The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 4

Scientific Articles | April 01, 2007

The Twenty to Twenty-five-Year Outcomes of the Harris Design-2 Matte-Finished Cemented Total Hip Replacement: A Concise Follow-up of a Previous Report*

Michael Skutek, MD¹; Robert B. Bourne, MD, FRCSC¹; Cecil H. Rorabeck, MD, FRCSC¹; Alexander Burns, MD, FRACS¹; Stephen Kearns, MD, FRCS¹; Gajan Krishna, HBSc¹

¹ London Health Sciences Centre, 339 Windermere Road, London, Ontario N6A 5A5, Canada

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Original Publication

Bourne RB, Rorabeck CH, Skutek M, Mikkelsen S, Winemaker M, Robertson D. The Harris Design-2 total hip replacement fixed with so-called second-generation cementing techniques. A ten to fifteen-year follow-up. J Bone Joint Surg Am. 1998;80:1775-80.

Investigation performed at the London Health Sciences Centre, London, Ontario, Canada

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Apr 01;89(4):814-818. doi: 10.2106/JBJS.F.00837

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Abstract

We previously reported the ten to fifteen-year results for 195 matte-finished Harris Design-2 total hip replacements that had been inserted with cement by two surgeons in 166 patients with osteoarthritis. The purpose of the present report is to update that study and report the twenty to twenty-five-year outcomes. The patients were followed prospectively on the basis of clinical assessment with use of the Harris hip score and radiographic analysis. One hundred and forty-nine patients (90%) had a functioning implant at the time of death or, if living, at twenty to twenty-five years of follow-up. A total of ten patients (ten hips; 5%) underwent a revision because of aseptic loosening of the acetabular component (two hips; 1%), the femoral component (four hips; 2%), or both components (four hips; 2%).

At twenty-five years, Kaplan-Meier analysis revealed a survival rate of 83% ± 6% with revision for any reason as the end point. The survival rate was 86% ± 6% for the femoral component and 93% ± 3% for the acetabular component with aseptic loosening as the end point.

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

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Background

Background | Methods | Results | Discussion | References

Our original study consisted of a consecutive, selected series of 195 cemented, matte-finished total hip replacements that were inserted in 166 patients with osteoarthritis who were followed for ten to fifteen. The mean age of the eighty-two men and eighty-four years¹ women at the time of surgery was sixty-eight years (range, thirty-one to eighty-nine years). The Harris Design-2 (HD-2) total hip replacement (a cobalt-chromium femoral component and an all-polyethylene acetabular socket) was used in all patients. The components were fixed with use of socalled second-generation cementing techniques (use of an intramedullary plug, lavage, drying, a cement gun, and multiple acetabular fixation holes).

All study data were acquired prospectively. At a mean of twelve years of follow-up, forty-eight patients (fifty-four hips) had died. Five patients (3%) had had a revision because of aseptic loosening related to wear-induced osteolysis. Three patients (four hips) were lost to follow-up. One hundred and eighty-six (97%) of 191 implants were in situ at the time of the study or had been in situ at the time of death.

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Fig. 1: A fifty-two-year-old woman underwent a Harris Design-2 total hip replacement for the treatment of osteoarthritis in 1981. This anteroposterior radiograph, made twenty-five years after the initial procedure, reveals an excellent result with no signs of loosening.

The purpose of the present study is to update the clinical and radiographic results and to calculate the Kaplan-Meier survival rate after a minimum duration of follow-up of twenty years and a maximum of twenty-five years in order to allow our results to be comparable with those of other long-term studies^2-6.

Methods

Background | Methods | Results | Discussion | References

One hundred and ninety-five monoblock Harris Design-2 total hip replacements (Howmedica, East Rutherford, New Jersey) were performed between July 1978 and June 1985 by the senior ones of us (R.B.B. and C.H.R.) in 166 patients who had osteoarthritis. The mean age of the eighty-two men and eighty-four women at the time of the operation was sixty-eight years (range, thirty-one to eighty-nine years).

The rounded rectangular cobalt-chromium femoral stems featured a proximal teardrop configuration, which gave the stem an I-beam appearance on cross-section. The monoblock stem had a collar and 26-mm femoral head and came in small, medium, and large sizes, which varied only in cross-sectional dimensions but not stem length. The neck-shaft angle was 135°. The surface finish was matte with an Ra value of 30 µm⁷. The stem neck was rectangular with rounded edges to enhance hip range of motion. Limb length was adjusted by selecting a short, standard, or long-neck femoral stem (Fig. 1).

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Fig. 2-A: Figs. 2-A, 2-B, and 2-C Cumulative survival curves as determined with the Kaplan-Meier method¹⁵. The I-bars indicate the 95% confidence intervals. Fig. 2-A Kaplan-Meier survival curve with revision for any reason (e.g., aseptic loosening, osteolysis, component breakage, or infection) as the end point.

All of the total hip replacements were inserted through a posterolateral operative approach⁸. The acetabular component was all-polyethylene with an eccentric articulation that maximized the thickness of the polyethylene in the superior and posterior quadrants.

The patients were evaluated preoperatively and at six weeks, three months, six months, one year, and yearly thereafter with use of a modified Harris hip score that incorporated radiographic parameters⁹. The clinical and radiographic data collected at the time of the latest follow-up were gathered by three orthopaedic surgeons who were not associated with the original operation (A.B., S.K., and M.S.). The quality of the cementing technique was evaluated radiographically with use of the zones of Gruen et al.¹⁰ on the femoral side and those of DeLee and Charnley¹¹ on the acetabular side. Radiographic assessment of the original cementing technique for both the acetabular component and the femoral component was performed with use of the method of Barrack et al.¹². The components were assessed radiographically at the time of the latest examination and were categorized as possibly, probably, or definitely loose according to the criteria of Harris et al.¹³ on the femoral side and those of Hodgkinson et al.¹⁴ on the acetabular side.

At the time of the study, thirty-three patients (thirty-nine hips) were willing and able to return to the clinic for a full clinical and radiographic evaluation. Five other patients (seven hips) were either unable or unwilling to have clinical evaluation. Instead, these patients were interviewed by telephone and the Harris hip score was updated. Of these patients, two were more than ninety years old and did not want to return to the clinic, two had dementia, and one had had a stroke with residual impairment. In the latter three patients, information was gathered from spouses, children, or next of kin as to whether the original implant was still in place (with no revision having been performed elsewhere) and whether the patients had a pain-free, functioning hip.

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Fig. 2-B: Kaplan-Meier survival curve with revision because of aseptic loosening of the femoral component as the end point.

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Fig. 2-C: Kaplan-Meier survival curve with revision because of aseptic loosening of the acetabular component as the end point.

If a patient had died, information from the spouse, children, or next of kin was used to determine if the implant had been functioning well at the time of death. In general, patients or their representatives generously agreed to give information. Seven patients (eight hips) with a mean age of 84.6 years were lost to follow-up.

Kaplan-Meier survival curves were generated with five different end points: (1) revision for any reason (e.g., aseptic loosening, osteolysis, component breakage, or infection), (2) revision because of aseptic loosening of the femoral component, (3) revision because of aseptic loosening of the acetabular component, (4) definite radiographic evidence of loosening of the femoral component, and finally (5) definite radiographic evidence of loosening of the acetabular component.

Results

Background | Methods | Results | Discussion | References

Since the beginning of the series, 121 patients with 141 total hip replacements had died. Of these, seventy-three patients (eighty-seven hips) had died since the previous report, leaving thirty-eight living patients (forty-six hips) with a mean age of 84 ± 8 years. The mean time to death after the index operation was 13 ± 4 years (range, one to twenty-two years). In the patients who had died, all hip implants were functioning well, clinically and radiographically, at the time of death.

At the time of the latest follow-up, a total of ten hips (5%) had been revised in the entire series; of these, five had been revised since the original report¹. Six patients, with six revisions, were still living. The four patients with a revision who had died prior to the latest follow-up had well-functioning implants at the time of death. All revisions had been performed because of aseptic loosening of one or both components. Four hips (2%) had been revised because of aseptic loosening of the femoral component, two hips (1%) had been revised because of aseptic loosening of the acetabular component, and four hips (2%) had been revised because of aseptic loosening of both the femoral component and the acetabular component (Table I). All patients with a revision were satisfied with the result. For the five revisions that had been performed since the original report¹, the mean time to revision was twenty years (range, eighteen to twenty-two years). In two patients, the acetabular component was revised to a metal-backed acetabular component without cement. In another patient, a sixty-two-year-old woman, the femoral component had been revised to an extensively porous-coated uncemented femoral stem. Finally, two patients underwent revision because of aseptic loosening of both the femoral component and the acetabular component (Table I). All revised hips continued to function well at the time of this report.

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TABLE I Data on Ten Patients (Ten Hips) Who Underwent a Revision*

Gender	Age at Primary Replacement (yr)	Time from Replacement to Revision (yr)	Component That Loosened	Type of Revision
Female	78	14	Acetabular and femoral	Extensively porous-coated femoral component, metal-backed acetabular component without cement
Female	68	11	Femoral	Hybrid, impaction grafting
Male	81	13	Femoral	Without cement
Male	62	6	Femoral	Without cement
Male	83	9	Acetabular and femoral	Hybrid
Female	64	22	Acetabular and femoral	Without cement
Female	41	21	Femoral	Extensively porous-coated femoral component
Male	61	19	Acetabular	Metal-backed acetabular component without cement + bone graft
Male	66	18	Acetabular	Metal-backed acetabular component without cement
Male	66	18	Acetabular and femoral	Extensively porous-coated femoral component, metal-backed acetabular component without cement

All revisions were performed because of aseptic loosening of one or both components.

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TABLE I Data on Ten Patients (Ten Hips) Who Underwent a Revision*

Gender	Age at Primary Replacement (yr)	Time from Replacement to Revision (yr)	Component That Loosened	Type of Revision
Female	78	14	Acetabular and femoral	Extensively porous-coated femoral component, metal-backed acetabular component without cement
Female	68	11	Femoral	Hybrid, impaction grafting
Male	81	13	Femoral	Without cement
Male	62	6	Femoral	Without cement
Male	83	9	Acetabular and femoral	Hybrid
Female	64	22	Acetabular and femoral	Without cement
Female	41	21	Femoral	Extensively porous-coated femoral component
Male	61	19	Acetabular	Metal-backed acetabular component without cement + bone graft
Male	66	18	Acetabular	Metal-backed acetabular component without cement
Male	66	18	Acetabular and femoral	Extensively porous-coated femoral component, metal-backed acetabular component without cement

All revisions were performed because of aseptic loosening of one or both components.

The results were categorized according to the Harris hip score⁹ as excellent (90 to 100 points), good (80 to 89 points), fair (70 to 79 points), or poor (less than 70 points). Of the forty retained primary hip replacements in living patients, eleven hips (28%) had an excellent result, eighteen (45%) had a good result, nine (23%) had a fair result, and two (5%) had a poor result.

In the entire series, early complications (those occurring less than four weeks postoperatively) included dislocation (three patients), pulmonary embolus (one), and death (one). Late complications included dislocation (two patients), aseptic loosening (ten), and periprosthetic fracture (one).

Evaluation of the radiographs of thirty-nine hips in thirty-three living patients demonstrated that, on the basis of the criteria of Harris and Hodgkinson^13,14, no femoral components were probably or definitely loose and that five acetabular components (13%) were possibly loose. At the time of the latest follow-up, no definitely loose acetabular components were observed.

The overall Kaplan-Meier survival rate (the cumulative survival rate after twenty to twenty-five years and a mean of twenty-two years) for the HD-2 Total Hip Replacement was calculated¹⁵. The cumulative survival rate (and standard error) was 0.83 ± 0.06 with revision for any reason as the end point (Fig. 2-A). The survival was 0.86 ± 0.06 with aseptic loosening of the femoral component as the end point (Fig. 2-B) and 0.93 ± 0.03 with aseptic loosening of the acetabular component as the end point (Fig. 2-C).

Discussion

Background | Methods | Results | Discussion | References

One hundred and ninety-five Harris Design-2 total hip replacements that were fixed with so-called second-generation cementing techniques were reviewed after twenty to twenty-five years of follow-up. At twenty-five years, the predicted survival rate was 83%; these results are superior to those reported for implants inserted with first-generation cementing techniques^10,16.

Revision was performed because of aseptic loosening in ten hips (5%) over a period of twenty-five years. Seventy-three percent of the hips in living patients who retained the original implant had a good or excellent result and a well-functioning implant even after twenty-five years. In contrast to the findings in other long-term reports, the eccentric all-polyethylene acetabular component had excellent durability and a small rate of osteolysis^2,17,18.

Whether the use of a proportionally longer femoral stem, a proximally textured or precoated femoral component, a centralizer, or porosity-reduced cement would have improved the results of the present study is not known¹⁹.

Our results compare favorably with those reported for smooth polished stems at ten years of follow-up and represent a benchmark for other long-term studies²⁰. ?

References

Background | Methods | Results | Discussion | References

Schulte KR, Callaghan JJ, Kelley 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 in: J Bone Joint Surg Am. 1993;75:1418.75961 1993

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]

Wroblewski BM, Taylor GW, Siney P. Charnley low-friction arthroplasty: 19- to 25-year results. Orthopedics. 1992;15: 421-4.15421 1992 [PubMed]

Halley DK, Glassman AH. Twenty- to twenty-six-year radiographic review in patients 50 years of age or younger with cemented Charnley low-friction arthroplasty. J Arthroplasty. 2003;18(7 Suppl 1): 79-85.1879 2003 [CrossRef]

Older J. Charnley low-friction arthroplasty: a worldwide retrospective review at 15 to 20 years. J Arthroplasty. 2002;17: 675-80.17675 2002 [CrossRef]

Crowninshield RD, Jennings JD, Laurent ML, Maloney WJ. Cemented femoral component surface finish mechanics. Clin Orthop Relat Res. 1998;355: 90-102.35590 1998 [PubMed][CrossRef]

Harris WH. A new approach to total hip replacement without osteotomy of the greater trochanter. Clin Orthop Relat Res. 1975;106: 19-26.10619 1975 [CrossRef]

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]

Gruen TA, McNeice GM, Amstutz HC. "Modes of failure" of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res. 1979;141: 17-27.14117 1979 [PubMed]

Charnley J. Low friction arthroplasty of the hip. Theory and practice. New York: Springer; 1979. 1979

Barrack RL, Mulroy RD Jr, Harris WH. Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. A 12-year radiographic review. J Bone Joint Surg Br. 1992;74: 385-9.74385 1992

Harris WH, McCarthy JC Jr, O'Neill DA. Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am. 1982;64: 1063-7.641063 1982 [PubMed]

Hodgkinson JP, Shelley P, Wroblewski BM. The correlation between the roentgenographic appearance and operative findings at the bone-cement junction of the socket in Charnley low friction arthroplasties. Clin Orthop Relat Res. 1988;228: 105-9.228105 1988 [PubMed]

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

Bourne RB. Total hip arthroplasty: cemented operative techniques. In: Evarts CM, editor. Surgery of the muskuloskeletal system. 2nd ed, vol 3. New York: Churchill Livingstone; 1990. p 2957-97.32957 1990

Callaghan JJ, Templeton JE, Liu SS, Pedersen DR, Goetz DD, Sullivan PM, Johnston RC. Results of Charnley total hip arthroplasty at a minimum of thirty years. A concise follow-up of a previous report. J Bone Joint Surg Am. 2004;86: 690-5.86690 2004 [PubMed]

Nercessian OA, Martin G, Joshi RP, Su BW, Eftekhar NS. A 15- to 25-year follow-up study of primary Charnley low-friction arthroplasty: a single surgeon series. J Arthroplasty. 2005;20: 162-7.20162 2005 [CrossRef]

Davies JP, Jasty M, O'Connor DO, Burke DW, Harrigan TP, Harris WH. The effect of centrifuging bone cement. J Bone Joint Surg Br. 1989;71: 39-42.7139 1989

Williams HD, Browne G, Gie GA, Ling RS, Timperley AJ, Wendover NA. The Exeter universal cemented femoral component at 8 to 12 years. A study of the first 325 hips. J Bone Joint Surg Br. 2002;84: 324-34.84324 2002 [CrossRef]

Topics

femur ; hip replacement arthroplasty

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Michael Skutek, Robert B. Bourne, Cecil H. Rorabeck, Alexander Burns, Stephen Kearns, Gajan Krishna; The Twenty to Twenty-five-Year Outcomes of the Harris Design-2 Matte-Finished Cemented Total Hip ReplacementA Concise Follow-up of a Previous Report*. The Journal of Bone & Joint Surgery. 2007 Apr;89(4):814-818.

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