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ABSTRACT: BACKGROUND: Dual-mobility (DM) cups were introduced to minimize the risk of THA dislocation. The overall rate of dislocation of DM cups (including both large and small articulations) is controversial and ranges from 0% to 5% in previous studies. QUESTIONS/PURPOSES: We therefore recorded (1) the dislocation rate, (2) loosening and osteolysis, and (3) subsequent related revisions with DM cups. METHODS: Between 1998 and 2003, 2480 primary THAs with DM cups were undertaken in 2179 patients. The mean age was 69 years (range, 19-94 years). This group underwent specific clinical and radiographic evaluation at a minimum followup of 0.17 years (mean, 7 years; range, 0.17-11 years) to assess dislocation, reoperation, osteolysis, and cup fixation. RESULTS: There were 22 dislocations (0.88%): 15 dislocations of large articulations (0.6%), with two (0.08%) recurring but only one requiring revision (0.04%), and seven intraprosthetic small articulation dislocations (0.28%), all needing revision surgery. At last followup, mean Harris hip score was 91 (range, 60-100); 2439 cups (98%) showed no signs of loosening; and 141 patients (145 hips) had osteolysis (6%). Osteolysis and cup loosening were more frequent in patients younger than 50 years at the time of surgery. The 10-year survivorship considering revision for any reason was 93% (95% CI, 91%-95%). CONCLUSIONS: DM cups had a low dislocation rate in primary THA, with a limited frequency of adverse effects. We recommend DM cups to minimize dislocation in populations at high risk for instability, but they should be avoided in younger, active patients at higher risk for osteolysis. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 03/2013; · 2.53 Impact Factor
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ABSTRACT: PURPOSE: Although the resumption of low-impact sports activities is compatible with total hip arthroplasty (THA), participation in high-impact sports seems problematic, and there is no consensus as to whether it is advisable. The purpose of this article is to evaluate the quality and possibility of resuming high-impact physical activities after hip resurfacing. MATERIALS: The study was performed in an on-going, single-surgeon, prospective series of 215 resurfacing arthroplasties (RSA). Mean follow-up was 44.1 months (range, 39.1-54.5). Clinical evaluation included the Postel-Merle d'Aubigné (PMA) score, the Oxford hip score, the Harris hip score (HHS), Devane score, and UCLA activity score. A specific questionnaire analysing sports activities was administered to each patient to assess the number and level of physical activities performed (both before the operation and at final follow-up). RESULTS: In the series of 202 consecutive patients (215 RSA), 50 patients (55 RSA) engaged regularly in at least one high-impact activity before their operation and the onset of pain, 102 patients practised at least one intermediate-impact activity, and the 50 remaining patients undertook only low-impact activities. Harris hip score increased from 44.8 (range, 23-68) before the operation to 97.8 (range, 85-100) at the last follow-up. Mean time to sports resumption after surgery was 14.6 weeks (range, 7-29). The resumption rate was 98 % for sports of any impact level and 82 % for high-impact activities. No osteolysis or implant loosening was observed at follow-up. No revision was performed. CONCLUSION: In 2012, no consensus recommendations yet exist for the resumption of sports activities after RSA. Existing recommendations concern only conventional THA. We believe that RSA allows younger and more active patients to resume physical and sports activities without restriction. The rate of return to sports after RSA appears to be excellent and unequalled by conventional hip prostheses. High-impact sports seem to be compatible with hip resurfacing, although no long-term studies have analysed the impact of these activities on wear and/or aseptic loosening.
International Orthopaedics 03/2013; · 2.03 Impact Factor
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ABSTRACT: Dual mobility (DM) cups of mobile polyethylene were introduced to prevent total hip arthroplasty (THA) dislocation, but no large series with this design to treat recurrent instability have been reported.
Our retrospective investigation ascertained the efficiency of DM cups in correction of recurrent dislocation and assessed any adverse effects.
One hundred eighty THAs with recurrent instability were revised to DM cups in 180 patients (mean age, 67.4 ± 11.7 years; range, 19 to 92 years). Thirty-one patients (17.2%) underwent at least one earlier THA revision, and 15 (10.3%) incurred non-union of the greater trochanter. Of the initial group in 2009, 145 patients had completed evaluations which included assessment of the Harris Hip Score and a radiographic assessment at a mean follow-up of 7.7 ± 2.2 years (range, 4 to 14 years). The rate of survival was calculated considering any reason for revision as failure.
At follow-up, Harris hip score was 83.9 ± 16.1 (range, 21 to 100). Dislocation of the large articulation occurred in seven hips (4.8%), and only two recurred (1.4%) (one requiring additional revision). In addition, two intra-prosthetic dislocations of the small articulation (1.4%) were observed and needed revision surgery. The large number of earlier surgeries and non-union of the greater trochanter were related to recurrent instability. Two cups (1.4%) showed signs of definite loosening; six (4.1%) presented signs of possible loosening. Twenty-nine hips manifested femoral or acetabular osteolysis (20%), but only three were severe. Eight-year survival rate considering revision for any reason was 92.6% (95% CI, 85.5-96.4%).
This series indicates that DM cups are a viable option to treat recurrent THA instability. Their design provides a low risk of recurrent instability without increasing mechanical complications.
HSS Journal 10/2012; 8(3):251-6.
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ABSTRACT: Metal-on-metal hip resurfacing is offered as an alternative to traditional hip arthroplasty for young, active adults with advanced osteoarthritis. The concept of hip resurfacing is considered very attractive for this specific population (hard-on-hard bearing component with a large femoral head limiting the risk of dislocation, and allowing femoral bone stock preservation).
A prospective clinical trial was designed to investigate the outcome of hip resurfacing in young patients (under 30 years old). We studied 24 hips in 22 patients. Mean age at operation was 24.9 years (range 17.1-29.9). No patient was lost to follow-up.
There was no revision at average follow-up of 50.6 months (44-59). Mean UCLA activity score improved from 5.5 (1-9) pre-operatively to 7.6 (1-10) postoperatively (p < 0.001). Mean Harris hip score increased from 43.9 (19-67) to 89.3 (55-100) (p < 0.001). Radiological analysis discerned no osteolysis and no implant migration.
The absence of short-term complications, such as mechanical failure or dislocation, is encouraging and leads us to think that mid-term results will be satisfactory. Moreover, the specific advantages of hip resurfacing (bone stock preservation, excellent stability, low risk of dislocation, large-diameter head) make the procedure a very attractive option for young subjects.
International Orthopaedics 05/2012; 36(9):1789-94. · 2.03 Impact Factor
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ABSTRACT: The ability to return to sports activities (especially running) after hip resurfacing arthroplasty seems to be very important for young and active patients who have developed osteoarthritis.
To assess the quality of return to sports after hip resurfacing arthroplasty by examining the time spent running, weekly mileage, and the possibility of returning to competition in a series of patients.
Case series; Level of evidence, 4.
A prospective, consecutive series of 202 patients (215 hip resurfacings) was assessed to evaluate the possible resumption of running activity (time spent, weekly mileage, return to competition). Of this initial cohort, 40 patients (43 resurfacings, 21%) practiced running preoperatively. Mean age at hip resurfacing arthroplasty was 50.7 years (range, 31-61 years). No patients underwent revision surgery. A questionnaire was administered to assess the number, type, and level of sports activities. Among patients who practiced running, we determined, preoperatively and at last follow-up, their weekly mileage and whether they were competitors.
At last follow-up, 33 of 40 patients (36/43 hips) still practiced running (P = .74), with 91.6% of them resuming running. Mean average recovery time before running at a level assessed as good by patients was 16.4 weeks (range, 5-36 weeks). The number of patients running more than 4 hours per week increased from 18 to 23. Similarly, the time devoted to running at last follow-up remained high (mean, 3.1 hours per week) with no statistically significant difference from the preoperative period (P = .54). Moreover, patients were still engaged in competition without statistical difference between the 2 periods (P = .82).
Running is possible after hip resurfacing, and runners can even return to some level of competition, but this short follow-up series of hip resurfacing in athletes should be interpreted with caution regarding implant survival.
The American journal of sports medicine 02/2012; 40(4):889-94. · 3.61 Impact Factor
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ABSTRACT: Minimally invasive surgery has gained popularity over the past several years. Early results have shown better functional outcome with early recovery and rapid rehabilitation.
Evaluation of the short-term clinical and functional outcome of minimally invasive surgery total knee arthroplasty (MIS-TKA) compared with the traditional total knee arthroplasty (TKA).
During 2009, all cases scheduled for primary TKA through the modified mini-mid-vastus approach (MIS group) were studied. This group included 40 knees and was compared to a cohort control group of similar number of patients (40 knees) that underwent the procedure through the standard conventional technique (standard group).
Patients in the MIS group showed significant decrease in postoperative pain, blood loss in first 24 hours, and in hospital stay. Furthermore, they achieved motion considerably faster than the standard group with earlier return of quadriceps function and greater early flexion.
This study proved that MIS-TPA has the ability to couple the benefits of less invasive surgical approach.
North American journal of medical sciences. 02/2012; 4(2):81-5.
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ABSTRACT: Young adults with osteochondral lesions of the femoral head are at risk of rapid progression to symptomatic arthritis of the hip joint. Between January 2008 and July 2009, 10 patients were treated for femoral cartilage damage by a osteochondral mosaicplasty of the femoral head through a trochanteric flap with dislocation of the hip. The consecutive series had the following exclusion criteria: acetabular chondropathy, age above 25 years, and femoral head osteonecrosis. Patients were followed up after surgery using the Oxford-12 score, Harris hip score and the Merle d'Aubigné score, and activity assessed by the UCLA and Devane scores. Radiological evaluation by computed tomographic (CT) arthrography was undertaken in all patients at 6 months and plain radiographs. Mean follow-up was 29.2 months (20-39 months). The Postel Merle d'Aubigné score improved from the pre-operative period to the latest follow-up, from 10.5 points (8-13) to 15.5 points (12-17). Global range of motion increased from 175.4° (140-215) to 210.7° (175-240). All radiological investigations at latest follow-up showed that the autograft plugs were well-incorporated at the site of osteochondroplasty in the femoral head with intact cartilage over them and smooth interfaces between articulating bony surfaces. Osteochondral autograft transplantation may be a new alternative option for osteochondral lesions of the femoral head, but this has to be confirmed with longer follow-up and in a larger number of patients. The results of similar surgery in the knee have been mixed, and in the hip the technique is demanding, requiring familiarity with surgical hip dislocation.
Hip international: the journal of clinical and experimental research on hip pathology and therapy 09/2011; 21(5):542-8. · 0.34 Impact Factor
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ABSTRACT: Groin pain may persist in up to 4.3% of patients after total hip arthroplasty and up to 18% of patients one year after hip resurfacing. The incidence of this problem after total hip arthroplasty with a large-diameter femoral head is unknown.
We analyzed the natural history of groin pain and its clinical consequences during the first two years after three types of hip arthroplasty. Data were collected prospectively on 279 patients. Eighty-five patients had a polyethylene sandwich metal-on-metal total hip arthroplasty with a 28-mm-diameter femoral head, 105 had hip resurfacing, and eighty-nine had a total hip arthroplasty with a large-diameter femoral head component with three other cup designs (forty-nine in this group had the same monoblock acetabular cup design as those who had hip resurfacing).
At the twenty-four-month follow-up evaluation, seventy-seven patients (28%) reported at least one painful area around the hip and thirty-four patients (12.2%) had pain at more than one location. At three months, the incidence of groin discomfort was significantly increased in those who had hip resurfacing (30.5%) and in those who had total hip arthroplasty with a large-diameter femoral head (30%) compared with those who had total hip arthroplasty with a 28-mm femoral head (18.3%). This incidence decreased at two years (14.9%, 16.9%, and 12.9%, respectively). At twenty-four months postoperatively, eleven (four who had hip resurfacing, six who had total hip arthroplasty with the large-diameter head, and one who had total hip arthroplasty with the 28-mm head) of forty-one patients who had groin pain had not reported groin pain at previous follow-up evaluations. Of the forty-one patients reporting groin pain at the time of the last follow-up, twenty-three patients (56%) did not seek further evaluation or treatment, nine had revision surgery (22%), and the remaining nine patients thought the pain was substantial enough to warrant further evaluation and treatment.
When the exact source of groin pain cannot be found after total hip arthroplasty, careful follow-up should be done as local reactions to metal-on-metal implants and component loosening may take time to become apparent clinically or on imaging studies.
The Journal of Bone and Joint Surgery 05/2011; 93 Suppl 2:93-8. · 3.27 Impact Factor
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ABSTRACT: We previously reported the outcomes of a case-control study, at a minimum of five years of follow-up, comparing metal-on-metal and ceramic-on-polyethylene bearings for cementless primary hip arthroplasty in active patients below the age of fifty years. This report is an update on these groups after a minimum duration of follow-up of twelve years.
Thirty-nine metal-on-metal cementless hip replacements with a 28-mm-diameter Metasul articulation were compared with a control group that included thirty-nine cementless ceramic-on-polyethylene hip replacements performed with a 28-mm-diameter head. The Metasul group included thirty patients with a mean age of forty years (range, twenty-three to forty-nine years), and the control group included thirty-two patients with a mean age of forty-one years (range, fifteen to forty-nine years). The groups were matched for age, activity level, preoperative Harris hip score, acetabular cup diameter, and indication for hip arthroplasty. All patients had a high level of activity, with 82% rated as grade IV or V according to the Devane scale.
After a mean duration of follow-up of thirteen years (twelve to fourteen years), only one hip (3%) had asymptomatic acetabular osteolysis and no hip (0%) had been revised in the metal-on-metal group, whereas eighteen hips (46%) had osteolysis and eleven hips (28%) had been revised because of wear or osteolysis in the ceramic-on-polyethylene group (p < 0.003). In the metal-on-metal group, the median Co concentration in the whole blood was 0.95 μg/L (0.4 to 4.8 μg/L) and the median Cr concentration was 1.2 μg/L (0.1 to 5.6 μg/L). The twelve-year survival rate (with reoperation for any reason as the end point) was 100% in the metal-on-metal group and 70% (95% confidence interval, 63% to 77%) in the ceramic-on-polyethylene group (p = 0.003).
After twelve to fourteen years of follow-up, metal-on-metal implants demonstrated better radiographic and survival results than ceramic-on-polyethylene implants in young, very active patients. Current wrought metal-on-metal implants with a 28-mm-diameter head and high carbide concentration did not produce the high rates of osteolysis and allergic reactions that may be observed with cast low-carbide metal-on-metal bearings after a shorter duration of follow-up.
The Journal of Bone and Joint Surgery 05/2011; 93 Suppl 2:137-42. · 3.27 Impact Factor
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ABSTRACT: Reduced range of motion of the hip has a detrimental influence on lower limb function. Large diameter head total hip arthroplasty may theoretically have a greater potential for restoring normal hip range of motion due to greater head-neck diameter ratio, and hence provide better function compared to conventional or hip resurfacing arthroplasty.
At minimum one year follow-up, range of motion of the operated and contra lateral hips was clinically assessed using digital photographs and bony landmarks in a clinical comparative study. We assessed if 1) large diameter head total hip arthroplasty (55 patients) restores better hip range of motion compared to 28 mm total hip arthroplasty (50 patients) or hip resurfacing (60 patients) 2) large diameter head total hip arthroplasty achieves same hip range of motion as contra lateral normal hips and 3) hip range of motion correlates with the WOMAC score.
The large diameter head total hip arthroplasty group had significantly greater total arcs of motion (approximately 20°), mostly due to an increase of hip flexion and external rotation, but did not reach normal hip motion. The hip range of motion showed significant correlation with the WOMAC score, especially the flexion arc.
The better hip range of motion of large diameter head total hip arthroplasty is likely due to the greater head to neck diameter ratio and hence seems to be the best option to optimize range of hip motion and improve function after hip arthroplasty.
Clinical biomechanics (Bristol, Avon) 11/2010; 26(3):267-73. · 1.76 Impact Factor
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ABSTRACT: Numerous reports of THAs in patients younger than 30 years indicate a high risk of revision. Although risk factors for revision have been reported for older patients, it is unclear whether these risk factors are the same as those for patients younger than 30 years.
We therefore (1) determined function and survivorship of revision THAs performed in patients younger than 30 years, and (2) assessed the risk factors for revision THAs in this younger population by comparison with a group of patients younger than 30 years who did not undergo revision.
We retrospectively reviewed the clinical records and radiographs of 55 patients younger than 30 years (average age at revision, 24.3 years; range, 14-30 years) who underwent 77 hip revisions. Revision was performed, on average, 4.6 years (range, 0.4-12 years) after the primary THA. The results for these 55 patients (77 revision THAs) were compared with results for a nonrevised group, including 819 THAs in patients younger than 30 years. Minimum followup of the revision group was 1 year (mean, 6.2 years; range, 1-15 years).
At followup after the revision, the Merle d'Aubigné-Postel score improved from 12.2 to 14.6. The rates of dislocation, neurologic lesions, and fractures were 15%, 7.8%, and 14%, respectively. The 10-year survival rate was 36% (95% confidence interval [CI], 21%-51%). Compared with the nonrevised group, the independent revision risk factors were young age at primary THA (OR 1.14 [1.07-1.19]), high number of previous surgeries (OR 5.41 [2.67-10.98]), and occurrence of at least one dislocation (OR 3.98 [1.74-9.07]). Hard-on-soft bearings had a higher risk (OR 3.42 [1.91-6.1]) of revision compared with hard-on-hard bearings.
Revision THAs are likely in patients younger than 30 years, and the complication rate is high. The survivorship of hip revision in this population is low and alternative solutions should be advocated whenever possible.
Level III, therapeutic study, case control study. See the Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 11/2010; 469(4):1141-7. · 2.53 Impact Factor
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ABSTRACT: Total hip arthroplasty in patients younger than thirty years of age represents a long-term challenge. As polyethylene wear secondary to a high activity level could be problematic, hard-on-hard bearings have been proposed to reduce wear. The aim of this retrospective case series was to assess the clinical and radiographic results of primary metal-on-metal total hip arthroplasty in patients thirty years of age or younger.
We retrospectively studied thirty-four patients (forty-seven hips) who had undergone metal-on-metal total hip arthroplasty and analyzed the radiographic and clinical measurements after a mean duration of follow-up of 108 months (range, 62.4 to 153.6 months). The mean age of the patients at the time of surgery was twenty-five years (range, fifteen to thirty years). The diameter of the head of the femoral component was 28 mm in all hips except five, in which it was 32 mm. The metal-on-metal bearing was the same in all patients.
The mean Merle d'Aubigné score increased from 10.6 (range, 1 to 14) to 17.1 (range, 12 to 18). No wear was found on the latest radiograph, but osteolysis was noted in three femora and two acetabula. Two revisions were performed, one because of impingement secondary to cup malorientation and the other because of acetabular loosening with osteolysis. Kaplan-Meier analysis with revision of either component as the end point revealed a ten-year survival rate of 94.5% (95% confidence interval, 80% to 98.6%). The survival rate of the femoral stem was 100%.
These encouraging intermediate-term results indicate that hip arthroplasty with metal-on-metal bearing components may be a suitable solution for young and active patients with hip osteoarthritis or osteonecrosis of the femoral head.
The Journal of Bone and Joint Surgery 10/2010; 92(14):2419-26. · 3.27 Impact Factor
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The Journal of arthroplasty 06/2010; 25(4):661-2; author reply 662. · 1.79 Impact Factor
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ABSTRACT: Preoperative and postoperative ion concentrations were measured in 29 metal-on-metal, large-diameter head total hip arthroplasty (LDH-THA) patients. Mean chromium, cobalt (Co), and titanium levels from LDH-THA were 1.3, 2.2, and 2.7 μg/L at 12 months. The open femoral head design showed significantly higher Co concentrations than the closed design (3.0 vs 1.8 μg/L, P = .037). Compared with previously published ion levels from a hip resurfacing system presenting the same bearing characteristics, Co levels were significantly higher in LDH-THA (2.2 vs 0.7 μg/L, P < .001). This study has demonstrated that the addition of a sleeve with modular junctions and an open femoral head design of LDH-THA causes more Co release than bearing surface wear (157% and 67%, respectively). Even if no pathologic metal ion threshold level has been determined, efforts should be made to minimize its release. We recommend modification or abandonment of the modular junction and femoral head open design for this specific LDH-THA system.
The Journal of arthroplasty 03/2010; 26(2):282-8. · 1.79 Impact Factor
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ABSTRACT: The purpose of this study was to evaluate the clinical and radiological results of Metasul cups cemented into reinforcement rings for young and active patients. Twenty-three total hip arthroplasties with Metasul cups were cemented into Muller reinforcement rings. Mean follow-up was 6.1 years (5-10). At final follow-up, the Harris hip score increased from 62.2 (39-85) to 95.2 (84-100, P = .01): no revision was undertaken for aseptic loosening or fixation failure. Considering reoperation and bearing revision as end points, survival rates were 95.8% and 100%, respectively. The mean blood concentrations of chromium, cobalt, and titanium were 1.85 μg/L, 1.24 μg/L, and 9.62 μg/L, respectively. A longer follow-up is mandatory, but it seems possible to use hard-on-hard bearings with metallic rings in young patients during hip revisions or in dysplastic cases with encouraging intermediate follow-up results.
The Journal of arthroplasty 12/2009; 26(1):103-9. · 1.79 Impact Factor
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Journal of Medical Microbiology 07/2009; 58(Pt 6):842-3. · 2.50 Impact Factor
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ABSTRACT: We report the clinical and radiological results of 140 primary THAs, randomized to receive metal-polyethylene or alumina-alumina bearing surfaces. At last follow-up (average 79 months), no significant difference was found on clinical scores (WOMAC and Merle D'Aubigné) between the two groups. However, linear wear of 1 mm or more of the liner was observed in 89% (50/56) of polyethylene cases, whereas no measurable wear was noted in the alumima-on-alumina group. Calcar resorption was noted in 34% (19/56) of cases in the polyethylene group versus 6% (3/51) in the alumina group. Although no aseptic loosening was present in either group, 2 hips in the polyethylene group underwent revision for severe liner wear, and 2 more are pending. No specific complication was associated with alumina components. This study is in line with other reports indicating that alumina-alumina bearing surfaces have better wear properties than metal-on standard polyethylene and should be considered for THA in young and active patients.
Acta orthopaedica Belgica 09/2007; 73(4):468-77. · 0.40 Impact Factor
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ABSTRACT: Lesions of the acetabular labrum have been suspected to be one factor responsible for failures of Chiari osteotomy. We undertook a prospective investigation to adress this question. Twenty-six adult patients (mean age 34.5 years) with 26 dysplastic hips were enrolled consecutively. All the hips studied showed arthritic changes. The labrum was inspected by arthroscopy during surgery (19 shelf acetabuloplasties and 7 Chiari procedures). All hips were followed for a minimum of 12 years (12-14 years). Sixteen dysplastic hips (62%) were found to have labrum tears. Computed tomography (CT)-arthrography findings were similar to arthroscopic observations in 13 hips. Coxomety results showed that the acetabular roof angle (HTE), cervico-diaphyseal angle (CDA) and lateralisation were higher in cases with acetabular labral tears. On the other hand, the ventral center-edge angle (VCEA) was lower in hips with labral tears. During the follow-up period, eight hips which had undergone a Chiari osteotomy were converted to total hip replacement. Adult dysplastic hips are at risk for presenting labral tears. Clinical signs appear to have limited diagnostic value. Coxa valga, a small lateral center edge angle and a high acetabular roof angle were found in this study to be associated with a higher incidence of labral tears. Contrary to previous data reported in retrospective studies, the results of the present prospective investigation suggest that labral tears do not compromise the outcome of acetabulum enlargement procedures.
Acta orthopaedica Belgica 03/2007; 73(1):38-43. · 0.40 Impact Factor
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ABSTRACT: To address femoral bone loss in revision total hip arthroplasty (THA) we developed a technique involving impaction allografting with intramedullary mesh moulded around the revision stem, to prevent excessive cement penetration of the allograft. The length of the revision stem was determined by the extent of femoral bone loss. Between 1986 and 1998, 32 such procedures were undertaken on 28 patients. The mean pre-operative HHS for function was 22 (range 5 to 42), improving to 41 (range 12 to 47) at final follow-up. Only 1 patient presented with aseptic loosening after revision at 147 months (12.2 years). The 12.5 year survivorship for the stem was 92.8%. The technique has provided stable and durable reconstruction, with good new bone formation visible radiologically. It is technically demanding and time consuming, but it avoids the previously published problem of massive subsidence within the bone graft.
Hip international: the journal of clinical and experimental research on hip pathology and therapy 21(1):14-20. · 0.34 Impact Factor
