The Accolade TMZF is a tapered-wedge cementless metaphyseal-coated femoral stem that was widely utilized from 2002 to 2012. In recent years, there have been reports of early catastrophic failure of ...this implant. The purposes of the present study were to establish the long-term survival of this stem and to analyze patients who underwent aseptic revision to understand the causes and risk factors for failure.
We retrospectively reviewed the records of all patients who had undergone primary total hip arthroplasty with use of an Accolade TMZF stem at a high-volume arthroplasty center. The causes and timing of revision surgery were documented. Survivorship analysis was performed with use of Kaplan-Meier curves to determine the overall and aseptic survival rates at the time of the latest follow-up. Patient and implant factors commonly associated with aseptic failure were extracted, and a Cox proportional hazards model was used.
A consecutive series of 2,609 patients who had undergone unilateral primary total hip arthroplasty with use of an Accolade TMZF femoral stem were included. The mean time from the primary procedure was 11.3 years (range, 0 days to 19.4 years). The cumulative survival rate was 95.5% ± 0.1% at the time of the latest follow-up. One hundred and seven patients underwent revision surgery, with aseptic loosening of the femoral component being the most common cause of aseptic failure in this cohort (33 of 2,609; 1.3%). Smaller femoral size and larger femoral head offset were independent risk factors for aseptic failure.
To our knowledge, this is the largest series representing the longest follow-up of this tapered-wedge cementless femoral implant. Despite early concerns, the Accolade TMZF stem had excellent survivorship in this cohort. Trunnionosis as the cause for revision surgery was rare.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Dislocation remains the leading indication for revision of total hip arthroplasty (THA). The objective of this study was to use a computational model to compare the overall resistance to both ...anterior and posterior dislocation for the available THA constructs commonly considered by surgeons attempting to produce a stable joint. Patient‐specific musculoskeletal models of THA patients performing activities consistent with anterior and posterior dislocation were developed to calculate joint contact forces and joint positions used for simulations of dislocation in a finite element model of the implanted hip that included an experimentally calibrated hip capsule representation. Dislocations were then performed with consideration of offset using +5 and +9 offset, iteratively with three lipped liner variations in jump distance (10°, 15°, and 20° lips), a size 40 head, and a dual‐mobility construct. Dislocation resistance was quantified as the moment required to dislocate the hip and the integral of the moment‐flexion angle (dislocation energy). Increasing head diameter increased resistive moment on average for anterior and posterior dislocation by 22% relative to a neutral configuration. A lipped liner resulted in increases in the resistive moment to posterior dislocation of 9%, 19%, and 47% for 10°, 15°, and 20° lips, a sensitivity of approximately 2.8 Nm/mm of additional jump distance. A dual‐mobility acetabular design resulted in an average 38% increase in resistive moment and 92% increase in dislocation energy for anterior and posterior dislocation. A quantitative understanding of tradeoffs in the dislocation risk inherent to THA construct options is valuable in supporting surgical decision making.
This paper constitutes an analysis of the issues, relationships, emerging hospital strategies, and policy needs surrounding hip and knee implants. Demand for hip and knee replacements is rising ...annually, and growth is expected to be substantial. Costs are high, reaching $11 billion for hospitals in 2004 and $5 billion for Medicare in 2006. Relationships among stakeholders add complexity. Case studies reveal emerging strategies by hospitals for management of implants. Policy considerations include development of a national council for data and technology assessment, a national joint registry, price transparency, and incentives.
Background
The best approach for surgical treatment of an infected THA remains controversial. Two-stage revision is believed to result in lower reinfection rates but may result in significant ...functional impairment. Some authors now suggest that single-stage revision may provide comparable results in terms of infection eradication while providing superior functional outcomes.
Questions/purposes
We performed a systematic review to determine whether single- or two-stage revision for an infected THA provides lower reinfection rates and higher functional outcome scores.
Methods
We conducted a comprehensive search of PubMed and Embase, using the search string Infection AND (“total hip replacement” OR “total hip arthroplasty”) AND revision. All studies comparing reinfection rates or functional scores for single- and two-stage revision were retrieved and reviewed. A systematic review was performed according to the PRISMA checklist.
Results
The initial search retrieved 1128 studies. Following strict exclusion criteria, we identified nine comparative studies comparing reinfection rates (all nine studies) or functional scores (four studies) between single- and two-stage revisions. The overall quality of studies was poor with no randomized studies being identified. Groups often varied in their baseline characteristics. There was no consensus among the studies regarding the relative incidence of reinfection between the two procedures. There was a trend toward better functional outcomes in single-stage surgery, but this reached significance in only one study.
Conclusions
In appropriate patients, single-stage revision appears to be associated with similar reinfection rates when compared with two-stage revision with superior functional outcomes. This concurs with earlier studies, but given the methodologic quality of the included studies, these findings should be treated with caution. High-quality randomized studies are needed to compare the two approaches to confirm these findings, and, if appropriate, to determine which patients are appropriate for single-stage revision.
The implantation of uncemented prostheses requires the application of sufficient forces to achieve a press-fit of the implant in the bone. Excessive forces have to be omitted to limit bone damage. ...Force measurements along the force transmission path between mallet and implant are frequently used to investigate this trade-off. Placing a load cell at a position of interest (PoI), which might be the implant bone interface or the head taper junction, is technically challenging or even impossible so that nearby positions are chosen. Thus, a certain inertia and stiffness remain between the PoI and the sensor, and consequently the measured dynamic forces differ from those at the PoI. This experimental and numerical study aimed to investigate the amount of force reduction along the transmission path while joining femoral heads to stem tapers. Forces were measured in vitro at the tip of the mallet, directly above the polymer tip of the impactor and below the stem taper. Springs and masses were used to represent the responding tissue of a patient. A semi-empirical numerical model of the force transmission path was developed and validated in order to simulate a larger range of responding tissue properties than experimentally possible and to investigate the influence of different surgical instruments. A distinct attenuation was observed since the peak forces at the impactor reached 35% of the applied peak forces and 21% at the stem taper, respectively. The force curves were replicated with a median root mean square error of 3.8% of the corresponding mallet blow for the impactor and 3.6% for the stem. The force measurement position and the used surgical instruments have a strong influence on the measured forces. Consequently, the exact measurement conditions with regard to sensor positioning and used surgical instruments have to be specified and hence only studies with similar setups should be compared to avoid misestimation of the forces at the PoI. The proposed dynamic numerical model is a useful tool to calculate the impact of the chosen or changed mechanical parameters prior to executing experiments and also to extrapolate the effect of changing the applied forces to the resulting forces at the PoI.
In this study, 35 retrieved ceramics femoral heads with evidence of metallic dark lines on the surface were analyzed. The surface roughness of these femoral heads was acquired using both a stylus ...contact profiler and an optical non-contact profilometer. The metallic deposition on hip ball surface, also known as Metal Transfer (MT), appeared as dark metallic and can occur during the surgery or during the reduction of a dislocated prosthesis. In this study, we validate a new protocol to measure surface roughness on retrieved femoral heads, by using the aforementioned two different acquisition techniques and also to investigate the hypothesis that such metal transfer retrieved ceramic femoral head is associated with increased surface roughness.
All femoral components of this investigation showed remarkable differences in roughness values between MT-affected and MT-unaffected areas. The two acquisition procedures – conventional stylus and 3D confocal profilometer – confirmed a satisfying agreement, even considering the obvious resolution difference.
•A novel design of functionally graded porous acetabular component is proposed.•The optimization framework integrated a genetic algorithm with FE analysis.•A sensitivity analysis assessed the ...influence of each design parameter.•The efficacy of the novel design was evaluated based on common failure mechanisms.•A CAD model of the optimal functionally graded porous design was generated.
Generation of polyethylene wear debris and peri‑prosthetic bone resorption have been identified as potential causes of acetabular component loosening in Total Hip Arthroplasty. This study was aimed at optimization of a functionally graded porous acetabular component to minimize peri‑prosthetic bone resorption and polyethylene liner wear. Porosity levels (porosity values at acetabular rim, and dome) and functional gradation exponents (radial and polar) were considered as the design parameters. The relationship between porosity and elastic properties were obtained from numerical homogenization. The multi-objective optimization was carried out using a non-dominated sorting genetic algorithm integrated with finite element analysis of the hemipelvises subject to various loading conditions of common daily activities. The optimal functionally graded porous designs (OFGPs −1, −2, −3, −4, −5) exhibited less strain-shielding in cancellous bone compared to solid metal-backing. Maximum bone-implant interfacial micromotions (63–68 μm) for OFGPs were found to be close to that of solid metal-backing (66 μm), which might facilitate bone ingrowth. However, OFGPs exhibited an increase in volumetric wear (3–10 %) compared to solid metal-backing. The objective functions were found to be more sensitive to changes in polar gradation exponent than radial gradation exponent, based on the Sobol’ method. Considering the common failure mechanisms, OFGP-1, having highly porous acetabular rim and less porous dome, appears to be a better alternative to the solid metal-backing.
•This study makes use of experimental results in which 14 participants are recruited to perform walking, stair ascending (AS) and descending activities (DS) to extract kinematic and kinetic data for ...each cycle by using marker based Qualisys motion capture (MOCAP) system.•Multibody simulations are performed in the Anybody Modeling System using the Calibrated Anatomical System Technique (CAST) full body marker set.•The 3D generic musculoskeletal model used in this study is a marker-based full-body motion capture model (AMMR,2.3.1 MoCapModel) consisting of the upper extremity and the Twente Lower Extremity Model (TLEM2).•For dynamic wear modelling, Ls-Dyna modelling software is utilized to predict the linear wear rates of CoCr-on-XLPE bearing couple under stair ascending and descending activities based on the walk-to-stair ratio (15.9:1) over 5 million cycles.•The volumetric wear rates of XLPE liner under AS, DS, and walking activities over 5-Mc are predicted as 27.43, 23.22, and 18.84 respectively.•The volumetric wear rate of XLPE is predicted as 22.02 which is equivalent to 19.41% of walking, which is concluded to be included in life span estimations of implants for realistic outcomes.
Total hip arthroplasty (THA) surgeries among young patients are on the increase, so it is crucial to predict the lifespan of hip implants correctly and produce solutions to improve longevity. Current implants are designed and tested against walking conditions to predict the wear rates. However, it would be reasonable to include the additional effects of other daily life activities on wear rates to predict convergent results to clinical outputs. In this study, 14 participants are recruited to perform stair ascending (AS), descending (DS), and walking activities to obtain kinematic and kinetic data for each cycle using marker based Qualisys motion capture (MOCAP) system. AnyBody Modeling System using the Calibrated Anatomical System Technique (CAST) full body marker set are performed Multibody simulations. The 3D generic musculoskeletal model used in this study is a marker-based full-body motion capture model (AMMR,2.3.1 MoCapModel) consisting of the upper extremity and the Twente Lower Extremity Model (TLEM2). The dynamic wear prediction model detailing the intermittent and overall wear rates for CoCr-on-XLPE bearing couple is developed to investigate the wear mechanism under 3D loading for AS, DS, and walking activities over 5 million cycles (Mc) by using finite element modelling technique. The volumetric wear rates of XLPE liner under AS, DS, and walking activities over 5-Mc are predicted as 27.43, 23.22, and 18.84 mm3/Mc respectively. Additionally, the wear rate was predicted by combining stair activities and gait cycles based on the walk-to-stair ratio. By adding the effect of stair activities, the volumetric wear rate of XLPE is predicted as 22.02 mm3/Mc which is equivalent to 19.41% of walking. In conclusion, in this study, the effect of including other daily life activities is demonstrated and evidence is provided by matching them to the clinical data as opposed to simulator test results of implants under ISO 14242 boundary conditions.
Measuring cup orientation is time consuming and inaccurate, but orientation influences the risk of impingement and dislocation following total hip arthroplasty (THA). This study designed an ...artificial intelligence (AI) program to autonomously determine cup orientation, correct for pelvis orientation, and identify cup retroversion from an antero-posterior pelvic radiographs.
There were 2,945 patients between 2012 and 2019 identified to have 504 computed tomographic (CT) scans of their THA. A 3-dimensional (3D) reconstruction was performed on all CTs, where cup orientation was measured relative to the anterior pelvic plane. Patients were randomly allocated to training (4,000 x-rays), validation (511 x-rays), and testing (690 x-rays) groups. Data augmentation was applied to the training set (n = 4,000,000) to increase model robustness. Statistical analyses were performed only on the test group in their accuracy with CT measurements.
AI predictions averaged 0.22 ± 0.03 seconds to run on a given radiograph. Pearson correlation coefficient was 0.976 and 0.984 for AI measurements with CT, while hand measurements were 0.650 and 0.687 for anteversion and inclination, respectively. The AI measurements more closely represented CT scans when compared to hand measurements (P < .001). Measurements averaged 0.04 ± 2.21°, 0.14 ± 1.66°, −0.31 ± 8.35°, and 6.48° ± 7.43° from CT measurements for AI anteversion, AI inclination, hand anteversion, and hand inclination, respectively. AI predictions identified 17 radiographs as retroverted with 100.0% accuracy (total retroverted, n = 45).
The AI algorithms may correct for pelvis orientation when measuring cup orientation on radiographs, outperform hand measurements, and may be implemented in a timely fashion. This is the first method to identify a retroverted cup from a single AP radiograph.
Accurate acetabular component positioning is paramount to the success of total hip arthroplasty (THA). Two-dimensional imaging alone remains a popular tool for implant position assessment despite ...known limitations. We investigated the accuracy of a novel method for assessing acetabular component position based upon orthogonal simultaneous biplanar X-ray images.
There were forty consecutive patients who had a preexisting THA on the contralateral side who underwent both computed tomography (CT) and simultaneous orthogonal biplanar radiographic scans for preoperative planning of THA. The operative inclination (OI) and operative anteversion (OA) of the acetabular cup were calculated by a new measurement method using the biplanar simultaneous scans. Those measurements were compared to measurement of the cup orientation on CT. The measurements were made by 2 independent observers. Interobserver correlation coefficients were calculated between the 2 observers to measure reliability.
The mean error in OA measurement of the acetabular cup between simultaneous orthogonal biplanar radiographic and CT imaging was 0.5° (SD: 1.9°, minimum −4.0°, maximum 5.0°), the mean error in OI was 0.0° (SD: 1.7°, minimum −5.0°, maximum 4.0°). The average absolute error was 1.5° for OA and 1.2° for OI. Interobserver correlation coefficient was 0.83 for OA and 0.93 for OI.
The novel method of measuring cup orientation using simultaneous biplanar radiographic scans utilized in this study was accurate and reproducible between observers compared to CT measurements.
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