Factors associated with early loosening of cemented total hip prostheses

Patient data and radiograms from a series of 237 consecutive total hip replacements were evaluated by means of a computer programme in an attempt to study factors correlated with early loosening. We found that the loosening rate was significantly influenced by several factors. The CAD-prosthesis (Computer Assisted Design, Howmedica) was found to be superior to the Charnley-Müller-prosthesis. The viscosity of the cement seemed to be an important factor in that low viscosity was positively correlated to loosening whereas high viscosity showed a negative correlation. Several technical details in the performance of the operations as well as loosening correlated with the surgeon. Males who preoperatively had fairly unrestricted physical activity and high body weight were more prone to early loosening. No correlation was found with the diagnosis, previous hip surgery, age, osteoporosis or cortisone treatment preoperatively. We wish to underline the importance of a thorough technique and suggest that total hip replacement should be performed by specialized surgeons.     

An attempt to treat loosening of the total hip endoprosthesis in Paget disease with Aredia]

A case history of Paget's disease around the hip is presented from 1977 (intraoperative diagnosis) to 1998. Primary Weller THR as well as revision PM replacement in 1990 failed due to loosening. The use of bisodium pamidronian (Aredia, Ciba-Geigy) allowed for loosening arrest (remission of pain, preservation of extremity length, no further radiological changes) for 4 years. Aredia was well tolerated, side effects were transient and did not required therapy.     

Revision total hip arthroplasty with titanium ingrowth prosthesis and bone grafting for failed cemented femoral component loosening

Fifty-seven hips (55 patients) had revision for failed cemented femoral component loosening using titanium ingrowth femoral components and cancellous bone grafting. The patients' average age was 59 years (range, 25-86 years), and the average follow-up period was 2.8 years (range, two to six years). The preoperative hip score averaged 45.5 (range, 10.0-80.7) and the postoperative hip score averaged 82.5 (range, 43.0-100.0). Complications included dislocation (4.0%), infection (4.0%, one recurrence from a previously infected hip and one acute hematogenous infection), and a 4.0% revision rate for loose femoral component. Another patient had a revision for a loose acetabular component. All parameters of hip function (i.e., pain, limp, activities of daily living, use of support, and distance walked) improved with time. Femoral component loosening is classified into four types based on the severity of loosening and instability. In Type I there is minimal endosteal or inner cortical bone loss, i.e., loosening from the cement-metal-bone interface or a broken stem (seven hips). In Type II there is proximal canal enlargement with cortical thinning of 50% or more and sometimes a lateral wall defect with an intact circumferential wall (23 hips). In Type III there is a posteromedial wall defect involving the lesser trochanter (23 hips). In Type IV there is total proximal circumferential bone loss in varying distances below the lesser trochanter (three hips). The Harris hip scores for the four groups were 93.0, 83.0, 80.0, and 78.0, respectively.     

A scoring system to determine radiological loosening in cemented total hip arthroplasty

Summary A radiological scoring system was developed to identify grades of loosening of the components of a cemented hip replacement. In grade 1, there are mild changes, usually of minor significance; in grade 2 moderate changes which need regular observation, and in grade 3 severe changes which indicate impending failure. Three parameters are used for the socket, giving a score of 10 points, and 5 for the stem, with a score of 15 points. This method can be used to provide a comparison between different series with a long-term follow up.

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Résumé Pour quantifier le descellement d'une prothèse totale de hanche, les auteurs proposent une cotation radiologique en trois degrés. Degré 1: altérations mineures sans signification particulière. Degré 2: altérations modérées imposant une surveillance régulière. Degré 3: altérations majeures traduisant l'échec. Trois critères ont été utilisés pour le cotyle: 1) l'étendue circonférentielle du liseré os-ciment, 2) la largueur du liseré, 3) la migration de la cupule. Un score de dix points a été attribué à cette analyse du cotyle (3, 3 et 4 points respectivement pour chacun des trois paramètres). Pour la tige de la prothèse fémorale, cinq critères ont été utilisés: 1) le nombre de localisations du liseré, 2) la largeur de celui-ci, 3) l'enfoncement de la tige de la prothèse dans le ciment, 4) l'enfoncement du fourreau de ciment, 5) la résorption des corticales de la partie proximale du fémur. Un score de quinze points a été attribué à cette analyse de la tige prothétique (3 points pour chaque critère).

     

Reactivation of a tuberculous coxitis due to loosening of a total hip endoprosthesis

A 45-year-old woman who suffered from juvenile tuberculous coxitis at the age of 4 is presented. Her hip joint replacement lasted for 18 years and then needed replacing. Intraoperatively removed caseous soft tissue and an opalescent secretion histologically resembled a tuberculous focus, and bacteriological culture grew a Mycobacterium tuberculosis strain. Four months after the replacement, the patient suffered from a tuberculosis-induced septic loosening of the newly replaced hip joint endoprosthesis. The tuberculosis relapse was probably due to aseptic loosening of the first hip joint endoprosthesis.     

Revision arthroplasty in aseptic loosening of cemented sockets of hip prosthesis]

The aim of this paper was to assess early results of revision arthroplasty in aseptic loosening of cemented sockets. A group of 67 patients (53 females and 14 males) age ranging from 47 to 78 years (average: 72 years) who underwent revision arthroplasty because of aseptic loosening of cemented sockets. Early surgical treatment can spare the patient from a risky procedure and lead to better end results. In cases with massive bone destruction of the pelvis good results can be achieved by using bone grafts and anti-protrusion cages.     

Evaluation of bone metabolism in patients after total hip replacement based on bone turnover markers]

Serum bone markers: N-mid osteocalcin (OCN-Mid) and Cross-Laps were evaluated in 51 patients (15 men and 36 women), age 50-81y. (mean 69) with OA undergoing elective cemented THR. Samples were collected at the day before operation and 3 days, 1, 2, 6 weeks, 3, 6, 12 months after the operation and markers measured by direct chemoluminescency using Modular E-170. Lowest values of both markers were noted at the 3-rd day after operation. Cross-Laps levels rose rapidly reaching highest levels 2 weeks after operation and still were significantly (alpha = 0,05) elevated after 6 weeks. The highest but not statistically significant levels of OCN-Mid were noted after 6 months. After 12 months both markers returned to preoperative values. OCN-Mid/Cross-Laps ratio were lowest after 2 weeks (maximal resorption), then rose over the preoperative value after 3 months, being still significantly elevated after 12 months, indicating that bone formation still occurred. No significant differences were found according to sex, radiolucencies around the endoprosthesis (14 patients) and periarticular ossification (9 patients). Serum bone markers can show the process of bone healing around endoprosthesis, but because of different basic levels of bone metabolism, evaluation of this process can be achieved only with comparison to preoperative values.     

Acute phase response following total hip replacement and in patients with aseptic loosening]

INTRODUCTION: Aseptic loosening is a result of the chronic inflammatory reaction in periprosthetic tissues. Its intensity depends on the implants construction material and reactivity of the host's tissues. The aim of the study was the evaluation of the acute phase proteins in various periods following total hip replacement and comparison between acute phase response observed in patients with well-functioning implants and with aseptic loosening. MATERIAL: The study group consisted of 97 patients following THR due to the hip osteoarthritis. Patients of Group I were evaluated before the surgery and 6 months after primary THR. Group II consisted of patients 3-4 years after primary THR. Group consisted of patients with aseptic loosening. Patients of all groups were divided according to the implant type (cemente/uncemented). METHODS: Concentrations of evaluated acute phase proteins: C-reactive protein (CRP), transferrin (Tf) and alpha-glycoprotein were assessed using immunoelectrophoresis. RESULTS: In vast majority of patients (71-95%) following THR had present w3 variant of AGP which should be negative in physiological conditions. The average concentrations of AGP and AGP-RC were higher in patients following cemented THR. CONCLUSIONS: Implantation of the endoprosthesis raises a chronic inflammatory reaction expressed by changes in the profiles of acute phase proteins. This process is more visible in patients following cemented THR. The profiles of the acute phase proteins in patients with aseptic loosening were not different than those observed in patients with well-functioning implants, what makes them useless as a diagnostic tool for loosening. This lack of differences may be caused by adaptation of the generalised response to long lasting process of aseptic loosening     

Peripheral nerve lesions after total hip endoprosthesis]

AIM OF THE STUDY: Lesions of peripheral nerves are serious complications associated with total hip replacements. Prognostic factors and treatment concepts have not been sufficiently defined. Improvements can occur spontaneously. This study aimed to evaluate risk factors and diagnostic aids, such as the velocity of nerve conduction (VNC) and electromyography (EMG). Furthermore, the effect of prognostic factors as well as conservative and invasive therapeutic measures on the regression of clinical symptoms was examined. METHOD: From 1990 to 1996 1833 patients underwent total hip replacement. 1447 procedures were primary total hip replacements and 386 were revisions. 14 femoral nerve lesions (0.8%), 7 sciatic nerve lesions (0.4%) and 8 peroneal nerve lesions (0.4%) occurred. 19 patients were examined clinically, electromyographically and by means of VNC, 10 patients only clinically. In 5 patients a neurolysis was performed within the first postoperative year. All 29 patients underwent a recall examination in 1997 to evaluate the development of the clinical symptoms and if possible, VNC and EMG were performed. RESULTS: Of the 7 patients with sciatic nerve lesions, two were free from symptoms at the time of recall, two still complained about residual symptoms and two showed no improvement of the lesion. One patient did not appear for follow-up. Of the 8 patients with peroneal nerve lesions, five were free from symptoms at the time of their recent examination, two showed residual symptoms and one patient did not appear. Of the 14 patients with femoral nerve lesions, four had recovered completely, eight showed residual symptoms, one patient did not improve and one patient had died. CONCLUSIONS: Prognostic statements regarding the improvement after nerve lesions are possible only to a limited degree. However, it was found that the motor function tended to recover earlier than sensibility. We could not determine with clinical evaluations why some patients showed an improvement of their lesion while others did not. As well no clear correlation between the EMG and VNC results and the recession of the symptoms could be established.     

Aseptic loosening of BonelocR cemented hip prostheses

Summary. We present a systematic clinical and radiographic study of 147 patients who had total hip replacements from February 1992 to May 1993. Boneloc ^R cement was used in 108, and Palacos^R cement with gentamicin in 39 patients who had an increased risk of infection. At follow-up after 24 to 39 months, 26 cases with Boneloc^R cement had failed; there were no clinical failures in the Palacos^R group.

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Résumé. Nous présentons ici les résultats d’un suivi systématique post-opératoire sur deux ans, à la fois clinique et radiologique, réalisé sur un groupe de 147 patients qui ont eu entre février 1992 et mai 1993 une prothése totale de la hanche. Pour 108 prothéses ordinaires on a utilisé le ciment Boneloc ^? et pour 39 qui présentaient un risque accru d’infection on a utilisé le ciment Palacos^? avec Gentamicine. A la fin de la période d’observation (de 24 à 39 mois) on a constaté 26 cas d’échec dans les prothéses réalisées avec Boneloc?, aucun dans celles réalisées avec Palacos? avec Gentamicine.

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Accepted: 25 September 1996     

A histopathologic study of late aseptic loosening of cemented total hip prostheses.

Eighteen patients being treated for revision total hip arthroplasty for aseptic loosening an average of 9.5 years after primary cemented hip arthroplasty were studied. The patients were found to have been symptomatic an average of one year before revision. Review of the roentgenograms at the time of revision revealed that most patients had moderate to severe loosening of the prostheses by Charnley's criteria. These findings were confirmed at surgery. Study of the tissue surrounding the prostheses suggests that the prominent particles were methylmethacrylate "pearls" caused by cement fragmentation. These particles were surrounded by histiocytes that were actively synthesizing and releasing protein. Cement fragmentation and not polyethylene wear may be the major cause of late aseptic loosening of cemented hip prostheses.     

Complications after total endoprosthesis of the hip joint]

On the grounds of the literature data and his own findings the author analyzes the complications occurring in total endoprothetics of the hip joint. The following complications were observed: formation of para-articular ossifications (7), wound infection (1), dislocation of the endoprothesis socket from the acetabulum (1), fracture of the femur (2), laxity of the prothesis pedicle (1), thrombophlebitis (2), postoperative bleeding (1). Various aspects of this problem are covered in the article.     

Biochemical markers of bone turnover in aseptic loosening in hip arthroplasty

The aim of this study was to determine the diagnostic value of systemic biochemical markers of bone turnover in aseptic loosening in hip arthroplasty, namely the urine levels of three bone resorption peptides – crosslinked n-telopeptides (NTX), c-telopeptides (CTX I) and deoxypyridinoline (DPD). We compared 52 patients with surgically proven component loosening with 52 patients without clinical or radiological signs of endoprosthetic loosening and 52 healthy individuals. All three markers were measured using commercially available enzyme-linked immunoassays. We found significantly increased levels of DPD in the loosening group (p < 0.05), but there was no significant difference between the loosening group and the two reference groups for the other two markers tested. Our data suggest that DPD can be used as an additional tool in the diagnosis of aseptic loosening in hip arthroplasty but CTX I and NTX have no predictive value in this context.

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Résumé  Le but de cette étude est de déterminer la valeur diagnostic de marqueurs bio-chimiques dans le descellement aseptique des prothèses totales de hanche, en mesurant un certain nombre peptides issus de la résorption osseuse (crosslinked n-telpeptides [NTX], c-telpepetides [CTX I] et deoxypyridinoline [DPD]. nous avons comparé les paramètres de 52 individus présentant un descellement aseptique à 52 individus sains. Tous les paramètres ont été mesurés par la méthode ELISA. nous avons trouvé une augmentation significative des DPD dans le groupe prothèses descellées (p < 0.05). Il n’y a pas de différence significative entre les deux groupes pour les autres marqueurs. nous suggérons que la DPD peut être utilisée comme un marqueur additionnel du diagnostic des descellements aseptiques des prothèses totales de hanche par contre, il n’y a pas de valeurs prédictives pour les marqueurs CTX1 et NTX.

     

Factors associated with heterotopic bone formation in cemented total hip prostheses

A series of 237 total hip replacements were analysed by means of a computer program. High body weight and postoperative fever, as well as several indications of a technically demanding operation, occurred significantly more often in the group of patients which developed paraarticular ossification postoperatively. The results point to a causal relation between tissue trauma and heterotopic bone formation. We wish to underline the importance of a gentle handling of tissues in the performance of a total hip replacement if the rate of ectopic bone is to be reduced to a minimum.     

An analysis of selected risk factors of aseptic loosening of hip endoprosthesis]

An analysis of selected risk factors of aseptic loosening of hip endoprosthesis has been attempted on the ground of retrospective evaluation of 57 hips in 54 patients (41 females, 13 males) who underwent revision of the hip replacement. Age of the patients at primary surgery ranged from 18 to 73 years (mean 55.6 years). Follow-up ranged from 8 to 212 months (mean 83 months). Originally, in 45 cases cemented hip replacement was done and in 12 cementless endoprosthesis was implanted. In 34 cases both components were replaced, in 14 cases acetabular component, in 9 cases stem only and in 1 case the endoprosthesis was removed. Clinical evaluation was done according to Merle-d'Aubignea criteria, radiologic assessment was done according to DeLee and Charnley classification and the one of Gruen. Within 10 years after primary surgery all cementless hips were revised (all Parhofer-M?nch type within 5 years). Among Weller cemented replacements both components were replaced in 18 cases, acetabulum in 8, the stem in 5 and 1 endoprosthesis was removed. McKee-Farrar implants were replaced completely in all but 2 cases. Most of revisions among cemented hip replacements took place 10 years after primary operation. Angular migration of the acetabular component was found in 40 cases; in 8 cases no migration was observed. Forty-three hips with loosened stem have been analyzed: to small size of the stem was found in 6 cases, varus deviation was found in 14 cases and valgus deviation in 6. Special attention has been paid to the technical errors that are essential for long-term result of hip replacement.     

Periprosthetic bone loss after cemented total hip arthroplasty

In this prospective 5-year study, we determined the periprosthetic bone loss after cemented total hip arthroplasty (THA) in 15 patients using dual energy X-ray absorptiometry (DXA). A reduction in the periprosthetic bone mineral density (BMD) of 5-18% occurred in all Gruen regions, or regions of interest (ROI), during the first 3 months after THA. The bone loss continued up to 6 months in almost all ROIs. From 1 to 5 years, we found only minor changes in BMD in periprosthetic bone. After the follow-up, the mean greatest bone loss (26%) was seen in the femoral calcar area. The reduction in mean BMD was 5% in men, and 16% in women. The lower the preoperative BMD, the higher was the postoperative bone loss. We found that after the phase of acute bone loss, further loss was minimal, reflecting merely the normal ageing of bone after uncomplicated THA.