Institute of Bone and Joint Surgery

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Hybrid stem fixation in revision total knee arthroplasty (TKA).

Surg Technol Int. 2004;12:214-20

Authors: Chon JG, Lombardi AV, Berend KR

The purpose of this study was to retrospectively compare the clinical and radiographic results of the Maxim Posterior Stabilized Constrained (PCS) (Biomet Orthopaedics, Inc., Warsaw, IN, USA) knee system using the hybrid fixation versus the fully cemented fixation of stems of the same length. The cohort in this study included 115 knees in 104 patients, with a minimum 2-year follow up postoperatively. All patients were evaluated with the Knee Society clinical rating score and roentgenographic evaluation. Of the 115 revision total knee arthroplasty (TKA) cases, the hybrid-fixation technique was used on both the femoral and tibial components of 75 (Group I-hybrid femur, hybrid tibia); the fully cemented technique was used on both components of 24 (Group II-cemented femur, cemented tibia); the hybrid-fixation technique was used on the femoral component and full cement on the tibial component of 13 (Group III-hybrid femur, cemented tibia); the femoral component was fully cemented, and tibial component had the hybrid-fixation technique used on 3 (Group IV-cemented femur, hybrid tibia). The average follow up was 44 (range: 24-126) months. At the most recent evaluation, the Knee Society score improved from an average preoperative value of 51.7 to 76.7, the pain score improved from 14.0 to 33.3, and the functional score improved from 40.5 to 47.0. The average stem-to-canal fill ratio was 80% in the femur and 85% in the tibia (p<0.05). Stem-to-canal fill ratio did not appear to influence clinical outcome. Radiolucent lines less than 2 cm were observed more frequently in the hybrid-cemented stems (89%) than the fully cemented stems (58%) at an average 8-year follow up postoperatively (p<0.05). A lower, but not statistically significant, failure rate was observed in the hybrid group in comparison with the cemented group.

PMID: 15455329 [PubMed - indexed for MEDLINE]

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The effects of early rollback in total knee arthroplasty on stair stepping.

J Arthroplasty. 2002 Sep;17(6):723-30

Authors: Draganich LF, Piotrowski GA, Martell J, Pottenger LA

We investigated the effects of early compared with late (ie, in flexion) rollback on quadriceps efficiency during stair stepping. We studied 10 patients with the IB II (Zimmer, Warsaw, IN) total knee arthroplasty (TKA), designed to enforce rollback at 73 degrees of knee flexion; 9 patients with the Maxim PS (Biomet, Inc, Warsaw, IN) TKA, designed to enforce rollback between 20 degrees and 30 degrees of flexion; 8 patients with the TRAC PS (Biomet, Inc, Warsaw, IN) mobile bearing TKA, designed to enforce rollback at 8 degrees of flexion; and 21 healthy control subjects during stair stepping. We measured the external knee flexion moments, which must be largely balanced by quadriceps force acting over the quadriceps lever arm, as indicators of quadriceps efficiency. The peak external knee flexion moment generated by the IB II patients during stair stepping was 12.4% and occurred at 65 degrees of knee flexion. This moment was significantly less (P=.006) than the peak moment, 17.6%, generated by the healthy controls. Knee flexion for the IB II patients did not reach 73 degrees, and rollback was not enforced until after the peak moment (ie, maximum demands on the quadriceps) had been attained. The peak moments generated by the TRAC PS patients, 14.2%, and Maxim patients, 14.8%, were not significantly different from that of the controls. These results suggest that early as compared with late rollback returns more normal quadriceps efficiency during stair stepping.

PMID: 12216026 [PubMed - indexed for MEDLINE]

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An algorithm for the posterior cruciate ligament in total knee arthroplasty.

Clin Orthop Relat Res. 2001 Nov;(392):75-87

Authors: Lombardi AV, Mallory TH, Fada RA, Hartman JF, Capps SG, Kefauver CA, Adams JB

The fate of the posterior cruciate ligament in primary total knee arthroplasty is controversial. An algorithmic approach is presented that is based on pathologic criteria for evaluating and treating patients with primary total knee arthroplasty that will aid in the posterior cruciate ligament decision-making process, producing more predictable procedures and outcomes. A consecutive series of the first 120 patients (171 knees) who had primary posterior cruciate-retaining arthroplasty and the first 120 patients (180 knees) who had primary posterior-stabilized arthroplasty with a minimum 5-year followup in which the Maxim Complete Total Knee System and the algorithmic approach were used were compared. No statistically significant differences in outcome between the groups were observed. Among the patients who had posterior cruciate-retaining arthroplasty, no revisions attributable to aseptic loosening have been reported at an average followup of 6.39 years. The average followup Knee Society total score was 162.16 points, with 91 (54.8%) knees having excellent outcome ratings. No revisions attributable to aseptic loosening have been reported among the patients who had posterior-stabilized arthroplasty at an average followup of 5.98 years. The average followup Knee Society total score was 158.05 points, with excellent outcome ratings reported in 96 (54.9%) knees. The use of a standardized algorithm has streamlined the treatment of patients having primary total knee arthroplasty, consistently providing excellent clinical results when either retaining or sacrificing the posterior cruciate ligament.

PMID: 11716428 [PubMed - indexed for MEDLINE]

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Freeman-Samuelson total arthroplasty of the knee.

Clin Orthop Relat Res. 1985 Jan-Feb;(192):46-58

Authors: Freeman MA, Samuelson KM, Bertin KC

Experience with cementless fixation over the last six years indicates that the technique offers greater opportunities for bone conservation. Thus, when cement is used, and especially if it is forced into the skeleton under pressure, the amount of bone incorporated into the implant is considerable. Conversely, if no cement is used, grafting techniques to fill defects are becoming increasingly routine, so that today no bone may be removed from the replaced knee or hip--all fragments that are excised are repositioned as grafts in defects. Thus, cementless fixation meets the fundamental orthopedic maxim of the conservation of bone stock. Given that an implant can be fixed with satisfactory clinical results without cement and without bone ingrowth, it becomes difficult to demonstrate a clinical advantage for the latter. Nevertheless, bone ingrowth is possible both experimentally and (with less confidence) in man. Thus, it is clearly a technique that should be evaluated. However, it is not, in the senior author's view, a technique that should as yet be generally used. Hopefully, investigations of this problem will take place in a restrained scientific way rather than by the current method, which is in response to the dictates of fashion and commerce.

PMID: 3967440 [PubMed - indexed for MEDLINE]

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Acute Liner Disassociation of a Pinnacle Acetabular Component.

J Arthroplasty. 2008 Jun 12;

Authors: Mesko JW

A primary total hip arthroplasty using a cementless Pinnacle cup and neutral Marathon polyethylene liner mated via a 32-mm cobalt chrome head to a Summit pore coated stem (Depuy, Warsaw, IN). At 23 months postoperative an acute disassociation occurred. This was resolved with a liner exchange to a 36-mm metal liner with a 36-mm metal head. The retrieved polyethylene liner was noted to have 3 of the 6 peripheral locking tabs sheared off.

PMID: 18555645 [PubMed - as supplied by publisher]

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Acetabular component deformation with press-fit fixation.

J Arthroplasty. 2006 Sep;21(6 Suppl 2):72-7

Authors: Squire M, Griffin WL, Mason JB, Peindl RD, Odum S

Acetabular component deformation secondary to forces encountered during insertion is a potential consequence of the press-fit technique. This study characterized the stiffness of Pinnacle 100 cups (DePuy, Warsaw, Ind) via mechanical testing and used this information with intraoperative measurements of cup deformation to calculate the in vivo forces acting on cups inserted during hip arthroplasty in 21 patients. We found that 90.5% of cups had measurable compression deformity, averaging 0.16 +/- 0.16 mm. The corresponding forces acting on these cups averaged 414 +/- 421 N. For hard-on-hard bearing surfaces, such in vivo deformation of acetabular shells may result in negative clinical consequences such as equatorial loading with increased wear and potential seizing of components, chipping of ceramic inserts, or locking mechanism damage.

PMID: 16950065 [PubMed - indexed for MEDLINE]

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Long-term porous-coated cup survivorship using spikes, screws, and press-fitting for initial fixation.

J Arthroplasty. 2004 Oct;19(7 Suppl 2):54-60

Authors: Engh CA, Hopper RH, Engh CA

This study examined the long-term outcome of a single institution's experience with 4,289 primary total hip arthroplasties using hemispheric porous-coated cups. Initial fixation was achieved with spikes (255 AML TriSpike cups), by press-fitting with rim screws (427 Arthropor cups) or by press-fitting the component (83 Harris-Galante, 391 ACS Triloc+, 2,537 Duraloc, and 596 Pinnacle cups). Among 203 revised hips, only 18 cups were found to be loose at the time of revision. Using revision for any reason as an end point, 15-year survivorship was 82.9% +/- 5.6% (95% confidence interval) for spiked components, 71.6% +/- 8.5% for press-fit cups with adjunctive rim screws, and 72.0% +/- 12.6% for press-fit components (P<.001, log rank). Using revision for aseptic loosening as an end point, 15-year survivorship was 94.7% +/- 3.4% for spiked cups, 98.4% +/- 1.9% for press-fit cups with screws and 100% +/- 0.1% for press-fit cups. Despite an increasing incidence of polyethylene wear-related revisions, porous-coated acetabular components have demonstrated excellent long-term fixation.

PMID: 15457419 [PubMed - indexed for MEDLINE]

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Hydroxyapatite-coated RM cup in primary hip arthroplasty.

Int Orthop. 2003;27(2):90-3

Authors: Ali MS, Kumar A

We reviewed 113 patients with 127 primary total hip arthroplasties using a hydroxyapatite-coated RM (Robert Mathys) cup. Average patient age was 61 (30-70) years and mean follow-up was 9.4 (6-13) years. Four patients were lost to follow-up and nine patients died of unrelated causes during the course of the study. Three acetabular components were revised; two cups were radiologically loose and one was revised for marginal erosion. No radiolucency was noted in any of the three zones in the remaining cups. There were no cases of cup migration or dislocation. The life table method predicted a 10-year survival rate of 97.9% with revision of the acetabular component for any cause as the endpoint.

PMID: 12700931 [PubMed - indexed for MEDLINE]

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Cementless coated and noncoated Mathys acetabular cups: radiographic and histologic evaluation.

Orthopedics. 1999 Jan;22(1):39-41

Authors: Roffman M, Kligman M

This study evaluated 185 cementless Mathys coated and uncoated acetabular cups inserted for total hip replacement since September 1984. All of the cups were high-density polyethylene. Sixty were uncoated (group A), 96 were coated with hydroxyapatite (group B), and 29 were coated with titanium (group C). Cup survival was assessed clinically, histologically, and radiographically, and a computer-assisted EBRA method was used to evaluate cup migration. After a mean follow-up of 8 years, five cups in group A that had previously shown migration were revised as a result of aseptic loosening, while no loosening of hip sockets occurred in groups B and C. These results suggest that Mathys cups should be used only if coated with hydroxyapatite or titanium. Furthermore, the histologic evaluation in four cups from groups B and C revealed normal bone formation without inflammation or fibrotic tissue around the cups, promising long-term survival.

PMID: 9925196 [PubMed - indexed for MEDLINE]

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[Results of cement-free implanted, Robert Mathys isoelastic acetabular cup]

Unfallchirurgie. 1998 Apr;24(2):49-54

Authors: Olivier LC, Neudeck F, Hippel C, Kaiser S, Schmit-Neuerburg KP

In 163 patients--125 (76.7%) female, 38 (23.3%) male--172 cementfree isoelastic acetabular cups were implanted. The average patient age was 72.6 years (range: 16 to 96 years). Sixty-seven (41.1%) patients with 72 (41.9%) cups could be followed-up for an average of 6.0 years (range: 2.0 to 12.2 years) after the procedure. Using the Harris-hip-score we found 49 (68.1%) "very good" to "fair" results. In 23 (31.9%) hips scoring had to be classified as "bad". The rate of cup-loosenings in the collective was low at 3.5% (6/172), probably due to the reduced physical activity of our comparatively older patients. Because after the 8th year symptomatic loosening must be routinely expected, the procedure is not indicated for younger patients. In older patients with femoral neck fractures the cementfree isoelastic acetabular cup has proven itself effective in our experience.

PMID: 9606850 [PubMed - indexed for MEDLINE]

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Isoelastic total hip replacement: clinical evaluation of prosthetic isoelasticity.

J Formos Med Assoc. 1994 Jun;93(6):497-502

Authors: Au MK

By using the lower modulus material, polyacetal, ie, prosthesis made by R. Mathys', isoelastic hip prosthesis is claimed to reduce stress shielding effects and secure long-term, stable fixation of prostheses. In Tri-Service General Hospital from October 1985 to October 1989, 23 patients (25 hips) were treated using this prosthesis. Twenty patients (22 hips) were followed for clinical and radiographic evaluation for an average of 44.8 months (29-58 months). In clinical evaluation, the overall results were comparable to other cemented or cementless hip prostheses. The Merle d'Aubigne and Postel score for pain, motion and walking were improved from 1.6, 3.9, and 2.4 to 4.6, 4.3, and 4.9, respectively. The acetabular cup showed more favorable radiographic evaluation with a total mean score by combined Charnley and Engh's system of 7.9. It was not optimal on the femoral side and it showed that 20 of the femoral stems were stable fibrous fixations with a mean score of 15.8. Early complications included two dislocations, two significant femoral shaft fractures, and five medial neck cracks at surgery. The late complications included one loosening, one screw breakage, and one screw back out. The isoelastic hip always gained an inferior score in clinical evaluation from the "self comparison" in three patients with one side isoelastic hip and the other side different cemented or cementless prosthesis. There is no obvious benefit in radiographic evaluation, both in elimination of stress shielding and enhancement of fixation stability. As a result, the theoretical advantages of the isoelasticity concept are difficult to justify in our clinical practice.

PMID: 7858438 [PubMed - indexed for MEDLINE]

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Nine-year follow-up of the Mathys uncemented acetabular cup: a radiological evaluation.

Bull Hosp Jt Dis. 1993;53(1):51-3

Authors: Roffman M, Juhn A

Radiological studies were performed in patients who underwent hip arthroplasty using the Mathys acetabular cup. The development of radiolucent and sclerotic lines, subsidence, changes in position of the implants, changes in bone density, and the significance of these findings are discussed.

PMID: 8374492 [PubMed - indexed for MEDLINE]

Related Articles

Special instruments and prosthetic cups for the removal and replacement of a total hip prosthesis.

Arch Orthop Trauma Surg. 1979 Mar 19;93(3):191-9

Authors: Stühmer G, Weber BG, Mathys R

In the course of replacing more than 500 total hip prostheses over a period of five years the authors have developed a new set of instruments for the removal of the defective prosthesis and cement and for improved anchorage of the new prosthetic cup. The set comprises: 1. A set of special chisels and an axially guided drill for removal of the old cement from the femur. These instruments greatly simplify the latter procedure. 2. A new type of prosthetic cup with a weight-bearing collar. This cup is used for cases in which the amount or structure of the acetabular bone is such that it will not support a conventional cup. 3. A new type of drill with a flexible drive and easily exchangeable drill bits for cutting anchorage holes in otherwise inaccessible parts of the acetabular bone.

PMID: 464755 [PubMed - indexed for MEDLINE]

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Fracture of the hydroxyapatite-ceramic-coated JRI-Furlong femoral component: body mass index and implications for selection of the implant.

J Bone Joint Surg Br. 2007 Jun;89(6):742-5

Authors: Harvie P, Haroon M, Henderson N, El-Guindi M

We describe three cases of fracture of the titanium JRI-Furlong hydroxyapatite-ceramic (HAC)-coated femoral component. We have examined previous case reports of failure of this stem and conclude that fracture may occur in two places, namely at the neck-shoulder junction and at the conical-distal cylindrical junction. These breakages are the result of fatigue in a metallurgically-proven normal femoral component. All the cases of failure of the femoral component have occurred in patients with a body mass index of more than 25 in whom a small component, either size 9 or 10, had been used. In patients with a body mass index above normal size 9 components should be avoided and the femoral canal should be reamed sufficiently to accept a large femoral component to ensure that there is adequate metaphyseal fixation.

PMID: 17613497 [PubMed - indexed for MEDLINE]

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Long-term follow-up (11 years plus) results of JRI (Furlong) total hip arthroplasty in young patients: cause for concern regarding acetabular cup?

Int Orthop. 2006 Oct;30(5):375-80

Authors: Sharma DK, Brooks S

We describe the clinical and radiological long-term outcomes of 77 primary total hip replacements in 69 patients using the fully hydroxyapatite-coated JRI (Furlong) total hip replacement. The total cases followed up were 77 hips, performed at a mean duration of 11 years and 2 months. Twelve hips could not be followed up for various reasons, which are discussed in the results section. The mean Harris hip score was 89. Seventeen acetabular cups were revised for aseptic loosening. Only one femoral stem was revised, for fracture. By Engh's criteria there were a further two unstable cups with no symptoms, and all femoral stems were stable. Kaplan-Meier survivorship analysis revealed a survival of 98.8% for the femoral stem, 78.7% for the acetabular cup, and a combined survival of 77.8% for both components. Our findings suggest that the JRI (Furlong) hip gives a durable femoral stem implant fixation, whereas the prosthesis-bone interface achieved with the acetabular component is questionable.

PMID: 16761147 [PubMed - indexed for MEDLINE]

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Revision of cemented hip arthroplasty using a hydroxyapatite-ceramic-coated femoral component.

J Bone Joint Surg Br. 2005 Aug;87(8):1061-7

Authors: Raman R, Kamath RP, Parikh A, Angus PD

We report the clinical and radiological outcome of 86 revisions of cemented hip arthroplasties using JRI-Furlong hydroxyapatite-ceramic-coated acetabular and femoral components. The acetabular component was revised in 62 hips and the femoral component in all hips. The mean follow-up was 12.6 years and no patient was lost to follow-up.The mean age of the patients was 71.2 years. The mean Harris hip and Oxford scores were 82 (59 to 96) and 23.4 (14 to 40), respectively. The mean Charnley modification of the Merle d'Aubigné and Postel score was 5 (3 to 6) for pain, 4.9 (3 to 6) for movement and 4.4 (3 to 6) for mobility. Migration of the acetabular component was seen in two hips and the mean acetabular inclination was 42.6 degrees. The mean linear polyethylene wear was 0.05 mm/year. The mean subsidence of the femoral component was 1.9 mm and stress shielding was seen in 23 (28%) with bony ingrowth in 76 (94%). Heterotopic ossification was seen in 12 hips (15%). There were three re-revisions, two for deep sepsis and one for recurrent dislocation and there were no re-revisions for aseptic loosening. The mean EuroQol EQ-5D description scores and health thermometer scores were 0.69 (0.51 to 0.89) and 79 (54 to 95), respectively. With an end-point of definite or probable loosening, the probability of survival at 12 years was 93.9% and 95.6% for the acetabular and femoral components, respectively. Overall survival at 12 years, with removal or further revision of either component for any reason as the end-point, was 92.3%.Our study supports the continued use of this arthroplasty and documents the durability of hydroxyapatite-ceramic-coated components.

PMID: 16049239 [PubMed - indexed for MEDLINE]

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Hydroxyapatite-ceramic-coated femoral stems in revision hip surgery.

J Bone Joint Surg Br. 2005 Aug;87(8):1055-60

Authors: Trikha SP, Singh S, Raynham OW, Lewis JC, Mitchell PA, Edge AJ

We describe the clinical and radiological results of 120 consecutive revision hip replacements in 107 patients, using the JRI Furlong hydroxyapatite-ceramic-coated femoral component. The mean age of the patients at operation was 71 years (36 to 92) and the mean length of follow-up 8.0 years (5.0 to 12.4). We included patients on whom previous revision hip surgery had taken place. The patients were independently reviewed and scored using the Harris hip score, the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and the Charnley modification of the Merle d'Aubigné and Postel score. Radiographs were assessed by three reviewers for the formation of new bone, osteolysis, osseointegration and radiolucent lines in each Gruen zone.The mean Harris hip score was 85.8 (42 to 100) at the latest post-operative review. The mean WOMAC and Merle d'Aubigné and Postel scores were 34.5 and 14.8, respectively. The mean visual analogue score for pain (possible range 0 to 10) was 1.2 overall, but 0.5 specifically for mid-thigh pain. There were no revisions of the femoral component for aseptic loosening. There were four re-revisions, three for infection and one for recurrent dislocation. Radiological review of all the femoral components, including the four re-revisions showed stable bony ingrowth and no new radiolucent lines in any zone. Using revision or impending revision for aseptic loosening as an end-point, the cumulative survival of the femoral component at ten years was 100% (95% confidence interval 94 to 100). We present excellent medium- to long-term clinical, radiological and survivorship results with the fully hydroxyapatite-ceramic-coated femoral component in revision hip surgery.

PMID: 16049238 [PubMed - indexed for MEDLINE]

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Results of a hydroxyapatite-coated (Furlong) total hip replacement: a 13- to 15-year follow-up.

J Bone Joint Surg Br. 2005 Aug;87(8):1050-4

Authors: Shetty AA, Slack R, Tindall A, James KD, Rand C

We describe the survival of 134 consecutive JRI Furlong hydroxyapatite-coated uncemented total hip replacements. The mean follow-up was for 14.2 years (13 to 15).Patients were assessed clinically, using the Merle d'Aubigné and Postel score. Radiographs were evaluated using Gruen zones for the stem and DeLee and Charnley zones for the cup. Signs of subsidence, radiolucent lines, endosteal bone formation (spot welds) and pedestal formation were used to assess fixation and stability of the stem according to Engh's criteria. Cup angle, migration and radiolucency were used to assess loosening of the cup. The criteria for failure were revision, or impending revision because of pain or loosening. Survival analysis was performed using a life table and the Kaplan-Meier curve.The mean total Merle d'Aubigné and Postel score was 7.4 pre-operatively and 15.9 at follow-up. During the study period 22 patients died and six were lost to follow-up. None of the cups was revised. One stem was revised for a periprosthetic fracture following a fall but none was revised for loosening, giving a 99% survival at 13 years. Our findings suggest that the long-term results of these hydroxyapatite-coated prostheses are more than satisfactory.

PMID: 16049237 [PubMed - indexed for MEDLINE]

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The hydroxyapatite-coated JRI-furlong hip. Outcome in patients under the age of 55 years.

J Bone Joint Surg Br. 2005 Jan;87(1):12-5

Authors: Robertson A, Lavalette D, Morgan S, Angus PD

We present the clinical and radiographic outcome of 68 consecutive primary total hip replacements performed in 54 patients under the age of 55 years using a hydroxyapatite-coated femoral component and threaded cup with a modular ceramic head (JRI-Furlong). We reviewed 62 (91%) hips at a median follow-up of 8.8 years (5 to 13.8) after implantation; six (9%) were lost to follow-up. At review there had been four (6%) revisions but only one for aseptic loosening (acetabulum). Radiographic review of the remaining hips did not identify any evidence of femoral or acetabular loosening. The median Harris and Merle d'Aubigné and Postel hip scores were 95.9 (42.7 to 100) and 17 (3 to 18) respectively. The JRI-Furlong hip gives promising functional and radiographic results in young patients in the medium term.

PMID: 15686230 [PubMed - indexed for MEDLINE]

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Hydroxyapatite ceramic-coated femoral stems in young patients. A prospective ten-year study.

J Bone Joint Surg Br. 2004 Nov;86(8):1118-23

Authors: Singh S, Trikha SP, Edge AJ

We describe the clinical and radiological results of 38 total hip replacements (THR) using the JRI Furlong hydroxyapatite-ceramic (HAC)-coated femoral component in patients younger than 50 years. The mean age at the time of operation was 42 years (22 to 49) and the mean length of follow-up was ten years (63 to 170 months). All patients receiving a Furlong HAC THR were entered into the study regardless of the primary pathology including patients who had undergone previous hip surgery. The mean Harris hip score improved from 44 before operation to 92 at the last post-operative review. After 12 years the cumulative surivival for the stem was 100% (95% confidence interval 89 to 100). No femoral component was revised. Our results show that the Furlong HAC implant gives excellent long-term results in young patients with high demands.

PMID: 15568523 [PubMed - indexed for MEDLINE]