The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 6

Scientific Articles | June 01, 2004

Primary Total Hip Arthroplasty with a Porous-Coated Acetabular Component: A Concise Follow-up of a Previous Report*

Craig J. Della Valle, MD¹; Richard A. Berger, MD¹; Susan Shott, PhD¹; Aaron G. Rosenberg, MD¹; Joshua J. Jacobs, MD¹; Laura Quigley, MS¹; Jorge O. Galante, MD¹

¹ Department of Orthopaedic Surgery, Rush University Medical Center, 1725 West Harrison Street, Suite 1063, Professional Building, Chicago, IL 60612. E-mail address for C.J. Della Valle: craigdv@yahoo.com

View Disclosures and Other Information

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). Also, a commercial entity (Zimmer) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Original Publication

Tompkins GS, Jacobs JJ, Kull LR, Rosenberg AG, Galante JO. Primary total hip arthroplasty with a porous-coated acetabular component. Seven-to-ten-year results. J Bone Joint Surg Am. 1997;79:169-76.

Investigation performed at the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois

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J Bone Joint Surg Am, 2004 Jun 01;86(6):1217-1222

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Abstract

We previously reported the seven-to-ten-year results of the use of a porous-coated acetabular metal shell in a consecutive series of 204 primary total hip arthroplasties. In the present study, we evaluated the longer-term outcomes of these arthroplasties, at fifteen to eighteen years. One hundred and thirty-six (96%) of the 142 hips available for study retained the original acetabular metal shell. Three of the 142 metal shells failed secondary to aseptic loosening. Ten hips (7%) required a change of the modular acetabular liner because of excessive wear or for the treatment of osteolysis. The fifteen-year rate of survival of the metal shell, with failure defined as revision because of loosening or radiographic evidence of loosening, was 99%. The rate of survival of cementless acetabular reconstructions was excellent at fifteen years, although osteolysis and reoperations were noted to occur much more frequently as the duration of follow-up increased. The majority of the complications were related to wear of the polyethylene liner.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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Background

Background | Methods | Results | Conclusions | References

We previously reported the seven-to-ten-year results of the use of a porous-coated acetabular metal shell inserted without cement (Harris-Galante I; Zimmer, Warsaw, Indiana) in a consecutive series of 204 primary total hip arthroplasties performed in 184 patients by four surgeons at our institution¹. The acetabular metal shell is hemispherical, made of commercially pure titanium, and fully coated with sintered titanium fiber-metal mesh. The surgical technique included reaming of the acetabulum, with hemispherical reamers, to the same diameter as the component to be inserted and the use of three to six bone screws for supplemental fixation.

The acetabular liner was made of ram-extruded, machined GUR 415 polyethylene sterilized by gamma irradiation in air. A 28-mm femoral head was used in all hips. One hundred and ninety of the femoral heads were cobalt-chromium and fourteen were titanium alloy. The femoral components consisted of 151 cementless Harris-Galante-I components, thirty-nine cemented Harris Precoat components, and fourteen cementless Gustilo-Kyle components (all manufactured by Zimmer).

The mean age of the patients at the time of surgery was fifty-two years (range, twenty to eighty-four years). After seven to ten years of follow-up, twenty-eight hips had undergone a reoperation. No cup had been revised because of aseptic loosening, although one cup was loose radiographically (Tables I and II). The goal of this update was to present the longer-term outcomes associated with this implant.

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TABLE I Reoperations Following the Two Hundred and Four Arthroplasties

Type of Reoperation	7 to 10-Yr Follow-up*	15 to 18-Yr Follow-up*
All	28 (14)	63 (31)
Femoral revision with liner exchange	14 (7)	36 (18)
Femoral revision without liner exchange	4 (2)	4 (2)
Liner exchange because of liner wear and/or osteolysis	3 (1)	10 (5)
Revision of well-fixed acetabular component	2 (1)	5 (2)
Revision of loose acetabular component	0 (0)	1 (0.5)

The values are given as the number of hips, with the percentage in parentheses.

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TABLE I Reoperations Following the Two Hundred and Four Arthroplasties

Type of Reoperation	7 to 10-Yr Follow-up*	15 to 18-Yr Follow-up*
All	28 (14)	63 (31)
Femoral revision with liner exchange	14 (7)	36 (18)
Femoral revision without liner exchange	4 (2)	4 (2)
Liner exchange because of liner wear and/or osteolysis	3 (1)	10 (5)
Revision of well-fixed acetabular component	2 (1)	5 (2)
Revision of loose acetabular component	0 (0)	1 (0.5)

The values are given as the number of hips, with the percentage in parentheses.

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TABLE II Radiographic Results

Radiographic Result	7 to 10-Yr Follow-up* (N = 165)	15 to 18-Yr Follow-up* (N = 107)
Well-fixed	156 (95)	101 (94)
Definitely loose	1 (1)	3 (3)
Probably loose	0 (0)	0 (0)
Possibly loose	8 (5)	3 (3)
Periacetabular osteolysis	7 (4)	27 (25)

The values are given as the number of hips, with the percentage in parentheses.

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TABLE II Radiographic Results

Radiographic Result	7 to 10-Yr Follow-up* (N = 165)	15 to 18-Yr Follow-up* (N = 107)
Well-fixed	156 (95)	101 (94)
Definitely loose	1 (1)	3 (3)
Probably loose	0 (0)	0 (0)
Possibly loose	8 (5)	3 (3)
Periacetabular osteolysis	7 (4)	27 (25)

The values are given as the number of hips, with the percentage in parentheses.

Methods

Background | Methods | Results | Conclusions | References

The patients were evaluated prospectively, and the data were reviewed retrospectively at a minimum of fifteen years postoperatively. Institutional review board approval was obtained for the study. Clinical evaluation was performed with use of the Harris hip score², and the clinical result was considered excellent if the score was =90 points, good if it was between 80 and 89 points, fair if it was between 70 and 79 points, and poor if it was <70 points¹. The techniques utilized for radiographic evaluation (including definitions of definitely loose, probably loose, and possibly loose) have been previously reported by Martell et al.³. Osteolysis was defined according to the criteria described by Archibeck et al.⁴.

Kaplan-Meier survivorship analyses⁵ were performed with the use of several different end points: revision of the acetabular metal shell because of aseptic loosening or radiographic evidence of definite loosening, a reoperation on the hip for any problem related to the acetabular metal shell, periacetabular osteolysis, and revision of the femoral component. All radiographic and clinical data available for all 204 hips were used for these analyses. Log-rank tests and bivariate and multivariate Cox proportional hazards regression analyses were performed to determine whether sex, age, weight, body mass index, diagnosis, thickness of the polyethylene liner, type of femoral head (cobalt-chromium or titanium), or acetabular inclination angle were related to the risk of failure, with failure defined as described above for the Kaplan-Meier analyses. A 0.05 significance level was used for all statistical tests.

Results

Background | Methods | Results | Conclusions | References

At a minimum of fifteen years postoperatively, fifty-one patients (fifty-six total hip arthroplasties) had died and five patients (six total hip arthroplasties) had been lost to follow-up, leaving 142 hips in 128 patients. Ninety-four patients (107 hips) had both clinical and radiographic evaluations, and thirty-four patients (thirty-five hips) had only a clinical evaluation. Thirty of these patients (thirty-one hips) completed a telephone questionnaire. The latest clinical and radiographic evaluations were performed at a mean of 196 months (range, 180 to 217 months) postoperatively.

The Harris hip score for the unrevised hips improved from a mean of 53 points preoperatively to a mean of 91 points at the time of follow-up (p < 0.001; nonparametric Friedman test). A comparison of the Harris hip scores in the present study and those determined at seven to ten years is shown in Table III. Eight patients (eight hips; 6%) had a poor result. Four of them were living in nursing homes, three had other musculoskeletal problems, and one had a nonunion of the greater trochanter following a femoral component revision.

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TABLE III Clinical Results

Clinical Result	7 to 10-Yr Follow-up* (N = 173)	15 to 18-Yr Follow-up* (N = 142)
Good or excellent	144 (83)	119 (84)
Fair	9 (5)	15 (10)
Poor	20 (12)	8 (6)

The values are given as the number of hips, with the percentage in parentheses.

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TABLE III Clinical Results

Clinical Result	7 to 10-Yr Follow-up* (N = 173)	15 to 18-Yr Follow-up* (N = 142)
Good or excellent	144 (83)	119 (84)
Fair	9 (5)	15 (10)
Poor	20 (12)	8 (6)

The values are given as the number of hips, with the percentage in parentheses.

At the most recent evaluation, ten (5%) of the 204 hips had required exchange of the polyethylene liner, five well-fixed acetabular metal shells (2%) had been revised, and one loose acetabular metal shell (0.5%) had been revised (Table I). The three additional revisions of well-fixed acetabular components since the last report were performed for the treatment of osteolysis at 103, 123, and 138 months postoperatively. Of the 142 hips followed for more than fifteen years or until revision surgery, 136 (96%) retained the original acetabular metal shell.

Since the original report, an additional seven hips underwent exchange of the modular acetabular liner (Table I); thus, a total of ten (7%) of the 142 hips followed for more than fifteen years required exchange of the modular acetabular liner, at a mean of 133 months (range, seventy-nine to 187 months). Seven liners were exchanged because of wear, and three were exchanged because of wear and osteolysis.

Table II shows a comparison of the radiographic results at seven to ten years with those at fifteen to eighteen years. Of the eight cups that had been considered to be possibly loose at seven to ten years, one cup became definitely loose, four showed no progression of the loosening, and three were in patients who declined to have further radiographic evaluation. One of these three patients was noted to have a stable cup at the time of femoral revision, but we were unable to obtain adequate radiographs for evaluation. The patients who survived for more than fifteen years had a total of three definitely loose cups; one loose cup was scheduled for revision surgery at the time of writing, one cup was asymptomatic (a Harris hip score of 98 points at eighteen years), and the third cup was in a patient who died without requiring revision surgery.

Periacetabular osteolysis was seen in seven (4%) of the 165 hips evaluated radiographically at seven to ten years (Table II). Progressive, retroacetabular osteolysis subsequently developed in three of these hips, and one of them underwent revision of a well-fixed cup at another institution. Progressive peripheral osteolysis developed in a third hip, in which the cup became loose as seen radiographically. In two hips, the osteolysis decreased following femoral revision and exchange of the acetabular liner. In the final hip, the osteolysis did not progress.

Of the 107 hips in which the acetabular metal shell survived for more than fifteen years and for which radiographs were available, twenty-seven (25%) had periacetabular osteolysis (Table II), which was first observed at a mean of 151 months (range, forty-two to 210 months). Nineteen hips showed small peripheral lesions, three showed large peripheral lesions, one showed a small retroacetabular lesion, one showed a large retroacetabular lesion, and three showed combined lesions (two of which were large retroacetabular lesions combined with a small peripheral lesion). Osteolysis was seen in seven of the fourteen hips that had a titanium femoral head.

Kaplan-Meier survivorship analysis, with failure defined as revision of the acetabular metal shell because of aseptic loosening or radiographic evidence of definite loosening, demonstrated that the fifteen-year survival rate for the entire cohort of 204 acetabular metal shells was 99% (Fig. 1). With failure defined as a reoperation on the hip for any problem related to the acetabular component (e.g., aseptic loosening of the component, severe wear of the liner, or osteolysis), the fifteen-year survival rate was 93% (Fig. 2). Survivorship analysis revealed that, at eighteen years, 75% of the metal shells were not associated with radiographic evidence of osteolysis (Fig. 3).

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Fig. 1: Kaplan-Meier survivorship curve with revision of the acetabular component because of aseptic loosening or radiographic evidence of definite loosening as the end point.

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Fig. 2: Kaplan-Meier survivorship curve with a reoperation on the hip for any problem related to the acetabular component as the end point.

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Fig. 3: Kaplan-Meier survivorship curve showing the time of the first radiographic evidence of osteolysis. At eighteen years, 75% of the hips had no evidence of periacetabular osteolysis.

Although not the focus of this report, the outcomes of the femoral components were also studied. Nine (64%) of the fourteen Gustilo-Kyle stems, thirty (20%) of the 151 Harris-Galante-I stems, and two (5%) of the thirty-nine Harris Precoat stems were revised. The rate of survival of the femoral components, with revision considered the end point, was 76% at fifteen years (Fig. 4).

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Fig. 4: Kaplan-Meier survivorship curve with revision of the femoral component as the end point.

A higher risk of a reoperation for a problem related to the acetabular component was associated with thinner polyethylene liners (p = 0.001), younger patient age (p = 0.007), lower patient weight (p = 0.035), and higher acetabular inclination angles (p = 0.046). The risk of osteolysis was greater when a titanium femoral head had been used (p < 0.001), and the risk decreased as patient age at the time of the operation increased (p = 0.003). No patient in this study who was more than fifty-nine years old at the time of the operation required a reoperation for a problem related to the acetabular component, and no patient who was more than sixty-five years old at the time of the operation had osteolysis.

Conclusions

Background | Methods | Results | Conclusions | References

On the basis of our results, we continue to use a cementless, porous-coated acetabular component with fiber-metal mesh for the majority of primary total hip arthroplasties at our institution. Although good results have been reported after arthroplasties in which a cementless acetabular metal shell was inserted with a press-fit technique without screws⁶, we continue to use screws in the majority of reconstructions as an adjunct to obtaining a press-fit of the component by underreaming the acetabulum by 1 or 2 mm. The increased number of reoperations because of liner wear and the increased prevalence of osteolysis underscore the importance of close radiographic monitoring of all patients who have undergone a total hip arthroplasty, since both liner wear and osteolysis are often asymptomatic. As the majority of the reoperations in this cohort were related to wear of the polyethylene liner (and not to loss of component fixation), the use of more wear-resistant bearing surfaces may yield a lower reoperation rate.

References

Background | Methods | Results | Conclusions | References

Tompkins GS, Jacobs JJ, Kull LR, Rosenberg AG, Galante JO. Primary total hip arthroplasty with a porous-coated acetabular component. Seven-to-ten-year results. J Bone Joint Surg Am.1997;79: 169-76.79169 1997

Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am.1969;51: 737-55.51737 1969 [PubMed]

Martell JM, Pierson RH 3rd, Jacobs JJ, Rosenberg AG, Maley M, Galante JO. Primary total hip reconstruction with a titanium fiber-coated prosthesis inserted without cement. J Bone Joint Surg Am.1993;75: 554-71.75554 1993

Archibeck MJ, Berger RA, Jacobs JJ, Quigley LR, Gitelis S, Rosenberg AG, Galante JO. Second-generation cementless total hip arthroplasty. Eight to eleven-year results. J Bone Joint Surg Am.2001;83: 1666-73.831666 2001

Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc.1958;53: 457-81.53457 1958 [CrossRef]

Udomkiat P, Dorr LD, Wan Z. Cementless hemispheric porous-coated sockets implanted with press-fit technique without screws: average ten-year follow-up. J Bone Joint Surg Am.2002;84: 1195-200.841195 2002

Topics

femur ; hip region ; metals ; osteolysis ; repeat surgery ; hip replacement arthroplasty ; polyethylene

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Craig J. Della Valle, Richard A. Berger, Susan Shott, Aaron G. Rosenberg, Joshua J. Jacobs, Laura Quigley, Jorge O. Galante; Primary Total Hip Arthroplasty with a Porous-Coated Acetabular ComponentA Concise Follow-up of a Previous Report*. The Journal of Bone & Joint Surgery. 2004 Jun;86(6):1217-1222.

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