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Acetabular Revision Arthroplasty Using an Uncemented Deep Profile Jumbo Component: A Ten to Sixteen Year Follow-Up Study
Accepted Manuscript Acetabular Revision Arthroplasty using an Uncemented Deep Profile Jumbo Component: A Ten to Sixteen Year Follow-up Study Jeffrey R. McLaughlin, M.D., Kyla R. Lee, M.D. PII:
S0883-5403(17)30785-4
DOI:
10.1016/j.arth.2017.09.002
Reference:
YARTH 56076
To appear in:
The Journal of Arthroplasty
Received Date: 30 May 2017 Revised Date:
14 August 2017
Accepted Date: 1 September 2017
Please cite this article as: McLaughlin JR, Lee KR, Acetabular Revision Arthroplasty using an Uncemented Deep Profile Jumbo Component: A Ten to Sixteen Year Follow-up Study, The Journal of Arthroplasty (2017), doi: 10.1016/j.arth.2017.09.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Acetabular Revision Arthroplasty using an Uncemented Deep Profile Jumbo Component:
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A Ten to Sixteen Year Follow-up Study
Jeffrey R. McLaughlin, M.D. *
* Corresponding Author—Email@: [email protected] The Kennedy Center
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@ Mercy Medical Center
Suite 125, 2700 W. Ninth Avenue Oshkosh, WI 54901
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Telephone: 920-223-0123 Fax: 920-223-0370
Kyla R. Lee, M.D.
Clinical Associate Professor Gundersen Lutheran Medical Center 1836 South Ave LaCrosse, WI 54601
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Acetabular Revision Arthroplasty using an Uncemented
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Deep Profile Jumbo Component:
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A Ten to Sixteen Year Follow-up Study
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Aims: The purpose of the present study was to evaluate the outcome of revision total hip
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arthroplasty using an uncemented deep profile jumbo acetabular component in patients who had
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been followed for a minimum of ten years postoperatively.
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Patients and Methods: Between 1997 and 2001, 61 revision total hip arthroplasties were
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performed in 58 patients, with use of the +5 Deep Profile acetabular shell. The outcome with
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regard to retention versus re-revision of the acetabular component was determined for every hip.
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At a mean of 13 years, (range, 10 to 16 years) post operatively, 30 patients (32 hips) were living.
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The Harris hip score, radiographic results, complications and Kaplan-Meier survivorship were
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evaluated.
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Results: In the entire cohort of 61 hips, 4 acetabular components have been re-revised. Two
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shells were re-revised for sepsis, one shell was re-revised for aseptic loosening and one for
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recurrent dislocation. In the 32 hips followed for a minimum of ten years postoperatively, two
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cups have been re-revised, one for aseptic loosening and one for recurrent dislocation. One
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additional shell was loose by radiographic criteria. With failure defined as re-revision for any
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reason, implant survival (95% CI) was 92.6% (81.0 - 97.2) at 16 years. With failure defined as
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re-revision for aseptic loosening, implant survival was 97.4% (82.8 - 99.6) at 16 years.
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Conclusion: Revision total hip arthroplasty with the +5 Deep Profile acetabular component was
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associated with a good rate of survival at 16 years.
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Key words
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Revision Hip Arthroplasty
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Deep profile
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Jumbo cups
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Survivorship
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Uncemented
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Acetabular Revision
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Level of Evidence: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence
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Introduction
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Revision total hip replacement surgery accounts for over 10% of the hip arthroplasty
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surgeries performed in the United States today. The incidence is expected to dramatically
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increase in the ensuing decades [1]. In acetabular revision surgeries moderate to severe bone loss
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is frequently encountered. The Paprosky classification is commonly used to describe these
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defects [2]. It is not surprising that the severity of acetabular bone loss correlates well with the
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success of revision surgery. To address this, porous coated jumbo acetabular components fixed
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with screws have been used. Jumbo cups are defined as ≥ 62mm in women and ≥ 66mm in men
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[3]. These devices have been associated with good to excellent results in several published series
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[3-11]. The incidence of re-revision has been reported to range from 3% to 17% at mid to long
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term follow-up. In the majority of these reviews a low profile acetabular shell was used [3, 4, 6,
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7, 8, 11]. The +5 Deep Profile acetabular component is a fully hemispheric shell that was
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developed to address medial wall defects encountered during revision surgery. These defects
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may result from osteolysis, infection, loose prosthetic components or multiple previous surgeries
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[12, 13]. The +5 Deep Profile revision shell was designed to achieve stable fixation on host bone,
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increase horizontal offset and restore the native center of hip rotation. The purpose of this study
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is to report our results using a fully hemispheric deep profile jumbo acetabular component in
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revision total hip surgery at a mean follow-up of 13 years.
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Patients and Methods 3
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Between November 1997 and October 2001, 61 revision total hip arthroplasties
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were performed on 58 patients, using an uncemented deep profile jumbo acetabular component.
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All revision surgeries were performed by a single surgeon. The 58 patients (61 hips) were
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followed until death, acetabular component re-revision or a minimum of ten years. Twenty-eight
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patients (29 hips) died prior to obtaining a minimum 10-year follow-up. Of these, two patients (2
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hips) had undergone re-revision of the acetabular component. The remaining 26 patients (27
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hips) died with their acetabular component in place. This left 32 hips in 30 patients. Among
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those living patients, two acetabular components have undergone re-revision surgery. In the
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remaining 30 hips in 28 patients clinical follow-up was obtained at a mean of 13 years (range, 10
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to 16 years). One patient provided clinical follow-up, but declined radiographic follow-up.
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Therefore, complete radiographic follow-was obtained on the remaining 27 patients (29 hips) at a
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mean follow-up of 13 years (range, 10-16). The mean age of the 14 women (15 hips) and 14
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men (15 hips) at the time of surgery was 71 years (range, 36-79). The average body mass index
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was 33 (range, 24 to 52) kg/m2. The indication for revision arthroplasty was aseptic loosening in
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26 hips, recurrent dislocation in three hips and severe osteolysis in one hip.
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The McLaughlin +5 Deep Profile acetabular component (Zimmer-Biomet, Warsaw, IN)
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was used for all revision surgeries (Fig 1). It is an uncemented shell made of wrought titanium
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alloy (Ti-6Al-4v). The implant has a porous coating consisting of an identical titanium alloy
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applied by a plasma spray technique. The acetabular component is a full hemisphere and has
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5mm of additional metal on the dome of the shell which allows for the use of rim screws. The
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sizes of the acetabular components used in this series were 62mm in 7 hips, 64 mm in 8 hips, 66
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mm in 11 hips, 68mm in 5 hips and 70mm in 1 hip. An Arcom (Zimmer-Biomet) polyethylene
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liner manufactured from Himont 1900 resin (Montell Polyolefins) was used in all hips. A 28 or
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32mm chrome-cobalt femoral head was used in all cases. Operative Technique
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A posterolateral approach to the hip was used. The existing acetabular component was
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removed with care to preserve as much bone as possible. Removal of cement, fibrous tissue and
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osteolytic debris was meticulously performed. The acetabulum was gently reamed progressively
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in 2 mm increments until contact with bleeding cancellous bone was obtained. Acetabular
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deficiencies were packed with allograft bone chips and local bone obtained from reaming. The
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acetabulum was under-reamed by 2mm. A trial component was placed and trial reduction
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performed to evaluate mechanical stability of the implant. After insertion of the true acetabular
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shell, multiple screws were placed. An intra-operative radiograph was obtained on every hip to
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assess the position of the component, the screws and to evaluate leg lengths. Intravenous
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antibiotics were administered after intraoperative cultures were obtained and were continued for
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48 hours after operation. Patients were allowed 50% weight bearing with a walker or crutches
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for four weeks, and thereafter advanced as tolerated. Warfarin was administered orally on the
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day of surgery and continued for one month.
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Clinical Follow-up and Radiographic Analysis The procedures for this study were approved by the Institutional Review Board and
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written informed consent was obtained from all patients. Complete clinical follow-up at a
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minimum of 10 years after the index operation was obtained for all 28 living patients (30 hips)
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who had not undergone re-revision surgery. The Harris hip score was used to determine the
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functional level and to evaluate pain [14]. Radiological evaluation at a mean of 13 years 5
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(range, 10-16) consisted of anteroposterior (AP) views of the hip and pelvis and a true lateral
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view of the hip. These were compared with the immediate post-operative radiographs and with
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those obtained at subsequent follow-up. They were evaluated by an independent investigator
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who was not the operating surgeon. The acetabular components were evaluated for
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radiolucencies and osteolysis in the zones described by De Lee and Charnley [15].
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Radiolucencies with a scalloped or cystic appearance, or > 2mm in width, were recorded as
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osteolysis. All measurements were corrected for magnification based on the true size of the
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femoral head. Fixation of the acetabular component was assessed by the criteria of Massin, et al
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[16]. It was considered loose if there was migration from the inter-teardrop or vertical line, a
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continuous radiolucency, or a change > 4° in the angle of abduction. Acetabular deficiency was
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evaluated by the criteria described by Paprosky et al [2]. In the 30 patients (32) hips who
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survived a minimum of ten years post operatively, acetabular deficiency at the time of revision
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surgery was classified as Type I in two hips, IIA in five hips, IIB in eleven hips, IIC in twelve
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hips, IIIA in two hips and IIIB in no hips.
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Statistical Analysis
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Data analysis was calculated using the SAS software version 9.3 (SAS Institute Inc.,
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Carey NC). The Kaplan-Meier method was used to generate survivorship curves with
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corresponding 95% CI [17]. The end points were revision of the acetabular component for any
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reason and revision of the acetabular component for aseptic loosening. All 61 hips in this series
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were included in the survivorship analysis. A Multivariate proportional hazards regression model
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was used to identify associations between demographic factors and implant survival. Survival
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times for implants that did not fail were censored at date of last contact or date of death.
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Results
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At the time of this review 30 patients (32 hips) were still living and 28 patients (29 hips)
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had died. Fifty-seven (93%) of the original 61 +5 Deep Profile acetabular components remained
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in place at the time of death or at the time of final follow-up. A total of four shells (7%) had
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been re-revised. In two hips the acetabular component was explanted for sepsis at two weeks
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and one year post-operatively. One well fixed acetabular component was re-revised for recurrent
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dislocation at two years post-operatively and one shell was re-revised for aseptic loosening at ten
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years.
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Complications
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In the entire cohort of 58 patients (61 hips) complications occurred in seven patients (7 hips) (11%). Three patients (5%) sustained post-operative dislocations. One patient was treated
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with closed reduction and bracing for six weeks without subsequent dislocation. One patient
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sustained multiple late dislocations and required re-revision two years post operatively. A third
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patient sustained multiple dislocations and required reoperation with femoral head exchange
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without further dislocation. Two patients required explantation of the acetabular component for
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deep infection at two weeks and one year post operatively. Deep vein thrombosis was diagnosed
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and treated in one patient.
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Living Patients: Thirty patients (32 hips) were alive at an average follow-up of 13 years
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(range, 10-16). Two patients (2 hips) had undergone acetabular re-revision. One acetabular
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component was re-revised for aseptic loosening at ten years post-operatively. In this patient a
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64mm cup had been used and the acetabular deficiency at the time of the index procedure was
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Paprosky Type IIIA. One additional acetabular component was re-revised for recurrent 7
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dislocation at two years. At the time of re-revision surgery the acetabular component was found
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to be well fixed. The size of the acetabular component re-revised in this patient was 62mm and
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the Paprosky acetabular deficiency found at the initial revision surgery was Type IIA. With the
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numbers available there was no association between acetabular component re-revision and
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component size (p=0.65) or Paprosky acetabular deficiency classification (p=0.84).
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Of the thirty living patients (32 hips) twenty-eight (30 hips) had not undergone re-
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revision of the acetabular component. In these 28 patients (30 hips) the average Harris hip score
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improved from 49 points (37-59) pre-operatively to 86 points (64-94) at the time of last follow-
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up.
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Radiographic Analysis
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Radiographs were obtained on 29 of the 30 hips in living patients who had not undergone re-revision surgery [Fig.2]. The mean duration of radiographic follow-up was 13 years (range,
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10-16). Radiolucencies, not present on the immediate post-operative radiograph occurred in
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eight hips (28%), most commonly in zone A. A continuous radiolucency, measuring 2mm, was
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identified around one cup. Osteolysis was identified around four shells (14%). Major osteolysis
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occurred in only one hip. Twenty-eight of the 29 shells were considered stable. The one shell
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with a continuous radiolucency had migrated and was considered loose.
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Survival Analysis
With re-revision of the shell for any reason as the end point, Kaplan-Meier analysis, demonstrated a survival rate (95% CI) of 92.6 % (81.0 - 97.2) at 16 years for the entire series of
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61 revision total hip arthroplasties. With revision of the cup because of aseptic loosening as the
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endpoint, the 16 year survival rate was 97.4 % (82.8 - 99.6) (Fig. 3). Discussion
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The purpose of the present study was to evaluate the 10 to 16 year results using the +5
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Deep Profile acetabular component in patients requiring acetabular revision surgery. In the
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entire series of 61 acetabular revisions, four components have required re-revision surgery, only
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one for aseptic loosening. One additional shell was loose by radiographic criteria. The numbers
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of complications were comparable with those reported in the literature at mid-term follow-up.
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Survivorship analysis with re-revision of the acetabular component for any reason as the
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endpoint was 92.6 % (81.0 - 97.2) at 16 years. These findings support the use of a deep profile
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acetabular component in patients with moderate acetabular bone loss who require revision
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surgery.
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Limitations of this study include the death of 28 patients (29 hips) prior to the ten-year follow-up interval. The outcome, however, of every reconstruction was determined, including in
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those patients who had died. A strength of this study was the high rate of follow-up. In patients
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who had survived a minimum of ten years post revision procedure, clinical follow-up was
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obtained on 100% and radiographic follow-up in 97%
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Over the past four decades several surgical techniques have been used to address
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moderate acetabular bone loss in revision hip surgery [12, 13]. These have included cemented
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cups, impaction grafting with cemented shells and porous coated jumbo cups. High failure rates
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have been reported using cemented polyethylene cups in revision surgery. Kavanagh et al
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reported a loosening rate of 50% at only 4.6 years [18]. The results using impaction bone 9
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grafting and cemented cups are significantly better. Stroet et al reported a 72.1 % survivorship
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with revision for aseptic loosening as the endpoint at 25 years [19]. With revision for any reason
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survivorship fell to 58.0%. There are now several papers with good to excellent mid to long
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term results using uncemented jumbo cups fixed with screws [3-11]. Lachiewicz and Watters
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have pointed out that these procedures are relatively straight forward, the components maintain
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contact over a large surface area of native bone, and they attempt to maintain a normalized hip
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center of rotation [20]. Van Roth reported an 83% survivorship at 20 years with this procedure
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[11].
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The current report represents the results using a fully hemispheric uncemented
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deep profile acetabular component in revision surgery. Overall, the cups performed well. In the
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entire cohort of 61 hips, one acetabular component required revision for aseptic loosening and
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one additional cup was loose by radiographic criteria, giving a total incidence of acetic loosening
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of 3%. Survivorship analysis with revision for any reason was 92.6% (95% CI =81.0 - 97.2) at
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16 years.
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On the basis of these results, we believe that the +5 Deep Profile fully hemispheric shell is a viable option in patients requiring acetabular revision surgery.
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References
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Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007; 89(4): 780-5.
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2.
Paprosky WG, Perona PG, Lawrence JM. Acetabular defect classification and surgical reconstruction in revision arthroplasty. A 6-year follow-up evaluation. J Arthroplasty.1994; 9(1): 33-44.
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3.
Whaley AL, Berry DJ, Harmsen WS. Extra-large uncemented hemispherical acetabular components for revision total hip arthroplasty. J Bone Joint Surg Am. 2001; 83(9):1352-7.
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Tanzer M, Drucker D, Jasty M, McDonald M, Harris WH. Revision of the acetabular component with an uncemented Harris-Galante porous-coated prosthesis. J Bone Joint Surg Am. 1992; 74(7):987-94.
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Gustke KA, Levering MF, Miranda MA. Use of jumbo cups for revision of acetabulae with large bony defects. J Arthroplasty. 2014; 29(1):199-203.
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Lachiewicz PF, Soileau ES. Fixation, survival and dislocation of jumbo acetabular components in revision hip arthroplasty. J Bone Joint Surg Am.2013; 95: 543-8.
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Dearborn JT, Harris WH. Acetabular revision arthroplasty using so-called jumbo cementless components: an average 7-year follow-up study. J Arthroplasty. 2000; 15(1):8-15.
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Hendricks KJ, Harris WH. Revision of failed acetabular components with use of so-called jumbo noncemented components. A concise follow-up of a previous report*. J Bone Joint Surg Am. 2006; 88(3): 559-63.
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Patel JV, Masonis JL, Bourne RB, Rorabeck CH. The fate of cementless jumbo cups in revision hip arthroplasty. J Arthroplasty. 2003; 18(2):129-33.
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Wedemeyer C, Neuerburg C, Heep H. et al, Jumbo cups for revision of acetabular defects after total hip arthroplasty: a retrospective review of a case series. Arch Orthop Trauma Surg. 2008; 128: 545-50.
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Von Roth P, Abdel M, Harmsen WS, Berry DJ. Uncemented jumbo cups for revision total hip arthroplasty: A concise follow-up, at a mean of twenty years, of a previous report*. J Bone Joint Surg Am. 2015; 97:284-7.12. Sporer SM, Paprosky WG, O’Rourke MR. Managing bone loss in acetabular revision. Instr Course Lect. 2006; 55:287-97.
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Sheth NP, Nelson CL, Springer BD, Fehring TK, Paprosky WG. Acetabular bone loss in revision total hip arthroplasty: evaluation and management. J Am Acad Orthop Surg. 2013; 21: (3):128-139.
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14.
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DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop. 1976; 121:20-32.
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Massin P, Schmidt L, and Engh CA. Evaluation of cementless acetabular component migration. An experimental study. J Arthroplasty. 1989; 4(3):245-51.
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Sporer SM, Paprosky WG, O’Rourke MR. Managing bone loss in acetabular revision. Instr Course Lect. 2006; 55:287-97. 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 evaluation. J Bone Joint Surg Am. 1969; 51(4): 737-55.
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Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J American Stat Assoc. 1958; 53: 457-81.
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Kavanagh BF, Ilstrup DM and Fitzgerald RH Jr. Revision total hip arthroplasty. J Bone Joint Surg Am. 1985; 517-26.
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te Stroet, MAJ, Keurentjes JC, Rinjnen WHC, et al. Acetabular revision with impaction bonegrafting and a cemented polyethylene acetabular component: Comparison of the Kaplan-Meier analysis to the competing risk analysis in 62 revisions with 25 to 30 years follow-up. Bone Joint J. 2015; 97-B: 1338-44.
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Lachiewicz PF, Watters TS. The jumbo acetabular component for acetabular revision. Bone Joint J. 2016; 98-B (1Suppl A):64-67.
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Figure 1. The +5 Deep Profile acetabular component used in this study.
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2a. Survivorship cures with a 95% CI as determined with the Kaplan Meier method. With revision of the acetabular component for any reason as the end point, the survivorship was 92.6 % (95% CI=81.0 - 97.2) at 16 years.
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2b. Kaplan Meier survivorship curve with revision of the acetabular component for aseptic loosening as the endpoint, the survivorship was 97.4 % (95% CI= 82.8 - 99.6) at 16 years.
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3a) Preoperative anterior posterior (AP) radiograph of the left hip in a patient requiring acetabular revision.
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3b) The AP radiograph taken 1 month and c) 16 years after revision arthroplasty.
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S0883-5403(17)30785-4
DOI:
10.1016/j.arth.2017.09.002
Reference:
YARTH 56076
To appear in:
The Journal of Arthroplasty
Received Date: 30 May 2017 Revised Date:
14 August 2017
Accepted Date: 1 September 2017
Please cite this article as: McLaughlin JR, Lee KR, Acetabular Revision Arthroplasty using an Uncemented Deep Profile Jumbo Component: A Ten to Sixteen Year Follow-up Study, The Journal of Arthroplasty (2017), doi: 10.1016/j.arth.2017.09.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Acetabular Revision Arthroplasty using an Uncemented Deep Profile Jumbo Component:
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A Ten to Sixteen Year Follow-up Study
Jeffrey R. McLaughlin, M.D. *
* Corresponding Author—Email@: [email protected] The Kennedy Center
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@ Mercy Medical Center
Suite 125, 2700 W. Ninth Avenue Oshkosh, WI 54901
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Telephone: 920-223-0123 Fax: 920-223-0370
Kyla R. Lee, M.D.
Clinical Associate Professor Gundersen Lutheran Medical Center 1836 South Ave LaCrosse, WI 54601
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Acetabular Revision Arthroplasty using an Uncemented
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Deep Profile Jumbo Component:
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A Ten to Sixteen Year Follow-up Study
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Aims: The purpose of the present study was to evaluate the outcome of revision total hip
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arthroplasty using an uncemented deep profile jumbo acetabular component in patients who had
25
been followed for a minimum of ten years postoperatively.
26
Patients and Methods: Between 1997 and 2001, 61 revision total hip arthroplasties were
27
performed in 58 patients, with use of the +5 Deep Profile acetabular shell. The outcome with
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regard to retention versus re-revision of the acetabular component was determined for every hip.
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At a mean of 13 years, (range, 10 to 16 years) post operatively, 30 patients (32 hips) were living.
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The Harris hip score, radiographic results, complications and Kaplan-Meier survivorship were
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evaluated.
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Results: In the entire cohort of 61 hips, 4 acetabular components have been re-revised. Two
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shells were re-revised for sepsis, one shell was re-revised for aseptic loosening and one for
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recurrent dislocation. In the 32 hips followed for a minimum of ten years postoperatively, two
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cups have been re-revised, one for aseptic loosening and one for recurrent dislocation. One
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additional shell was loose by radiographic criteria. With failure defined as re-revision for any
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reason, implant survival (95% CI) was 92.6% (81.0 - 97.2) at 16 years. With failure defined as
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re-revision for aseptic loosening, implant survival was 97.4% (82.8 - 99.6) at 16 years.
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Conclusion: Revision total hip arthroplasty with the +5 Deep Profile acetabular component was
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associated with a good rate of survival at 16 years.
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Key words
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Revision Hip Arthroplasty
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Deep profile
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Jumbo cups
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Survivorship
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Uncemented
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Acetabular Revision
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Level of Evidence: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence
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Introduction
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Revision total hip replacement surgery accounts for over 10% of the hip arthroplasty
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surgeries performed in the United States today. The incidence is expected to dramatically
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increase in the ensuing decades [1]. In acetabular revision surgeries moderate to severe bone loss
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is frequently encountered. The Paprosky classification is commonly used to describe these
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defects [2]. It is not surprising that the severity of acetabular bone loss correlates well with the
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success of revision surgery. To address this, porous coated jumbo acetabular components fixed
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with screws have been used. Jumbo cups are defined as ≥ 62mm in women and ≥ 66mm in men
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[3]. These devices have been associated with good to excellent results in several published series
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[3-11]. The incidence of re-revision has been reported to range from 3% to 17% at mid to long
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term follow-up. In the majority of these reviews a low profile acetabular shell was used [3, 4, 6,
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7, 8, 11]. The +5 Deep Profile acetabular component is a fully hemispheric shell that was
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developed to address medial wall defects encountered during revision surgery. These defects
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may result from osteolysis, infection, loose prosthetic components or multiple previous surgeries
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[12, 13]. The +5 Deep Profile revision shell was designed to achieve stable fixation on host bone,
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increase horizontal offset and restore the native center of hip rotation. The purpose of this study
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is to report our results using a fully hemispheric deep profile jumbo acetabular component in
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revision total hip surgery at a mean follow-up of 13 years.
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Patients and Methods 3
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Between November 1997 and October 2001, 61 revision total hip arthroplasties
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were performed on 58 patients, using an uncemented deep profile jumbo acetabular component.
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All revision surgeries were performed by a single surgeon. The 58 patients (61 hips) were
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followed until death, acetabular component re-revision or a minimum of ten years. Twenty-eight
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patients (29 hips) died prior to obtaining a minimum 10-year follow-up. Of these, two patients (2
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hips) had undergone re-revision of the acetabular component. The remaining 26 patients (27
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hips) died with their acetabular component in place. This left 32 hips in 30 patients. Among
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those living patients, two acetabular components have undergone re-revision surgery. In the
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remaining 30 hips in 28 patients clinical follow-up was obtained at a mean of 13 years (range, 10
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to 16 years). One patient provided clinical follow-up, but declined radiographic follow-up.
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Therefore, complete radiographic follow-was obtained on the remaining 27 patients (29 hips) at a
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mean follow-up of 13 years (range, 10-16). The mean age of the 14 women (15 hips) and 14
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men (15 hips) at the time of surgery was 71 years (range, 36-79). The average body mass index
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was 33 (range, 24 to 52) kg/m2. The indication for revision arthroplasty was aseptic loosening in
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26 hips, recurrent dislocation in three hips and severe osteolysis in one hip.
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The McLaughlin +5 Deep Profile acetabular component (Zimmer-Biomet, Warsaw, IN)
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was used for all revision surgeries (Fig 1). It is an uncemented shell made of wrought titanium
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alloy (Ti-6Al-4v). The implant has a porous coating consisting of an identical titanium alloy
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applied by a plasma spray technique. The acetabular component is a full hemisphere and has
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5mm of additional metal on the dome of the shell which allows for the use of rim screws. The
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sizes of the acetabular components used in this series were 62mm in 7 hips, 64 mm in 8 hips, 66
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mm in 11 hips, 68mm in 5 hips and 70mm in 1 hip. An Arcom (Zimmer-Biomet) polyethylene
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liner manufactured from Himont 1900 resin (Montell Polyolefins) was used in all hips. A 28 or
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32mm chrome-cobalt femoral head was used in all cases. Operative Technique
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A posterolateral approach to the hip was used. The existing acetabular component was
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removed with care to preserve as much bone as possible. Removal of cement, fibrous tissue and
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osteolytic debris was meticulously performed. The acetabulum was gently reamed progressively
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in 2 mm increments until contact with bleeding cancellous bone was obtained. Acetabular
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deficiencies were packed with allograft bone chips and local bone obtained from reaming. The
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acetabulum was under-reamed by 2mm. A trial component was placed and trial reduction
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performed to evaluate mechanical stability of the implant. After insertion of the true acetabular
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shell, multiple screws were placed. An intra-operative radiograph was obtained on every hip to
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assess the position of the component, the screws and to evaluate leg lengths. Intravenous
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antibiotics were administered after intraoperative cultures were obtained and were continued for
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48 hours after operation. Patients were allowed 50% weight bearing with a walker or crutches
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for four weeks, and thereafter advanced as tolerated. Warfarin was administered orally on the
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day of surgery and continued for one month.
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Clinical Follow-up and Radiographic Analysis The procedures for this study were approved by the Institutional Review Board and
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written informed consent was obtained from all patients. Complete clinical follow-up at a
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minimum of 10 years after the index operation was obtained for all 28 living patients (30 hips)
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who had not undergone re-revision surgery. The Harris hip score was used to determine the
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functional level and to evaluate pain [14]. Radiological evaluation at a mean of 13 years 5
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(range, 10-16) consisted of anteroposterior (AP) views of the hip and pelvis and a true lateral
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view of the hip. These were compared with the immediate post-operative radiographs and with
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those obtained at subsequent follow-up. They were evaluated by an independent investigator
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who was not the operating surgeon. The acetabular components were evaluated for
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radiolucencies and osteolysis in the zones described by De Lee and Charnley [15].
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Radiolucencies with a scalloped or cystic appearance, or > 2mm in width, were recorded as
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osteolysis. All measurements were corrected for magnification based on the true size of the
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femoral head. Fixation of the acetabular component was assessed by the criteria of Massin, et al
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[16]. It was considered loose if there was migration from the inter-teardrop or vertical line, a
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continuous radiolucency, or a change > 4° in the angle of abduction. Acetabular deficiency was
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evaluated by the criteria described by Paprosky et al [2]. In the 30 patients (32) hips who
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survived a minimum of ten years post operatively, acetabular deficiency at the time of revision
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surgery was classified as Type I in two hips, IIA in five hips, IIB in eleven hips, IIC in twelve
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hips, IIIA in two hips and IIIB in no hips.
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Statistical Analysis
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Data analysis was calculated using the SAS software version 9.3 (SAS Institute Inc.,
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Carey NC). The Kaplan-Meier method was used to generate survivorship curves with
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corresponding 95% CI [17]. The end points were revision of the acetabular component for any
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reason and revision of the acetabular component for aseptic loosening. All 61 hips in this series
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were included in the survivorship analysis. A Multivariate proportional hazards regression model
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was used to identify associations between demographic factors and implant survival. Survival
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times for implants that did not fail were censored at date of last contact or date of death.
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Results
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At the time of this review 30 patients (32 hips) were still living and 28 patients (29 hips)
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had died. Fifty-seven (93%) of the original 61 +5 Deep Profile acetabular components remained
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in place at the time of death or at the time of final follow-up. A total of four shells (7%) had
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been re-revised. In two hips the acetabular component was explanted for sepsis at two weeks
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and one year post-operatively. One well fixed acetabular component was re-revised for recurrent
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dislocation at two years post-operatively and one shell was re-revised for aseptic loosening at ten
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years.
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Complications
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In the entire cohort of 58 patients (61 hips) complications occurred in seven patients (7 hips) (11%). Three patients (5%) sustained post-operative dislocations. One patient was treated
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with closed reduction and bracing for six weeks without subsequent dislocation. One patient
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sustained multiple late dislocations and required re-revision two years post operatively. A third
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patient sustained multiple dislocations and required reoperation with femoral head exchange
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without further dislocation. Two patients required explantation of the acetabular component for
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deep infection at two weeks and one year post operatively. Deep vein thrombosis was diagnosed
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and treated in one patient.
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Living Patients: Thirty patients (32 hips) were alive at an average follow-up of 13 years
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(range, 10-16). Two patients (2 hips) had undergone acetabular re-revision. One acetabular
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component was re-revised for aseptic loosening at ten years post-operatively. In this patient a
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64mm cup had been used and the acetabular deficiency at the time of the index procedure was
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Paprosky Type IIIA. One additional acetabular component was re-revised for recurrent 7
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dislocation at two years. At the time of re-revision surgery the acetabular component was found
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to be well fixed. The size of the acetabular component re-revised in this patient was 62mm and
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the Paprosky acetabular deficiency found at the initial revision surgery was Type IIA. With the
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numbers available there was no association between acetabular component re-revision and
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component size (p=0.65) or Paprosky acetabular deficiency classification (p=0.84).
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Of the thirty living patients (32 hips) twenty-eight (30 hips) had not undergone re-
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revision of the acetabular component. In these 28 patients (30 hips) the average Harris hip score
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improved from 49 points (37-59) pre-operatively to 86 points (64-94) at the time of last follow-
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up.
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Radiographic Analysis
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Radiographs were obtained on 29 of the 30 hips in living patients who had not undergone re-revision surgery [Fig.2]. The mean duration of radiographic follow-up was 13 years (range,
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10-16). Radiolucencies, not present on the immediate post-operative radiograph occurred in
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eight hips (28%), most commonly in zone A. A continuous radiolucency, measuring 2mm, was
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identified around one cup. Osteolysis was identified around four shells (14%). Major osteolysis
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occurred in only one hip. Twenty-eight of the 29 shells were considered stable. The one shell
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with a continuous radiolucency had migrated and was considered loose.
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Survival Analysis
With re-revision of the shell for any reason as the end point, Kaplan-Meier analysis, demonstrated a survival rate (95% CI) of 92.6 % (81.0 - 97.2) at 16 years for the entire series of
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61 revision total hip arthroplasties. With revision of the cup because of aseptic loosening as the
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endpoint, the 16 year survival rate was 97.4 % (82.8 - 99.6) (Fig. 3). Discussion
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The purpose of the present study was to evaluate the 10 to 16 year results using the +5
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Deep Profile acetabular component in patients requiring acetabular revision surgery. In the
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entire series of 61 acetabular revisions, four components have required re-revision surgery, only
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one for aseptic loosening. One additional shell was loose by radiographic criteria. The numbers
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of complications were comparable with those reported in the literature at mid-term follow-up.
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Survivorship analysis with re-revision of the acetabular component for any reason as the
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endpoint was 92.6 % (81.0 - 97.2) at 16 years. These findings support the use of a deep profile
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acetabular component in patients with moderate acetabular bone loss who require revision
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surgery.
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Limitations of this study include the death of 28 patients (29 hips) prior to the ten-year follow-up interval. The outcome, however, of every reconstruction was determined, including in
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those patients who had died. A strength of this study was the high rate of follow-up. In patients
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who had survived a minimum of ten years post revision procedure, clinical follow-up was
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obtained on 100% and radiographic follow-up in 97%
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Over the past four decades several surgical techniques have been used to address
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moderate acetabular bone loss in revision hip surgery [12, 13]. These have included cemented
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cups, impaction grafting with cemented shells and porous coated jumbo cups. High failure rates
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have been reported using cemented polyethylene cups in revision surgery. Kavanagh et al
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reported a loosening rate of 50% at only 4.6 years [18]. The results using impaction bone 9
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grafting and cemented cups are significantly better. Stroet et al reported a 72.1 % survivorship
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with revision for aseptic loosening as the endpoint at 25 years [19]. With revision for any reason
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survivorship fell to 58.0%. There are now several papers with good to excellent mid to long
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term results using uncemented jumbo cups fixed with screws [3-11]. Lachiewicz and Watters
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have pointed out that these procedures are relatively straight forward, the components maintain
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contact over a large surface area of native bone, and they attempt to maintain a normalized hip
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center of rotation [20]. Van Roth reported an 83% survivorship at 20 years with this procedure
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[11].
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The current report represents the results using a fully hemispheric uncemented
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deep profile acetabular component in revision surgery. Overall, the cups performed well. In the
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entire cohort of 61 hips, one acetabular component required revision for aseptic loosening and
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one additional cup was loose by radiographic criteria, giving a total incidence of acetic loosening
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of 3%. Survivorship analysis with revision for any reason was 92.6% (95% CI =81.0 - 97.2) at
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16 years.
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On the basis of these results, we believe that the +5 Deep Profile fully hemispheric shell is a viable option in patients requiring acetabular revision surgery.
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References
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Sporer SM, Paprosky WG, O’Rourke MR. Managing bone loss in acetabular revision. Instr Course Lect. 2006; 55:287-97. 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 evaluation. J Bone Joint Surg Am. 1969; 51(4): 737-55.
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te Stroet, MAJ, Keurentjes JC, Rinjnen WHC, et al. Acetabular revision with impaction bonegrafting and a cemented polyethylene acetabular component: Comparison of the Kaplan-Meier analysis to the competing risk analysis in 62 revisions with 25 to 30 years follow-up. Bone Joint J. 2015; 97-B: 1338-44.
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Legend
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Figure 1. The +5 Deep Profile acetabular component used in this study.
Figure 2
2a. Survivorship cures with a 95% CI as determined with the Kaplan Meier method. With revision of the acetabular component for any reason as the end point, the survivorship was 92.6 % (95% CI=81.0 - 97.2) at 16 years.
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2b. Kaplan Meier survivorship curve with revision of the acetabular component for aseptic loosening as the endpoint, the survivorship was 97.4 % (95% CI= 82.8 - 99.6) at 16 years.
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3a) Preoperative anterior posterior (AP) radiograph of the left hip in a patient requiring acetabular revision.
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3b) The AP radiograph taken 1 month and c) 16 years after revision arthroplasty.
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