JBJS | Article

The Journal of Bone & Joint Surgery, Volume 84, Issue 4

Scientific Article | April 01, 2002

Comparison of Clinical Outcomes in Total Hip Arthroplasty Using Rough and Polished Cemented Stems with Essentially the Same Geometry

Dennis K. Collis, MD; Craig G. Mohler, MD

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Investigation performed at Orthopedic Healthcare Northwest, Eugene, Oregon

Dennis K. Collis, MD
Craig G. Mohler, MD
Orthopedic Healthcare Northwest, 1200 Hilyard Street, Suite 600, Eugene, OR 97401

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Zimmer. In addition, one or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Zimmer). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

The Journal of Bone & Joint Surgery. 2002; 84:586-592

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Abstract

Background: Aseptic loosening of the cemented stem is the most common cause of revision of total hip arthroplasties. The loosening is often associated with substantial lysis of the surrounding bone. The surface finish of femoral components is suspected as a contributing factor to this bone lysis. The purpose of this study was to compare the results associated with a rough surface and those associated with a polished surface in a consecutive series of cemented stems with essentially the same geometry.

Methods: The study included 244 consecutive total hip arthroplasties with a cemented femoral component performed by one surgeon. There was no difference in patient selection criteria or surgical techniques between the group treated with a polished stem and that treated with a grit-blasted stem. All arthroplasties were hybrid, with an uncemented acetabular component. Generally, patients were over the age of sixty years (mean age, 70.6 years). The stems inserted in the initial 122 hips had a grit-blasted surface with a roughness of 2.1 mm. The stem surface in the second 122 hips was polished (roughness, 0.1 mm). The results of clinical and radiographic assessments performed immediately after surgery were compared with those performed at the most recent visit. The average duration of clinical follow-up for the patients treated with the grit-blasted and polished stems was 5.98 years and 5.32 years, respectively.

Results: Four hips treated with the grit-blasted stem had aseptic loosening with substantial surrounding lysis and required revision. An additional two hips in this group had radiographic evidence of substantial lysis and were judged to have an impending need for revision. In contrast, no hip treated with the polished stem required revision, and only one had minimal lysis. This difference regarding failures and impending failures was significant (p = 0.05). The clinical results were comparable, with an Iowa hip rating of 98 points at the time of follow-up in both groups.

Conclusions: There was a significant difference between grit-blasted and polished stems with respect to the prevalence of revisions and impending revisions, all of which were identified in a relatively short follow-up period. The results in this series favor the use of a polished stem when cement is employed for fixation of the femoral component.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Aseptic loosening is the most common reason for revision of a cemented femoral component following total hip replacement ^1-13 . Initial reports attributed this aseptic loosening and the destruction of surrounding bone to "cement disease" ^5,7,14-16 . Subsequently, concerns have been raised about the potential for stems with rough metal surfaces to abrade cement and cause bone lysis ^{2,4,6,10,12,17-19} .

The clinical experience of the senior one of us (D.K.C.) encompasses the application of both Charnley's original technique of grouting a polished stem with cement and the subsequent technique of using a roughened stem bonded to the cement ^3,4,20,21 . Initially, the senior author used polished stems, but he switched to a roughened stem in the late 1970s ³ . Early failures of these roughened stems, characterized by aseptic loosening and surrounding bone lysis, prompted him to return to the use of cemented stems with a polished surface10.

This paper presents the results of a consecutive series of total hip arthroplasties, 122 of which were performed with a cemented Iowa stem (Zimmer, Warsaw, Indiana) with a polished surface (roughness, 0.1 μm) and the preceding 122 of which were performed with a cemented Iowa stem with a rough surface (roughness, 2.1 μm). The femoral components had essentially the same geometry but different surface characteristics. The early dramatic difference between the outcomes achieved with these stems prompted this report.

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Fig. 1-A:: Figs. 1-A through 1-D A woman who was 160 cm tall and who weighed 63 kg had a total hip replacement with a grit-blasted stem in September 1992, when she was sixty years old. She was doing well at the one-year examination, but when she returned at five years, radiographs showed definite osteolysis and loosening of the stem with substantial bone destruction. Surgery was recommended at that time, but before it could be scheduled the patient sustained a fracture of the femur, which required allografting with a cortical allograft strut as well as revision of the stem. Fig. 1-A Postoperatively, a Grade-A cement mantle was seen.

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Fig. 1-B:: By five years postoperatively, major lysis was seen.

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Fig. 1-C:: Fracture through the lytic bone.

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Fig. 1-D:: Revision requiring allografting with an allograft cortical strut.

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Fig. 2-A:: Figs. 2-A, 2-B, and 2-C A man who was 175 cm tall and who weighed 91 kg had an arthroplasty with a polished stem at the age of seventy-seven years. It debonded by one year. No change or lysis was seen after five more years of follow-up. Fig. 2-A Appearance of the polished stem six months postoperatively.

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Fig. 2-B:: By one year postoperatively, the stem was seen to be debonded.

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Fig. 2-C:: At five years and three months postoperatively, there was no lysis.

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TABLE I: Patient Demographics

	Iowa Stem
Grit-Blasted	Polished
Gender (no. of patients)
Male	46 (38%)	54 (44%)
Female	76 (62%)	68 (56%)
Mean age (and standard deviation) (yr)	71.0 ±; 8.6	70.2 ±; 8.0
Age of <60 yr (no. of patients)	4	10
Degenerative joint disease as preop. diagnosis	85%	86%
Mean duration of follow-up (yr)	5.98	5.32
Mean Iowa hip rating (points)
Preop.	47.9	48.0
Follow-up	97.8	98.2

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TABLE I: Patient Demographics

	Iowa Stem
Grit-Blasted	Polished
Gender (no. of patients)
Male	46 (38%)	54 (44%)
Female	76 (62%)	68 (56%)
Mean age (and standard deviation) (yr)	71.0 ±; 8.6	70.2 ±; 8.0
Age of <60 yr (no. of patients)	4	10
Degenerative joint disease as preop. diagnosis	85%	86%
Mean duration of follow-up (yr)	5.98	5.32
Mean Iowa hip rating (points)
Preop.	47.9	48.0
Follow-up	97.8	98.2

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

A consecutive series of 244 total hip arthroplasties were performed by the senior author between February 1992 and August 1994. The initial 122 stems had a rough surface and the subsequent 122 stems were polished. During this study period, the senior author also implanted sixty-four uncemented, proximally porous-coated stems, for the most part in patients under the age of sixty years who had good bone cortex without substantial osteoporosis and who anticipated resuming an active lifestyle. Therefore, the 244 hips with a cemented stem that are included in this study represent a selected but consecutive series.

The Iowa stems were made of cobalt-chromium and had a cobra-shaped proximal geometry selected on the basis of the findings of a published basic-science study22. The Iowa stem initially had a bead-blasted surface finish with a roughness of approximately 0.8 μm. Beginning in 1986, the manufacturer, in response to reports of early aseptic loosening of other stems, applied a precoating of polymethylmethacrylate to the proximal third of the stem. To secure the polymethylmethacrylate, the manufacturer grit-blasted the stem to a surface roughness of 2.1 μm. Because of failures of these stems ¹⁰ , the senior author and Dr. Richard Johnston, one of the original developers of the Iowa stem, subsequently asked the manufacturer to provide a stem with a polished surface (roughness, 0.1 μm). The essential geometry of this oval-shaped stem was not changed. An effort was made to slightly flatten the anterior and posterior surfaces, but this change removed only <1.0 mm of metal from the anterior-posterior dimension of the middle portion of the stem.

The patient demographics of the two groups were similar ( Table I ). Surgical and cement techniques did not vary over the course of the study. An anterolateral surgical approach was used in all but three hips treated with the grit-blasted stem and in all but two hips treated with the polished stem. The cement technique consistently included careful preparation of the canal by curetting, pressurized lavage with saline solution, and drying with an adrenaline sponge. In every case, a distal plug was placed in the femoral canal and vacuum-mixed Simplex cement (Howmedica, Rutherford, New Jersey) was inserted at a relatively late stage. The cement was pressurized manually. A porous ingrowth hemispherical cup was inserted without cement in all of the hips in this study. All patients were given prophylactic intravenous cefazolin and either warfarin or enoxaparin as prophylaxis against deep-vein thrombosis and pulmonary embolism.

The postoperative rehabilitation was the same for all patients. The patients walked on the first postoperative day and were discharged between four and six days postoperatively. They used crutches for six weeks and then a cane for an additional six weeks. Follow-up office visits were routinely scheduled at six weeks, three months, six months, one year, two years, and then every two years. For this study, patients in both groups who had not had a five-year follow-up evaluation were asked to return to the office for radiographs and clinical examination.

By January 2001, twenty-two patients treated with the grit-blasted stem and eighteen treated with the polished stem had died. Seventeen patients treated with the grit-blasted stem and five treated with the polished stem were considered lost to follow-up, because they had not returned for the one-year postoperative office visit and had not responded to written and telephone communications. The average duration of follow-up was 5.98 years for the remaining eighty-three hips treated with the grit-blasted stem and 5.32 years for the remaining ninety-nine hips treated with the polished stem. Seventy-eight hips treated with the grit-blasted stem and seventy-one treated with the polished stem were followed for five years or longer. Immediate postoperative radiographs were evaluated independently by both surgeons. The criteria described by Barrack et al. in 19921 were used to grade the cement technique, without knowledge of whether the stem was polished or grit-blasted. Because the grit-blasted and polished stems were not designed to provide any method for distal centralization, the tip of the prosthesis was sometimes noted to be eccentric in the canal. In such cases, it often was not possible to distinguish between cement and bone around the distal aspect of the prosthesis. Therefore, the grading of the cement mantles in this study was difficult, but we attempted to grade each one according to the method originally discussed by Barrack et al. The most recent radiographs were compared with the initial and interim radiographs to identify lysis or debonding of the prostheses.

Clinical results were assessed prospectively with the Iowa hip rating system ²³ . The mean preoperative hip rating was 47.9 points (range, 7 to 78 points) for the hips treated with the grit-blasted stem and 48.0 points (range, 25 to 76 points) for those treated with the polished stem. At the most recent follow-up examination, the ratings were 97.8 points (range, 58 to 99 points) and 98.2 points (range, 85 to 99 points), respectively.

Kaplan-Meier survivorship analysis was used to estimate and compare the survival rates between the two groups. Failure was defined as revision of the femoral component because of aseptic loosening or impending revision because of pain and limp noted at the clinical examination and radiographic changes of bone.

Results

Introduction | Materials and Methods | Results | Discussion | References

As of January 2001, four of the 122 grit-blasted stems had been revised because of aseptic loosening and pain ( Figs. 1-A , 1-B , 1-C , and 1-D ). Each of these revisions was complicated by substantial surrounding bone lysis and required major bone-grafting. In addition, two hips treated with the grit-blasted stem had substantial bone loss from lysis and were judged to need a revision. Three of the four revisions were in hips that had been judged to have a Grade-A cement mantle postoperatively, and the remaining revision was in a hip that had had a Grade-B mantle. All four patients had been doing well two years postoperatively, but the four revisions were required at three, four, five, and seven years after the initial surgery. In contrast, none of the hips that received a polished stem required a revision or was judged to have substantial bone loss or to need a revision.

Radiographic Evaluation

We determined that thirty-six of the hips treated with the grit-blasted stem and twenty-five of those treated with the polished stem had a Grade-A cement mantle. Twelve of the hips with a grit-blasted stem had a C1 mantle and ten had a C2 mantle compared with seventeen and thirteen, respectively, of the hips treated with the polished stem. The remaining mantles were rated as Grade B, which was the senior author's desired postoperative radiographic outcome.

A review of the most recent follow-up radiographs showed that one femur treated with the grit-blasted stem had a large area of bone lysis measuring 6 by 110 mm in femoral zones 4, 5, and 6 and was judged to require a revision. Three other hips treated ²⁴ with the grit-blasted stem had lesser but substantial lysis and were also judged as likely candidates for revision. In contrast, only a single case of bone lysis, located in zone 5 and measuring 12 by 2 mm, was noted in association with the polished stems.

One grit-blasted stem was found to have debonded and was associated with substantial lysis. In contrast, the single polished stem that was noted to be debonded was not associated with bone lysis at five years ( Figs. 2-A , 2-B , and 2-C ).

Nine grit-blasted stems were associated with bone-cement lucency measuring 2 to 4 mm in one or more zones. Similar areas of lucency were seen in eight hips treated with the polished stem. These bone-cement lucencies were considered to be adaptive remodeling changes at the bone-cement interface rather than lysis because they did not have the classic scalloping and erosive destruction and thinning of the cortex typical of true bone lysis. Two cups in hips treated with the grit-blasted stem and one in a hip treated with the polished stem were noted to have a measurable amount of wear (2 to 4 mm) on follow-up radiographs.

The estimated survival rate for the grit-blasted stems was 91.9% (95% confidence interval, 84.5 to 99.3%) at seven years after surgery; the failures included four revisions and two impending revisions. The survival rate of the polished stems was 100% seven years after surgery; there were no revisions or impending revisions. The difference between the two groups was significant (p = 0.05).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

In his early description of the use of cement to fix components to bone, Charnley stated that cement was to be used as a grout, not a bonding agent ²⁵ . The original prosthesis used by Charnley had a polished surface26,27. Good long-term results with the use of a grouted, polished Charnley prosthesis have been consistently reported at many centers ^{2,6,9,11-13,17,28} . Schulte et al. ¹¹ noted only a 3% prevalence of aseptic loosening of the femoral component requiring revision after a minimum duration of follow-up of twenty years. Those authors also reported a 38% prevalence of debonding of the prosthesis from the cement mantle. Although these stems were often debonded for many years, the patients maintained excellent clinical function with no notable pain. The senior author of the present study used the Charnley prosthesis in 168 hips from 1970 to 1975; at a minimum of twenty years, only eight stems needed revision. None of these hips had any evidence of bone lysis ^3,20 . Studies from the Mayo Clinic ⁹ and from England ^8,13 have shown similar results.

By the late 1970s, manufacturers were routinely producing stems with matte finishes ²⁹ . Fowler et al. ¹⁸ and Rockborn and Olsson ¹⁹ noted that the results of matte-finished stems were distinctly inferior to those of polished stems. Dall et al. ⁶ compared the results of 264 first-generation polished Charnley stems with those of 402 second-generation and subsequent-generation stems of similar geometry but with a matte finish. They found that the matte stems had a nearly fourfold higher prevalence of loosening (11.8%) than the polished stems (3.1%).

In the early 1980s, the concept of bonding the stem with the use of cement as an adhesive rather than as a grouting agent became popular. So-called second-generation cementing techniques, including distal plugging of the canal, pressurized lavage of bone with saline solution, and drying and compression of the cement into the plugged distal part of the canal, were introduced ^7,30,31 . Excellent results were reported with bead-blasted femoral components inserted with second-generation cementing techniques ^1,16,31 . So-called third-generation techniques, including diminishing voids in the cement by centrifugation or vacuum mixing, were subsequently introduced ¹⁴ . In addition, manufacturing processes were changed to make the surface finish of stems rougher and, in some cases, a precoating of polymethylmethacrylate was applied to enhance bonding at the bone-cement interface.

The senior author (D.K.C) was involved in a study that demonstrated relatively early loosening of a small percentage (1%) of rough-surfaced Iowa stems ¹⁰ . Although this prevalence was quite low, the early loosening along with the major bone loss that was associated with it was of concern to the authors. They attributed this problem in part to the geometry of the stem but also, more importantly, to the rough surface finish. Generally, during the period of that study, the senior author of the present study used uncemented stems in patients under the age of sixty years. Therefore, the average age of the patients in whom he inserted a cemented Iowa stem was sixty-eight years. The rate of loosening of these 1041 rough Iowa stems still remains low, at 4.0% (forty-two stems). In contrast, Dr. Richard Johnston (another of the authors) used the cemented Iowa prosthesis in all age-groups. In his patients who were under fifty years of age, the rate of aseptic loosening of second-generation, grit-blasted Iowa stems (roughness, 2.1 μm) was 18% (eight stems), whereas the rate of aseptic loosening of first-generation, smoother Iowa stems (roughness, 0.8 μm) was 6% (two stems) ¹² . Both of these rates are higher than the rate of 3% (three stems) that Dr. Johnston obtained with the use of polished Charnley stems in the early 1970s ¹¹ .

A careful study of the radiographic appearance of the hips in the present study also provided interesting results. The cement grade was assessed on the initial postoperative radiograph to be consistent with the grading methodology originally described by Barrack et al. in 1992 ¹ . The four failed femoral stems that required revision had either a Grade-A (three stems) or Grade-B (one stem) cement mantle as assessed on immediate postoperative radiographs.

In contrast to the conclusion of this study, in a recent report of the results of the use of cemented Iowa stems, Cannestra et al. ³² attributed the failures to the geometry, shape, and increased offset of the stems, and to the effect that these factors had on the cementing technique and strain, rather than to the surface finish. Also, those authors found a relationship between a lower cement grade and the prevalence of failure, a finding that was just the opposite of ours. Unfortunately, those authors compared their series of Iowa stems to a series of Harris precoated stems previously reported on by one of us (C.G.M.) ³³ . These two series were derived from two different populations of patients, and the authors compared stems with different geometries and offsets that had been implanted in different time-periods by several surgeons over a nine-year period. In contrast, the series of hips in the present report was consecutive and was treated in a 2.5-year period with the same surgical techniques by the same surgeon. Our two groups were nearly the same with regard to gender and age, and the geometry, shape, and offset of the two stems were essentially the same as well. The only notable difference was the surface finish. These factors support the conclusion that the significant difference between the results in the two groups was due to the difference in surface finish.

The difference in the early outcomes in this study of 244 hips, in conjunction with favorable outcomes with polished stems reported in studies ^{3,4,9,11-13,15,17,18,27} with longer follow-up has compelled us to use only a polished stem with a rectangular geometry (similar to the original Charnley implant) when we perform a total hip arthroplasty with cementing of the femoral component.

References

Introduction | Materials and Methods | Results | Discussion | References

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Callaghan JJ, Forest EE, Sporer SM, Goetz DD,Johnston RC. Total hip arthroplasty in the young adult. Clin Orthop,1997;344: 257-62.. 344257 1997 [PubMed]

Collis DK. The value of maintaining outcomes in an individual practice for 25 years. Clin Orthop,1997;344: 69-80.. 34469 1997 [PubMed]

Collis DK,Mohler CG. Loosening rates and bone lysis with rough finished and polished stems. Clin Orthop,1998;355: 113-22.. 355113 1998 [PubMed]

Cornell CN,Ranawat CS. Survivorship analysis of total hip replacements. Results in a series of active patients who were less than fifty-five years old. J Bone Joint Surg Am,1986;68: 1430-4.. 681430 1986 [PubMed]

Dall DM, Learmonth ID, Solomon MI, Miles AW,Davenport JM. Fracture and loosening of Charnley femoral stems. Comparison between first-generation and subsequent designs. J Bone Joint Surg Br,1993;75: 259-65.. 75259 1993 [PubMed]

Harris WH,McGann WA. Loosening of the femoral component after use of the medullary-plug cementing technique. Follow-up note with a minimum five-year follow-up. J Bone Joint Surg Am,1986;68: 1064-6.. 681064 1986 [PubMed]

Joshi AB, Porter ML, Trail IA, Hunt LP, Murphy JC,Hardinge K. Long-term results of Charnley low-friction arthroplasty in young patients. J Bone Joint Surg Br,1993;75: 616-23.. 75616 1993 [PubMed]

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Mohler CG, Callaghan JJ, Collis DK,Johnston RC. Early loosening of the femoral component at the cement-prosthesis interface after total hip replacement. J Bone Joint Surg Am,1995;77: 1315-22.. 771315 1995 [PubMed]

Schulte KR, Callaghan JJ, Kelly SS,Johnston RC. The outcome of Charnley total hip arthroplasty with cement after a minimum twenty-year follow-up. The results of one surgeon. J Bone Joint Surg Am,1993;75: 961-75. Erratum 1993;75:1418.. 75961 1993 [PubMed]

Sporer SM, Callaghan JJ, Olejniczak JP, Goetz DD,Johnston RC. The effects of surface roughness and polymethylmethacrylate precoating on the radiographic and clinical results of the Iowa hip prosthesis. A study of patients less than fifty years old. J Bone Joint Surg Am,1999;81: 481-92.. 81481 1999 [PubMed]

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Fig. 1-B:: By five years postoperatively, major lysis was seen.

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Fig. 1-C:: Fracture through the lytic bone.

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Fig. 1-D:: Revision requiring allografting with an allograft cortical strut.

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Fig. 2-B:: By one year postoperatively, the stem was seen to be debonded.

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Fig. 2-C:: At five years and three months postoperatively, there was no lysis.

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TABLE I: Patient Demographics

	Iowa Stem
Grit-Blasted	Polished
Gender (no. of patients)
Male	46 (38%)	54 (44%)
Female	76 (62%)	68 (56%)
Mean age (and standard deviation) (yr)	71.0 ±; 8.6	70.2 ±; 8.0
Age of <60 yr (no. of patients)	4	10
Degenerative joint disease as preop. diagnosis	85%	86%
Mean duration of follow-up (yr)	5.98	5.32
Mean Iowa hip rating (points)
Preop.	47.9	48.0
Follow-up	97.8	98.2

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TABLE I: Patient Demographics

	Iowa Stem
Grit-Blasted	Polished
Gender (no. of patients)
Male	46 (38%)	54 (44%)
Female	76 (62%)	68 (56%)
Mean age (and standard deviation) (yr)	71.0 ±; 8.6	70.2 ±; 8.0
Age of <60 yr (no. of patients)	4	10
Degenerative joint disease as preop. diagnosis	85%	86%
Mean duration of follow-up (yr)	5.98	5.32
Mean Iowa hip rating (points)
Preop.	47.9	48.0
Follow-up	97.8	98.2