Failure Of Hip Resurfacing Arthroplasty Research Articles

Can hip resurfacing be safely revised with short-stem total hip arthroplasty? A case series of six patients

BackgroundThe usage of short stems in primary total hip arthroplasty (THA) has constantly gained popularity over the last decade, however, to date, short stems are not eligible to be used as revision implants. The aim of this study was to retrospectively evaluate the outcome of revision surgery of failed hip resurfacing arthroplasty (HRA) using short-stem THA. MethodsIn a single center, retrospective analysis, 6 consecutive patients who were treated with a calcar-guided short stem after failure of HRA were evaluated. The mean follow-up was 3.25 years (SD 0.45). Patient reported outcome measurements (PROMs) were recorded using the Harris hip score (HHS) and The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The health status was evaluated by the EQ-5D-5L score. Pain and satisfaction were obtained using the visual analogue scale (VAS). Radiographic analysis was performed by evaluating osteolysis, stress shielding, alignement and signs of aseptic loosening. Complications were documented. ResultsAt last follow-up, clinical outcome was excellent (HHS ≥ 90) in 5 patients and good (HHS = 87) in 1 patient. The mean WOMAC score was 5.73% (SD 3.66%). The mean EQ-5D-5L index was 0.914 (SD 0.07). Pain and satisfaction on VAS was 1.83 (SD 5.18) and 8.67 (SD 0.94), respectively. Radiologically, no signs of subsidence, aseptic loosening, stress shielding and fracture were obvious. No major complications occurred. To date, no further revision surgery was needed. ConclusionsThe outcomes of the present case series propose that HRA can be safely revised using short-stem THA in a selected patient group. Clinical and radiological results are encouraging. Based on the present data, short stems may be considered as a revision implant for failed HRA for experienced surgeons.

Revision of hip resurfacing arthroplasty with a bone-conserving short-stem implant: a case report and review of the literature

IntroductionSuitable treatment of early failure of total hip replacement is critical in younger patients, as bone stock is lost and the functional outcome is impaired.Case presentationWe report the case of a 56-year-old Caucasian woman with early failure of hip resurfacing arthroplasty. While revision is usually performed with a conventional hip implant, this case report describes for the first time a revision procedure with a bone-conserving short-stem hip implant.ConclusionsOur approach allows further conservation of femoral bone stock and provides a long-term solution to the patient, which maintains the possibility of using a conventional hip implant should a second revision become necessary.

Sex differences in the morphological failure patterns following hip resurfacing arthroplasty

BackgroundMetal-on-metal hybrid hip resurfacing arthroplasty (with a cementless acetabular component and a cemented femoral component) is offered as an alternative to traditional total hip arthroplasty for the young and active adult with advanced osteoarthritis. Although it has been suggested that women are less appropriate candidates for metal-on-metal arthroplasty, the mechanisms of prosthesis failure has not been fully explained. While specific failure patterns, particularly osteonecrosis and delayed type hypersensitivity reactions have been suggested to be specifically linked to the sex of the patient, we wished to examine the potential influence of sex, clinical diagnosis, age of the patient and the size of the femoral component on morphological failure patterns in a large cohort of retrieved specimens following aseptic failure of hip resurfacing arthroplasty.MethodsFemoral remnants retrieved from 173 hips with known patient's sex were morphologically analyzed for the cause of failure. The results were compared with the control group of the remaining 31 failures from patients of unknown sex. The odds ratios (OR) and 95% confidence intervals (CI) of the following morphologically defined variables were calculated using logistic regression analysis: periprosthetic fractures (n = 133), osteonecrosis (n = 151), the presence of excessive intraosseous lymphocyte infiltration (n = 11), and interface hyperosteoidosis (n = 30). Logistic regression analysis was performed both unadjusted and after adjustment for sex, age, the size of the femoral component, and preoperative clinical diagnosis.ResultsFemoral remnants from female patients had a smaller OR for fracture (adjusted OR: 0.29, 95% CI 0.11, 0.80, P for difference = 0.02) and for the presence of osteonecrosis (adjusted OR: 0.16, 95% CI 0.04, 0.63, P for difference = 0.01). However, women had a higher OR for both the presence of excessive intraosseous lymphocyte infiltration (adjusted OR: 10.22, 95% CI 0.79, 132.57, P for difference = 0.08) and interface hyperosteoidosis (adjusted OR: 4.19, 95% CI 1.14, 15.38, P for difference = 0.03).ConclusionsWithin the limitations of this study, we demonstrated substantial sex differences in distinct failure patterns of metal-on-metal hip resurfacing. Recognition of pathogenically distinct failure modes will enable further stratification of risk factors for certain failure mechanisms and thus affect future therapeutic options for selected patient groups.

Hip resurfacing arthroplasty: current status and future perspectives

Hip resurfacing arthroplasty (HRA) is a concept of hip replacement that allows treating young active patients with a femoral bone preserving procedure. The proposed advantages of resuming an active lifestyle with increased frequency and duration of sports activities have been shown to be realistic. The 30-year cost-effectiveness in young male patients has been shown to be higher in resurfacing compared to conventional total hip replacement (THA). However, prognosticators of an inferior outcome have also been identified. The most important patient related factors are secondary osteoarthritis as the indication for surgery such as post-childhood hip disorders or AVN, female gender, smaller component sizes and older age (>65 years for males and >55 years for females). In addition, surgical technique (approach and cementing technique) and component design are also important determinant factors for the risk of failure. Moreover, concerns have surfaced with respect to high metal ion concentrations and metal ion hypersensitivities. In addition, the presumed ease of revising HRA has not reflected in improved or equal survivorship in comparison to a primary THA. This highlights the importance of identifying patient-, surgery-, and implant-related prognosticators for success or failure of HRA. Rather than vilifying the concept of hip resurfacing, detailed in depth analysis should be used to specify indications and improve implant design and surgical techniques.

Association of Osteonecrosis and Failure of Hip Resurfacing Arthroplasty

Association of Osteonecrosis and Failure of Hip Resurfacing Arthroplasty

Birmingham hip resurfacing

Despite the increasing interest and subsequent published literature on hip resurfacing arthroplasty, little is known about the prevalence of its complications and in particular the less common modes of failure. The aim of this study was to identify the prevalence of failure of hip resurfacing arthroplasty and to analyse the reasons for it. From a multi-surgeon series (141 surgeons) of 5000 Birmingham hip resurfacings we have analysed the modes, prevalence, gender differences and times to failure of any hip requiring revision. To date 182 hips have been revised (3.6%). The most common cause for revision was a fracture of the neck of the femur (54 hips, prevalence 1.1%), followed by loosening of the acetabular component (32 hips, 0.6%), collapse of the femoral head/avascular necrosis (30 hips, 0.6%), loosening of the femoral component (19 hips, 0.4%), infection (17 hips, 0.3%), pain with aseptic lymphocytic vascular and associated lesions (ALVAL)/metallosis (15 hips, 0.3%), loosening of both components (five hips, 0.1%), dislocation (five hips, 0.1%) and malposition of the acetabular component (three hips, 0.1%). In two cases the cause of failure was unknown. Comparing men with women, we found the prevalence of revision to be significantly higher in women (women = 5.7%; men = 2.6%, p < 0.001). When analysing the individual modes of failure women had significantly more revisions for loosening of the acetabular component, dislocation, infection and pain/ALVAL/metallosis (p < 0.001, p = 0.004, p = 0.008, p = 0.01 respectively). The mean time to failure was 2.9 years (0.003 to 11.0) for all causes, with revision for fracture of the neck of the femur occurring earlier than other causes (mean 1.5 years, 0.02 to 11.0). There was a significantly shorter time to failure in men (mean 2.1 years, 0.4 to 8.7) compared with women (mean 3.6 years, 0.003 to 11.0) (p < 0.001).

Reply to Letter to the Editor: Association of Osteonecrosis and Failure of Hip Resurfacing Arthroplasty

Reply to Letter to the Editor: Association of Osteonecrosis and Failure of Hip Resurfacing Arthroplasty

Letter to the Editor: Association of Osteonecrosis and Failure of Hip Resurfacing Arthroplasty

To the Editor: We read with interest, the article titled “Association of Osteonecrosis and Failure of Hip Resurfacing Arthroplasty” by Zustin et al. [12]. The authors discussed the findings in femoral head remnants retrieved from failed resurfacings with particular emphasis on the role of osteonecrosis, induced by the total hip resurfacing, in causing failure of surface arthroplasty. The role of osteonecrosis in causing failure of resurfacing has been debated among arthroplasty surgeons. Osteonecrosis may be caused by insult to the vascular supply [1, 11] or by thermal damage [6, 8]. However, postoperative radionuclide imaging studies have revealed no evidence of reduction in vascularity [5, 10]. Implant retrieval analyses after failed resurfacings have shown evidence of osteonecrosis of varying prevalence. Bradley et al. found evidence of osteonecrosis in two of 25 failed resurfacings [3], Howie et al. saw evidence in one of 72 [7], Little et al. saw evidence in 12 of 13 [9], and Campbell et al. saw evidence in seven of 98 [4]. We have some concerns regarding the study by Zustin et al. [12]. First, the assumption that histologic evidence of osteonecrosis observed in the retrieved specimens is induced by the resurfacing procedure is questionable in cases with periprosthetic fractures of the femoral neck. The osteonecrosis may be secondary to the femoral neck fracture [7]. Zustin et al. did not specify whether this issue was addressed. Histologic evidence of advanced osteonecrosis alone is insufficient as the time between the fracture and the revision surgery is not known and might be long enough to cause histologically advanced osteonecrosis after the periprosthetic fracture. Bogoch et al. [2] observed a biologic reaction at the bone-cement interface, which included a foreign body reaction to the polymethylmethacrylate, as evidenced by histiocytes, giant cells, and crystals of polymethylmethacrylate which are birefringent in polarized light. This reaction was observed to occur if the remnant head remains viable after resurfacing and would be absent if osteonecrosis was induced by the procedure. A remnant head retrieved after a periprosthetic fracture and showing a biologic reaction at the bone-cement interface along with evidence of osteonecrosis would suggest that the femoral head remained viable after the resurfacing procedure but underwent osteonecrosis after fracture of the femoral neck. Zustin et al. did not mention whether they analyzed the interface for any such evidence. Second, in cases with femoral loosening, areas adjacent to the interface may show evidence of superficial osteonecrosis [7]. Howie et al. advocate using sections from the central area of remnant heads to differentiate this from the generalized osteonecrosis caused by resurfacing [7]. Zustin et al. did not specify any precaution that they have taken to avoid this error. Third, patients with posttraumatic arthritis might have had posterior dislocation or posterior fracture-dislocation as the initial traumatic event or could have undergone surgery through the posterior approach and osteonecrosis developed before the resurfacing procedure. It would be interesting to know if such patients were included.

Association of Osteonecrosis and Failure of Hip Resurfacing Arthroplasty

Osteonecrosis (ON) has been reported in femoral remnants removed after failure of hip resurfacing arthroplasty. Experimental and clinical studies have further described thermal effects of the cementation technique, damage of extraosseous blood vessels, and intraoperative hypoxemia as possible causative factors. We analyzed histologically a series of 123 retrieved specimens with a preoperative diagnosis other than ON to investigate the incidence and extent of advanced ON. ON was found in 88% of cases and associated with 60% (51 of a total of 85) of periprosthetic fractures. The fracture incidence correlated with the extent of ON. Collapse of necrotic tissue in three (2%) cases resulted in disconnection of the bone stock-femoral component. We observed smaller regions of superficial ON in the majority of the remaining femoral remnants with periprosthetic fractures and in hips that failed for reasons other than fracture.