The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 1

Scientific Articles | January 01, 2007

Total Hip Arthroplasty with a Cemented, Polished, Collared Femoral Stem and a Cementless Acetabular Component: A Follow-up Study at a Minimum of Ten Years

Daniel E. Firestone, BS¹; John J. Callaghan, MD¹; Steve S. Liu, MD¹; Devon D. Goetz, MD²; Patrick M. Sullivan, MD²; David A. Vittetoe, MD²; Richard C. Johnston, MD¹

¹ Department of Orthopaedics, University of Iowa Health Care, 200 Hawkins Drive, Iowa City, IA 52242. E-mail address for J.J. Callaghan: john-callaghan@uiowa.edu
² Des Moines Orthopaedic Surgeons West, 6001 Westown Parkway, West Des Moines, IA 50266

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Disclosure: In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from the National Institutes of Health (RO1 AR047653-04) and DePuy. 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 (DePuy). Also, a commercial entity (DePuy) 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.

Investigation performed at University of Iowa Health Care, Iowa City, and Des Moines Orthopaedic Surgeons, Des Moines, Iowa

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Jan 01;89(1):126-132. doi: 10.2106/JBJS.E.01214

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Abstract

Background: Recent studies have suggested that cemented femoral components with a polished surface may provide superior long-term fixation when compared with femoral components with a roughened surface. The purpose of this study was to evaluate the results of total hip arthroplasty with a cemented femoral component with a polished surface finish and compare them with the results of total hip arthroplasty performed with a similar design of cemented femoral component with a rougher surface finish.

Methods: We retrospectively reviewed a consecutive group of 132 patients (149 hips) in whom primary total hip arthroplasty had been performed by one surgeon using a cemented collared femoral component with a polished (0.1-µm Ra) surface finish and a cementless acetabular component. Ninety-eight patients (115 hips) were followed for a minimum of ten years. We compared the survivorship of this prosthesis with that of a femoral component of similar design but with rougher surfaces (matte or grit-blasted).

Results: No polished stems were revised because of aseptic loosening or demonstrated radiographic evidence of loosening; however, eight hips (5.4%) with a polished stem demonstrated osteolysis distal to the greater or lesser tro-chanter. In contrast, six stems (2.0%) with a matte surface finish of 0.8-µm Ra were revised because of aseptic loosening, and an additional five stems were seen to be loose radiographically. Eleven stems (9.2%) with a grit-blasted surface finish of 2.1-µm Ra were revised because of aseptic loosening, and an additional four stems were seen to be loose radiographically. The difference in the prevalence of revision due to aseptic loosening between the group with the 0.1-µm Ra surface and the group with the 2.1-µm Ra surface was significant (p = 0.001), as was the difference between the prevalence of revision due to aseptic loosening between the group with the 0.8-µm Ra surface and the group with the 2.1-µm Ra surface (p = 0.001). No cups were revised because of aseptic loosening, and one hip had radiographic signs of acetabular loosening.

Conclusions: This study demonstrated excellent durability of a prosthesis consisting of a cemented, collared, polished femoral component and a cementless acetabular component. While no hips were revised because of aseptic loosening, distal femoral osteolysis was observed in eight hips (5.4%), a higher prevalence than has been reported by others after similar durations of follow-up of tapered, collarless, polished femoral components.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

The senior author (R.C.J.) previously reported the prevalence of revision to be 2.3% for femoral components with a 0.8-µm Ra (matte) roughened surface finish and 9.2% for those with a 2.1-µm Ra (grit-blasted) roughened finish and the prevalence of aseptic loosening to be 2.3% and 14.2%, respectively^1,2. Those worrisome results led to the use of a femoral component of similar design but with a polished (0.1-µm Ra) surface finish. The purpose of this study was to evaluate the results, at a minimum of ten years, of a consecutive series of total hip arthroplasties performed with a cemented, polished, collared femoral component and a cementless ace-tabular component. We hypothesized that a stem with a polished surface finish would provide more durable long-term results than similar femoral components with rough surface finishes.

Materials and Methods

Materials and Methods | Results | Discussion | Appendix | References

Between April 1993 and July 1994, the senior one of us (R.C.J.) performed 149 primary total hip replacements with the Iowa femoral component (Zimmer, Warsaw, Indiana) in 132 consecutive non-selected patients. The component was fabricated from chromium-cobalt alloy and had a proximal cobra shape³, a 132° or 140° neck-shaft angle, and a 0.1-µm Ra (polished) surface finish. The tip of the stem was slightly squared off as a result of the polishing process (Fig. 1). The ace-tabular component was a cementless HG-II (Harris-Galante-II) design (Zimmer). The polyethylene was gamma-irradiated in air. A 28-mm-diameter modular head was used in fifty-one (34.2%) of the hips, and a 22-mm-diameter modular head was used in ninety-eight (65.8%) of the hips. The average age of the patients at the time of surgery was 68.7 years (range, thirty-two to eighty-seven years). There were eighty-four women and forty-eight men.

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Fig. 1: From left to right: The Iowa femoral component stems with the 2.1-µm Ra surface, the 0.8-µm Ra surface, and the polished 0.1-µm Ra surface. The stem designs were similar but not identical.

Preoperatively, the clinical evaluation included documentation of the level of activity, range of motion of the hip, level of pain, gait pattern, and level of performance of activities of daily living with the use of a standard system of terminology⁴. The preoperative diagnosis was osteoarthritis for 128 hips (85.9%), trauma for five (3.4%), congenital hip dysplasia for one (0.7%), rheumatoid arthritis for five, osteonecrosis for five, and another diagnosis for five.

The operative technique involved a lateral approach with a transverse osteotomy of the greater trochanter and a complete capsulectomy in ninety-one hips (61%) and an ante-rolateral approach with a partial capsulectomy in fifty-eight (39%). The femoral canal was prepared by removal of all loose cancellous bone and drying of the canal. A cement plug was placed distally, and a cement gun was used to introduce cement (Simplex P; Howmedica, Rutherford, New Jersey) in the doughy stage into the femoral canal in a retrograde manner. The cement was always centrifuged to reduce porosity. The acetabulum was prepared with line-to-line reaming. Fixation of the cup was augmented by two dome screws in all hips. Perioperative prophylactic antibiotics were used, and the operations were performed in an operating room with a high number of air exchanges. Body exhaust systems were worn by the entire surgical team. The trochanter was reattached as far laterally as possible, with use of three stainless-steel wires (two placed vertically and one, horizontally).

Postoperatively, the patients were managed with bed rest on the first day, followed by partial weight-bearing with crutches for six weeks, and progressing to full weight-bearing as tolerated.

The latest follow-up evaluation was conducted at a mean of 8.1 years (range, 0.15 to 11.6 years) after the index arthroplasty for all patients and at a mean of 10.1 years (range, 10.0 to 11.6 years) for the living patients. We attempted to interview all living patients and the families of the patients who had died. The living patients either returned for follow-up or, if they were unable to return, were asked to send radiographs (made locally) to us for evaluation. At the time of final follow-up, ninety-eight patients (115 hips) were living, thirty-four patients (thirty-four hips) had died, and no patient had been lost to follow-up. A radiograph made at a minimum of ten years was available for ninety-two (80.0%) of the 115 hips in the living patients. All living patients were evaluated in person or were interviewed by telephone with use of a standard system of terminology for reporting results as described by one of us (R.C.J.) and colleagues⁴. In addition, at the time of final follow-up, we calculated a WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score for all available patients⁵.

Radiographic Evaluation

Observations and measurements were based on anteroposterior radiographs of the pelvis that included the tip of the stem and, when possible, oblique views⁶ of the pelvis made early in the postoperative period and at the latest follow-up visit. Radiographs were evaluated by two observers (J.J.C. and D.E.F.) with agreement by consensus. Correction for magnification was performed by standardization of all measurements against the magnification of the measured size of the femoral head as compared with the known size. Osteolysis was defined as any nonlinear radiolucency at the bone-cement interface that was at least 5 mm² and was recorded according to the seven femoral zones delineated by Gruen et al.⁷. The position of the femoral stem was determined on the basis of the angle formed between the central axis of the prosthesis and the lateral endosteal cortex.

Loosening of the femoral component was classified according to the criteria of Harris et al.^8,9. Definite loosening was defined as subsidence of the femoral component, fracture of the cement or stem, or so-called debonding (defined as a radiolucent line at the cement-prosthesis interface at the supero-lateral aspect of the shoulder of the prosthesis [in Gruen zone I]) as seen on serial radiographs. Probable loosening was characterized by a continuous radiolucent line along the entire bone-cement interface. Possible loosening was indicated by a radiolucent line at the bone-cement interface that encompassed >50% but <100% of the circumference of the stem on the anteroposterior radiograph.

Subsidence of the femoral component, determined with use of the method of Loudon and Charnley¹⁰, was defined as an increase of at least 5 mm (with magnification taken into account) in the distance from a line drawn perpendicular to the central axis of the femoral stem and intersecting the tip of the stem and a line drawn perpendicular to the central axis and intersecting the point where the trochanteric wire passes through the lesser trochanter, or to the inferior portion of the lesser trochanter if a greater trochanter osteotomy was not performed, between the initial postoperative radiograph and those made at the latest follow-up evaluation.

Acetabular components were evaluated for bone-prosthesis radiolucencies and osteolysis in the zones described by DeLee and Charnley¹¹. Migration of the acetabular component was evaluated according to the method of Massin et al.¹². The acetabular component was considered to be loose radiographically if it had migrated >5 mm or if the radiographs demonstrated circumferential radiolucent lines, including in the area around the screws¹³.

The anteroposterior radiograph of the hips made immediately postoperatively was used to grade the cementing technique according to the criteria of Schmalzried and Harris¹⁴.

Wear

Linear wear was determined by edge-detection techniques developed by Shaver et al.¹⁵. Volumetric wear was calculated with use of the equation derived by Kabo et al.¹⁶.

Comparison of This Series with Previous Series of Femoral Components with Rougher Surface Finishes

The two comparison groups consisted of consecutive series of total hip arthroplasties performed by the same surgeon using the same surgical technique and employing stems that were similar in design (chromium-cobalt, proximal cobra shape, external collar, 140 mm in length, and either 132° or 140° neck-shaft angle), with the following notable exceptions. The 304 stems with a 0.8-µm Ra surface finish (implanted between January 1984 and December 1985) were nonmodular, had a 28-mm head, and were mated to a cemented TiBac acetabular shell (Zimmer). The 120 stems with a 2.1-µm Ra surface finish (implanted between January 1986 and December 1987) were modular, had a 28-mm head, had proximal methylmethacry-late precoating, and were mated to an HG-I cementless ace-tabular shell (Fig. 1).

The Kaplan-Meier¹⁷ method was used to evaluate survival of the implant with regard to revision or loosening. Survivorship curves with corresponding 95% confidence intervals were generated, with failure defined according to the following end points: (1) revision of the femoral and/or acetabular component for any reason; (2) revision of the femoral component due to aseptic loosening; (3) radiographic signs of loosening of the femoral component, defined as definite or probable radiographic loosening or revision because of aseptic loosening; (4) revision of the acetabular component due to aseptic loosening; and (5) radiographic signs of acetabular loosening, defined as definite or probable loosening or revision because of aseptic loosening^18-20.

In addition, the Wilcoxon rank-sum test was used to evaluate differences in wear rates between hips with and those without osteolysis.

Results

Materials and Methods | Results | Discussion | Appendix | References

Hips with the Polished (0.1-µm Ra) Iowa Stem

At the time of follow-up, six (4.0%) of the 149 hips had required a revision. Three were revised because of dislocation; one, because of excessive polyethylene wear; and two, because of deep hip infection. No hip was revised because of aseptic loosening (see Appendix). Of the 115 hips in the ninety-eight patients who were alive at a minimum of ten years postoperatively, four (3.5%) had been revised. Two hips were revised because of dislocation; one, because of polyethylene wear; and one, because of deep hip infection. The average WOMAC score for the ninety-eight living patients was 14.7 points (range, 0 to 82 points).

Radiographic Results

Radiographs were made at least ten years after the index arthroplasty for ninety-two (80.0%) of the 115 hips in patients who were still alive. In the entire series of 149 hips, ninety-two (61.7%) had a radiograph made at a minimum of ten years. The average interval between the index arthroplasty and the most recent radiograph was 6.5 years (range, 0.15 to 11.6 years) for the entire series of 149 hips and eight years (range, 0.15 to 11.6 years) for the 115 hips in the living patients.

On the immediate postoperative anteroposterior pelvic radiographs, the cementing technique was grade A or B in 91% of the hips. It was grade A in twelve hips (8.1%), grade B in 124 (83.2%), grade C1 in five (3.4%), and grade C2 in six (4.0%).

Of the 149 hips, twenty-four (16.1%) demonstrated femoral osteolysis in Gruen zone VII. Two of these hips had additional osteolytic lesions, which were in zone I in one and in zones IV and V in the other. Osteolysis was noted in one or two locations in zones II through VI in eight hips (5.4%), all of which were seen to have had either grade-A (one hip) or grade-B (seven hips) cementing technique on the initial postoperative radiographs (Table I). In four of those hips, the osteolysis occurred at the tip of the stem (including zone IV). Four osteolytic lesions measured >1 cm², and three of these were at the tip of the stem. There were no instances of de-bonding, and no femoral component was loose. There was no progression of the very few bone-cement radiolucencies seen on initial radiographs, and there were no new radiolucencies at the time of final follow-up.

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TABLE I Prevalence of Femoral Osteolysis in Gruen Zones II Through VI (N = 8)

Case	Gruen Zone(s)	Size of Lesion (cm²)	Cement Grade	Linear Wear Rate (mm/yr)	Volumetric Wear Rate (mm³/yr)
1	IV	1 × 0.5	B	0.739	200.66
2	IV	2 × 1	A	0.097	24.27
3	IV, V	2 × 1	B	0.04	7.34
4	IV, V	2 × 1	B	0.264	67.74
5	VI	1 × 0.5	B	0.139	30.51
6	V	2 × 0.3	B	0.0514	39.37
7	II, VI	>2 × 1	B	0.131	46.20
8	II	2 × 0.8	B	0.06	6.89

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TABLE I Prevalence of Femoral Osteolysis in Gruen Zones II Through VI (N = 8)

Case	Gruen Zone(s)	Size of Lesion (cm²)	Cement Grade	Linear Wear Rate (mm/yr)	Volumetric Wear Rate (mm³/yr)
1	IV	1 × 0.5	B	0.739	200.66
2	IV	2 × 1	A	0.097	24.27
3	IV, V	2 × 1	B	0.04	7.34
4	IV, V	2 × 1	B	0.264	67.74
5	VI	1 × 0.5	B	0.139	30.51
6	V	2 × 0.3	B	0.0514	39.37
7	II, VI	>2 × 1	B	0.131	46.20
8	II	2 × 0.8	B	0.06	6.89

One acetabular component migrated 5 mm within the first year postoperatively, but the migration had not progressed at five years postoperatively. There were no circumferential bone-prosthesis radiolucencies that included the screws. In addition, there was no periacetabular osteolysis.

Wear

The average linear polyethylene wear rate in the current series was 0.148 mm/yr (range, 0.011 to 0.739 mm/yr), and the average volumetric wear rate was 36.73 mm³/yr (range, 2.12 to 200.66 mm³/yr). In the eight hips with femoral osteolysis in one or two locations in Gruen zones II through VI, the average linear and volumetric wear rates were 0.190 mm/yr and 52.87 mm³/yr, respectively. In the four hips with femoral osteolysis at the distal tip, the average linear and volumetric wear rates were 0.285 mm/yr and 75.00 mm³/yr, respectively. Because of the small number of hips with osteolysis, the difference in the wear rates between hips with and without osteolysis was not significant (p = 0.05).

Comparison of the Present Series with Two Previous Series

A comparison of the prevalence of aseptic loosening of the femoral component among the three series is presented in Table II. Comparisons of the group with the 0.1-µm Ra surface and the group with the 0.8-µm Ra surface, the group with the 0.1-µm Ra surface and the group with the 2.1-µm Ra surface, and the group with the 0.8-µm Ra surface and the group with the 2.1-µm Ra surface all showed significant differences (p = 0.025, p = 0.001, and p = 0.001, respectively).

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TABLE II Prevalence of Aseptic Loosening of the Femoral Component at a Minimum of Ten Years Postoperatively

	0.1-µm Ra Femoral Component			0.8-µm Ra Femoral Component			2.1-µm Ra Femoral Component
	All Hips (N = 149)	Hips of Patients Living =10 Yr After Index Operation (N = 115)	All Hips (N = 304)	Hips of Patients Living =10 Yr After Index Operation (N = 159)	All Hips (N = 120)	Hips of Patients Living =10 Yr After Index Operation (N = 72)
Revision of femoral component due to aseptic loosening	0 (0.0%), p = 0.10^*, p = 0.001†	0 (0.0%), p = 0.025^*, p = 0.001†	6 (2.0%), p = 0.001‡	6 (3.8%), p = 0.01‡	11 (9.2%)	11 (15.3%)
Definite or probable radiographic loosening of femoral component (including components revised because of aseptic loosening)	0 (0.0%), p = 0.025^*, p = 0.001†	0 (0.0%), p = 0.025^*, p = 0.001†	11 (3.6%), p = 0.001‡	7 (4.4%), p = 0.001‡	15 (12.9%)	15 (20.9%)

0.1-µm compared with 0.8-µm (chi-square test)0.1-µm compared with 2.1-µm (chi-square test)0.8-µm compared with 2.1-µm (chi-square test)

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TABLE II Prevalence of Aseptic Loosening of the Femoral Component at a Minimum of Ten Years Postoperatively

	0.1-µm Ra Femoral Component			0.8-µm Ra Femoral Component			2.1-µm Ra Femoral Component
	All Hips (N = 149)	Hips of Patients Living =10 Yr After Index Operation (N = 115)	All Hips (N = 304)	Hips of Patients Living =10 Yr After Index Operation (N = 159)	All Hips (N = 120)	Hips of Patients Living =10 Yr After Index Operation (N = 72)
Revision of femoral component due to aseptic loosening	0 (0.0%), p = 0.10^*, p = 0.001†	0 (0.0%), p = 0.025^*, p = 0.001†	6 (2.0%), p = 0.001‡	6 (3.8%), p = 0.01‡	11 (9.2%)	11 (15.3%)
Definite or probable radiographic loosening of femoral component (including components revised because of aseptic loosening)	0 (0.0%), p = 0.025^*, p = 0.001†	0 (0.0%), p = 0.025^*, p = 0.001†	11 (3.6%), p = 0.001‡	7 (4.4%), p = 0.001‡	15 (12.9%)	15 (20.9%)

0.1-µm compared with 0.8-µm (chi-square test)0.1-µm compared with 2.1-µm (chi-square test)0.8-µm compared with 2.1-µm (chi-square test)

Survivorship Analysis

The Kaplan-Meier¹⁷ analyses of survivorship, at a minimum of ten years, of the polished (0.1-µm Ra) femoral components were compared with those of the matte (0.8-µm Ra) femoral components and the grit-blasted (2.1-µm Ra) proximally pre-coated femoral components (Table III and Appendix).

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TABLE III Kaplan-Meier Survivorship Curves at Ten Years

	Percent Survival with 95% Confidence Interval
End Point at 10 Yr	0.1-µm Ra Femoral Component	0.8-µm Ra Femoral Component	2.1-µm Ra Femoral Component
Revision for any reason	95.3 ± 4, p = 0.856^*, p = 0.046†	94.1 ± 3, p = 0.016‡	86.8 ± 6
Revision of femoral component due to aseptic loosening	100, p = 0.168^*, p = 0.001†	97.5 ± 2, p = 0.0007‡	89.2 ± 6
Definite or probable radiographic loosening of femoral component (including components revised because of aseptic loosening)	100, p = 0.043^*, p = 0.0006†	95.2 ± 3, p = 0.022‡	87.7 ± 7
Revision of acetabular component due to aseptic loosening	100, p = 0.110^*, none†	97.5 ± 2, p = 0.081‡	100
Definite or probable radiographic loosening of acetabular component (including components revised because of aseptic loosening)	94.2 ± 10, p = 0.147^*, p = 0.06†	92.4 ± 4, p = 0.012‡	100

0.1-µm compared with 0.8-µm (log-rank test)0.1-µm compared with 2.1-µm (log-rank test)0.8-µm compared with 2.1-µm (log-rank test)

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TABLE III Kaplan-Meier Survivorship Curves at Ten Years

	Percent Survival with 95% Confidence Interval
End Point at 10 Yr	0.1-µm Ra Femoral Component	0.8-µm Ra Femoral Component	2.1-µm Ra Femoral Component
Revision for any reason	95.3 ± 4, p = 0.856^*, p = 0.046†	94.1 ± 3, p = 0.016‡	86.8 ± 6
Revision of femoral component due to aseptic loosening	100, p = 0.168^*, p = 0.001†	97.5 ± 2, p = 0.0007‡	89.2 ± 6
Definite or probable radiographic loosening of femoral component (including components revised because of aseptic loosening)	100, p = 0.043^*, p = 0.0006†	95.2 ± 3, p = 0.022‡	87.7 ± 7
Revision of acetabular component due to aseptic loosening	100, p = 0.110^*, none†	97.5 ± 2, p = 0.081‡	100
Definite or probable radiographic loosening of acetabular component (including components revised because of aseptic loosening)	94.2 ± 10, p = 0.147^*, p = 0.06†	92.4 ± 4, p = 0.012‡	100

0.1-µm compared with 0.8-µm (log-rank test)0.1-µm compared with 2.1-µm (log-rank test)0.8-µm compared with 2.1-µm (log-rank test)

With revision for any reason as the end point, there were significant differences between the 0.1-µm Ra surface-finish group and the 2.1-µm Ra group (p = 0.046) and between the 0.8-µm Ra group and the 2.1-µm Ra group (p = 0.016). With revision of the femoral component due to aseptic loosening as the end point, there were significant differences between the 0.1-µm Ra group and the 2.1-µm Ra group (p = 0.001) and between the 0.8-µm Ra group and the 2.1-µm Ra group (p = 0.0007). With radiographic evidence of loosening of the femoral component (including hips revised because of aseptic loosening) as the end point, there were significant differences between the 0.1-µm Ra group and the 0.8-µm Ra group (p = 0.043), between the 0.1-µm Ra group and the 2.1-µm Ra group (p = 0.0006), and between the 0.8-µm Ra group and the 2.1-µm Ra group (p = 0.022).

In the 0.1-µm Ra group, no cups were revised because of aseptic loosening and only one cup demonstrated radiographic evidence of loosening (Table III). In the 0.8-µm Ra group, eight cups (2.6%) were revised because of aseptic loosening and an additional seventeen cups (5.6%) were loose radiographically. In the 2.1-µm Ra group, no cups were revised because of aseptic loosening or demonstrated radiographic evidence of loosening. The only significant difference in the survivorship of the acetabular component among the three groups was for the end point of radiographic evidence of loosening of the acetabular component (including hips revised because of aseptic loosening): there was a significant difference between the 0.8-µm Ra group and the 2.1-µm Ra group (p = 0.012) (Table III).

Discussion

Materials and Methods | Results | Discussion | Appendix | References

The senior author (R.C.J.) and colleagues developed a fem-oral component in the late 1970s on the basis of the concept that, because cement was the weak link in the femoral fixation construct, a cemented femoral component should minimize cement strains. They designed a femoral component that was slightly longer (140 mm) than its contemporaries, was fabricated from chromium-cobalt alloy, and had a cobra-shaped design proximally³. A collar was added to the component because of its popularity in the United States at the time. The stem was originally available with a 0.8-µm Ra surface finish and later, in the mid-1980s, became available with a 2.1-µm Ra finish with proximal methylmethacrylate precoating².

In the early 1990s, the senior author began observing early failure of the design with the 2.1-µm Ra surface finish and elected to use a component manufactured with a polished (0.1-µm Ra) surface finish. The decision to polish the femoral component was based on the favorable long-term results reported by the senior author and by others using the polished flatback Charnley femoral components²¹ as well as the report by Fowler et al.²² that demonstrated more satisfactory results with use of a tapered, collarless, polished femoral component than with the same design with a rougher matte finish.

In the present study of a collared, polished femoral component implanted with contemporary cementing techniques, we found durable results with no revisions due to aseptic femoral loosening and no radiographic evidence of femoral loosening at a minimum of ten years. Although the prevalence of osteolysis in zone VII (proximally) was high (16.1%), we attributed this, as have other authors²³, to particulate debris from the bearing surface. However, osteolysis developed distal to the greater and lesser trochanters in eight hips (5.4%), and four lesions were >1 cm². These results are in contrast to some of the findings of Williams et al.²³, who reviewed the Exeter group's experience with double-tapered, collarless, polished cemented femoral components followed for eight to twelve years. Like us, they reported no revisions due to aseptic loosening, after a similar mean duration of follow-up, but, in contrast to our findings, they noted only one instance of distal femoral osteolysis. The mean subsidence of the Exeter stem within the cement mantle was 1.32 mm. In contrast, the Iowa stem demonstrated no subsidence, probably because of the presence of a collar and the proximal cobra geometry.

The Exeter group hypothesized that, with a polished, tapered, collarless stem, distal osteolysis was prevented by subsidence of the stem into the cement, which sealed the distal cement-bone interface from any egress of debris from the proximal prosthesis-cement interface. This egress can occur if there are distal cement cracks that are not sealed proximally by the tapered stem-cement construct^24,25. Theoretically, when a tapered stem subsides, the larger diameter of the stem at a more proximal point can seal the cement-prosthesis interface. In our series, the collared stem and proximal cobra geometry probably prevented subsidence but may have allowed egress of debris from the bearing surface to the distal bone-cement interface. Several hips with distal femoral osteolysis had excessive polyethylene wear (Table I), but with the radiographs available (mostly anteroposterior views of the femur) we were unable to demonstrate defects in the cement mantle or cracks in the cement. An alternative hypothesis is that, with a collared, cobra-shaped prosthesis, cement strains are high at the distal tip and distal micromotion of the stem can occur, creating production of cement particles distally²⁶.

Our study of polished femoral components demonstrated a significant improvement in the durability of femoral fixation at a minimum of ten years postoperatively compared with that of two femoral constructs of similar design but with rough surface finishes (Table II and III). Similar results have been reported at a minimum of five years postoperatively²⁷. It should be noted that, in our series, the stems with the 2.1-µm Ra surface had a proximal methylmethacrylate precoating, and one cannot exclude this as a potential confounding variable.

No acetabular components were revised because of aseptic loosening and only one demonstrated radiographic loosening. The cementless acetabular fiber-mesh component appears to be an improvement over cemented metal-backed components in terms of fixation, as was determined by the lower rate of radiographic loosening (p = 0.012) at ten years postoperatively.

We are encouraged by these results and continue to use a polished femoral component in our cemented femoral fixation constructs. We are exploring the use of tapered collarless polished components in the hope of further reducing the prevalence of distal femoral osteolysis.

Appendix

Materials and Methods | Results | Discussion | Appendix | References

A table summarizing the cases with revision for any reason as well as figures showing the results of the survivor-ship analyses are available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). ?

References

Materials and Methods | Results | Discussion | Appendix | References

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Topics

femur ; follow-up ; hip region ; osteolysis ; hip replacement arthroplasty

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Daniel E. Firestone, John J. Callaghan, Steve S. Liu, Devon D. Goetz, Patrick M. Sullivan, David A. Vittetoe, Richard C. Johnston; Total Hip Arthroplasty with a Cemented, Polished, Collared Femoral Stem and a Cementless Acetabular ComponentA Follow-up Study at a Minimum of Ten Years. The Journal of Bone & Joint Surgery. 2007 Jan;89(1):126-132.

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