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NÚMERO 4. MAYO DE 2013 Resultados clínicos a largo
plazo de la prótesis total de
cadera Furlong H.A.C
25 años del implante pionero en el uso de hidroxiapatita



Ronald Furlong, pionero de la prótesis total de cadera recubierta con hidroxiapatita, nació en Woolwich (Londres, Reino Unido) en 1909. Fue alumno de Rowley Bristow, Director de Ortopedia del londinense Hospital St Thomas. Estudiante brillante, se licenció en cirugía a una edad excepcionalmente temprana.
En 1969 fue nombrado Director del Departamento de Ortopedia del Hospital St Thomas, donde una de sus responsabilidades fue la enseñanza de la cirugía de reemplazo de cadera. Sus dudas acerca de los implantes disponibles en aquel momento le llevaron a estudiar biomecánica, y en 1978 fue galardonado con la Medalla de Pauwels, siendo uno de los cinco poseedores de tal distinción en todo el mundo.
Gracias a sus conocimientos de biomecánica comenzó a diseñar una nueva prótesis, buscando en primer lugar la estabilidad mecánica de la misma. El segundo objetivo era recubrir el implante con un agente bioactivo, que permitiera una fijación fisiológica de larga duración. Su investigación acerca del uso de hidroxiapatita le puso en contacto con el profesor Johannes Osborn, que había escrito un libro y más de 30 artículos sobre la hidroxiapatita y su uso en el tratamiento de las fracturas conminutas abiertas de la mandíbula.
Trabajando en colaboración con una empresa alemana de expertos en tecnología de pulverización de plasma de llama, Furlong y Osborn lograron desarrollar un recubrimiento para la prótesis de cadera. El resultado fue Furlong HAC®, el primer implante revestido con recubrimiento de hidroxiapataita osteoconductor.
La primera prótesis Furlong HAC® fue implantada en septiembre de 1985 y, tras su éxito, en 1988 se fundó la Furlong Research Foundation, para apoyar la investigación científica, la evaluación clínica y la difusión del conocimiento en este campo. A la vista de los excelentes resultados los cirujanos siguen indicándola hoy en día, convencidos de haber encontrado el buen camino para solucionar la patología coxofemoral con una prótesis segura.
Artículos originales publicados en The Bone and Joint Journal (JBJS Br) THE BRITISH EDITORIAL SOCIETY OF BONE & JOINT SURGERY
Registered charity no: 209299 BJJ Print ISSN: 2049-4394 Online ISSN: 2049-4408 Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
Reemplazo total de
cadera primaria con
un vástago Furlong de
aleación de titanio con
recubrimiento completo
de hidroxiapatita
Resultados con un seguimiento mínimo de

20 años
Presentamos la extensión del seguimiento (≥ 20 años)
de una serie de vástagos femorales recubiertos con hi- droxiapatita utilizados en 72 prótesis primarias de cade- ra (PTC). Los resultados tempranos de esta cohorte ya habían sido publicados previamente. Todos los procedi- mientos fueron realizados entre 1986 y 1991. La serie incluía a 45 mujeres, 15 hombres y 12 procedimientos bilaterales. Su edad media en el momento de la cirugía era de 60 años (46 a 80) y la duración media del segui- miento ha sido de 22.5 años (20 a 25). En el seguimiento final, la media de la escala de Merle d'Aubigne y Postel fue de 5.5 (4.5 a 6), 3.8 (3.5 a 5) y 3.3 (3.0 a 5.0) para dolor, movilidad y función, respectivamente. El 92% de los pacientes estaban muy satisfechos en el momento del seguimiento final.
Ha habido siete revisiones: seis del componente aceta- bular por aflojamiento aséptico y otra por aflojamiento acetábulo y del vástago debido a una infección profunda. La supervivencia de esta prótesis a 22.5 años tomando la revisión por cualquier causa como punto final es del 91.7% (intervalo de confianza al 95% de 84 a 99). La su- pervivencia con aflojamiento aséptico del vástago como punto final fue del 100% (intervalo de confianza al 95% de 90 a 100).
Esta prótesis alivia el dolor en el largo plazo. La supervi- vencia de este componente es comparable a los mejores resultados en PTC primaria que emplee cualquier método de fijación.
MBA Institute. Número 4. Mayo de 2013 / 3
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
HIP
Primary total hip replacement with a Furlong
fully hydroxyapatite-coated titanium alloy
femoral component
RESULTS AT A MINIMUM FOLLOW-UP OF 20 YEARS
We present the extended follow-up (≥ 20 years) of a series of fully hydroxyapatite-coated
C. Doctor,
femoral components used in 72 primary total hip replacements (THRs). Earlier results of this
S. S. Rajaratnam,
cohort have been previously published. All procedures were performed between 1986 and
S. Ahmed,
1991. The series involved 45 women and 15 men with 12 bilateral procedures. Their mean
D. J. East,
age at the time of surgery was 60 years (46 to 80) and the mean duration of follow-up was
K. Miles,
22.5 years (20 to 25). At final follow-up, the mean Merle d'Aubigné and Postel hip scores
were 5.5 (4.5 to 6), 3.8 (3.5 to 5) and 3.3 (3.0 to 5.0) for pain, mobility and function,
J. A. N. Shepperd
respectively. Of the patients 92% were very satisfied at the time of final follow-up.
There were seven revisions: six of the acetabular component for aseptic loosening and
From Conquest one of both the stem and the acetabular component for loosening due to deep infection.
Hospital, St Leonards The survival of this prosthesis at 22.5 years with revision for any reason as the endpoint was
on Sea, United
91.7% (95% confidence interval (CI) 84 to 99). Survival with aseptic loosening of the stem as
the endpoint was 100% (95% CI 90 to 100).
This prosthesis provides pain relief in the long term. Survival of this component is
comparable to the best results for primary THR with any means of fixation.
 N. Sandiford, MRCS, Cite this article: Bone Joint J 2013;95-B:467–71.
MSc(SEM), SpR Trauma and Orthopaedics Primary uncemented total hip replacement prosthesis was used in our department for all  C. Doctor, MRCS, Senior House Officer in Trauma and (THR) has become an accepted method of pro- patients in whom an uncemented THR was viding pain relief and return to function in required. All procedures were performed by or  D. J. East, DPT, MSc, Head of Research patients with symptomatic osteoarthritis (OA) under the direct supervision of a single surgeon  K. Miles, DPT, Research of the hip. Good medium-term results have been (JANS). No patients were lost to follow-up.
Physiotherapist A. Butler-Manuel, FRCS, reported with the use of partially1,2 as well as Bilateral procedures were performed in Consultant Orthopaedic and fully hydroxyapatite (HA)-coated femoral com- 12 patients (four men, eight women). These Trauma Surgeon J. A. N. Shepperd, FRCS, ponents at follow-up of up to ten years.3,4 were staged procedures in five patients and Consultant Orthopaedic and A recent review identified relatively few under the same anaesthetic in seven. The mean Trauma SurgeonConquest Hospital, The Ridge, long-term survival reports on uncemented fem- age of this cohort was 82.9 years (70 to 100) at St Leonards on Sea, Hastings oral components.5 Only 17 unique studies the final follow-up. At the time of surgery TN37 7RD, UK.
were found that included a minimum of 11 patients were < 55 years of age (Table I). All  S. S. Rajaratnam, 50 patients. Two reviews of registry data com- patients presented with disabling hip pain.
FRCS(Orth), Consultant Orthopaedic and Trauma paring > 150 patients were found with follow- Surgical technique and prosthesis. All proce-
up periods > 15 years. A total of 16 femoral dures were performed via a Watson Jones  S. Ahmed, MRCS, SpR Trauma and Orthopaedics components were included, both HA- and non- approach6 with the patient in the supine posi- Eastbourne District General HA coated. Survival rates > 90% were found tion. Each patient received three doses of pro- Hospital, King's Drive, Eastbourne, East Sussex BN21 for these uncemented stems.5 phylactic antibiotics and subsequently were This study presents the results at a minimum allowed to bear full weight on the first post- Correspondence should be sent 20-year follow-up of a previously reported operative day.
to Mr N. A. Sandiford; e-mail: nemsandiford@hotmail.com cohort of patients treated with a fully HA- The Furlong femoral component (JRI Ltd) coated femoral component.
was used in all cases. This is manufactured from 2013 The British Editorial Society of Bone and Joint a titanium alloy (Ti-6Al-4V). The surface of the Patients and Methods
body and distal stem are plasma sprayed with a doi:10.1302/0301-620X.95B4. 30445 $2.00 This prospective study was performed between 200 μm-thick layer of hydroxyapatite of high 1986 and 1991 and includes 72 primary THRs crystallinity. The stem is collared and designed Bone Joint J 2013;95-B:467–71.
performed in 60 patients (45 women and to achieve primary stability via a metaphyseal Received 13 July 2012; 15 men) using the Furlong femoral component fit, and has a trunnion with a 12/14 Morse Accepted after revision 10 January 2013 (JRI Ltd, London, United Kingdom). This taper. A Furlong UHMWPE acetabular VOL. 95-B, No. 4, APRIL 2013 4 / MBA Institute. Número 4. Mayo de 2013
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
N. SANDIFORD, C. DOCTOR, S. S. RAJARATNAM, S. AHMED, D. J. EAST, K. MILES, A. BUTLER-MANUEL, J. A. N. SHEPPERD Table I. Characteristics of the 60 patients at operation
Kaplan-Meier method with 95% confidence intervals (CI).
All analyses were performed using GraphPad software Characteristic
Gender (n, %)
(GraphPad, San Diego, California).
Results
The mean duration of follow-up was 22.5 years (20 to 25).
Mean age at surgery (yrs) (range) At the last follow-up the mean scores for the pain, mobility and function components of the MDP score were 5.5 (4.5to 6), 3.8 (3.5 to 5) and 3.3 (3.0 to 5.0), respectively. Two patients (3.3%) were not satisfied, three (5%) were moder- ately satisfied and 55 (91.7%) were very satisfied with their result up to the last follow-up. The latter group had a VAS Bilateral procedures ≥ 8. Clinical improvement was noted at the six-week fol-low-up and was maintained. All patients reported excellentpain relief at their last review.
The mean MDP scores for pain, function and mobility at component was used in 47 patients (59 hips) and a HA- ten years were 5.8 (4 to 6), 5.6 (3 to 6) and 5.5 (1 to 6), coated threaded acetabular shell with an ultra-high molecu- respectively, and at 17 years they were 5.6 (3 to 6), 5.4 (2 to lar weight polyethylene (UHMWPE) liner (JRI Ltd) was used 6) and 3.8 (0 to 6), respectively. There was no statistically in 13 patients (13 hips). A modular 32 mm ceramic femoral significant difference between the ten- and 17-year MDP head was used in all hips.
scores (p = 0.87). Similarly, there was no significant differ- Follow-up. Clinical and radiological follow-up was per-
ence between these parameters between the 17- to 22.5-year formed at six weeks, 12 weeks, six months and 12 months follow-up (p = 0.82).
post-operatively, and annually thereafter. Patients were In all, at the final review 17 patients (17 hips) had died: interviewed, examined, the wound was assessed, and all six at 20 years post-operatively, four at 21 years, three at medical and surgical complications were documented. Spe- 22 years, three at 23 years and one at 25 years post- cific enquiry was made about anterior thigh pain. Clinical operatively. Their deaths were not related to their hip sur- assessment of pain, mobility and function was performed gery. These patients were all reviewed within a year of their using the Merle d'Aubigné and Postel (MDP) scoring sys- deaths and were therefore included in this study. We tem.7 Patient satisfaction was assessed using a visual ana- reviewed their clinical notes as well as their radiographs logue scale (VAS), which ranged from 0 (poor satisfaction) and contacted their GPs to determine whether they had any to 10 (high satisfaction).
complaints regarding their hips, and none were identified.
Radiological review. At each visit anteroposterior (AP) and
A total of seven patients (seven hips) had undergone revi- lateral radiographs of the pelvis and operated hip were sion surgery. This involved both components in one patient obtained and reviewed by two separate reviewers (NS, CD).
and the acetabular component alone in six. Loosening of the These were examined for changes in the position or orien- femoral component occurred in one patient 21 years after tation of the components as well as for evidence of osseo- their primary procedure associated with deep infection. This integration or loosening of the prosthesis.
was the patient who had both components revised and Signs of loosening included lytic lesions (balloon-shaped accounted for the only stem revision in this series. There were lucencies around the prosthesis), migration of the implant no cases of aseptic loosening of the stem in this cohort. At final (measured as the distance between the shoulder of the follow-up one female patient was awaiting revision of the ace- implant and the greater trochanter), radiolucent lines (RLL; tabular component but had a well-fixed femoral component linear lucencies > 2 mm at the bone–prosthesis interface8 in situ. There were no dislocations in this group.
and occupying > 30% of any Gruen zone9). Solid fixation Survival analysis. With revision of the femoral component
was indicated by ‘spot welding' and trabeculae of cancel- for any reason as the endpoint, survival at a mean follow- lous bone extending to the stem as described by Engh, up of 22.5 years was 98% (95% CI 90 to 99). With revision Sychterz and Engh.10 for aseptic loosening as the endpoint survival was 100% Radiographs were also assessed for signs of heterotopic (95% CI 90 to 100) (Fig. 1). If we consider the endpoint to ossification (HO) and stress shielding of the calcar region of be revision for any reason, then survival of the femoral the femur: HO was classified according to the system of component was 91% (95% CI 88.6 to 98.9) at a mean Brooker et al,11 and stress shielding was considered to be 22.5 years follow-up (Fig. 2).
significant if there was selective bone resorption of the cal- Radiological results. There were no cases of subsidence of
car region of the femoral neck.12 the femoral components. Radiological evidence of solid Statistical analysis. Statistical analysis was performed
stem fixation, including ‘spot weld' formation12 as well as using Student's t-test. The level of significance was set at an osteoblastic reaction at the stem tip, was observed in all p < 0.05. Survival analysis was performed using the radiographs (Fig. 3).
THE BONE & JOINT JOURNAL MBA Institute. Número 4. Mayo de 2013 / 5
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
PRIMARY TOTAL HIP REPLACEMENT WITH A FURLONG FULLY HYDROXYAPATITE-COATED TITANIUM ALLOY FEMORAL COMPONENT Radiograph of an hydroxyapatite-coated Furlong stem at 25 years post-operatively, showing an osteoblastic reaction at the tip of the stem (A), trabeculae extending to the surface of the prosthesis (B), and localised bone resorption immedi- ately under the polished collar (C).
Kaplan-Meier survival curve with 95% confidence intervals, showing revision for aseptic loosening as the endpoint.
Table II. Radiolucent lines around the femoral and acetabular com-
ponents at the last follow-up Femoral component Acetabular component
Zones of interest
(number of patients)
15 (zones 1, 2 &3) two lived independently at the time of final follow-up withno expressed concerns about their operated hips.
The radiolucent lines were predominantly present in Gruen zones 2 and 3. They were 1 mm wide and non-pro- gressive over two years (Table II). They were not associatedwith pain and there were no overt signs of movement of the femoral components.
Kaplan-Meier survival curve with 95% confidence intervals, illustrating the Focal areas of resorption of the calcar were noted in ten worst-case survival scenario with all revisions considered as failures.
hips (Fig. 3). This feature was associated with signs of goodfixation of the metaphyseal segment. These patients had nocomplaints that might suggest loosening of the implant. On Radiolucent lines were seen in 19 femoral components. Of 35 radiographs (48.6%) HO was observed. This was this group, 16 patients (16 hips) died at a mean of 22.0 years Brooker grade 2 or 3 in 57.1% of cases (Table III).
(20 to 23) post-operatively. One of these patients had RLLs were noted around 29 acetabular components undergone isolated revision of the acetabular component for (40.3%). These were present in DeLee and Charnley13 zone wear and loosening two years before death. Specific enquiry 1 (12 hips), zone 2 (five hips) and zones 1 to 3 (15 hips).
of their GPs, family members and review of their notes Five patients (five hips), all of whom had RLLs in acetabu- implied no complaints regarding their hips between their last lar zones 1 to 3, had mild to moderate start-up pain. How- clinical review and the time of their deaths. Of the three ever, four patients did not wish to have any further surgery patients who were alive, one had undergone revision of the because of their age, and one was awaiting acetabular revi- femoral component for septic loosening and the remaining sion at the time of final follow-up.
VOL. 95-B, No. 4, APRIL 2013 6 / MBA Institute. Número 4. Mayo de 2013
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
N. SANDIFORD, C. DOCTOR, S. S. RAJARATNAM, S. AHMED, D. J. EAST, K. MILES, A. BUTLER-MANUEL, J. A. N. SHEPPERD Table III. Distribution of hetero-
reports of the Furlong femoral component in primary THR topic ossification according to have been encouraging, with survival rates of 100% and 97.4% at ten and 17 years, respectively.3,22 In this now extended series, survivorship of the remaining femoral com- ponents with aseptic loosening as the endpoint at a mean 22.5-year follow-up is 100% (Fig. 1). If all revisions includ-ing those for the acetabulum and revision for infection areconsidered to be failures, then survivorship is 91%.
The mobility and functional components of the MDP score show a gradual deterioration from ten to 22.5 years,whereas the pain score shows that pain relief continues tobe sustained. We believe this reflects an age-related decreasein general function and mobility. This change was not sta-tistically significant at any of the three measured timepoints up to a mean of 22.5 years. It is likely that the lackof pain contributed to the high levels of satisfactionreported by 96.7% of this cohort.
All femoral stems showed signs of stable fixation (Fig. 3).
Although focal areas of bone resorption were noted in thecalcar region immediately adjacent to the collar in tenpatients (Fig.3), this did not correspond to pain or decreasedfunction. This may possibly relate to localised stress shield-ing of the calcar region immediately adjacent to the collar after full bonding of the bone to implant had occurred. RLLswere noted around acetabular components in 29 patients Radiograph showing an asymptomatic peri- prosthetic fracture at 25 years post-operatively.
(29 hips), which in 52% involved zones 1 to 3.
High early revision rates for uncemented primary THR are thought by some to be due predominantly to peri-prostheticfractures occurring during stem insertion.23 Our patients Complications. There were four calcar fractures that
experienced four such fractures but recovered without seque- occurred at the time of the original surgery. These were lae. Merle et al5 alluded to the paucity of true long-term treated with cerclage wires in one hip and conservatively in results for uncemented stems. They found good to excellent three hips. All patients with these fractures were mobilised results with these components at a minimum of 15 years, and non-weight-bearing with crutches for the first six weeks suggested that this technique of fixation is reliable and should after their procedure. This included the one patient who become a standard treatment option in appropriate patients.
developed a deep infection 21 years after surgery, which The 2010 report of the Swedish Hip Registry found no was successfully treated with a two-stage revision. No significant differences between cemented and uncemented patients reported anterior thigh pain.
fixation regarding the risk of revision, irrespective of At the final follow-up a peri-prosthetic fracture was cause.23 Data from the ninth report of the United Kingdom noted in an asymptomatic male patient (Fig. 4) who, on National Joint Registry24 suggest that the use of unce- enquiry, had no history of trauma or pain. The femoral mented components is increasing but is associated with a stem was well fixed radiologically and there were no clini- higher revision rate for uncemented components in the first cal signs of pain or impaired mobility. The time and cause ten years. The lowest revision rates up to this point have of this injury remains uncertain.
been found for cemented components. Between four andeight years the revision rates for uncemented components Discussion
with the ceramic-on-polyethylene bearing couple have been Our results represent those of a non-designer surgeon the lowest of all combinations of uncemented components.
series. They suggest that HA-coated fixation remains Data from the Swedish registry demonstrates that after the reliable and predictable in the long term, even as the patient nine- to ten-year period the failure rate for cemented com- ages and the corticomedullary ratio of the femur ponents surpasses that for uncemented components.
increases.14 The fact that HA is soluble in vivo and possibly There are several limitations to this study. The sample size delaminates does not seem to affect long-term survival.15 is small, as the number of patients who remained alive has Good long-term results of primary THR using fully HA- decreased. No pre-operative MDP scores were recorded.
coated titanium stems have been reported in young as well as However, our database provides an accurate record of scores older age groups.3,16-22 Similar results have been reported from the time of surgery, and the VAS was consistently used when these stems are used in the revision setting.21 Previous as a patient-reported tool to augment our clinical data.
THE BONE & JOINT JOURNAL MBA Institute. Número 4. Mayo de 2013 / 7
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
PRIMARY TOTAL HIP REPLACEMENT WITH A FURLONG FULLY HYDROXYAPATITE-COATED TITANIUM ALLOY FEMORAL COMPONENT Our cohort reported significant improvements in pain, 12. McCullough CJ, Remedios D, Tytherleigh-Strong G, Hua J, Walker PS. The
mobility and function in their early post-operative phase use of hydroxyapatite-coated CAD-CAM femoral components in adolescents and young adults with inflammatory polyarthropathy: ten-year results. J Bone Joint that has been maintained at the ten-, 17- and now 22.5- Surg [Br] 2006;88-B:860–864.
year follow-up. There were no cases of aseptic loosening 13. DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip
of the femoral component. These results are comparable replacement. Clin Orthop Relat Res 1976;121:20–32.
to the best long-term outcomes in terms of both survival 14. Beaupied H, Lespessailles E, Benhamou CL. Evaluation of macrostructural
bone biomechanics. Joint Bone Spine 2007;74:233–239.
of the component and maintained clinical results for 15. Epinette JA, Manley MT. Uncemented stems in hip replacement--hydroxyapatite
primary THR with any means of fixation of the femoral or plain porous: does it matter? Based on a prospective study of HA Omnifit stems at 15-years minimum follow-up. Hip Int 2008;18:69–74.
16. Shetty AA, Slack R, Tindall A, James KD, Rand C. Results of a hydroxyapatite
No benefits in any form have been received or will be received from a commer- coated (Furlong) total hip replacement: a 13- to 15-year follow-up. J Bone Joint cial party related directly or indirectly to the subject of this article.
Surg [Br] 2005;87-B:1050–1054.
This article was primary edited by G. Scott and first-proof edited by D. Rowley.
17. Robertson A, Lavalette D, Morgan S, Angus PD. The hydroxyapatite coated
JRI-Furlong hip: outcome in patients under the age of 55 years. J Bone Joint Surg 18. Hallan G, Lie SA, Furnes O, et al. Medium- and long-term performance of 11,516
1. Mannan K, Freeman MA, Scott G. The Freeman femoral component with
uncemented primary femoral stems from the Norwegian arthroplasty register. J hydroxyapatite coating and retention of the neck: an update with a minimum follow- Bone Joint Surg [Br] 2007;89-B:1574–1580.
up of 17 years. J Bone Joint Surg [Br] 2010;92-B:480–485.
19. Gabbar OA, Rajan RA, Londhe S, Hyde ID. Ten- to twelve-year follow-up of the
2. Muirhead-Allwood SK, Sandiford N, Skinner JA, et al. Uncemented custom
furlong hydroxyapatite-coated femoral stem and threaded acetabular cup in computer-assisted design and manufacture of hydroxyapatite-coated femoral compo- patients younger than 65 years. J Arthroplasty 2008;23:413–417.
nents: survival at 10 to 17 years. J Bone Joint Surg [Br] 2010;92-B:1079–1084.
20. Vidalain JP. Twenty-year results of the cementless Corail stem. Int Orthop
3. McNally SA, Shepperd JA, Mann CV, Walczak JP. The results at nine to twelve
years of the use of a hydroxyapatite-coated femoral stem. J Bone Joint Surg [Br] 21. Trikha SP, Singh S, Raynham OW, et al. Hydroxyapatite ceramic coated femoral
stems in revision hip surgery. J Bone Joint Surg [Br] 2005;87-B:1055–1060.
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22. Rajaratnam SS, Jack C, Tavakkolizadeh A, et al. Long-term results of a
THA: the Artro Group. Acta Orthop Belg 1997;63(Suppl):93–95.
hydroxyapatite-coated femoral component in total hip replacement: a 15- to 21- 5. Merle C, Clarius M, Aldinger PR. Long-term results of uncemented stems in total
year follow-up study. J Bone Joint Surg [Br] 2008;90-B:27–30.
hip arthroplasty: analysis of survival rates with a minimum 15-year follow-up. Ortho- 23. No authors listed. Swedish Hip Arthroplasty Register. Annual Report 2010. http:/
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VOL. 95-B, No. 4, APRIL 2013 8 / MBA Institute. Número 4. Mayo de 2013
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
PRIMARY TOTAL HIP REPLACEMENT WITH A FURLONG FULLY HYDROXYAPATITE-COATED TITANIUM ALLOY FEMORAL COMPONENT Our cohort reported significant improvements in pain, 12. McCullough CJ, Remedios D, Tytherleigh-Strong G, Hua J, Walker PS. The
Uso de componentes
mobility and function in their early post-operative phase use of hydroxyapatite-coated CAD-CAM femoral components in adolescents and young adults with inflammatory polyarthropathy: ten-year results. J Bone Joint that has been maintained at the ten-, 17- and now 22.5- Surg [Br] 2006;88-B:860–864.
femorales recubiertos
year follow-up. There were no cases of aseptic loosening 13. DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip
of the femoral component. These results are comparable replacement. Clin Orthop Relat Res 1976;121:20–32.
de hidroxiapatita en
to the best long-term outcomes in terms of both survival 14. Beaupied H, Lespessailles E, Benhamou CL. Evaluation of macrostructural
bone biomechanics. Joint Bone Spine 2007;74:233–239.
pacientes jóvenes con
of the component and maintained clinical results for 15. Epinette JA, Manley MT. Uncemented stems in hip replacement--hydroxyapatite
primary THR with any means of fixation of the femoral or plain porous: does it matter? Based on a prospective study of HA Omnifit stems seguimientos de entre 16
at 15-years minimum follow-up. Hip Int 2008;18:69–74.
16. Shetty AA, Slack R, Tindall A, James KD, Rand C. Results of a hydroxyapatite
y 19 años
No benefits in any form have been received or will be received from a commer- coated (Furlong) total hip replacement: a 13- to 15-year follow-up. J Bone Joint cial party related directly or indirectly to the subject of this article.
Surg [Br] 2005;87-B:1050–1054.
Actualización de una publicación anterior
This article was primary edited by G. Scott and first-proof edited by D. Rowley.
17. Robertson A, Lavalette D, Morgan S, Angus PD. The hydroxyapatite coated
JRI-Furlong hip: outcome in patients under the age of 55 years. J Bone Joint Surg En 2004 describimos los resultados prospectivos a diez 18. Hallan G, Lie SA, Furnes O, et al. Medium- and long-term performance of 11,516
1. Mannan K, Freeman MA, Scott G. The Freeman femoral component with
uncemented primary femoral stems from the Norwegian arthroplasty register. J años de 38 reemplazos de cadera empleando el vástago hydroxyapatite coating and retention of the neck: an update with a minimum follow- Bone Joint Surg [Br] 2007;89-B:1574–1580.
femoral recubierto de hidroxiapatita Furlong en 35 pa- up of 17 years. J Bone Joint Surg [Br] 2010;92-B:480–485.
19. Gabbar OA, Rajan RA, Londhe S, Hyde ID. Ten- to twelve-year follow-up of the
cientes con menos de 50 años de edad. Ahora hemos re- 2. Muirhead-Allwood SK, Sandiford N, Skinner JA, et al. Uncemented custom
furlong hydroxyapatite-coated femoral stem and threaded acetabular cup in visado las 35 artroplastias supervivientes en 33 pacientes computer-assisted design and manufacture of hydroxyapatite-coated femoral compo- patients younger than 65 years. J Arthroplasty 2008;23:413–417.
nents: survival at 10 to 17 years. J Bone Joint Surg [Br] 2010;92-B:1079–1084.
20. Vidalain JP. Twenty-year results of the cementless Corail stem. Int Orthop
con una media de 16 años (10.3 a 19.9). La edad media 3. McNally SA, Shepperd JA, Mann CV, Walczak JP. The results at nine to twelve
de los pacientes supervivientes en el momento de la ope- years of the use of a hydroxyapatite-coated femoral stem. J Bone Joint Surg [Br] 21. Trikha SP, Singh S, Raynham OW, et al. Hydroxyapatite ceramic coated femoral
ración era de 41.3 años (26.0 a 49.0). De estos, ocho han stems in revision hip surgery. J Bone Joint Surg [Br] 2005;87-B:1055–1060.
sufrido la revisión de su componente acetabular por aflo- 4. Vidalain JP. HA coating: ten-year experience with the CORAIL system in primary
22. Rajaratnam SS, Jack C, Tavakkolizadeh A, et al. Long-term results of a
THA: the Artro Group. Acta Orthop Belg 1997;63(Suppl):93–95.
hydroxyapatite-coated femoral component in total hip replacement: a 15- to 21- jamiento aséptico. Ninguno de los componentes femora- 5. Merle C, Clarius M, Aldinger PR. Long-term results of uncemented stems in total
year follow-up study. J Bone Joint Surg [Br] 2008;90-B:27–30.
les ha sufrido revisión por aflojamiento aséptico, siendo hip arthroplasty: analysis of survival rates with a minimum 15-year follow-up. Ortho- 23. No authors listed. Swedish Hip Arthroplasty Register. Annual Report 2010. http:/
su tasa de supervivencia del 100% a 16 años (intervalo de pade 2010;39:80–86 (in German).
/www.shpr.se/en/Publications/DocumentsReports.aspx (date last accessed 16 January 2013).
confianza al 95% de 89% a 100%).
6. Hart FD, Watson-Jones R. Arthritis of the hip. Trans Med Soc Lond 1956;72:33–44.
24. No authors listed. National Joint Registry for England and Wales: Ninth Annual
7. Merle d'Aubigne R, Postel M. Functional results of hip arthroplasty with acrylic
El vástago recubierto de hidroxiapatita Furlong ofrece un prosthesis. J Bone Joint Surg [Am] 1954;36-A:451–475.
comportamiento excelente en supervivencia a largo plazo 8. Manaster JF, Andrews CL, Conway F, Fleckenstein JL, Kaplan PA. Musculo-
last accessed 10 February 2013).
en pacientes jóvenes y activos.
skeletal radiology. Radiology 1996;198:618–621.
25. Hallan G, Lie SA, Furnes O, et al. Medium- and long-term performance of 11,516
9. Gruen TA, McNeice GM, Amstutz HC. "Modes of failure" of cemented stem-type
uncemented primary femoral stems from the Norwegian arthroplasty register. J femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res Bone Joint Surg [Br] 2007;89-B:1574–1580.
26. Carrington NC, Sierra RJ, Gie GA, et al. The Exeter Universal cemented femoral
10. Engh CA Jr, Sychterz C, Engh C Sr. Factors affecting femoral bone remodelling
component at 15 to 17 years: an update on the first 325 hips. J Bone Joint Surg [Br] after cementless total hip arthroplasty. J Arthroplasty 1999;14:637–644.
11. Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ossification fol-
27. Lehtimäki MY, Lehto MU, Kautiainen H, Savolainen HA, Hämäläinen MM.
lowing total hip replacement: incidence and a method of classification. J Bone Joint Survivorship of the Charnley total hip arthroplasty in juvenile chronic arthritis: a fol- Surg [Am] 1973;55-A:1629–1632.
low-up of 186 cases for 22 years. J Bone Joint Surg [Br] 1997;79-B:792–795.
VOL. 95-B, No. 4, APRIL 2013 MBA Institute. Número 4. Mayo de 2013 / 9
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
Hydroxyapatite-ceramic-coated femoral
components in young patients followed-up
for 16 to 19 years
AN UPDATE OF A PREVIOUS REPORT
N. N. Shah,
In 2004 we described the ten-year prospective results of 38 total hip replacements using the
A. J. Edge,
Furlong hydroxyapatite-ceramic-coated femoral component in 35 patients < 50 years old. We
D. W. Clark
have now reviewed the surviving 35 arthroplasties in 33 patients at a mean of 16 years
(10.3 to 19.9). The mean age of the surviving patients at the time of operation was 41.3 years

From Worthing and (26.0 to 49.0). Of these, eight have undergone revision of their acetabular component for
Southlands Hospitals aseptic loosening. None of the femoral components has had revision for aseptic loosening
NHS Trust, giving a survival rate of 100% at 16 years (95% confidence interval 89% to 100%).
Shoreham-by-Sea, The Furlong hydroxyapatite-ceramic-coated femoral component gives excellent long-term
survival in young and active patients.
Previous studies have shown that cemented in one (3%), rheumatoid arthritis in one (3%) total hip replacement (THR) is a successful and Still's disease in two (5%) (Table I).
procedure in elderly and low-demand patients, Staged bilateral procedures were performed but the failure rate is higher in young and active in four patients and one patient had both hips patients.1-3 Long-term failure of cemented replaced under the same anaesthetic. Although THR components is usually due to aseptic the Furlong HAC-coated stem was used in all loosening caused by wear debris stimulating patients the acetabular components varied. The the formation of osteoclasts and subsequent initial 14 hips (37%) received a cemented poly- osteolysis. Hydroxyapatite-ceramic (HAC)- ethylene component (JRI) and the remaining 24 coated implants facilitate a biological bond had JRI Cancellous Screw Fixation HAC- between the implant and bone producing a coated acetabular components with polyethyl- ene liners. Alumina oxide ceramic modular In November 2004 we described the results heads were used in 36 hips of which 23 were of at ten years of the use of the HAC-coated 28 mm and 13 of 32 mm in diameter. Cobalt- Furlong implant (Joint Replacement Instru- chrome heads were used in two hips, one of mentation (JRI), London, United Kingdom) 28 mm and one of 32 mm diameter.
which showed no evidence of aseptic loosen- The Harris hip score (HHS)7 was completed „ N. N. Shah, MS, MSc, MCh(Orth), FRCS(Trauma & ing.5 We have now reviewed the same series at pre-operatively and at a mean follow-up of Orth), Furlong Clinical Fellow a mean of 16 years (10.3 to 19.9).
16.0 years (10.3 to 19.9) and the Oxford hip „ A. J. Edge, FRCS, Consultant Orthopaedic Surgeon score (OHS),8 University of California Los „ D. W. Clark, FRCS, Consultant Patients and Methods
Angeles (UCLA) activity scale9 and patient sat- Orthopaedic SurgeonWorthing & Southlands Between December 1988 and October 1997, isfaction were also used as outcome measures.
Hospitals NHS Trust, 38 THRs in 33 patients (22 men, 11 women) Radiological assessment was carried out Southlands Hospital, Upper Shoreham Road, Shoreham- with a mean age of 42 years (22 to 49) were by independent observers (NNS, DWC).
by-Sea, West Sussex BN43 performed by the senior author (AJE) or under Anteroposterior (AP) radiographs of the his direct supervision using the Hardinge pelvis were assessed for stability and fixation Correspondence should be sent to Mr N. N. Shah; e-mail: approach.6 All these patients were recalled for of the femoral component according to the further follow-up and clinical and radiological criteria described by Engh, Massin and 2009 British Editorial Society evaluation. The series has been described in Suthers.10 Lateral radiographs were also of Bone and Joint Surgery detail previously5 (Table I).
reviewed at the final follow-up. The distribu- doi:10.1302/0301-620X.91B7. 22311 $2.00 The principal diagnosis was osteoarthritis in tion of osteolysis or radiolucencies was 19 hips (50%), developmental dysplasia of the recorded according to the zones of Gruen, J Bone Joint Surg [Br] 2009;91-B:865-9.
hip (DDH) in ten (26%), post-traumatic McNeice and Amstutz11 using the criteria of Received 16 January 2009; arthritis in three (8%), Perthes' disease in two Goetz, Smith and Harris.12 The femoral com- Accepted after revision 27 February 2009 (5%), slipped upper femoral epiphysis (SUFE) ponent was considered to be stable if there VOL. 91-B, No. 7, JULY 2009 10 / MBA Institute. Número 4. Mayo de 2013


Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
N. N. SHAH, A. J. EDGE, D. W. CLARK Table I. The indications for total hip replacement and the distribution of implants in the original series of 33
patients (38 hips)5 HAC* Furlong stem Developmental dysplasia Post-traumatic arthritis Acetabular components Cemented polyethylene Slipped upper femoral epiphysis 1 JRI cancellous screw fixation HAC-coated with polyethylene liners Rheumatoid arthritis Modular headsAlumina ceramic * HAC, hydroxyapatite-ceramic heterotopic bone was recorded according to the criteria of
Brooker et al.14
Statistical analysis. The changes in the pre- and post-
operative hip scores were compared using the Mann-
Whitney U test. A p-value ≤ 0.05 was considered to be signif-
icant. Cumulative survival analysis for both components was
performed using revision for any reason and revision for
aseptic loosening or impending revision as the endpoints,
with 95% confidence intervals (CI).
Results
At the time of this review two patients (three hips) had
died from unrelated causes. One of these (one hip) had
osteoarthritis and the other had Still's disease (2 hips).
One patient had moved and was unable to attend, but
completed a postal questionnaire. The remaining 34
THRs in 30 patients (19 men, 11 women) from the origi-
nal series5 were available for follow-up and radiological
study and were included in the statistical analysis. The
mean age at operation of these patients was 41.3 years
(26.0 to 49.0).
Clinical and radiological findings. The mean pre-operative
Radiograph showing the Furlong hydroxyapatite- HHS for the original series was 44 (31 to 55).5 The mean ceramic-coated hip replacement with the Gruen zones.11 Increased formation of bone is seen in zones 2 to 6 and post-operative HHS at the final review was 89 (78 to 100).
rounding of the calcar under the collar in zone 7.
For the eight patients who underwent revision of theacetabular component the mean post-operative HHS was92 (71 to 100) and for the remaining patients it was 86(78 to 100). This was statistically significant (Mann-Whit- was evidence of osseointegration and unstable if there ney U test, p < 0.001). The mean OHS was 16 (12 to 40) at was evidence of migration. Additionally, the leg length the ten-year follow-up5 and 18 (12 to 40) at this latest fol- was measured directly from the radiographs.
low-up which was also statistically significant (Mann- On the AP view osteolysis or radiolucencies around the Whitney U test, p < 0.001). The UCLA activity score was 7 acetabular component were recorded as described by DeLee or more for 21 patients with a mean of 6 (6 to 9) at the and Charnley.13 The acetabular component was considered final review.
to be loose if there was a continuous or progressive radio- All the patients were asked at each review about the lucent line at the prosthesis-bone interface or any change in occurrence of anterior thigh pain. None had experienced position of the acetabular component. The formation of this at any stage.
THE JOURNAL OF BONE AND JOINT SURGERY MBA Institute. Número 4. Mayo de 2013 / 11
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
HYDROXYAPATITE-CERAMIC-COATED FEMORAL COMPONENTS IN YOUNG PATIENTS FOLLOWED-UP FOR 16 TO 19 YEARS Table II. The cumulative survival for the Furlong stem
Years since
Effective number
Cumulative
survival rate (%)
ments. This was reduced and fixed by a cable/plate system.
At operation it was noted that the femoral component was well bonded. The fracture healed satisfactorily. Despite his extensive surgery he was capable of working as an office clerk and walked with one stick.
From measurements on the AP pelvic radiographs a leg- length discrepancy was found in 14 hips. In six the shorten- ing was between 5 mm and 1 cm and in eight there was lengthening between 5 mm and 12 mm. At the latest review of 12 surviving cemented polyethylene acetabular compo- nents, five had required revision because of aseptic loosen- ing associated with polyethylene wear. The mean time from Time since operation (yrs) primary surgery to revision was 11 years (9 to 13). Four had a head diameter of 32 mm while the other had a mod- The cumulative survival curve for the Furlong femoral component with ular head diameter of 28 mm. They were all revised to can- the 95% confidence interval shown.
cellous screw fixation acetabular components withceramic-on-ceramic bearing surfaces.
Of 22 HAC-coated cancellous screw fixation acetabu- lar components, three were revised because of asepticloosening associated with radiolucency in DeLee and Peri-operative complications were rare. There were no Charnley zones 1 and 2. The diameter of the femoral head cases of infection or thromboembolism. One patient had a was 28 mm for these three patients. They were all revised dislocation after 12 years. This patient had a cemented to HAC-coated cancellous screw fixation acetabular com- polyethylene acetabular component articulating with a ponents with ceramic inserts. One required additional 32 mm ceramic head. Acetabular revision was performed for aseptic loosening and polyethylene wear. There were no Radiological assessment of the femoral components did not peri-operative fractures associated with insertion of the show any radiolucent lines and serial radiographs did not Furlong stem. One late complication occurred in a 27-year- reveal any evidence of subsidence. All were stable with evi- old man with Still's disease with bilateral hip and knee dence of bonding according to criteria described by Engh et replacements. He fell two years after his second THR and al.10 Formation of new bone with a trabecular pattern was sustained a mid-shaft fracture of the femur at the junction seen in relation to all femoral components in all the Gruen of the femoral components of the hip and knee replace- zones except zone 7 (Fig. 1). In 11 hips at the level of the calcar VOL. 91-B, No. 7, JULY 2009 12 / MBA Institute. Número 4. Mayo de 2013
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
N. N. SHAH, A. J. EDGE, D. W. CLARK Table III. The cumulative survival table with revision of any acetabular component as the endpoint
Years since
Effective
Cumulative
number at risk
survival rate (%)
The long-term results of cemented THR in elderly and low- demand patients can be excellent,15-17 but in young and active patients they are variable, although some studies have shown excellent results in this age group.18,19 The Furlong HAC-coated femoral stem was introduced in 1985 with the intention of obtaining a permanent bond between the implant and host bone. This has been substantiated by studies which have shown excellent long-term results in both elderly and young patients, including revisions.5,20-23 The initial report on our series of young patients at a mean follow-up of ten years found 100% survival for the Time since operation (yrs) femoral component.5 Extended follow-up of the same group at a mean of 16 years has found no aseptic loosening The cumulative survival curve with revision of any acetabular compo- in any of these implants.
nent as the endpoint with the 95% confidence interval shown.
New bone grows into the HA coating on the prosthesis at about the same rate as that of the healing of a fracture.24Living bone replaces the HA over time and in these circum- in Gruen zone 7, an area of bone resorption with rounding of stances new bone grows on to the titanium prosthesis with- calcar was seen extending distally from 2 mm to 5 mm.
out an intervening layer of fibrous tissue.24 The HA-coated Grade-I heterotopic ossification was observed in 16 hips component forms a strong bond to the host bone, which is and grade-II in two. Of these 18 THRs, eight had required comparable to the strength of the cortical bone itself.25 revision of the acetabular component.
Radiographs show new trabeculae in the proximity of load- Survivorship. There were no revisions or impending revi-
bearing areas of the femoral component indicating that new sions because of aseptic loosening of the femoral compo- bone is laid down where it is most needed. Relative nent, giving a cumulative survival of the implant of 100% osteopenia occurs in areas of stress shielding (Fig. 1). If the at 16 years (95% CI 89 to 100) (Table II, Fig. 2). The cumu- geometry of the implant allows new bone to grow into the lative survival of all acetabular components was 77% at a HA coating in this manner it will create a sealing effect and follow-up of 16 years. The individual survivorship for limit the migration of wear particles around the implant cemented polyethylene components was 59% and for thereby protecting osteolysis induced by these particles.
uncemented cancellous screw fixation components 86% at The poor survivorship of the polyethylene acetabular the same interval (Table III, Fig. 3).
components in our series may have been due to a variety of THE JOURNAL OF BONE AND JOINT SURGERY MBA Institute. Número 4. Mayo de 2013 / 13
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
HYDROXYAPATITE-CERAMIC-COATED FEMORAL COMPONENTS IN YOUNG PATIENTS FOLLOWED-UP FOR 16 TO 19 YEARS factors such as an abducted position of the component, the 8. Dawson J, Fitzpatrick R, Carr A, Murray D. Questionnaire on the perceptions of
use of polyethylene which had to be sterilised in air and the patients about total hip replacement. J Bone Joint Surg [Br] 1996;78-B:185-90.
use of heads of 32 mm diameter which is a known risk fac- 9. Amstutz HC, Thomas BJ, Jinnah R, et al. Treatment of primary osteoarthritis of
the hip: a comparison of total joint and surface replacement arthroplasty. J Bone tor for polyethylene wear. Despite the fact that the HAC Joint Surg [Am] 1984;66-A:228-41.
Furlong femoral components were exposed to the same 10. Engh CA, Massin P, Suthers KE. Roentgenographic assessment of the biologic
particle load associated with acetabular failure there was fixation of porous-surfaced femoral components. Clin Orthop 1990;257:107-28.
no case of aseptic loosening and any bone loss was limited 11. Gruen TA, McNeice GM, Amstutz HC. "Modes of failure" of cemented stem-
to Gruen zone 7 without compromising fixation. We type femoral components: a radiographic analysis of loosening. Clin Orthop observed bone loss of between 2 mm and 5 mm in 11 12. Goetz DD, Smith EJ, Harris WH. The prevalence of femoral osteolysis associated
patients just beneath the collar of the femoral component with components inserted with or without cement in total hip replacements: a ret- which we believe was due to stress shielding. We think that rospective matched pair series. J Bone Joint Surg [Am] 1994;76-A:1121-9.
the collar of the Furlong stem helps to provide early 13. DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip
replacement. Clin Orthop 1976;121:20-32.
mechanical stability until host bone has bonded to the HA 14. Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ossification fol-
coating. The stress-shielding effect of the collar was never lowing total hip replacement: incidence and a method of classification. J Bone seen to produce progressive lysis.
Joint Surg [Am] 1973;55-A:1629-32.
Concerns have been expressed about the migration of 15. Berry DJ, Harmsen WS, Cabanela ME, Morrey BF. Twenty-five-year survivor-
HA particles into the joint space resulting in third-body ship of two thousand consecutive primary charnley total hip replacements: factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg wear.26 Bauer et al27 compared the surface roughness of the femoral head and polyethylene in HA- and porous-coated, 16. Callaghan JJ, Templeton JE, Liu SS, et al. Results of Charnley total hip arthro-
and cemented THRs. The HA hips had the best surface plasty at a minimum of thirty years: a concise follow-up of a previous report. J Bone Joint Surg [Am] 2004;86-A:690-5.
characteristics and they were unable to detect HA particles 17. Nercessian OA, Martin G, Joshi RP, Su BW, Eftekhar NS. A 15 to 25-year
follow-up study of primary Charnley low-friction arthroplasty: a single surgeon In this series of young patients we did not see the crack series. J Arthroplasty 2005;20:162-7.
microfracture phenomenon around any femoral component28 18. Joshi AB, Porter ML, Trail IA, et al. Long-term results of Charnley low-friction
and no patient reported pain in the anterior thigh. Such pain is arthroplasty in young patients. J Bone Joint Surg [Br] 1993;75-B:616-23.
thought to occur in the presence of movement of the femoral 19. Kim YH, Kim JS, Yoon SH. Long-term survivorship of the Charnley Elite Plus fem-
oral component in young patients. J Bone Joint Surg [Br] 2007;89-B:449-54.
component and has been described with other implants with 20. Raman R, Kamath RP, Parikh A, Angus PD. Revision of cemented hip arthro-
an incidence of between 4% and 22%.10,29-31 The absence of plasty using a hydroxyapatite-ceramic-coated femoral component. J Bone Joint this problem in our series is probably due to the good initial Surg [Br] 2005;87-B:1061-7.
mechanical stability provided by the geometry of the prosthe- 21. McNally SA, Shepperd JAN, Mann CV, Walzak JP. The results at nine to
sis until permanent fixation is provided by bone integration. It twelve years of the use of a hydroxyapatite-coated femoral stem. J Bone Joint Surg may also be related to the modulus of elasticity of the titanium 22. Shetty AA, Slack R, Tindall A, James KD, Rand C. Results of a hydroxyapatite
implant and to the bonding of the bone throughout its coated (Furlong) total hip replacement: a 13 to 15 year follow-up. J Bone Joint Surg At a mean follow-up of 16 years the Furlong HAC- 23. Rajaratnam SS, Jack C, Tavakkolizadeh A, et al. Long-term results of a
coated femoral component gives excellent fixation in young hydroxyapatite-coated femoral component in total hip replacement: a 15- to 21- year follow up study. J Bone Joint Surg [Br] 2008;90-B:27-30.
and active patients.
24. Geesink RGT, De Groot K, Klein CPAT. Bonding of bone to apatite coated
implants. J Bone Joint Surg [Br] 1988;70-B:17-22.
The authors wish to thank R. Knight for her help with the project and K. Grayson(Statistics by Design) for her help with the statistics.
25. Aebli N, Krebs D, Schwenke H, et al. Degradation of hydroxyapatite coating on
No benefits in any form have been received or will be received from a com- a well-functioning femoral component. J Bone Joint Surg [Br] 2003;85-B:499-503.
mercial party related directly or indirectly to the subject of this article .
26. Morscher EW, Hefti A, Aebi U. Severe osteolysis after third-body wear due to
hydroxyapatite particles from acetabular cup coating. J Bone Joint Surg [Br] 27. Bauer TW, Taylor SK, Jiang M, Medendorp SBV. An indirect comparison of
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VOL. 91-B, No. 7, JULY 2009 14 / MBA Institute. Número 4. Mayo de 2013
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
Resultados a largo
plazo de un vástago
femoral recubierto
de hidroxiapatita en
reemplazos totales de
cadera
Estudio con seguimientos de entre 15 y 21

años
Entre 1986 y 1991 implantamos de modo consecutivo
331 vástagos Furlong recubiertos de hidroxiapatita para el reemplazo total de cadera de 291 pacientes. Se empleó una prótesis acetabular cementada en 217 caderas y un componente recubierto de hidroxiapatita en 114. Descri- bimos la supervivencia a largo plazo tanto clínica como radiológica del componente femoral con un seguimiento medio de 17.5 años (15 a 21). Sólo dos pacientes (0.68%) fueron perdidos durante el seguimiento. Tomando la re- visión del componente femoral por cualquier causa como el punto final, la supervivencia a una media de 17 años fue del 97.4% (intervalo de confianza al 95% de 94.1 a 99.5), y tomando la revisión por aflojamiento aséptico como punto final, ésta fue del 100%. La supervivencia a un máximo de 21 años, tomando la revisión del com- ponente femoral por cualquier motivo como punto final, fue del 97.4% (intervalo de confianza al 95% de 81.0 a 99.5). Estos resultados superan a los mejores obtenidos a largo plazo con componentes femorales cementados o no cementados en el reemplazo total de cadera.
MBA Institute. Número 4. Mayo de 2013 / 15
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
Long-term results of a hydroxyapatite-coated
femoral component in total hip replacement
A 15- TO 21-YEAR FOLLOW-UP STUDY
S. S. Rajaratnam,
Between 1986 and 1991 we implanted 331 consecutive Furlong hydroxyapatite-coated
femoral components of a total hip replacement in 291 patients. A cemented acetabular
A. Tavakkolizadeh,
prosthesis was used in 217 hips and a hydroxyapatite-coated component in 114. We
M. D. George,
describe the long-term clinical and radiological survival of the femoral component at a
R. J. Fletcher,
mean follow-up of 17.5 years (15 to 21). Only two patients (0.68%) were lost to follow-up.
M. Hankins,
With revision of the femoral component for any reason as the endpoint, the survival at a
J. A. N. Shepperd
mean of 17 years was 97.4% (95% confidence interval 94.1 to 99.5), and with revision for
aseptic loosening as the endpoint it was 100%. The survival at a maximum of 21 years with

From Conquest revision of the femoral component for any reason as the endpoint was 97.4% (95%
Hospital, St confidence interval 81.0 or 99.5). These results compare favourably with the best long-term
Leonards-on-Sea, results of cemented or uncemented femoral components used in total hip replacement.
� S. S. Rajaratnam, FRCS (Tr & Orth), BSc (Hons), Senior Hip & The results of the titanium hydroxyapatite and were allowed to bear weight fully immedi- Knee Fellow Peninsula Orthopaedic (HA)-coated Furlong hip replacement (Joint ately after surgery.
Research Institute, 812 Replacement Instrumentation Ltd, London, The patients were reviewed clinically and Pittwater Road, Deewhy, Sydney, Australia.
United Kingdom) have previously been radiologically at 6, 12, 26 and 52 weeks after reported, showing survival of the femoral com- operation and annually thereafter. Antero- � C. Jack, MRCS, Specialist ponent of 100% at ten years and of 99% at a posterior radiographs of the pelvis and lateral Queen Elizabeth Hospital, mean of 13 years.2 We report the longest pro- radiographs of the hips were taken and the Woolwich, London SE18 4QH, UK.
spective series to date of an HA-coated femoral Merle d'Aubigne and Postel hip score3 was used � A. Tavakkolizadeh, FRCS (Tr & Ortho), MSc, Specialist for the assessment of pain, mobility and func- Kings College Hospital, Denmark Patients and Methods
Hill, London SE5 9RS, UK.
The stability and fixation of the femoral Between 1986 and 1991, in Hastings, United component was assessed by two independent � M. D. George, FRCS (Tr & Orth), Hip Fellow Kingdom, we performed 331 total hip observers (SSR, CJ) by a consensus of opinion.
Guy's Hospital, St Thomas' Street, replacements (THRs) in 291 patients with a The appearance of radiolucencies around the London Bridge, SE1 9RT, UK.
mean age of 71.2 years (31.1 to 89.8). A total component according to Gruen, McNiece and � R. J. Fletcher, MRCS, BSc(Hons), Research Registrar of 40 patients had bilateral THRs, 30 under Amstutz was noted, as was subsidence on � J. A. N. Shepperd, FRCS, one anaesthetic and ten in a staged procedure.
serial radiographs, the presence of increased Consultant Orthopaedic SurgeonConquest Hospital, The Ridge, St All the patients had a Furlong HA-coated bone density suggesting bony ingrowth, and Leonards-on-Sea, East Sussex THR. The operation was performed via a the appearance of radiolucent lines and pedes- TN37 7RD, UK.
Watson-Jones approach by, or under the tal formation at the tip of the stem. An assess- � M. Hankins, BSc(Hons), supervision of a consultant orthopaedic sur- ment of the radiographs was also made for FRSS, Senior Research Fellow/Statistician geon (JANS).
evidence of stress shielding and of each Gruen Brighton & Sussex Medical A total of 217 THRs were undertaken using zone for osteopenia.
School, Falmer BN1 9RH, UK.
a Furlong HA-coated femoral component and Correspondence should be sent to Mr S. S. Rajaratnam; e-mail: a Furlong ultra-high-density-polyethylene cemented acetabular component. The remain- The patients were followed up for a mean of 2008 British Editorial Society ing 114 THRs, operated on after 1 January 17.5 years (15 to 21). A total of 184 patients of Bone and Joint Surgery 1990, had an HA-coated threaded acetabular (63.2%; 211 hips) had died by the final follow- doi:10.1302/0301-620X.90B1. 19731 $2.00 component (Joint Replacement Instrumenta- up. All had been reviewed within one year of tion Ltd) and a HA-coated Furlong femoral their death and were therefore included in the J Bone Joint Surg [Br]2008;90-B:27-30.
component. A 32 mm modular ceramic head survival analysis.
Received 22 May 2007; was used in all patients. Each patient had three Of the remaining 107 patients with 120 Accepted after revision 29 August 2007 doses of prophylactic antibiotics (cefuroxime) THRs, 15 failed to attend the final review and VOL. 90-B, No. 1, JANUARY 2008 16 / MBA Institute. Número 4. Mayo de 2013


Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
S. S. RAJARATNAM, C. JACK, A. TAVAKKOLIZADEH, M. D. GEORGE, R. J. FLETCHER, M. HANKINS, J. A. N. SHEPPERD Anteroposterior pelvic radiograph showing well-fixed bilateral Furlong hydroxyapatite-coated femoral components and threaded acetabular components, 17 years after total hip replacement.
Lateral radiograph of the hip showing a well-fixed Furlong hydroxy- apatite-coated total hip replacement 17 years after operation.
were contacted via an extended telephone interview. Theirresults are included in the study. Two hips in two patients(0.68%) were lost to follow-up. One had moved abroad 2.5years after THR and could not be contacted. The other hada well functioning THR at six years post-operatively and There were no cases of aseptic loosening of the femoral refused further review.
component during the study period. In all cases, the fem- Clinical and radiological. The mean Merle D'Aubigne and
oral component remained well-fixed with no measured Postel3 score recorded for the 92 patients (105 hips) who migration at the latest follow-up, with radiological evi- attended the latest follow-up was 5.63 (3 to 6) for pain, dence of bonding in the form of spot-weld formation2 into 5.42 (2 to 6) for mobility and 4.50 (0 to 6) for function.
the stem and a blastic reaction at its tip (Figs 1 and 2). Six No patient reported anterior thigh pain at any review.
patients (1.8%) underwent revision of the femoral compo- Slight rounding of the femoral calcar under the collar nent for trauma, sepsis or trunion fretting, at which stage was seen in 43 of 105 hips (41%).
their well-fixed femoral component was removed (Table I).
Table I. Details of the revisions of the femoral components
Time since THR* (yrs) Indication for revision
Traumatic loosening of both components following road One-stage revision of femoral component Late infection following road traffic accident Two-stage revision of both components Loosening of the acetabular component One-stage revision Two-stage revision of both components Acetabular loosening leading to dissociation of ceramic head One-stage revision of femoral component Two-stage revision of femoral component Peri-prosthetic fracture and loosening One-stage revision of femoral component * THR, total hip replacement THE JOURNAL OF BONE AND JOINT SURGERY MBA Institute. Número 4. Mayo de 2013 / 17
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
LONG-TERM RESULTS OF A HYDROXYAPATITE-COATED FEMORAL COMPONENT IN TOTAL HIP REPLACEMENT Table II. Cumulative survival of the 331 hips (including the six revisions)
Years since operation
Number of hips Failures
Withdrawn Number at risk
Cumulative survival (%)
* 95% CI, 95% confidence interval Time since operation (yrs) Time since operation (yrs) Kaplan Meier survival curve (with 95% confidence intervals) with Kaplan Meier survival curve (with 95% confidence intervals) showing revision of the femoral component for any reason as the endpoint.
the worst case scenario. The two cases lost to follow-up have been included as stem failures.
There were 30 revisions (9.1%) of the acetabular cerclage wire was used to stabilise the fracture. All component for infection (3 hips), dislocation (4 hips), patients with iatrogenic proximal fractures of the femur aseptic loosening (18 hips) and polyethylene wear sustained during insertion of the stem went on to unite satisfactorily, and did not suffer any long-term conse- Per-operative fracture. There were 16 (4.8%) per-opera-
tive fractures, all of which were iatrogenic fractures of Survival analysis. The life-table survival for the femoral
the anterior femoral cortex. In 15 hips (15 patients) a component (including the six revisions) at a mean of minor per-operative proximal fracture of the femur was 17 years was 97.4% (95% confidence interval (CI) 94.1 identified during implantation of the femoral compo- to 99.5) and at a maximum of 21 years was 97.4% (95% nent, as previously described.1 All patients with per- CI 81.0 to 99.5) (Table II, Fig. 3). Figure 4 shows the operative fractures identified during surgery were mobi- worst case scenario, including the two patients lost to lised non-weight-bearing for six weeks. In one patient, a VOL. 90-B, No. 1, JANUARY 2008 18 / MBA Institute. Número 4. Mayo de 2013
S. S. RAJARATNAM, C. JACK, A. TAVAKKOLIZADEH, M. D. GEORGE, R. J. FLETCHER, M. HANKINS, J. A. N. SHEPPERD component loads the entire femur surrounding it ade- Previous studies on the Furlong HA-coated femoral compo- quately. However, we accept that we have not performed nent have shown excellent medium-term survival when bone densitometry of the proximal femur to accurately used as a primary1,2,5,6 or revision implant.6,7 quantify peri-prosthetic osteopenia.
Our current series includes the first 100 Furlong HA- A total of 16 peri-operative fractures occurred in our coated THRs which were previously reported at a mean of series, 11 of which were seen in the first 100 THRs, as ten years (9 to 12), with a 100% follow-up and a survival of reported previously,1 and comprised iatrogenic fractures of 98.95% at up to 12 years, with no cases of aseptic loosen- the anterior femoral cortex. The prevalence of these frac- ing of the femoral stem.1 tures in the early stages of the study most likely represents The Furlong HA-coated THR has also successfully been the learning experience encountered with the use of any new used in younger patients.5,6 Singh et al5 reported the suc- implant. Of the 16 fractures, 15 were proximal cracks of the cessful use of this implant in patients below the age of 50 anterior femoral cortex and did not require supplementary years with a 100% survival of the femoral component at a fixation. This type of fracture can be avoided by recognising mean of ten years (5.3 to 14.2). Robertson et al6 had a that adequate space needs to be cleared in the posterolateral 95.3% survival of the femoral component at a mean of 8.8 corner of the proximal femur to accommodate the relatively years (5 to 13.8) in patients less than 55 years of age. They bulky body of the implant. One fracture extended further did not identify any cases of aseptic loosening of the femo- distally and required cerclage wire fixation to stabilise the ral component.
implant. Nevertheless, all fractures united satisfactorily and The Furlong HA-coated THR has provided impressive there were no further complications.
medium-term results as a revision implant.7,8 At a mean Anterior thigh pain has been reported previously with follow-up of eight years (5 to 12.4) Trikha et al7 reported the use of uncemented hip prostheses.10,11 This was not the survival of the femoral component of 100% with aseptic case in our study. The absence of thigh pain in our study loosening as the endpoint, while Raman et al8 found sim- may be related to the modulus of elasticity of the titanium ilarly good results with survival of 95.6% at a mean implant and to the bonding of bone throughout its length as follow-up of 12 years when revising cemented THRs.
shown in a retrieval analysis.12 In our series of 331 consecutive THRs, survival of the fem- We would like to thank our research assistants Mrs. K. Goddard, Ms K. Miles oral component at a mean of 17 years was 97.4% (95% CI and Mrs. D. East for their invaluable efforts over the last 20 years in making this 94.1 to 99.5) and at a maximum of 21 years was 97.4% (95% prospective study possible.
No benefits in any form have been received or will be received from a com- CI 81.0 to 99.5), with revision for any reason as the endpoint.
mercial party related directly or indirectly to the subject of this article.
With aseptic loosening of the femoral component as the end-point, the survival would be 100%. These figures are similar to those in the literature for the same femoral component.1,2,5-8 1. McNally SA, Shepperd JAN, Mann CV, Walzac JP. The results at nine to twelve
The length of follow-up achieved in this study is largely years of the use of a hydroxyapatite-coated femoral stem. J Bone Joint Surg [Br] attributable to the static elderly population of our region.
2. Shetty AA, Slack R, Tindall A, James KD, Rand C. Results of a hydroxyapatite
Only two of the 331 THRs were unaccounted for, thereby coated (Furlong) total hip replacement: a 13-15 year follow-up. J Bone Joint Surg [Br] reducing the errors in the survival analysis highlighted by 3. Merle d'Aubigne R, Postel M. Functional results of hip arthroplasty with acrylic
Murray, Britton and Bulstrode.9 prosthesis. J Bone Joint Surg [Am] 1954;36-A:451-75.
The Merle D'Aubigne and Postel hip scoring system3 for the 4. Gruen TA, McNiece GM, Amstutz HC. "Modes of failure" of cemented stem-type
assessment of pain, mobility and function has been used since femoral components: a radiographic analysis of loosening. Clin Orthop 1979;141:17- the commencement of this study. However, the mobility and 5. Singh S, Trikha SP, Edge AJ. Hydroxyapatite ceramic-coated femoral stems in
function scores achieved at the latest follow-up were influ- young patients: a prospective 10 year study. J Bone Joint Surg [Br] 2004;86-B:1118- enced by the advancing age of the patients as the follow-up extended. This explains the good mean scores of 5.63 for pain 6. Robertson A, Lavalette D, Morgan S, Angus PD. The hydroxyapatite coated JRI-
Furlong hip: outcome in patients under the age of 55 years. J Bone Joint Surg [Br] and 5.42 for mobility, but the relatively modest score of 4.50 for function.
7. Trikha SP, Singh S, Raynham OW, et al. Hydroxyapatite ceramic coated femoral
The collar on the femoral component prevents early subsid- stems in revision hip surgery. J Bone Joint Surg [Br] 2005;87-B:1055-60.
ence of the prosthesis after implantation. Once bone has 8. Raman R, Kamath RP, Parikh A, Angus PD. Revision of cemented hip arthroplasty
using a hydroxyapatite-ceramic-coated femoral component. J Bone Joint Surg [Br] bonded to the prosthesis, its function becomes redundant.
This may account for the rounding of the bone under the fem- 9. Murray DW, Britton AR, Bulstrode C. Loss to follow-up matters. J Bone Joint Surg
oral collar seen on the radiographs at the final follow-up.
10. Engh CA, Bobyn JD, Glassman AH. Porous-coated hip replacement: the factors
Stress protection osteopenia occurs when a distally well- governing bone ingrowth, stress shielding and clinical results. J Bone Joint Surg [Br] fixed femoral component takes the load in preference to the proximal femur. From the plain radiographs we were 11. Engh CA, Massin P. Cementless total hip arthroplasty using the anatomic medullary
locking stem: results using a survivorship analysis. Clin Orthop 1989;249:141-56.
unable to identify any consistent pattern of osteopenia in 12. Furlong RJ, Osborn JF. Fixation of hip prosthesis by hydroxyapatite ceramic coat-
our series and believe that the Furlong HA-coated femoral ings. J Bone Joint Surg [Br] 1991;73-B:741-5.
THE JOURNAL OF BONE AND JOINT SURGERY Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
Resultados de un
reemplazo total de
cadera recubierto de
hidroxiapatita (Furlong)
Seguimiento de entre 13 y 15 años
Describimos la supervivencia de 134 reemplazos totales
de cadera JRI Furlong recubiertos de hidroxiapatita im- plantados de modo consecutivo. El seguimiento medio fue de 14.2 años (13 a 15). Los pacientes fueron valorados clínicamente utilizando la escala de Merle d'Aubigne y Postel. Las radiografías fueron evaluadas usando las zonas de Gruen para el vás- tago y las zonas de DeLee y Charnley para el acetábulo. Signos de movilización, líneas de radiotransparencia, formación de hueso endóstico (soldadura por puntos) y formación en pedestal fuero usados para evaluar la fija- ción y la estabilidad del vástago de acuerdo con los cri- terios de Engh. El ángulo del cotilo, migración y radio- transparencia fueron usados para evaluar el aflojamiento del acetábulo. El criterio para el fallo fue la revisión o una necesidad de la misma debido a dolor o aflojamiento. El análisis de supervivencia fue realizado utilizando una tabla vital y la curva de Kaplan-Meier.
La media total de la escala Merle d'Aubigne y Postel fue de 7.4 antes de la cirugía y de 15.9 durante el seguimien- to. Durante el período de estudio 22 pacientes fallecieron y 6 fueron perdidos para el seguimiento. Ninguno de los acetábulos fue revisado. Un vástago fue revisado por una fractura periprotésica tras caída, pero ninguna fue revisa- da por aflojamiento, arrojando una tasa de supervivencia del 99% a 13 años. Nuestras observaciones sugieren que los resultados a largo plazo de estas prótesis recubiertas con hidroxiapatita son más que satisfactorios.
20 / MBA Institute. Número 4. Mayo de 2013
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
Results of a hydroxyapatite-coated (Furlong)
total hip replacement
A 13- TO 15-YEAR FOLLOW-UP
A. A. Shetty,
We describe the survival of 134 consecutive JRI Furlong hydroxyapatite-coated
R. Slack,
uncemented total hip replacements. The mean follow-up was for 14.2 years (13 to 15).
A. Tindall,
Patients were assessed clinically, using the Merle d'Aubigné and Postel score.
K. D. James,
Radiographs were evaluated using Gruen zones for the stem and DeLee and Charnley zones
for the cup. Signs of subsidence, radiolucent lines, endosteal bone formation (spot welds)
and pedestal formation were used to assess fixation and stability of the stem according to

From Medway Engh's criteria. Cup angle, migration and radiolucency were used to assess loosening of the
Maritime Hospital, cup. The criteria for failure were revision, or impending revision because of pain or
Kent, England loosening. Survival analysis was performed using a life table and the Kaplan-Meier curve.
The mean total Merle d'Aubigné and Postel score was 7.4 pre-operatively and 15.9 at
follow-up. During the study period 22 patients died and six were lost to follow-up. None of
the cups was revised. One stem was revised for a periprosthetic fracture following a fall but

� A. A. Shetty, MCh, FRCS, none was revised for loosening, giving a 99% survival at 13 years. Our findings suggest that
FRCS(Orth), Senior Fellow in Orthopaedics the long-term results of these hydroxyapatite-coated prostheses are more than
King's College Hospital, Denmark Hill, London SE5 9RS, UK.
� R. Slack, MRCS, FRCS(Orth), Specialist Previous studies have reported a 100% ten- Table I. Pre-operative diagnoses
Registrar in Orthopaedics year survival for the JRI Furlong (Joint William Harvey Hospital, Number of hips
Ashford, Kent TN24 0LZ, UK.
Replacement Instrumentation Ltd, London, UK) hydroxyapatite (HA)-coated femoral � A. Tindall, MRCS, Specialist Registrar in prosthesis.1 Although the theoretical advan- Avascular necrosis Guy's Hospital, St Thomas' tages of an uncemented prosthesis, especially Street, London SE1 9RT, UK.
in the younger patient, are becoming more � K. D. James, BSc, MBBS, established, little long-term data exist on their Rheumatoid arthritis Orthopaedic Senior House use in practice. We present a prospective study * dysplasia (four hips), slipped upper femoral epi- Medway Maritime Hospital, of the HA-coated uncemented JRI Furlong Gillingham, Kent ME7 5NY, femoral component.
� C. Rand, FRCS, Patients and Methods
Table II. Pre-operative Charnley category3 for the 116
FRCS(Orth), Consultant Orthopaedic Surgeon All patients who required a primary total hip Princess Royal University Number of
Hospital, Farnborough replacement under the care of one surgeon Common, Orpington, Kent (CR) between November 1989 and December Class A, unilateral hip disease only BR6 8ND, UK.
1991 were entered into the study. There were Class B, bilateral hip disease only Correspondence should be no exclusion criteria. This longitudinal cohort Class C, multiple orthopaedic and/or sent to Mr A. A. Shetty at 6 Barncroft Drive, Hempstead, of 116 consecutive patients (134 hips) was fol- Gillingham, Kent ME7 3TJ, lowed up prospectively. The mean age of UK; e-mail: mraashetty@yahoo.co.uk patients was 75 years (26 to 95) with 88women and 28 men; 66 hips were right-sided, (Watson-Jones) approach. All had a fully HA- 2005 British Editorial Society of Bone and 32 were left-sided and 36 were bilateral (ten coated JRI stem and either a 28-mm cobalt- simultaneous, eight consecutive). The indica- chrome or ceramic head. The acetabular com- doi:10.1302/0301-620X.87B8. 16011 $2.00 tions for surgery and the pre-operative Charn- ponent was either an HA-coated threaded or a ley functional categories3 are shown in Tables I surface fixation cup (JRI Ltd, London, UK) J Bone Joint Surg [Br] 2005;87-B:1050-4.
(Table III). The change to a surface fixation cup Received 23 September The patients were operated upon by the during the study was a result of it being readily 2004; Accepted after revision 14 December 2004 same surgeon (CR) through an anterolateral available and, for the surgeon, technically sim- THE JOURNAL OF BONE AND JOINT SURGERY MBA Institute. Número 4. Mayo de 2013 / 21
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
RESULTS OF A HYDROXYAPATITE-COATED (FURLONG) TOTAL HIP REPLACEMENT Table III. Details of the implants used
quently recalled for clinical and radiological review for thisstudy. The mean follow-up was 14.2 years (13 to 15).
Number of hips
Clinical assessment was performed using Charnley's modification of the Merle d'Aubigné and Postel scores.4 In Surface fixation cup addition to overall pain, range of movement and walking score, we specifically asked about thigh pain.
Standardised anteroposterior (AP) and lateral radio- graphs were used for radiological assessment. The AP pro- * all cups had a polyethylene insert† femoral heads were all 28 mm in size and all fem- jection was based on the symphysis pubis and was taken at oral stems were fully hydroxyapatite-coated a standard distance of 1 m. The post-operative radiographswere assessed by Gruen zones5 for the femoral componentand DeLee and Charnley6 zones for the acetabular compo- pler to use. Ten patients also had a femoral head autograft for acetabular deficiency. Immediate weight-bearing was The fixation and stability of the stem were assessed using encouraged post-operatively and all patients received rou- Engh's radiological score for uncemented prostheses.7 This tine antibiotic and deep-vein thrombosis prophylaxis.
has two scales, fixation (maximum ten points) and stability The patients were assessed pre-operatively and at six (maximum 17 points). The higher the score, the better the weeks, three months, one, two and five years, and subse- fixation and stability. The degree of subsidence was also Annotated radiograph showing the reference line used to measure subsidence and the Gruen zones5 with the incidence of endosteal bone formation (EBF) or spot welds and reactive lines (RL).
VOL. 87-B, No. 8, AUGUST 2005 22 / MBA Institute. Número 4. Mayo de 2013
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
RESULTS OF A HYDROXYAPATITE-COATED (FURLONG) TOTAL HIP REPLACEMENT A. A. SHETTY, R. SLACK, A. TINDALL, K. D. JAMES, C. RAND Table III. Details of the implants used
quently recalled for clinical and radiological review for this DeLee and Charnley zones study. The mean follow-up was 14.2 years (13 to 15).
Number of hips
Clinical assessment was performed using Charnley's modification of the Merle d'Aubigné and Postel scores. In Surface fixation cup addition to overall pain, range of movement and walking score, we specifically asked about thigh pain.
Standardised anteroposterior (AP) and lateral radio- graphs were used for radiological assessment. The AP pro- * all cups had a polyethylene insert † femoral heads were all 28 mm in size and all fem- jection was based on the symphysis pubis and was taken at oral stems were fully hydroxyapatite-coated a standard distance of 1 m. The post-operative radiographswere assessed by Gruen zones5 for the femoral componentand DeLee and Charnley6 zones for the acetabular compo- pler to use. Ten patients also had a femoral head autograft Interteardrop line for acetabular deficiency. Immediate weight-bearing was The fixation and stability of the stem were assessed using encouraged post-operatively and all patients received rou- Engh's radiological score for uncemented prostheses.7 This tine antibiotic and deep-vein thrombosis prophylaxis.
has two scales, fixation (maximum ten points) and stability The patients were assessed pre-operatively and at six (maximum 17 points). The higher the score, the better the weeks, three months, one, two and five years, and subse- fixation and stability. The degree of subsidence was also Annotated radiograph to show the reference lines used to measure cup angle and migration. DeLee and Charnley zones are marked to show the percentage of endosteal bone formation (EBF) and reactive lines (RL).
measured by changes in the vertical distance between the Gruen or DeLee and Charnley zone.6 The formation of Annotated radiograph showing the reference line used tip of the greater trochanter and the most proximal point heterotopic ossification was graded according to the to measure subsidence and the Gruen zones5 with the on the implant; a change of more than 2 mm was consid- method described by Brooker et al.9 incidence of endosteal bone formation (EBF) or spot welds and reactive lines (RL).
ered to be evidence of subsidence (Fig. 1). Spot welds were The criteria for failure were either revision or an impend- defined as the presence of new bone formation bridging the ing revision because of pain or loosening.
gap between the endosteal surface and the surface of the implant. A bone pedestal was defined as a shelf of endosteal new bone, either partially or completely bridging the During the study period 22 patients died and six were lost intramedullary canal, at the tip of the implant. Calcar to follow-up.
remodelling was recorded as hypertrophic, atrophic or The Merle d'Aubigné and Postel scores improved for all patients, except one who developed Brooker grade IV Migration of the acetabular component was defined as heterotopic ossification. The mean total score rose from 7.4 significant if there was a > 3 mm linear change (medial, (SD 1.5) at pre-operative assessment to 15.9 (SD 1.8) at fol- superior or both) in relation to either Kohler's or the inter- low-up with each component of the score showing an teardrop line.8 Rotational change was regarded as signifi- improvement (Table IV). No patient complained of thigh cant if there was a change of > 3˚ in the angle of the acetabular component (Fig. 2).
The mean Engh score for fixation and stability was 24.7 Radiolucent and sclerotic lines at the acetabular and fem- (10 for fixation and 14.7 for stability). In 109 stems (81%) oral interfaces were also measured. A significant reactive there was a pedestal at its tip (Fig. 3). The development of line was classified as a lucency at the bone-implant interface endosteal bone formation in the form of spot welds is if it was 2 mm wide and occupied at least 50% of any one shown in Figure 1. There were no reactive lines at the bone- VOL. 87-B, No. 8, AUGUST 2005 THE JOURNAL OF BONE AND JOINT SURGERY MBA Institute. Número 4. Mayo de 2013 / 23
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
RESULTS OF A HYDROXYAPATITE-COATED (FURLONG) TOTAL HIP REPLACEMENT Table IV. Merle d'Aubigné and Postel clinical scores4*
component. There was no migration in either a vertical or ahorizontal direction and no change in cup angle.
Complications. There were two deep-vein thromboses, one
of which progressed to a fatal pulmonary embolus. There were also two transient femoral nerve palsies and one tran- sient common peroneal nerve palsy. There was one late * maximum score is 18 (6 for each category) deep infection with a persistent sinus and one femoral stemrevision for fracture after significant trauma. Five patientshad Brooker grades III and IV heterotopic ossification Table V. Post-operative complications
Number of cases
Survival analysis. In constructing a survival analysis, we
did not assume that the six patients who were lost to fol- low-up had similar results to those who were contactable.
Pulmonary embolism Deep-vein thrombosis Evidence suggests that the former group of patients may have worse outcomes than the latter.10 None of the 22 patients (27 hips) who died during the study period were Deep (with sinus) revised or were awaiting revision. At their last review, two to six years after surgery, all hips were well fixed and func- Common peroneal† tioning well. We therefore constructed a life table (Fig. 4) using best and worse case scenarios to account for those Femur - minor (anterior/posterior cortex) patients who were lost to follow-up.11-14 Acetabulum (posterior wall) Our series shows a survival rate of 99% at 13 years (95% confidence interval 94 to 100), equal to other published series of HA-coated femoral components1,15 and superior to other cementless implants.16,17 This is also the case when using our worst case scenario, accounting for patients who † common peroneal palsy followed a deep-vein thrombosis were lost to follow-up.11 Clinical results were very satisfactory with excellent improvement in the patients' Merle d'Aubigné and Postel stem interface, no changes at the interface and no subsid- scores. Deterioration in this score was seen in only one ence or osteolysis in any of the radiographs studied.
patient with unknown ankylosing spondylitis and who With regard to the acetabular component, there was developed Brooker grade IV heterotopic ossification.
endosteal bone formation in DeLee and Charnley zones 1 Another significant feature of our study was the absence of and 3 in all hips and in and zone 2 in 112 hips (84%, thigh pain, in contrast with reports of other cementless fem- Fig. 2). No reactive lines were seen in any zone, for any oral components without HA-coating.17,18 Radiographs showing a) spot weld and b) pedestal for- mation around the femoral stem.
VOL. 87-B, No. 8, AUGUST 2005 24 / MBA Institute. Número 4. Mayo de 2013
Resultados clínicos a largo plazo de la prótesis total de cadera Furlong H.A.C
A. A. SHETTY, R. SLACK, A. TINDALL, K. D. JAMES, C. RAND Cumulative survival (%) Cumulative survival (%) Survival curves showing the a) best and b) worst-case scenarios.
The mean Engh's radiological score in our series was 2. Theis JC, Ball C. Medium-term results of cementless hydroxyapatite-coated pri-
24.7, representing excellent stability and fixation, with the mary total hip arthroplasty: a clinical and radiological review. J Orthop Surg (Hong presence of spot welds and absence of radiolucent lines.
3. Charnley J. The long term results of low friction arthroplasty of the hip performed as
Engh described satisfactory bony ongrowth as a total score a primary intervention. J Bone Joint Surg [Br] 1972;54-B:61-76.
of ten points or more.7,19,20 Calcar atrophy, a positive sign 4. Merle d'Aubigne R, Postel M. Functional results of hip arthroplasty with acrylic
of stability,7 was noted in our study and in that by Engh prosthesis. J Bone Joint Surg [Am] 1954;36-A:451-75.
5. Gruen TA, McNeice GM, Amstutz HC. "Modes of failure" of cemented stem-type
early in the follow-up and was found to be non-progressive.
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ling of cysts around the acetabulum was also seen. For the ation of porous-surfaced femoral components. Clin Orthop 1990;257:107-28.
ten patients who received a femoral head autograft for ace- 8. Nunn D, Freeman MAR, Hill PF, Evans SJ. The measurement of migration of the
acetabular component of hip prostheses. J Bone Joint Surg [Br] 1989;71-B:629-31.
tabular deficiency, all showed incorporation of the graft, as 9. Brooker AF, Bowerman JW, Robinson RA, Riler LH Jr. Ectopic ossification fol-
demonstrated by trabecular re-orientation without evi- lowing total hip replacement: incidence and method of classification. J Bone Joint dence of significant graft resorption.21 Surg [Am] 1973;55-A:1629-32.
In our series there was no specific complication related to 10. Murray DW, Britton AR, Bulstrode C. Loss to follow-up matters. J Bone Joint Surg
the implant fixation by HA-coating. The incidence of intra- 11. Murray DW, Carr AJ, Bulstrode C. Survival analysis of joint replacements. J Bone
operative fractures seemed to be related to the experience of Joint Surg [Br] 1993;75-B:697-704.
the surgeon in using this prosthesis. All the fractures were 12. Carr AJ, Morris RW, Murray DW, Pynsent PB. Survival analysis in joint replace-
ment surgery. J Bone Joint Surg [Br] 1993;75-B:178-82.
managed conservatively and united uneventfully without 13. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am
any long-term effect on the stability, fixation, or clinical Stat Assoc 1958;53:457-81.
outcome. HA-coating may even have improved the chance 14. Murray DW, Carr AJ, Bulstrode CJ. Which primary total hip replacement? J Bone
of fracture union. One patient, who had a deep infection Joint Surg [Br] 1995;77-B:520-7.
with a persistent sinus, surprisingly did not show any evi- 15. Skinner JA, Kroon PO, Todo S, Scott G. Femoral component with proximal HA
coating: an analysis of survival and fixation at up to 10 years. J Bone Joint Surg [Br] dence of stem loosening. Our incidence of heterotopic ossi- fication was comparable with other reported series.9,22,23 16. Donnelly WJ, Kobayashi A, Freeman MAR, et al. Radiological and survival com-
parison of four types of fixation of a proximal femoral stem. J Bone Joint Surg [Br] The only prosthetic failure in our series was one peripros- thetic femoral fracture. However, during the revision it was 17. Engh CA, Bobyn JD, Glassman AH. Porous-coated hip replacement: the factors
noted that the stem was well fixed.24 governing bone ingrowth, stress shielding and clinical results. J Bone Joint Surg [Br] Our study shows a 99% survivorship at 13 to 15 years' 18. Engh CA, Massin P. Cementless total hip arthroplasty using the anatomic medullary
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series.1,2,15,18 HA-coating of implants appears to offer a sat- 20. Furlong RJ, Osborn JF. Fixation of hip prostheses by hydroxyapatite-ceramic coat-
isfactory solution to fixation. However, a valid concern ings. J Bone Joint Surg [Br] 1991;73-B:741-5.
may be later failure as a consequence of polyethylene wear.
21. Gerber SD, Harris WH. Femoral head autografting to augment acetabular defi-
ciency in patients requiring total hip replacement: a minimum five-year and an aver- No benefits in any form have been received or will be received from a commer- age seven-year follow-up study. J Bone Joint Surg [Am] 1986;68-A:1241-8.
cial party related directly or indirectly to the subject of this article.
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factors and consequence. Clin Orthop 1991;263:49-58.
23. Kasetti RJ, Shetty AA, Rand C. Heterotrophic ossification after uncemented
1. McNally SA, Shepperd JAN, Mann CV, Walczak JP. The results at nine to
hydroxyapatite coated primary total hip arthroplasty. J Arthroplasty 2001;16:1038-42.
twelve years of the use of a hydroxyapatite-coated femoral stem. J Bone Joint Surg 24. Lewallen DG, Berry DJ. Periprosthetic fracture femur after total hip arthroplasty:
treatment and results to date. J Bone Joint Surg [Am] 1997;79-A:1881-90.
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Determination of metformin in mouse, rat, dog and human plasma samples by laser diode thermal desorption/atmospheric pressure chemical ionization tandem mass spectrometry

ARTICLE IN PRESS Journal of Pharmaceutical and Biomedical Analysis xxx (2010) xxx–xxx Contents lists available at Journal of Pharmaceutical and Biomedical Analysis Short communication Determination of metformin in mouse, rat, dog and human plasma samples bylaser diode thermal desorption/atmospheric pressure chemical ionizationtandem mass spectrometry John G. Swales , Richard Gallagher, Raimund M. Peter

Topamax fi ohne korrekturkennung

Information for Healthcare Professionals NAME OF THE MEDICINAL PRODUCT Haldol-Janssen solution for injection 5 mg/mL QUALITATIVE AND QUANTITATIVE COMPOSITION 1 mL solution for injection contains 5 mg haloperidol. For a full list of excipients, see section 6.1. PHARMACEUTICAL FORM Solution for injection Clear, colourless solution.