or osteolysis. Mean polyethylene linear wear was 0.04 mm/year and volumetric wear was 6.22 mm3/year, with no significant differences between head size or material. Osteolysis was not present in any of the hips. Conclusion The use of HXLPE in THA for patients aged 50 years and younger has performed exceptionally well without evidence of significant wear causing mechanical loosening or necessitating revision. The radiolucent lines of the acetabular component must be followed to determine the prognostic significance. This investigation represents the longest clinical follow-up of a large, consecutive cohort of patients aged 50 years or younger with THA using HXLPE. This long-term analysis found negligible polyethylene wear, no incidence of aseptic loosening, and excellent clinical outcomes at and beyond 15 years of follow-up. Cite this article: Bone Joint J 2021;103-B(7 Supple B):78–83.

Porous-Coated Metaphyseal Sleeves in Revision Total Knee Arthroplasty: Midterm Results

Purpose The aim of this study was to evaluate the efficacy in terms of clinical results and radiographic findings of using metaphyseal sleeves in revision total knee arthroplasty (TKA), and to check if the use of sleeves without stems did not impair such results. Methods In this retrospective study, 141 patients (143 knees) operated in the period 2008 to 2015 met the above-mentioned criteria and were invited to a medical examination including X-rays. A total of 121 knees were available for the study (44 in the group without stems and 77 in the group with stems). Mean follow-up was 63 months for the stemless group and 89 for the group with stems. Knee Society Score (KSS) (objective knee score) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were used as outcome scores and compared with baseline values, range of motion (ROM) was also compared with preop value and X-rays were also examined and compared with immediate postop X-rays to check signs of loosening and radiolucent lines, if any, and bone ingrowth. Satisfaction of the patients was also investigated using a linear scale from 1 to 10. Results KSS improved from 34 to 81 postop (39 to 81 in the stemless group) (p < 0.01), while WOMAC from 82% preop to 39% postop (76 to 37% in the stemless group) (p < 0.01). Forty-six patients were satisfied, 20 partially satisfied, and 11 unsatisfied (respectively 25–14–5 in the stemless group). ROM improved from 89 degrees preop to 99 degrees postop (93 to 98 degrees in the stemless group). X-rays showed no loosening of the implant, radiolucent lines in 8 patients, and bone ingrowth in 113 out of 121 patients. Conclusion In this midterm follow-up study, we found a significant improvement in clinical results compared with preop values. We found no difference between the two groups (with and without stems) thus suggesting that the use of stemless sleeves does not impair results in revision TKA. Level of Evidence Therapeutic case series, level IV.

Early Term Radiographic Follow-Up of the Trident Tritanium Acetabular Component

INTRODUCTION: The purpose of this study was to evaluate the two year clinical and radiographic outcomes of patients undergoing a primary total hip arthroplasty (THA) using the Trident Tritanium primary Cup. METHODS: 197 patients who underwent a direct anterior THA using a Tritanium acetabular component between 2011 and 2015 were retrospectively reviewed by two surgeons from a single institution. The investigators, along with an independent physician, separately reviewed radiographs blinded to clinical data looking for radiolucent lines adjacent to the acetabular cup using the Charnley-DeLee zones. Clinical results were measured using acetabular revision surgery as an end point for failure. According to the American Academy of Orthopaedic Surgeons Levels of Evidence, this study was consistent with a Level III Therapeutic study. RESULTS: 101 (48.73%) subjects did not exhibit any radiolucent lines around the acetabular component. 53 (26.90%) subjects displayed radiolucency in only one zone. 27 (13.71%) subjects displayed radiolucency in two zones, and 16 (8.12%) displayed radiolucency in all three zones. Radiolucency was most prevalent in zone 1 at 2 years with 83 (42.13%) subjects displaying radiolucency. There were five (2.54%) acetabular failures within two years of the index surgery. Of those 5 subjects, 3 displayed radiolucency in 1 zone, 2 displayed radiolucency in >1 zone, and 2 displayed radiolucencies >1 mm. CONCLUSION: In our study, the Tritanium Cup demonstrated a 2.54% failure rate for aseptic loosening at 2 year follow-up. In addition, 48.73% of patients displayed a radiolucent line in at least one Charnley-DeLee zone. We also observed a progression of radiolucencies between the 6 month radiographs and the 2 year radiographs.

Radiographic assessment of radiolucent lines around a highly porous titanium cup (Tritanium) using digital tomosynthesis, after total hip arthroplasty

Background The objectives of this study were to assess radiolucent lines around a highly porous titanium cup (Tritanium) using digital tomosynthesis and to investigate the clinical and radiographic factors associated with radiolucent lines on tomosynthesis. Methods Fifty-five patients underwent total hip arthroplasty using a Tritanium cup, and digital tomosynthesis and plain radiography were performed at 1 week, 6 months, 1 year, and 2 years after surgery. The radiolucent lines around the cup were measured on both DTS and plain radiography at each postoperative period. Clinical evaluations were performed by the Japanese Orthopaedic Association hip disease evaluation questionnaire (JHEQ), and revision surgeries were examined. Based on the presence of radiolucent lines on digital tomosynthesis at 2 years postoperatively, patients were divided into RL (+) and RL (−) groups and investigated for related factors. Results There were 20 cases in the RL (+) group and 35 cases in the RL (−) group, and no revision surgeries were required. Statistically, there were more cases with radiolucent lines on digital tomosynthesis (45.4% at 1 week and 36.3% at 2 years) than on plain radiography (9.1% at 1 week and 9.1% at 2 years) at each postoperative point. Logistic analysis showed no significant associations between the presence of radiolucent lines at 2 years on digital tomosynthesis, and the JHEQ parameters of pain (p = 0.937), movement (p = 0.266), or mental status (p = 0.404). Conclusion In a short-term evaluation up to 2 years, digital tomosynthesis detected more radiolucent lines around the titanium cups than plain radiography. The occurrence of radiolucent lines was not related to the postoperative clinical evaluation.

Total hip arthroplasty using a three-dimensional porous titanium acetabular cup: an examination of micromotion using subject-specific finite element analysis

Background We investigated the mid-term clinical and radiological results of total hip arthroplasty (THA) using a three-dimensional (3D) porous titanium cup and analyzed the micromotion at the interface of the cup using subject-specific finite element (FE) analysis. Methods We evaluated 73 hips of 65 patients (6 men and 59 women; mean age at the time of surgery, 62.2 years; range, 45–86 years) who had undergone THA using a 3D porous titanium cup. Clinical evaluations were performed using the Japanese Orthopaedic Association (JOA) hip score system. We assessed the fixation of the acetabular component based on the presence of radiolucent lines and cup migration using anteroposterior radiographs. Subject-specific FE models were constructed from computed tomography data. Results The JOA score improved from a preoperative mean of 52.2 (range, 23–82) to a mean of 87.8 (range, 71–100) at the final follow-up. None of the patients underwent revisions during the follow-up period. Radiolucent lines were observed in 26 cases (35.6%) and frequently appeared at DeLee and Charnley Zone 3. Following the FE analysis, the micromotion at DeLee and Charnley Zone 3 was significantly larger than that at Zone 2. Furthermore, micromotion was large in the groups in which radiolucent lines appeared at Zone 3. Conclusions The mid-term clinical outcome of THA using a 3D porous titanium cup was excellent. However, radiolucent lines frequently appeared at DeLee and Charnley Zone 3. FE analysis indicated that micromotion was large at the same site, strongly suggesting that it contributes to the emergence of radiolucent lines. The 3D porous titanium cups are useful in THA, and with improvements focused on micromotion, we anticipate better long-term outcomes.