Sectioned femoral components retrieved from failed hip resurfacing arthroplasties show resorption of proximal femoral bone or formation of a fibrous membrane at the bone cement interface. We hypothesize that both scenarios create a functional discontinuity zone (FDZ), which exacerbates off-loading the proximal bone and promoting resorption. Our study uses Finite Element (FE) modeling to examine the effects of the presence of an FDZ on bone remodeling following hip resurfacing arthroplasty. A radiographic analysis of the proximal femur following hip resurfacing was conducted in order to draw a comparison to clinical findings

The hip resurfacing FE models were oriented in variable angles and a low-modulus (2 MPa) FDZ was simulated beneath the implant head. Femoral joint and muscle loads were applied. Interface stress was compared for the normal and simulated FDZ resurfaced femurs. Bone remodeling stimuli was determined using changes in strain energy. A range of implant orientations were compared to study the affect on bone remodelling. A retrospective radiological analysis was undertaken on 100 hips with a minimum of 5 years follow up. Measurements of femoral neck diameter at 2 and 5 years were undertaken.

The presence of the simulated FDZ in the FE analysis resulted in increased proximal-medial bone resorption and slightly greater bone formation surrounding the stem. Correspondingly, device-bone interface stresses were found to decrease proximally under the loading platform and increase at the stem, particularly adjacent to the stem-head junction. Valgus orientation showed increased resorption underneath the shell. Varus orientation showed increased bone formation at the stem tip. The radiological analysis identified 2 distinct patterns of neck thinning. Slow thinners (76%) had less than 5% reduction in neck diameter at 2 years and less than 10% at 5 years. Rapid thinner (24%) had more than 5% thinning at 2 years and more than 10% at 5 years. The mean reduction in neck diameter was signifanctly different between the two groups at the two time points (p< 0.01). The rapid group had a higher proportion of valgus aligned implants (88%) and a significant decrease in reconstructed offset (p=0.0023).

The FE results support the hypothesis that the presence of a FDZ decreases load transfer to the proximal bone, resulting in increased medial stress shielding and resorption. These results are consistent with the radiological findings. In order to better understand the cause of resurfacing implant failures, additional retrieval studies are necessary.

We report a consecutive series of 16 revision total knee arthroplasties using the Total Condylar III system in 14 patients with inflammatory arthritis which were performed between 1994 and 2000. There were 11 women and three men with a mean age of 59 years (36 to 78). The patients were followed up for 74 months (44 to 122).

The mean pre-operative Knee Society score of 37 points (0 to 77) improved to 88 (61 to 100) at follow-up (t-test, p < 0.001) indicating very good overall results. The mean range of flexion improved from 62° (0° to 120°) to 98° (0° to 145°) (t-test, p < 0.05) allowing the patients to stand from a sitting position. The mean Knee Society pain score improved from 22 (10 to 45) to 44 (20 to 50) (t-test, p < 0.05). No knee had definite loosening, although five showed asymptomatic radiolucent lines. Complications were seen in three cases, comprising patellar pain, patellar fracture and infection.

These results suggest that the Total Condylar III system can be used successfully in revision total knee arthroplasty in inflammatory arthritis.