Failed Total Hip Replacement Research Articles

Analysis of Achievement of Radiological Parameters in Uncemented Total Hip Replacement: A Retrospective Cohort Study

Introduction: The Total Hip Replacement (THR) procedure is indicated to the treatment of choice in chronic refractory joint pain and some types of proximal femoral fractures. Component malalignment is a major cause of THR failure, making it crucial to position the components anatomically for long-term joint survival. Aim: To assess the radiological parameters of uncemented THR surgery. Materials and Methods: This retrospective cohort study was conducted in the Department of Orthopaedic Surgery, King’s George Medical University (KGMU), Lucknow, Uttar Pradesh, India, from June 2017 to May 2021. It included 72 patients who underwent unilateral uncemented THR for isolated hip diseases. Data was collected over the first two years and analysed. Demographic information and radiographic characteristics such as acetabular cup inclination and anteversion, femoral stem placement, vertical and horizontal centers of rotation, and limb length discrepancy were determined. Data was entered into Microsoft Excel 2018-19, and Statistical Package for the Social Sciences (SPSS) software version 28.0 was used for statistical analysis. Results: The average age of the patients was 50.75±9.1 years. Comparison of acetabular cup inclination (preoperative 41.4±3.9° and postoperative 42.2±5.1°) and anteversion (preoperative 13.1±2.96° and postoperative 14.5±3.75°) showed non significant differences following treatment with a normal hip. However, there was a significant difference in the horizontal and vertical Centers Of Rotation (COR) following treatment with a normal hip. Conclusion: Preoperative radiological characteristics of the damaged hip were significantly restored to normal anatomy and alignment following surgery

What's New in the Diagnosis of Periprosthetic Joint Infections: Focus on Synovial Fluid Biomarkers.

Periprosthetic joint infections are some of the leading causes of revision prosthetic surgery, accounting for 25% of failed total knee replacements and 15% of failed total hip replacements. The search for a biomarker that, together with clinical and radiological findings, could improve the management of such patients is currently a significant challenge for orthopaedic surgeons. Synovial fluid is a viscous and mucinous substance produced by the synovium, a specialized connective tissue that lines diarthrodial joints. Synovial fluid is an ultrafiltrate of plasma but also contains proteins secreted from the surrounding tissues, including the articular cartilage and synovium. Therefore, synovial fluid represents a source of disease-related proteins that could be used as potential biomarkers in several articular diseases. Based on these findings, the study of synovial fluid has been gaining increasing importance in recent years. This review aims to assess the accuracy and the limitations of the most promising synovial fluid biomarkers-i.e., Alpha-Defensin, Leukocyte Esterase, C-Reactive Protein, Interleukin-6, Calprotectin, Presepsin and Neopterin-in the diagnosis of PJI. Special attention will be given to emerging synovial biomarkers, which could soon be important in diagnosing PJIs.

A novel synthesis method of carbide-derived carbon (CDC) in open air for hip implants

The inferior tribocorrosion behavior of commonly used biomedical alloys has led to the early failure of total hip replacements (THRs) and serious complications. Our previous results have shown that carbide-derived carbon (CDC) produced by direct chlorination can provide excellent protection to Ti6Al4V and has a high durability.In this study, a novel method has been developed to synthesize CDC on Ti6Al4V substrates by electrolysis from LiCl-KCl with a low melting point. Compared to previous preparation processes, this newly developed approach eliminates the exposure to chlorine gas and the requirement of the inert gas environment, which makes the synthesis process more controllable and the CDC layer more uniform. X-ray diffraction (XRD), Raman spectroscopy and scanning electron microscopy (SEM) techniques were utilized to characterize the products. Based on the characterization results, the produced CDC has a porous structure which may contain nanocrystalline graphite (NCG) and amorphous carbon (a-C). The theoretical thickness of the sample is estimated by a calculation which is approximately 1.44 μm. In addition, the performance of the new layer was tested in a tribocorrosion hip simulator. A system has a pin on ball contact and immersed in bovine calf serum of 30 g/L protein concentration, with a pH of 7.6 and a temperature of 37 °C. We applied a normal force of 16 N and ran the test for 3600 cycles with 1 Hz. According to the recordings of normal and tangential forces, the evolution of friction coefficient is deducted and reported in the results.The findings have shown that the CDC samples prepared by electrolysis method exhibit smaller friction coefficient (approximately 0.12) and potential drop (less than 0.1 V compared to 1.1 V for substrate). Therefore, it is promising that CDC prepared by the novel electrolysis approach can protect Ti6Al4V substrates from the tribocorrosive damages.

Computational method for bearing surface wear prediction in total hip replacements

Total hip replacement (THR) is a revolutionary treatment when a hip joint becomes severely damaged. Wear is known as one of the main reasons for THR failure. Current experimental techniques to investigate the wear at the bearing surfaces of THRs are time-consuming, complicated and expensive. In this study, an in-house fretting wear algorithm has been further developed to investigate the wear damage that occurs on bearing surfaces of THRs and its consequence on the longevity of the implants. A 3D finite element model has been created with a 36 mm diameter Cobalt–Chromium femoral head and a 4 mm thick cross-linked polyethylene bearing liner. A gait loading cycle was used to simulate walking for up to 5 million cycles (Mc). The wear algorithm extracts relative displacements and contact shear stresses from the finite element package to predict the linear and volumetric wear rates. This method is shown to have modelled the evolution of wear effectively and found it to be similar to those from experimental analyses. The linear and volumetric wear per million cycles predicted in this study were 0.0375mm/Mc and 33.6mm3/Mc which are comparable to those measured in-vivo THRs. The wear patterns obtained from this study are also comparable to the wear patterns shown on available conventional polyethylene liners. This method can be used to further aid in the design and clinical technique to reduce wear rate in THRs.

Comparing the performance of a deep convolutional neural network with orthopedic surgeons on the identification of total hip prosthesis design from plain radiographs.

A crucial step in the preoperative planning for a revision total hip replacement (THR) surgery is the accurate identification of the failed implant design, especially if one or more well-fixed/functioning components are to be retained. Manual identification of the implant design from preoperative radiographic images can be time-consuming and inaccurate, which can ultimately lead to increased operating room time, more complex surgery, and increased healthcare costs. In this study, we present a novel approach to identifying THR femoral implants' design from plain radiographs using a convolutional neural network (CNN). We evaluated a total of 402 radiographs of nine different THR implant designs including, Accolade II (130 radiographs), Corail (89 radiographs), M/L Taper (31 radiographs), Summit (31 radiographs), Anthology (26 radiographs), Versys (26 radiographs), S-ROM (24 radiographs), Taperloc Standard Offset (24 radiographs), and Taperloc High Offset (21 radiographs). We implemented a transfer learning approach and adopted a DenseNet-201 CNN architecture by replacing the final classifier with nine fully connected neurons. Furthermore, we used saliency maps to explain the CNN decision-making process by visualizing the most important pixels in a given radiograph on the CNN's outcome. We also compared the CNN's performance with three board-certified and fellowship-trained orthopedic surgeons. The CNN achieved the same or higher performance than at least one of the surgeons in identifying eight of nine THR implant designs and underperformed all of the surgeons in identifying one THR implant design (Anthology). Overall, the CNN achieved a lower Cohen's kappa (0.78) than surgeon 1 (1.00), the same Cohen's kappa as surgeon 2 (0.78), and a slightly higher Cohen's kappa than surgeon 3 (0.76) in identifying all the nine THR implant designs. Furthermore, the saliency maps showed that the CNN generally focused on each implant's unique design features to make a decision. Regarding the time spent performing the implant identification, the CNN accomplished this task in ~0.06s per radiograph. The surgeon's identification time varied based on the method they utilized. When using their personal experience to identify the THR implant design, they spent negligible time. However, the identification time increased to an average of 8.4min (standard deviation 6.1min) per radiograph when they used another identification method (online search, consulting with the orthopedic company representative, and using image atlas), which occurred in about 17% of cases in the test subset (40 radiographs). CNNs such as the one developed in this study can be used to automatically identify the design of a failed THR femoral implant preoperatively in just a fraction of a second, saving time and in some cases improving identification accuracy.

Detecting total hip replacement prosthesis design on plain radiographs using deep convolutional neural network.

Identifying the design of a failed implant is a key step in the preoperative planning of revision total joint arthroplasty. Manual identification of the implant design from radiographic images is time-consuming and prone to error. Failure to identify the implant design preoperatively can lead to increased operating room time, more complex surgery, increased blood loss, increased bone loss, increased recovery time, and overall increased healthcare costs. In this study, we present a novel, fully automatic and interpretable approach to identify the design of total hip replacement (THR) implants from plain radiographs using deep convolutional neural network (CNN). CNN achieved 100% accuracy in the identification of three commonly used THR implant designs. Such CNN can be used to automatically identify the design of a failed THR implant preoperatively in just a few seconds, saving time and improving the identification accuracy. This can potentially improve patient outcomes, free practitioners' time, and reduce healthcare costs.

Diagnosis of the failed total hip replacement

Diagnosis of the failed total hip replacement

Analysis of the Cause of Titanium Endoprosthesis Failure

This paper deals with the causes of failure of total hip replacement. Hip joint replacement is one of the most frequently used surgical procedures worldwide. More than 200,000 surgeries are performed only in Europe each year, following early attempts by John Charnley. Currently, more than 340 of the total 4431 implants per year are reoperated in Slovakia. Despite the excellent properties of the titanium alloy, endoprosthesis often fails and the hip replacement is necessary. Common causes are overloading and cracking, static or dynamic. Other causes of failure include injury, implantation failure, manufacturing inaccuracies, and non-compliance with the manufacturing process.

Leukocyte esterase strip test as a reliable intraoperative PJIs biomarker. Our experience.

Backgroud and aim of work: Prosthetic joint infection (PJI) is the most common cause of total knee replacement failure and the third most common cause of total hip replacement failure, accounting for 16.8% of all knee revisions and 14.8% of the hip revisions; nevertheless, the diagnosis of PJI is often a challenge for the orthopaedic surgeon. The aim of these study was to evaluate the reliability of the LE strip test for diagnosis of PJI. Materials and Methods: From December 2016 to January 2019, we enrolled 50 patients with suspected PJI; 32 females and 18 males, the average age at the time of the surgery was 76 years. Twenty-four patients underwent knee revision surgery and twenty-six hip revision surgery. In all patients during the surgery, the synovial fluid was aspirated and used for leukocyte esterase strip test. The result of the tests was compared to periprosthetic tissues culture, histological examination and sonication fluid culture for PJI. Results: Comparing the results obtained from the LE test with the results obtained from the other diagnostic methods, we found that the concordance between the results of the leukocyte-esterase test and those of the culture test with peri-prosthetic tissue or synovial fluid was shown to be 93%, between LE and histological examinations, the concordance was 93% and finally with the culture of the sonicated fluid the concordance was 86% of the cases. Conclusions: The results of our serie show a good intraoperative diagnostic accuracy of the LE test, especially in its ability to exclude the hypothesis of periprosthetic infection in case of a negative result. (www.actabiomedica.it)

Total hip replacement-the cause of failure in patients under 50years old?

To establish the mode of failure of primary total hip replacement in patients under 50years old. A total of 1062 revision total hip arthroplasties were performed over a 5-year period, with 146 on patients under 50years old. These were subdivided into early (< 5years) and late (> 5years) failures from the index procedure. The commonest mechanism of failure was aseptic loosening (42.3%) followed by metal-on-metal failure (15.8%), infection (14.4%) and instability (9.6%). The commonest cause of early revision surgery was due to metal-on-metal failure (27.8%) followed by aseptic loosening (19.7%) and infection (18.4%). In the late revision group, the main cause of failure was aseptic loosening (64%) and infection (10.7%). The changing trend of early revision due to metal-on-metal failure is important to recognise. Continuous review of the mechanism of primary total hip replacement failure is necessary to ensure the best patient outcome and maximise implant survivorship.

Can a “pre-worn” bearing surface geometry reduce the wear of metal-on-metal hip replacements? – A numerical wear simulation study

Total Hip Replacement (THR) is generally a highly successful treatment for late stage hip joint diseases and wear, however, wear continues to be one of the major causes of metal-on-metal THR's failure. Hip replacements typically experience a two-stage wear; a higher initial wear rate in the beginning followed by a lower steady-state one with the surface profile changed. This alludes to the potential use of a cup with a non-spherical interior cavity with an initial geometry similar to a worn surface which may benefit from lower wear rate. In this paper wear is numerically simulated with a cup having a non-spherical geometry inspired by the initial stage of wear.A wear model was recently developed by the authors for the THR, which considered the lubricated contact in both elastohydrodynamic lubrication (EHL) and mixed lubrication regime, rather than a dry contact used in most of other studies of wear modelling in the academic literature. In this study the wear model has been updated by introducing the ‘λ ratio’ (the ratio of film thickness to surface roughness) and addressing the non-Newtonian shear-thinning properties of the synovial fluid. This wear model was able to describe the non-linear wear evolution process due to the change of worn profiles. Firstly the wear of a spherical hip joint was simulated until a steady-state wear rate is achieved. Then a non-spherical joint was proposed in which the cup bearing geometry was generated by the previously predicted worn profile from the spherical joint. At last the wear of this “pre-worn” hip bearing was simulated and compared to the spherical one. Approximately 40% reduction in the steady-state wear rate and 50% in the total accumulated wear has been observed in the non-spherical hip joint. This study presented a full numerical analysis of the relationship between lubrication, wear reduction and the geometry change, and quantitatively suggested the optimal geometry to reduce running-in wear.

Mechanical, chemical and biological damage modes within head-neck tapers of CoCrMo and Ti6Al4V contemporary hip replacements.

Total hip replacement (THR) failure due to mechanically assisted crevice corrosion within modular head-neck taper junctions remains a major concern. Several processes leading to the generation of detrimental corrosion products have been reported in first generation modular devices. Contemporary junctions differ in their geometries, surface finishes, and head alloy. This study specifically provides an overview for CoCrMo/CoCrMo and CoCrMo/Ti6Al4V head-neck contemporary junctions. A retrieval study of 364 retrieved THRs was conducted which included visual examination and determination of damage scores, as well as the examination of damage features using scanning electron microscopy. Different separately occurring or overlapping damage modes were identified that appeared to be either mechanically or chemically dominated. Mechanically dominated damage features included plastic deformation, fretting, and material transfer, whereas chemically dominate damage included pitting corrosion, etching, intergranular corrosion, phase boundary corrosion, and column damage. Etching associated cellular activity was also observed. Furthermore, fretting corrosion, formation of thick oxide films, and imprinting were observed which appeared to be the result of both mechanical and chemical processes. The occurrence and extent of damage caused by different modes was shown to depend on the material, the material couple, and alloy microstructure. In order to minimize THR failure due to material degradation within modular junctions, it is important to distinguish different damage modes, determine their cause, and identify appropriate counter measures, which may differ depending on the material, specific microstructural alloy features, and design factors such as surface topography. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1672-1685, 2018.

Evaluation of a new methodology to simulate damage and wear of polyethylene hip replacements subjected to edge loading in hip simulator testing

Wear and fatigue of polyethylene acetabular cups have been reported to play a role in the failure of total hip replacements. Hip simulator testing under a wide range of clinically relevant loading conditions is important. Edge loading of hip replacements can occur following impingement under extreme activities and can also occur during normal gait, where there is an offset deficiency and/or joint laxity. This study evaluated a hip simulator method that assessed wear and damage in polyethylene acetabular liners that were subjected to edge loading. The liners tested to evaluate the method were a currently manufactured crosslinked polyethylene acetabular liner and an aged conventional polyethylene acetabular liner. The acetabular liners were tested for 5million standard walking cycles and following this 5million walking cycles with edge loading. Edge loading conditions represented a separation of the centers of rotation of the femoral head and the acetabular liner during the swing phase, leading to loading of the liner rim on heel strike. Rim damage and cracking was observed in the aged conventional polyethylene liner. Steady-state wear rates assessed gravimetrically were lower under edge loading compared to standard loading. This study supports previous clinical findings that edge loading may cause rim cracking in liners, where component positioning is suboptimal or where material degradation is present. The simulation method developed has the potential to be used in the future to test the effect of aging and different levels of severity of edge loading on a range of cross-linked polyethylene materials. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1456-1462, 2018.

Comment on: Modular titanium alloy neck failure in total hip replacement

To the Editor of the SICOT-J Orthopaedic Journal, I am writing to you as I would like to kindly express some considerations on the case-report of Dr. Marco Ceretti on “Modular titanium alloy neck failure in total hip replacement” published in your on-line journal last April (M. Ceretti and F. Falez SICOT J 2016, 2, 20). The Authors report on “a case of a repetitive modular femoral neck prosthesis fracture”; they had initially revised a broken modular Metha stem with a MODULUS stem, neck 135° long, head 36 medium in a 43-year-old woman with body mass index (BMI) 38.6 kg/m2 (weight 110 kg, height 170 cm); both stems presented modular necks in titanium alloy. The MODULUS stem was then revised with a Wagner monoblock uncemented titanium stem following the fracture at the neck-stem junction. This article reports a clinical case but it does not include any laboratory evidence in terms of fracture analysis to support the Authors’ conclusions and to elucidate the mechanisms of failure. No retrieval analysis on the two stems seems to have been in fact carried out, such as standard macroscopic inspection and observations, standard corrosion testing, micro analysis of the implant alloy, light microscopy, Scanning Electron Microscopy (SEM) and patient’s blood sample to check the release of metal ions. Besides, several publications nowadays report comparative analysis of cobalt-chromium and titanium modular femoral necks, showing that the first material present “improved resistance against fretting” with “lower incidence of surface micromotions” (e.g. [1, 2]). Nevertheless, the fracture of these two modular necks should be attributable to an error of indication and not to a failure of the devices themselves, meant to be used in patients with lower BMI. The surgical technique of the MODULUS stem reports: “Complications or failures of the total hip replacement may occur in heavy and highly active patients and high offset combinations. The surgeon should perform a careful evaluation of the patient’s clinical condition and level of physical activity before performing hip replacement. Patients who are overweight and/or have high activity levels may not be candidates for hip replacement with modular stems. Alternative devices, such as monoblock hip stems, should be used, when possible, in these patients.” The available literature sources clearly support these indications on the use of modular stems in the current clinical practice: “Among patients treated with the titanium alloy neck adapter, a combination of different parameters was identified as risk factors of implant failure. The parameters are intraoperative particle contamination of the cone connection, excessive loading due to a patient weight above 100 kg or high activity level, and male gender. In addition, the risk for failure rises with CCD angles of the cone adapter of 135° and smaller.” “Contamination with cortical bone particles in the interface was found to be the main influence factor on the fatigue behaviour of the titanium alloy neck adapter.” [1] “Various circumstances such as large femoral head with a long varus neck, corrosion, patients’ BMI, and activity level may participate in creating the necessary environment for fatigue failure of a modular hip replacement implant.” [3] Furthermore, I would like to take this opportunity to kindly bring to the attention of your Editorial Office that no failures of the MODULUS stem are recorded in some series of publications concerning clinical experience with this medical device, as indicated in the following articles [4–7]. Conflict of interest One of the author is a consultant of Lima Corporate as a Scientific Adviser.

Histopathological characterization of corrosion product associated adverse local tissue reaction in hip implants: a study of 285 cases.

BackgroundAdverse local tissue reaction (ALTR), characterized by a heterogeneous cellular inflammatory infiltrate and the presence of corrosion products in the periprosthetic soft tissues, has been recognized as a mechanism of failure in total hip replacement (THA). Different histological subtypes may have unique needs for longitudinal clinical follow-up and complication rates after revision arthroplasty. The purpose of this study was to describe the histological patterns observed in the periprosthetic tissue of failed THA in three different implant classes due to ALTR and their association with clinical features of implant failure.MethodsConsecutive patients presenting with ALTR from three major hip implant classes (N = 285 cases) were identified from our prospective Osteolysis Tissue Database and Repository. Clinical characteristics including age, sex, BMI, length of implantation, and serum metal ion levels were recorded. Retrieved synovial tissue morphology was graded using light microscopy. Clinical characteristics and features of synovial tissue analysis were compared between the three implant classes. Histological patterns of ALTR identified from our observations and the literature were used to classify each case. The association between implant class and histological patterns was compared.ResultsOur histological analysis demonstrates that ALTR encompasses three main histological patterns: 1) macrophage predominant, 2) mixed lymphocytic and macrophagic with or without features of associated with hypersensitivity/allergy or response to particle toxicity (eosinophils/mast cells and/or lymphocytic germinal centers), and 3) predominant sarcoid-like granulomas. Implant classification was associated with histological pattern of failure, and the macrophagic predominant pattern was more common in implants with metal-on-metal bearing surfaces (MoM HRA and MoM LHTHA groups). Duration of implantation and composition of periprosthetic cellular infiltrates was significantly different amongst the three implant types examined suggesting that histopathological features of ALTR may explain the variability of clinical implant performance in these cases.ConclusionsALTR encompasses a diverse range of histological patterns, which are reflective of both the implant configuration independent of manufacturer and clinical features such as duration of implantation. The macrophagic predominant pattern and its mechanism of implant failure represent an important subgroup of ALTR which could become more prominent with increased length of implantation.

Modified Girdlestone arthroplasty and hip arthrodesis using the Ilizarov external fixator as a salvage method in the management of severely infected total hip replacement.

Background:Resection arthroplasty or hip arthrodesis after total hip replacement (THR) can be used to salvage the limb in case with deep infection and severe bone loss. The Ilizarov fixator provides stability, axial correction, weight-bearing and good fusion rates.Materials and Methods:We retrospectively assessed the outcomes of 37 patients with severe periprosthetic infection after THR treated between 1999 and 2011. The treatment included implant removal, debridement and a modified Girdestone arthroplasty (29 cases) or hip arthrodesis (seven cases) using the Ilizarov fixator. The Ilizarov fixation continued from 45 to 50 days in the modified arthroplasty group and 90 days in the arthrodesis group. One case was treated using the conventional resection arthroplasty bilaterally.Results:Eighteen months after treatment, infection control was seen in 97.3% cases. Six hips were fused as one patient died in this group. Limb length discrepancy (LLD) averaged 5.5 cm. The Harris hip score ranged from 35 to 92 points. Hip joint motion ranged from 10° to 30° in the modified arthroplasty group. All subjects could walk independently or using support aids. No subluxation or LLD progression was observed.Conclusion:The modified Girdlestone arthroplasty and hip arthrodesis using the Ilizarov apparatus results in sufficient ability for ambulation and good infection control in cases of failed THR associated with severe infection.

Evidence that osteocyte perilacunar remodelling contributes to polyethylene wear particle induced osteolysis

Periprosthetic osteolysis (PO) leading to aseptic loosening, is the most common cause of failure of total hip replacement (THR) in the mid- to long-term. Polyethylene (PE) particulates from the wear of prosthesis liners are bioactive and are implicated in the initiation and or progression of osteolysis. Evidence exists that cells of the osteoblast/osteocyte lineage are affected by PE particles and contribute to the catabolic response by promoting osteoclastic bone resorption. In this study, we hypothesised that osteocytes contribute directly to PO by removing bone from their perilacunar matrix. Osteocyte responses to ultra-high molecular weight PE (UHMWPE) particles were examined in vitro in human primary osteocyte-like cultures, in vivo in the mouse calvarial osteolysis model, and in the acetabulum of patients undergoing revision total hip replacement (THR) surgery for PO. Osteocytes exposed to UHMWPE particles showed upregulated expression of catabolic markers, MMP-13, carbonic anhydrase 2 (CA2), cathepsin K (CTSK) and tartrate resistant acid phosphatase (TRAP), with no effect on cell viability, as assessed by Caspase 3 activity. Consistent with this catabolic activity causing perilacunar bone loss, histological analysis of calvarial sections from mice exposed to UHMWPE revealed a significant (p<0.001) increase in osteocyte lacunar area (Lac.Ar) compared to sham-operated animals. Furthermore, acetabular biopsies from patients with PO also showed significantly (p<0.001) increased osteocyte lacunar size in trabecular bone adjacent to PE particles, compared with osteocyte lacunar size in bone from primary THR patients. Together, these findings suggest a previously unrecognised action of UHMWPE wear particles on osteocytes, which directly results in a loss of osteocyte perilacunar bone. This action may exacerbate the indirect pro-osteoclastic action of UHMWPE-affected osteocytes, previously shown to contribute to aseptic loosening of orthopaedic implants. Statement of SignificanceThis study addresses the clinical problem of periprosthetic osteolysis, bone loss in response to polyethylene wear particles derived from materials used in orthopaedic implants. Periprosthetic osteolysis has been thought to be due largely to wear particles stimulating the activity of bone resorbing osteoclasts. However, in this study we demonstrate for the first time that polyethylene particles stimulate another type of bone loss, mediated by the direct activity of bone mineral embedded osteocytes, termed osteocytic osteolysis or osteocyte perilacunar remodelling. This study provides new mechanistic insight into wear-particle mediated bone loss and represents a new paradigm for the way in which bone cells, namely osteocytes, the key controlling cell type in bone, react to biomaterials.

Modular titanium alloy neck failure in total hip replacement: analysis of a relapse case.

Modular neck hip prosthesis born in the 1990 with the aim of allowing the surgeon to modify CCD angle, offset and femoral anteversion intra-operatively restoring patient’s original biomechanics. In order to achieve the best biomechanics of the reconstructed hip, preoperative planning is essential. In the last few years modularity has been questioned and an argument made for the return to mono block stems due to events of breakage or disconnection of modular components. Fretting or crevice corrosion may lead to failure of such modular device due to the contamination inside the modular coupling or to high loads. We present a case of repetitive modular femoral neck prosthesis fracture.

Predictive factors of aseptic loosening of cemented total hip prostheses

IntroductionLe descellement aseptique constitue la principale complication à long terme et signe la faillite de la prothèse totale de hanche. Les causes de descellement aseptique sont multiples et souvent intriquées. Le mal positionnement des implants reste le facteur le plus incriminé. D’autres facteurs liés au patient et à la prothèse prédisposent également au descellement mais à des degrés divers.MéthodesA travers une étude rétrospective portant sur 64 descellements aseptiques de prothèse totale de hanche, nous avons tenté d’individualiser les facteurs de descellement lié au patient, au type d’implant et à la technique chirurgicale et d’en dégager les recommandations visant à minimiser ce risque. Il s’agissait d’une étude rétrospective analytique portant sur 64 descellements aseptiques. La classification utilisée est celle de la Société Française de Chirurgie Orthopédique et Traumatologique.RésultatsLa moyenne d’âge au moment de la première arthroplastie était de 40 ans. Elle était de 62 au moment du descellement. La tige type Charnley a été implantée dans 55 cas, celle de type Muller dans 9 cas. La pièce cotyloïdienne a été bien positionnée dans 69% des cas avec une inclinaison moyenne de 47,8°. Les tiges étaient remplissantes dans 86% des cas avec un cimentage Grade A dans 60% des cas. Le délai moyen de la survenue du descellement était de 12 ans. 72% des prothèses avaient une survie supérieure à 10 ans. L’analyse statistique des résultats a individualisé les facteurs de risque du descellement que sont: L’âge, l’indexe de masse corporelle, le niveau d’activité, l’inclinaison de la cupule, le déport fémoral et la qualité du cimentage.ConclusionUne réduction significative des descellements aseptiques des prothèses totales de hanche ne pourra être obtenue que par une plus grande rigueur dans la sélection des patients, une plus grande sûreté dans l’acte technique et un meilleur choix de l’implant à poser.

Semaphorin-3a, neuropilin-1 and plexin-A1 in prosthetic-particle induced bone loss

Peri-prosthetic osteolysis (PPO) occurs in response to prosthetic wear particles causing an inflammatory reaction in the surrounding tissue that leads to subsequent bone loss. Semaphorin-3a (SEM3A), neuropilin-1 (NRP1) and plexin-A1 (PLEXA1) are axonal guidance molecules that have been recently implicated in regulating bone metabolism. This study investigated SEM3A, NRP1 and PLEXA1 protein and mRNA expression in human PPO tissue and polyethylene (PE) particle-stimulated human peripheral blood mononuclear cell (PBMC)-derived osteoclasts in vitro. In addition, the effects of tumour necrosis factor alpha (TNFα) on cultured osteoclasts was assessed. In PPO tissues, a granular staining pattern of SEM3A and NRP1 was observed within large multi-nucleated cells that contained prosthetic wear particles. Immunofluorescent staining confirmed the expression of SEM3A, NRP1 and PLEXA1 in large multi-nucleated human osteoclasts in vitro. Furthermore, SEM3A, NRP1 and PLEXA1 mRNA levels progressively increased throughout osteoclast differentiation induced by receptor activator of nuclear factor κB ligand (RANKL), and the presence of PE particles further increased mRNA expression of all three molecules. Soluble SEM3A was detected in human osteoclast culture supernatant at days 7 and 17 of culture, as assessed by ELISA. TNFα treatment for 72h markedly decreased the mRNA expression of SEM3A, NRP1 and PLEXA1 by human osteoclasts in vitro. Our findings suggest that SEM3A, NRP1 and PLEXA1 may have important roles in PPO, and their interactions, alone or as a complex, may have a role in pathological bone loss progression. Statement of SignificancePeri-prosthetic osteolysis occurs in response to prosthetic wear particles causing an inflammatory reaction in the surrounding tissue that leads to subsequent bone loss. The rate of hip and knee arthroplasty is increasing by at least 5% per year. However, these joint replacements have a finite lifespan, with data from the National Joint Replacement Registry (Australia) showing that the major cause of failure of total hip replacements is aseptic loosening. In aseptic loosening, wear particles liberated from prostheses are phagocytosed by macrophages, leading to release of inflammatory cytokines and up-regulation of osteoclast formation and activity. Semaphorin-3a, neuropilin-1 and plexin-A1 are axonal guidance molecules that have been recently implicated in regulating bone metabolism. This is the first report to show that these molecules may be involved in the implant failure.