Radiographic Outcomes of the Implants After the Index Revision
Radiographically, loosening of the cup was seen in twenty-two hips (21%), and loosening of the femoral component was seen in twenty-two. Sixteen of these hips had loosening of both components. Periprosthetic osteolysis appeared on the latest radiographs of twenty-two hips.
Factors Influencing Results
Change of the cup during the index revision: A repeat revision was performed in eight (57%) of the fourteen hips in which the cup had been retained and in twenty-three (26%) of the eighty-nine in which it had been revised.
Change of the stem during the index revision: Twenty-two (44%) of the fifty hips in which the stem had been retained and eleven (20%) of the fifty-five in which the stem had been revised had a repeat revision.
Material of the new femoral head inserted during the index revision: The rate of repeat revision was twenty-five (47%) of fifty-three for the hips in which a stainless-steel femoral head had been used, one (11%) of nine for those in which a cobalt-chromium head had been used, and three (17%) of eighteen for those in which a ceramic head had been used.
Extent of synovectomy: A repeat revision was done in sixteen (67%) of the twenty-four hips with a partial synovectomy and in thirteen (19%) of the sixty-seven with a complete synovectomy.
Comparison of survival rates in relation to surgical techniques used during the revision: The survival rate of the index total hip prostheses at five years was 36% (95% confidence interval, 1% to 71%) when the cup had not been changed and 68% (95% confidence interval, 55% to 81%) when it had been changed (p = 0.018), the rate was 49% (95% confidence interval, 32% to 66%) when a stainless-steel femoral head had been implanted for the index revision and 76.5% (95% confidence interval, 59% to 94%) when a ceramic head had been used (p = 0.004), and the rate was 49.5% (95% confidence interval, 28% to 60%) when a partial synovectomy had been performed and 73% (95% confidence interval, 58% to 88%) when a complete synovectomy had been done (p = 0.005) (see Appendix).
At an average of sixty-five months (range, eight to 144 months) after the index revision, no repeat revision had been performed in any of the seventeen hips in which the cup had been changed, a new cobalt-chromium or ceramic head had been fitted onto a new femoral stem, and a total synovectomy had been performed. Repeat revisions were more frequent in younger patients, with the average age (and standard deviation) being 63.5 ± 2 years for the patients who did not have a repeat revision and 57 ± 4 years for those who did (p = 0.02).
Multivariable analysis showed that two factors were independently related to the absence of a need for repeat revision: total synovectomy (odds ratio, 0.12; 95% confidence interval, 0.04 to 0.37) and age (odds ratio, 0.94 per year of age; 95% confidence interval, 0.90 to 0.99).
Histological examination of specimens of the surrounding tissues in eleven hips treated with repeat revision after implantation of a stainless-steel femoral head to replace the fractured ceramic head revealed intense, diffuse metallosis and infiltration of the neosynovial tissue by macrophages and giant multinucleated cells. Stainless-steel material was identified in the neosynovial tissue by histochemical reaction (hematoxylin, eosin, and safranin stain). Analysis of the surfaces of four femoral head implants with a scanning electron microscope revealed the presence of adherent particles. A microprobe analysis of the energy-dispersive spectrum demonstrated alumina in these particles. The same analysis was done on the polyethylene cups. The scanning electron microscope revealed the existence of a third, additional component that, according to the microprobe analysis, was made up of polyethylene wear debris and alumina particles. The analysis of the bottom of the cup demonstrated an accumulation of abrasive material lying on the polyethylene. The material was composed of alumina particles (200 to 600 μm in size) with some traces of metallic debris.
Fracture of a ceramic femoral head is rare today 5,16,17, but this complication can be disastrous, with the risk of several revisions. The operative technique for the treatment of a ceramic head fracture was very variable in our series. Three parameters appeared to be important: cup revision, the material of the femoral head, and total synovectomy.
We believe that the cup should be removed at the time of revision, even when it appears normal macroscopically, because microscopic ceramic particles may be embedded in it. A new ceramic femoral head can be inserted so that the toughness can be at least equal to that of the first femoral head implant, and to avoid wear of the femoral head, but a cobalt-chromium head also provides very satisfactory results. In contrast, a stainless-steel femoral head should not be used because of the abnormal wear that can occur. We believe that the wear found in our study resulted from alumina particles that were still present in the periprosthetic soft tissues and that amalgamated with the polyethylene wear debris. This led to the formation of a third abrasive component (polyethylene wear debris and alumina particles) at the interface between the cup and the femoral head, which promoted the wear of the stainless-steel femoral head.
Our study did not allow us to determine the best approach with regard to the Morse taper. If a new ceramic femoral head is used, a modification in the geometry of the femoral Morse taper may lead to a mismatch between the bore of the head and the metal taper, and this can cause high stress concetrations and predispose the ceramic femoral head to refracture 5,24. In our series, of the five revision ceramic heads that were implanted without exchange of the Morse taper, one fractured. Therefore, a ceramic femoral head probably should not be used on an existing Morse taper at the time of a revision arthroplasty 25. This concept necessitates removal of the femoral stem, which can be a very complex surgical procedure when the stem is stable. The use of a new head made of cobalt-chromium avoids this problem and provides satisfactory clinical results. Finally, a synovectomy has to be performed as extensively as possible to remove as much of the ceramic debris as possible. Use of the above approach in the rare cases of ceramic femoral head fracture that we identified led to satisfactory medium-term survivorship.
Survivorship curves related to exchange of the cup at revision, the material of the new femoral head, and the performance of synovectomy are available in the electronic versions of this article, on our web site at http://www.jbjs.org (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).
Note: The authors thank C. Argenson, J.M. Artigou, B. Balay, Z. Bassot, J. Bejui-Hugues, M. Bercovy, P. Biancharelli, J.P. Blanchard, P. Boileau, J.M. Bonnet, D. Burgot, J.C. Cartillier, M. Chanzy, A. Dambreville, A. Duquennoy, M. Fleuriel, J.L. Guillamon, D. Huten, X. Hy, J.Y. Jenny, I. Kempf, J.C. Lambotte, F. Langlais, P. Le Couteur, F. Lecuire, J.L. Lerat, J. Letenneur, J.P. Levai, J.H. Marotte, B. Melchior, J.Y. Nordin, C. Nourissat, C. Pages, N. Passuti, J.M. Postel, J. Preaut, H. Robert, H. Robin, E. Roland, G. Saillant, M. Serrault, B. Tayon, and S. Terver for their contributions to this study.
Investigation performed at Service de Chirurgie Orthopédique, Hôpital Henri Mondor, Créteil, France
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive 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, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
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