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The Porous-Coated Anatomic Total Hip Prosthesis, Inserted without Cement. A Prospective Study with a Minimum Ten Years of Follow-up*

JOHN S. XENOS, M.D., JOHN J. CALLAGHAN, M.D., R. DAVID HEEKIN, M.D., WILLIAM J. HOPKINSON, M.D., CARLTON G. SAVORY, M.D.# and MILAN S. MOORE, M.D., WASHINGTON, D.C.

Investigation performed at the Orthopaedic Surgery Service, Walter Reed Army Medical Center, Washington, D.C.

	Abstract

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One hundred consecutive primary total hip arthroplasties performed with use of a porous-coated anatomic total hip prosthesis, fixed without cement, in ninety-one patients were followed prospectively for a minimum of ten years. At the time of the most recent follow-up, twenty patients (twenty-three hips) had died and seventy-one patients (seventy-seven hips) were living. The average age of the living patients was sixty-six years (range, thirty-two to ninety-two years), and their average Harris hip score was 84 points (range, 33 to 100 points). Twelve percent (nine) of the seventy-seven hips were found to be associated with pain in the thigh when the patients were specifically questioned by the examiner. Eleven hips were revised during the follow-up period. Only the acetabular component was revised in six hips, only the femoral component was revised in one hip, and both the femoral and the acetabular components were revised in four hips. Of the ten acetabular revisions, one was performed because of acute dissociation of the component and eight, because of a combination of polyethylene wear, osteolysis, and loosening; the tenth acetabular revision consisted of exchange of the liner and curettage and bone-grafting of the osteolytic area. Of the five femoral revisions, two were performed because of loosening and three, because of extensive osteolysis of the proximal aspect of the femur. Including the revised components, twelve acetabular components and five femoral components had radiographic evidence of aseptic loosening. Acetabular osteolysis occurred in seventeen hips. Femoral osteolysis occurred in thirty-nine hips: in the proximal aspect of thirty-one hips, in the distal aspect of four, and in both the proximal and the distal aspect of four. The durability of the femoral fixation documented in this study is especially encouraging in view of the fact that this was our initial experience with devices fixed without cement and that a so-called first-generation femoral component was used. However, the study also demonstrated that not all acetabular components fixed without cement function well over the long term and that specific design considerations (adequate initial fixation, congruency between the liner and the shell, an optimum shell-liner capturing mechanism, and a smaller femoral head) are warranted.

	Introduction

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There are few reports in the literature in which the results of total hip arthroplasties performed without cement have been evaluated after a minimum follow-up period of ten years⁷. In addition, there have been few studies in which patients have been prospectively followed at serial intervals after hip replacement with or without cement. In the present study, patients were prospectively followed for a minimum of ten years after a total hip arthroplasty with a porous-coated anatomic total hip prosthesis (PCA; Howmedica, Rutherford, New Jersey) fixed without cement; earlier results of this study (after minimum follow-up periods of two² and five¹¹ years) were previously reported.

	Materials and Methods

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This study, which involved a longer follow-up of hips that had been reported on previously^2,11 was performed with use of a prospective protocol that was approved by the Human Use and Clinical Investigation Committee at the Walter Reed Army Medical Center. The original series, which included 100 consecutive primary total hip arthroplasties performed with a porous-coated anatomic total hip prosthesis, represents a consecutive series with minimum selectivity because all but four of the primary total hip replacements carried out at this institution during the interval of the study were performed with use of this prosthesis without cement.

As this series was previously reported on in The Journal of Bone and Joint Surgery^2,11, we will provide little detail with regard to the materials and methods. The original porous-coated anatomic total hip replacement, with both the acetabular and the femoral component fixed without cement, was used in all of the hips. The 100 total hip arthroplasties were performed in ninety-one consecutive patients between October 1983 and January 1986 at the Walter Reed Army Medical Center. The first sixty-six arthroplasties were performed with the direct lateral approach described by Hardinge⁹ (which was a modification of that described by Scheck et al.¹⁶), and the last thirty-four procedures were performed with the posterolateral approach. All of the procedures were performed or were supervised by one or two of us (C. G. S. and J. J. C.). There were sixty-two men and twenty-nine women. The average age at the time of the arthroplasty was fifty-eight years (range, twenty-two to eighty-one years). The preoperative diagnosis was osteoarthritis in sixty-two hips; osteonecrosis in fifteen; rheumatoid arthritis in nine; traumatic arthritis in three; and degenerative arthritis secondary to congenital dislocation in six, secondary to a slipped capital femoral epiphysis in three, and secondary to ankylosing spondylitis in two. Thirty-four patients were classified as having Charnley class-A involvement (unilateral involvement); thirty, Charnley class-B (bilateral involvement); and twenty-seven, Charnley class-C (involvement of other joints or systemic problems that limit activity)⁴.

Twenty patients (twenty-three hips) died of causes that were unrelated to the operation on the hip before the time of follow-up (minimum, ten years) for the present study. The data obtained from the annual follow-up evaluations that preceded the deaths were included in the study. Clinical ratings, as described by Harris¹⁰, were determined preoperatively; at three, six, and twelve months postoperatively; and annually thereafter. Anteroposterior radiographs of the pelvis and frog-leg lateral radiographs of the hip (with the tip of the prosthesis included on both radiographs) were made preoperatively; at one or two weeks postoperatively; at three, six, and twelve months postoperatively; and annually thereafter for most patients. All seventy-one living patients (seventy-seven hips) were evaluated, both clinically and with the anteroposterior and frog-leg lateral radiographs, for at least ten years after the procedure. The ratings were performed by one of two independent examiners (J. S. X. or R. D. H.) at the most recent follow-up evaluation. The average clinical and radiographic follow-up period was 11.6 years (range, ten to thirteen years). The average age at the time of follow-up was sixty-six years (range, thirty-two to ninety-two years).

Radiographic Analysis
The measurements on the anteroposterior and frog-leg lateral radiographs were similar to those reported at the follow-up evaluation that was performed at a minimum of five years¹¹. Radiodense lines and sclerosis were identified, at the various follow-up intervals, according to the acetabular zones described by DeLee and Charnley⁵ and according to the femoral zones described by Gruen et al.⁸. The femoral component was considered to have subsided if it had moved at least five millimeters as seen radiographically, with use of the lesser trochanter as a reference point. According to the criteria of Engh et al.⁶, the growth of bone into the femoral component was classified as bone ingrown, stable fibrous, or unstable fibrous on the basis of the latest follow-up radiograph for each hip or at the time of the revision.

As described by Massin et al.¹⁴, any change of more than five millimeters in the position of the acetabular component, with the pelvic teardrops used as reference points, was considered a migration. Measurements were made after a correction for magnification with the femoral head as a marker.

Areas of localized expansile cortical erosion that were at least five millimeters long or wide and that had discrete borders were considered osteolytic¹⁹. As was found at a minimum of five years¹¹, wear of the acetabular component could not be accurately measured, even with the use of newer edge-detection techniques¹⁸, because of the combination of a cobalt-chromium head with a cobalt-chromium acetabular shell, which makes the profile of the head indistinguishable from the shell.

	Results

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Clinical Results
The average Harris hip score¹⁰ was 93 points at two years, 92 points at five years, and 84 points (range, 33 to 100 points) at ten years (Table I). Hence, there was deterioration in the clinical ratings during the ten-year follow-up period. A good or excellent score was given to 73 percent (fifty-six) of the seventy-seven hips at ten years, whereas 91 percent (eighty-three) of the ninety-one hips had had such a score at five years.

Pain
Pain in the hip was considerably relieved after the total hip replacement. At two years after the operation, 98 percent (ninety-seven) of the ninety-nine hips were slightly or not painful. At five years, 98 percent (eighty-nine) of the ninety-one hips were slightly or not painful. By ten years, 96 percent (seventy-four) of the seventy-seven hips were slightly or not painful and 4 percent (three) were markedly painful (Table II).

Limp
At the follow-up evaluation performed at a minimum of five years, 11 percent (ten) of the ninety-one hips were associated with a moderate or severe limp; this prevalence increased to 22 percent (seventeen of seventy-seven hips) at ten years (Table IV). Similarly, the prevalence of the use of walking supports increased from 29 percent (twenty-six of ninety-one hips) at five years to 36 percent (twenty-eight of seventy-seven hips) at ten years (Table V).

Revisions
Of the original 100 hips, eleven were revised before the time of follow-up at a minimum of ten years. In six hips only the acetabular component was revised, in one hip only the femoral component was revised, and in four hips both the acetabular and the femoral components were revised. Of the ten acetabular revisions, one was performed within the first ten days after the total hip arthroplasty because of acute dissociation of the component from the acetabulum and eight were performed at an average of 9.3 years (range, five to thirteen years) because of a combination of polyethylene wear, osteolysis, and loosening. In the tenth acetabular revision, the shell was retained, the osteolytic area was treated with curettage and bone-grafting, and a new twenty-eight-millimeter liner was inserted into the shell with cement at twelve years. Of the five femoral revisions, two were performed because of loosening of the component and three were done because of extensive osteolysis. No hips were revised because of dislocation or infection. The average time to revision (excluding the one performed because of acute dissociation) was 9.4 years (range, five to thirteen years) (Table VI). Other than the one done because of acute dissociation, a revision was not performed until five years after the operation and all of the failures were associated with osteolysis. Kaplan-Meier survivorship analysis¹² demonstrated a survival rate (and 95 percent confidence interval) at ten years of 91 ± 3 percent for any revision of the hip, 93 ± 3 percent for any revision of the acetabular component, 95 ± 2 percent for any revision of the femoral component, 95 ± 2 percent for revision of the acetabular component because of aseptic loosening, and 97 ± 2 percent for revision of the femoral component because of aseptic loosening.

Radiographic Results
Acetabular loosening was defined as revision of the acetabular component because of aseptic loosening or migration of the acetabular component as seen radiographically. According to this definition, twelve acetabular components were radiographically loose (eight were revised, and four migrated without a revision). All of these loose components were in patients who were alive at the ten-year evaluation; hence, the prevalence of acetabular loosening was 16 percent (twelve of seventy-seven components). In an additional patient, the shell was retained, the osteolytic area of the pelvis was treated with curettage and bone-grafting, and a new liner was inserted into the shell with cement. Femoral loosening was defined as revision of the femoral component because of aseptic loosening or subsidence of the femoral component as seen radiographically. According to these criteria, five femoral components were radiographically loose (two were revised, and three subsided without a revision). These loose components were all in patients who were alive at ten years, so the prevalence of femoral loosening was 6 percent (five of seventy-seven components).

According to the criteria of Engh et al.⁶, ninety-four radiographs that had been made at least ten years postoperatively, at the final follow-up evaluation (for the patients who had died), or before a femoral revision demonstrated fixation of the femoral component by bone ingrowth, one demonstrated stable fibrous fixation, and five demonstrated unstable fibrous fixation (two of these were revised). There was no change in fixation between the five and ten-year follow-up intervals. All stems with bone ingrowth remained secure.

At the follow-up evaluation performed at a minimum of ten years, osteolysis was noted around seventeen acetabular components and thirty-nine femoral components. Eight of the acetabular revisions and three of the femoral revisions were performed in hips that had evidence of osteolysis. In another hip, bone-grafting of the osteolytic area around the acetabular component was necessary. Thirty-one hips demonstrated osteolysis of the proximal aspect of the femur (zone 1 or 7, or both, as described by Gruen et al.⁸). Four hips had distal osteolysis (zones 2 through 6, with three lesions occurring in zone 3). The distal osteolysis did not progress in any of the hips, and all four distal lesions became smaller over time. All of the distal osteolytic lesions occurred around fixed implants and were less than one centimeter in length. No hip was revised because of distal femoral osteolysis. Four loose femoral components (two that were revised and two that were not revised) were associated with osteolysis of the proximal and distal aspects of the femur.

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
To our knowledge, this is one of the few reports of a prospectively followed consecutive group of patients who had total hip arthroplasty. In addition, it is one of the few studies in which the results of hip replacement performed without cement were followed for a minimum of ten years. Although the component was a so-called first-generation design (available in a limited number of sizes and having a relatively narrow proximal cross-sectional geometry), femoral fixation was excellent in this group of patients (Figs. 1-A, 1-B, 1-C through 1-D); 94 percent of the 100 components showed osseous ingrowth, and only 2 percent were revised because of loosening. The senior ones of us (J. J. C. and C. G. S.) attempted to obtain a tight fit both proximally and distally, and many times they reamed the distal aspect of the canal to accommodate a larger component with a better proximal fit (Figs. 2-A and 2-B). This technique may account for the better results in terms of femoral fixation and the lower prevalence of pain in the thigh when compared with other series³ in which this device was used. The acetabular component was associated with more problems, as 10 percent of the 100 components needed revision (Figs. 3-A, 3-B, 3-C, 3-D through 3-E). This prevalence was probably related to the mode of fixation (on-line reaming with adjunctive peripheral peg fixation), the use of a thirty-two-millimeter femoral head, the inadequate shell-liner capturing mechanism, and the incongruent contact between the liner and the shell.

View larger version (60K): [in this window] [in a new window]   FIG1-A: Figs. 1-A through 1-D: Radiographs of a woman who had had a right total hip arthroplasty at the age of forty-five years because of congenital dysplasia of the hip. Figs. 1-A and 1-B: Anteroposterior and lateral radiographs made immediately postoperatively.

View larger version (85K): [in this window] [in a new window]   FIG1-B: Figs. 1-A through 1-D: Radiographs of a woman who had had a right total hip arthroplasty at the age of forty-five years because of congenital dysplasia of the hip. Figs. 1-A and 1-B: Anteroposterior and lateral radiographs made immediately postoperatively.

View larger version (54K): [in this window] [in a new window]   FIG1-C: Figs. 1-C and 1-D: Anteroposterior and lateral radiographs, made eleven years postoperatively, demonstrating secure acetabular and femoral fixation. The patient could walk unlimited distances without support and could perform moderate labor.

View larger version (73K): [in this window] [in a new window]   FIG1-D: Figs. 1-C and 1-D: Anteroposterior and lateral radiographs, made eleven years postoperatively, demonstrating secure acetabular and femoral fixation. The patient could walk unlimited distances without support and could perform moderate labor.

View larger version (66K): [in this window] [in a new window]   FIG2-A: Figs. 2-A and 2-B: Radiographs of a man who had had a total hip arthroplasty at the age of sixty-four years because of primary osteoarthritis. The radiographs demonstrate the distal reaming that was done to accommodate a larger femoral component with a better proximal fit. Fig. 2-A: Anteroposterior radiograph made immediately postoperatively.

View larger version (81K): [in this window] [in a new window]   FIG2-B: Fig. 2-B: Anteroposterior radiograph, made at ten years, demonstrating osteolysis of the proximal aspect of the femur and linear osteolysis of the medial aspect of the acetabulum, with secure femoral fixation. The patient continued to golf and to walk unlimited distances without support.

View larger version (72K): [in this window] [in a new window]   FIG3-A: Figs. 3-A through 3-E: Radiographs of a woman who had had a right total hip arthroplasty at the age of fifty-three years because of congenital dysplasia of the hip. Fig. 3-A: Anteroposterior radiograph made at two years.

View larger version (76K): [in this window] [in a new window]   FIG3-B: Fig. 3-B: Anteroposterior radiograph made at six years.

View larger version (65K): [in this window] [in a new window]   FIG3-C: Fig. 3-C: Anteroposterior radiograph, made at seven years, demonstrating acute loosening of the acetabular component, with surrounding pelvic osteolysis.

View larger version (74K): [in this window] [in a new window]   FIG3-D: Fig. 3-D: The osteolysis (arrow) superior to the acetabular component is best visualized on the lateral radiograph made at seven years.

View larger version (87K): [in this window] [in a new window]   FIG3-E: Fig. 3-E: Anteroposterior radiograph, made immediately after the revision, demonstrating the large femoral-head allograft that was required to fill the defect in the pelvis.

The clinical results in our series of patients deteriorated with time. This deterioration may be attributed to increasing comorbidities within the aging population. Most of the decrease in hip scores that was noted after a minimum of ten years of follow-up was not related to limited activity because of hip pain. Ninety-three percent (sixty-six) of the seventy-one patients indicated satisfaction with the result of the procedure, and 96 percent (sixty-eight) reported that they still had less pain as a result of the procedure. As was noted earlier, pain in the thigh has been reported with this device by us^2,11 and by other investigators^3,13. However, the prevalence of pain in the thigh decreased during the follow-up period and no patient in the present series had a revision because of pain in the thigh.

To our knowledge, the only other porous-coated device fixed without cement that has been the subject of a follow-up evaluation of at least ten years in duration is the Anatomic Medullary Locking (AML) prosthesis (with an extensively porous-coated stem) (DePuy, Warsaw, Indiana). After a minimum of ten years, Engh et al.⁷ reported a prevalence of revision of 2 percent (three of 178) for the femoral component of that device because of failure of ingrowth and a prevalence of revision of 2 percent (four of 178) for the acetabular component because of aseptic loosening. In our series, the results with regard to the femoral component were similar to those reported by Engh et al., with 2 percent of the 100 stems revised because of failure of ingrowth. However, an additional 3 percent of the 100 stems, which were proximally coated, were revised because of progressive osteolysis. For this reason, the senior ones of us presently use more extensively porous-coated femoral components so that, if proximal femoral osteolysis occurs, it does not compromise fixation of the distal aspect of the stem and revision is not necessary.

In terms of femoral fixation, our results compare favorably with those found in long-term follow-up evaluations of replacements performed with cement. After a minimum follow-up interval of fourteen years, Mulroy et al.¹⁵ reported that 2 percent (four) of 162 femoral components had been revised because of aseptic loosening and an additional 7 percent (seven) of the 102 femoral components in patients who were alive at the time of follow-up were radiographically loose but had not been revised. In a long-term follow-up evaluation of Charnley prostheses fixed with cement, Schulte et al.¹⁷ reported that 3 percent (three) of ninety-eight femoral components had been revised because of aseptic loosening in patients who were alive at a minimum of twenty years postoperatively. The clinical results in our study of a so-called first-generation stem fixed without cement were similar to the clinical results reported by Schulte et al. We reported an average Harris hip score of 84 points and pain in the thigh associated with 12 percent (nine) of the seventy-seven hips at a minimum of ten years, whereas Mulroy et al. reported an average hip score of 86 points at a minimum of fourteen years.

When we consider that this was our initial experience with fixation without cement and that the components were of a so-called first-generation design, we are sufficiently encouraged by the results of this study to use devices fixed without cement in total hip arthroplasty, especially in younger, heavier, and more active patients. The results in terms of the fixation of the femoral component are especially encouraging.

	Footnotes

 
*One or more of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. In addition, benefits have been or will be directed to a research fund, foundation, educational institution, or other nonprofit organization with which one or more of the authors is affiliated. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was National Institutes of Health Grant AR 43314.

Orthopaedic Surgery Service, Walter Reed Army Medical Center, Washington, D.C. 20307-5001.

Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, Iowa 52242. E-mail address: john-callaghan@uiowa.edu. Please address requests for reprints to Dr. Callaghan.

Loyola University Medical Center, 2180 First Avenue, Maywood, Illinois 60153.

#6262 Veterans Parkway, Columbus, Georgia 31909.

	References

Top Abstract Introduction Materials and Methods Results Discussion References

 

1. Astion, D. J.; Saluan, P.; Stulberg, B. N.; Rimnac, C. M.; and and Li, S.: The porous-coated anatomic total hip prosthesis: failure of the metal-backed acetabular component. J. Bone and Joint Surg., 78-A: 755-766, May 1996.[Abstract/Free Full Text]

2. Callaghan, J. J.; Dysart, S. H.; and and Savory, C. G.: The uncemented porous-coated anatomic total hip prosthesis. Two-year results of a prospective consecutive series. J. Bone and Joint Surg., 70-A: 337-346, March 1988.[Abstract/Free Full Text]

3. Campbell, A. C. L.; Rorabeck, C. H.; Bourne, R. B.; Chess, D.; and and Nott, L.: Thigh pain after cementless hip arthroplasty. Annoyance or ill omen. J. Bone and Joint Surg., 74-B(1): 63-66, 1992.

4. Charnley, J.: Low Friction Arthroplasty of the Hip. Theory and Practice, pp. 66-90. New York, Springer, 1979.

5. DeLee, J. G., and and Charnley, J.: Radiological demarcation of cemented sockets in total hip replacement. Clin. Orthop., 121: 20-32, 1976.

6. Engh, C. A.; Massin, P.; and and Suthers, K. E.: Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin. Orthop., 257: 107-128, 1990.

7. Engh, C. A., Jr.; Culpepper, W. J., II; and and Engh, C. A.: Long-term results of use of the anatomic medullary locking prosthesis in total hip arthroplasty. J. Bone and Joint Surg., 79-A: 177-184, Feb. 1997.[Abstract/Free Full Text]

8. Gruen, T. A.; McNeice, G. M.; and and Amstutz, H. C.: "Modes of failure" of cemented stem-type femoral components. A radiographic analysis of loosening. Clin. Orthop., 141: 17-27, 1979.

9. Hardinge, K.: The direct lateral approach to the hip. J. Bone and Joint Surg., 64-B(1): 17-19, 1982.

10. Harris, W. H.: 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 and Joint Surg., 51-A: 737-755, June 1969.[Abstract/Free Full Text]

11. Heekin, R. D.; Callaghan, J. J.; Hopkinson, W. J.; Savory, C. G.; and and Xenos, J. S.: The porous-coated anatomic total hip prosthesis, inserted without cement. Results after five to seven years in a prospective study. J. Bone and Joint Surg., 75-A: 77-91, Jan. 1993.[Abstract/Free Full Text]

12. Kaplan, E. L., and and Meier, P.: Nonparametric estimation from incomplete observations. J. Am. Statist. Assn., 53: 457-481, 1958.

13. Kim, Y.-H., and and Kim, V. E. M.: Uncemented porous-coated anatomic total hip replacement. Results at six years in a consecutive series. J. Bone and Joint Surg., 75-B(1): 6-13, 1993.

14. Massin, P.; Schmidt, L.; and and Engh, C. A.: Evaluation of cementless acetabular component migration. An experimental study. J. Arthroplasty, 4: 245-251, 1989.[Medline]

15. Mulroy, W. F.; Estok, D. M.; and and Harris, W. H.: Total hip arthroplasty with use of so-called second-generation cementing techniques. A fifteen-year-average follow-up study. J. Bone and Joint Surg., 77-A: 1845-1852, Dec. 1995.[Abstract/Free Full Text]

16. Scheck, M.; Gordon, R. B.; and and Glick, J. M.: The Kocher-McFarland approach to the hip joint for prosthetic replacements. Clin. Orthop., 91: 63-69, 1973.

17. Schulte, K. R.; Callaghan, J. J.; Kelley, S. S.; and and Johnston, R. C.: The outcome of Charnley total hip arthroplasty with cement after a minimum twenty-year follow-up. The results of one surgeon. J. Bone and Joint Surg., 75-A: 961-975, July 1993.[Abstract/Free Full Text]

18. Shaver, S. M.; Brown, T. D.; Hillis, S. L.; and and Callaghan, J. J.: Digital edge-detection measurement of polyethylene wear after total hip arthroplasty. J. Bone and Joint Surg., 79-A: 690-700, May 1997.

19. Zicat, B.; Engh, C. A.; and and Gokcen, E.: Patterns of osteolysis around total hip components inserted with and without cement. J. Bone and Joint Surg., 77-A: 432-439, March 1995.[Abstract/Free Full Text]

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