We have analysed from the Finnish Arthroplasty Register the long-term survivorship of the 12 most commonly-used cemented implants between 1980 and 2005 in patients aged 55 years or older with osteoarthritis.

Only two designs of femoral component, the Exeter Universal and the Müller Straight femoral component had a survivorship of over 95% at ten years with revision for aseptic loosening as the endpoint. At 15 years of the femoral and acetabular component combinations, only the Exeter Universal/Exeter All-poly implant had a survival rate of over 90% with revision for aseptic loosening as the endpoint. In the subgroup of patients aged between 55 and 64 years, survivorship overall was less than 90% at ten years.

The variation in the long-term rates of survival of different cemented hip implants was considerable in patients aged 55 years or older. In those aged between 55 and 64 years, none of the cemented prostheses studied yielded excellent long-term survival rates (≥ 90% at 15 years).

The popularity of cementless total hip replacement (THR) has surpassed cemented THR in England and Wales. This retrospective cohort study records survival time to revision following primary cementless THR with the most common combination (accounting for almost a third of all cementless THRs), and explores risk factors independently associated with failure, using data from the National Joint Registry for England and Wales. Patients with osteoarthritis who had a DePuy Corail/Pinnacle THR implanted between the establishment of the registry in 2003 and 31 December 2010 were included within analyses. There were 35 386 procedures. Cox proportional hazard models were used to analyse the extent to which the risk of revision was related to patient, surgeon and implant covariates. The overall rate of revision at five years was 2.4% (99% confidence interval 2.02 to 2.79). In the final adjusted model, we found that the risk of revision was significantly higher in patients receiving metal-on-metal (MoM: hazard ratio (HR) 1.93, p < 0.001) and ceramic-on-ceramic bearings (CoC: HR 1.55, p = 0.003) compared with the best performing bearing (metal-on-polyethylene). The risk of revision was also greater for smaller femoral stems (sizes 8 to 10: HR 1.82, p < 0.001) compared with mid-range sizes. In a secondary analysis of only patients where body mass index (BMI) data were available (n = 17 166), BMI ≥ 30 kg/m² significantly increased the risk of revision (HR 1.55, p = 0.002). The influence of the bearing on the risk of revision remained significant (MoM: HR 2.19, p < 0.001; CoC: HR 2.09, p = 0.001). The risk of revision was independent of age, gender, head size and offset, shell, liner and stem type, and surgeon characteristics.

We found significant differences in failure between bearing surfaces and femoral stem size after adjustment for a range of covariates in a large cohort of single-brand cementless THRs. In this study of procedures performed since 2003, hard bearings had significantly higher rates of revision, but we found no evidence that head size had an effect. Patient characteristics, such as BMI and American Society of Anesthesiologists grade, also influence the survival of cementless components.

Cite this article: Bone Joint J 2013;95-B:747–57.

Femoral stem version has a major influence on impingement and early post-operative stability after total hip arthroplasty (THA).

The main objective of this study was to evaluate the validity of a novel radiological method for measuring stem version. Anteroposterior (AP) radiographs and three-dimensional CT scans were obtained for 115 patients (female/male 63/72, mean age 62.5 years (50 to 75)) who had undergone minimally invasive, cementless THA. Stem version was calculated from the AP hip radiograph by rotation-based change in the projected prosthetic neck–shaft (NSA*) angle using the mathematical formula ST = arcos [tan (NSA*) / tan (135)]. We used two independent observers who repeated the analysis after a six-week interval. Radiological measurements were compared with 3D-CT measurements by an independent, blinded external institute.

We found a mean difference of 1.2° (sd 6.2) between radiological and 3D-CT measurements of stem version. The correlation between the mean radiological and 3D-CT stem torsion was r = 0.88 (p < 0.001). The intra- (intraclass correlation coefficient ≥ 0.94) and inter-observer agreement (mean concordance correlation coefficient = 0.87) for the radiological measurements were excellent.

We found that femoral tilt was associated with the mean radiological measurement error (r = 0.22, p = 0.02).

The projected neck–shaft angle is a reliable method for measuring stem version on AP radiographs of the hip after a THA. However, a highly standardised radiological technique is required for its precise measurement.

Cite this article: Bone Joint J 2015; 97-B:306–11.

The results of 140 total hip revision procedures for "non-septic" loosening, dislocation, and fracture of the femoral stem or shaft have been personally reviewed and rated by the Harris method. The minimum follow-up period was six months: thirty-three (24 per cent) showed excellent or good results, seventy-two (51 per cent) showed fair or poor results. Subsequent excision arthroplasty was performed in thirty-one patients. The infection rate for these revision procedures was very high, suggesting that many were already infected at the time of revision, and that every "loose" hip must be assumed to be infected until proved otherwise. The mortality rate of 3 per cent was surprisingly low after more than one major surgical procedure in these elderly patients.

Fatigue fractures which originate at stress-concentrating voids located at the implant-cement interface are a potential cause of septic loosening of cemented femoral components. Heating of the component to 44°C is known to reduce the porosity of the cement-prosthesis interface.

The temperature of the cement-bone interface was recorded intra-operatively as 32.3°C. A simulated femoral model was devised to study the effect of heating of the component on the implant-cement interface.

Heating of the implant and vacuum mixing have a synergistic effect on the porosity of the implant-cement interface, and heating also reverses the gradients of microhardness in the mantle.

Heating of the implant also reduces porosity at the interface depending on the temperature. A minimum difference in temperature between the implant and the bone of 3°C was required to produce this effect. The optimal difference was 7°C, representing a balance between maximal reduction of porosity and an increased risk of thermal injury. Using contemporary cementing techniques, heating the implant to 40°C is recommended to produce an optimum effect.

The issues surrounding raised levels of metal ions in the blood following large head metal-on-metal total hip replacement (THR), such as cobalt and chromium, have been well documented. Despite the national popularity of uncemented metal-on-polyethylene (MoP) THR using a large-diameter femoral head, few papers have reported the levels of metal ions in the blood following this combination. Following an isolated failure of a 44 mm Trident–Accolade uncemented THR associated with severe wear between the femoral head and the trunnion in the presence of markedly elevated levels of cobalt ions in the blood, we investigated the relationship between modular femoral head diameter and the levels of cobalt and chromium ions in the blood following this THR.

A total of 69 patients received an uncemented Trident–Accolade MoP THR in 2009. Of these, 43 patients (23 men and 20 women, mean age 67.0 years) were recruited and had levels of cobalt and chromium ions in the blood measured between May and June 2012. The patients were then divided into three groups according to the diameter of the femoral head used: 12 patients in the 28 mm group (controls), 18 patients in the 36 mm group and 13 patients in the 40 mm group. A total of four patients had identical bilateral prostheses in situ at phlebotomy: one each in the 28 mm and 36 mm groups and two in the 40 mm group.

There was a significant increase in the mean levels of cobalt ions in the blood in those with a 36 mm diameter femoral head compared with those with a 28 mm diameter head (p = 0.013). The levels of cobalt ions in the blood were raised in those with a 40 mm diameter head but there was no statistically significant difference between this group and the control group (p = 0.152). The levels of chromium ions in the blood were normal in all patients.

The clinical significance of this finding is unclear, but we have stopped using femoral heads with a diameter of ≤ 36 mm, and await further larger studies to clarify whether, for instance, this issue particularly affects this combination of components.

Cite this article: Bone Joint J 2014;96-B:43–7.

Using data from the Norwegian Arthroplasty Register, we have the assessed survival of 17 323 primary Charnley hip prostheses in patients with osteoarthritis based upon the type of cement used for the fixation of the implant.

Overall, 9.2% had been revised after follow-up for ten years; 71% of the failures involved aseptic loosening of the femoral component. We observed significantly increased rates of failure for prostheses inserted with CMW1 and CMW3 cements. Using implants fixed with gentamicin-containing Palacos cement as the reference, the adjusted Cox regression failure rate ratios were 1.1 (95% CI 0.9 to 1.4) for implants cemented with plain Palacos, 1.1 (95% CI 0.7 to 1.6) for Simplex, 2.1 (95% 1.5 to 2.9) for gentamicin-containing CMW1, 2.0 (95% CI 1.6 to 2.4) for plain CMW1 and 3.0 (95% CI 2.3 to 3.9) for implants fixed with CMW3 cement. The adjusted failure rate at ten years varied from 5.9% for implants fixed with gentamicin-containing Palacos to 17% for those fixed with CMW3.

We studied the rates of revision for 53 698 primary total hip replacements (THRs) in nine different groups of disease. Factors which have previously been shown to be associated with increased risk of revision, such as male gender, young age, or certain types of uncemented prosthesis, showed important differences between the diagnostic groups. Without adjustment for these factors we observed an increased risk of revision in patients with paediatric hip diseases and in a small heterogeneous ‘other’ group, compared with patients with primary osteoarthritis. Most differences were reduced or disappeared when an adjustment for the prognostic factors was made. After adjustment, an increased relative risk (RR) of revision compared with primary osteoarthritis was seen in hips with complications after fracture of the femoral neck (RR = 1.3, p = 0.0005), in hips with congenital dislocation (RR = 1.3, p = 0.03), and in the heterogenous ‘other’ group. The analyses were also undertaken in a more homogenous subgroup of 16 217 patients which had a Charnley prosthesis implanted with high-viscosity cement. The only difference in this group was an increased risk for revision in patients who had undergone THR for complications after fracture of the femoral neck (RR = 1.5, p = 0.0005).

THR for diagnoses seen mainly among young patients had a good prognosis, but they had more often received inferior uncemented implants. If a cemented Charnley prosthesis is used, the type of disease leading to THR seems in most cases to have only a minor influence on the survival of the prosthesis.

We report 16 cases of erythematous eruption on the skin within the flaps of the surgical incision after primary total hip replacement over an eight-year period. The symptoms began within nine months of operation in 13 hips, and two to three years after in three. Four patients had recurrent episodes. All were treated with antibiotics (15 intravenous, one oral) with complete resolution of the eruption within one to six days. The mean follow-up after the last episode of cellulitis was 27 months (14 to 76). There were no cases of periprosthetic sepsis or other sequelae.

We implanted 51 Metal-Cancellous Cementless Lübeck (MCCL) prostheses into 45 patients with dysplastic hips and followed 49 hips (96.1%) for five to nine years. One had needed revision for stem fracture and one for infection; the clinical outcome of the other 47 hips was assessed using the Merle d’Aubigné and Postel hip score.

All hips were either excellent (63%) or good (37%). Three patients (6%) had mild thigh pain at six months, but this had settled within two years. Serial radiographs showed stable fixation with bone ingrowth in all hips, with increased density of the cancellous bone in contact with the implant and some trabecular ingrowth. There was early varus shift of the stem in one hip, but this stabilised in three months. Osteolysis of the femoral cortex was seen in one hip at seven years after surgery, and mild bone resorption due to stress shielding in 31 (63%). Acetabular bone grafting with autogenous bone from the femoral head gave successful support to the socket in 13 hips.

The MCCL prosthesis gave satisfactory mid-term results in patients with osteoarthritis secondary to hip dysplasia.