Straight stem and threaded cup in patients under 60 years of age. 28.8-30.2 years of follow-up

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Methods: Between 1986 and 1987, 75 hips of 75 patients (mean age: 53.35±6.17 years) were consecutively implanted with an Alloclassic Zweymüller/Alloclassic SL stem and an Alloclassic CSF cup. 44 patients had died over the last 30 years. The remaining 31 patients (mean age: 82.9±6.4years) were reinvited for follow-up examinations. Clinical and radiographic evaluations were carried out. Results: At a mean follow-up of 29.5 (28.8-30.2), 4 patients (5.3%) were lost to follow up. For the endpoint aseptic loosening (defined as the removal of stem or the cup for 2 cases), the overall survival rate is 97.3%. For the endpoint revision for any reason (22 patients), the survival rate is 70.6%. Eleven patients needed an exchange of head and liner, caused by wear. The average time from implantation until change of head and liner was 21.44 years (SD 5.92). Other reasons for revison surgery were septic loosening (3 cases), aseptic loosening of stem and cup (1 case), aseptic loosening of stem (1 case), periprosthetic calcification (2 cases), implant fracture (1 case), periprosthetic fracture (1 case), intraoperative fissure of stem (1 case), total wear of liner including cup (1 case). Conclusion: The combination of a straight stem (Alloclassic) and a screw cup (CSF) shows excellent results in young patients under the age of 60 at ultra-longterm follow up at 30 years. Revisions due to wear of the polyethylene liner are more likely than in the older patients. Orthopedic Surgery total hip arthroplasty threaded cup CSF straight stem Alloclassic SL long-term follow-up young patients Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Various studies and registry data deal with short and midterm results of the cementless implanted Alloclassic Zweymüller hochgezogen, the Alloclassic SL and the Alloclassic CSF screw cup system[1-3]. These implants have excellent results in older patients[3]. Some studies describe long-term results up to 20 years[4]. Other well established stem systems are reported to have excellent long term results such as Bicontact[5,6], Taperloc[7], Corail[8,9], CLS[10-12] as well as threaded cups such as T-TAP ST[13]. Recent trends lead to bone and muscle preserving implants such as spherical press-fit cups and bone preserving, metaphyseal fixed short stems, especially in younger and more active patients. According to some authors, available data does not show satisfying evidence regarding the benchmark of 90% survivorship after 10 years, set by the National Institute of Clinical Excellence, NICE[14]. Up to now, only straight stems have an ODEP 13A* rating[http://www.odep.org.uk/products.aspx 15]. Threaded cups and conventional straights stems have proven excellent overall long term-results in various cohorts. Nevertheless, there is only limited published data for the combination of a straight stem with a screw cup in younger patients, who are mostly more physically active and demanding We already published first results of our cohort 15 years ago with excellent outcome[3]. Up to now, there is no published data reporting clinical and radiological results for a screw cup in combination with a straight stem in patients less than 60 years of age at time of implantation with an ultra-longterm follow-up of up to 30 years. Materials And Methods We established a retrospective observational study of one cohort. Between 1986 and 1987 seventyfive hips in 75 consecutive patients 60 years of age or younger at time of surgery were treated in our institution with a cementless total hip arthoplasty system. All patients received a straight uncemented stem (n=46, Alloclassic Zweymueller/ n=29, Alloclassic SL) and a uncemented threaded cup (n=75; Alloclassic CSF (AlloPro/Sulzer Medica; Centerpulse; Winterthur, Switzerland). In all cases, a standard non highly cross-linked PE liner was used with 28mm ceramic heads with 12/14 trunnion (Cerasul, AlloPro/SulzerMedica). The group included 38 women and 37 men. Mean age at surgery was 53.35 years (32.5 – 60.5; standard-deviation 6.17; 95%-Confidence Interval 51.9 – 54.7). 44 patients (44 hips) had died over the past 30 years. Using data from a previous study, we know for 42 of them if the arthroplasty system was in situ at death or revised for any reason. Four patients being still alive were lost to follow-up. The remaining 27 (Figure 1) patients (12 male, 15 female; 27 hips) were available and had a mean age of 82.9 years at follow-up (72.4 – 90.5; SD 6.4; 95%-CI 80.5 – 85.5). The patients were interviewed by telephone if the prostheses were still in situ and if there was any revision surgery or any problems over the past years, concerning the prostheses. If feasible, the patients were invited to come to our outpatient clinic for a routine clinical and radiological check-up. We were able to assess 16 patients clinically and radiologically. All other 11 patients refused to come to the hospital but data from a structured telephone-interview was available. The surgical indication (Table 1) for total hip arthroplasty was primary osteoarthritis in 55 cases (73 percent) and secondary osteoarthritis in 8 cases (16 percent). Others were revision surgeries in 12 cases (10.6 percent). For analyzing the osteolytic zones on biplanar x-rays, the image editing software GIMP, version 2.8, was used. In detail, using histograms made it possible to analyze the amount of colored pixels which was needed to cover the ball head and the radiolucent zones. With this measurements the size of the osteolysis could be calculated. The technique was described in 2017 by the authors.[16] We calculated the survival rate of the implanted system including graphs for survival curves according to Kaplan-Meier, the adverse events correlating with the implants over the past 30 years, the occurrence of radiolucent lines and osteolytic zones in the recent weight bearing x-rays according to the classification of DeLee and Charnley[17] and Gruen[18] on the a-p view and the patients’ satisfaction with the result after 30 years. Confidence-intervals are given for calculated values, if applicable. Patients without follow-up were excluded from further analysis. Survival curves were calculated for all implanted stems for aseptic loosening as well as revision for any reason. The software used was Microsoft Excel 12.2.6 and jamovi 0.9.5.12 for detailed statistical analysis. Results Survival rate and adverse events (Table 2): We had two cases of aseptic loosening as well as three cases of septic loosening. If the endpoint is defined as the removal of the stem or cup for aseptic loosening (2 cases), the overall calculated survival rate is 97.33% (Figure 2). If the endpoint is revision for any reason (22 cases), the calculated survival rate is 70.6% (Figure 3). Eleven patients needed revision surgery for exchange of head and liner, one of them was operated twice on one hip due to wear. The mean time from implantation until change of head and liner was 21.44 years (SD 5.92). One totally worn-out liner leaded to revision surgery of the acetabular component due to destruction of the acetabular component (Figures 5, 6 and 7). Those patients, who died over the last 30 years, have lived with the arthroplasty system for an average of 17.68 years (3.7 – 28.3; SD 7.3; 95%-CI 15.9 – 19.9). Radiological: According to the biplanar measurement of the x-rays using the technique as described by the studygroup in 2017, most of the radiolucent lines and osteolytic zones were found in the proximal Gruen-zones 1 (19 hips) and 7 (5 hips), in only 2 hips in zone 6. Osteolytic zones around the cup were seen in the lateral DeLee and Charnley zone 1 in 8 hips. Being aware of the mode of stress-shielding around components, none of the implanted stems and cups were considered to be at risk. Clinical: Overall satisfaction of our patients with the implanted total hip arthoplasty system was very good (Figure 4). None of the 27 patients described pain. Discussion From 1986 on, our institution has been implanting the described Alloclassic SL and CSF screw cup total hip arthroplasty system in primary and secondary hip surgery. This is the first study to provide a 30-year follow-up for young patients under 60 years of age treated with an uncemented total hip arthroplasty system consisting of a porous coated straight stem and threaded. Pursuing our published data for the Alloclassic stem system after 30 years of follow-up, our evaluation in combination with the cementless implanted Alloclassic CSF cup system is the first ultra-longterm-study in young and demanding patients with a mean follow up of 29.5 years[19,20]. During this timespan, a broad variety of complications occurred in our cohort. Reasons for revisions were various and represented the known modes of failure of total hip arthroplasty systems. Nevertheless, for a majority of 70.6%, the implantation of the evaluated THA-system was the last surgery needed involving the replaced joint. Previous data shows, that youth as well as higher activity levels may increase the incidence of mechanical failure of total hip prostheses. Wangen et al. showed a failure rate of 49 percent for the acetabular components (press fit and screw cups) due to mechanical failure in patients younger than 30 years after a mean follow-up of 16 years[21]. The main type of failure in our study did not occur in the interface between cup and bone, but wear of the polyethylene liner was the main reason for revision. Reigstad et al. presented a longterm follow-up (15-18 years) for a tapered stem (Zweymüller SL) and a threaded cup (Endler) in 75 hips. Averaging 52 years of age at surgery, the cohort is comparable to the one of this study group. The survival analysis for the implanted system showed a Kaplan-Meier survival rate of 88%, whereof 6 cups had to be revised due to polyethylene wear. The prefixed polyethylene was stated to be a serious drawback, because in case of progression of wear, the explantation of the whole cup-system is required.[22] In our population group 29.6% needed revision surgery for any reason, which seems to be on a high level compared to other published cohorts with a long-term follow-up in the third decade. It has to be noted, that in those cases, which needed revision surgery to exchange head and liner, a regular PE-liner had been implanted in primary surgery. As soon as ultra-high cross-linked UHMWPE liners have entered the market in 1998, secondary surgery was performed using this long material, which has proven about 10-times less wear in long-term follow-up cohorts. As a result, a far smaller revision rate due to wear can be expected.[23-25]. It can be assumed, that the known cost-effectiveness of THA gets stronger when the revision rate decreases[26,27]. Regarding the low wear rates of modern materials, the fear of wear-associated complications in younger individual over decades does not seem to be justified. Most of the radiolucent lines and osteolytic zones were seen in the lateral zone I according to DeLee and Charnley describing changes at the cup. Radiolucent lines around the stem were commonly seen in Gruen-zones 1 and 7, but none of the implanted systems was considered to be at risk[3,28]. The authors were able to show in a previous study, that there may be a positive effect for the reduction of osteolytic zones around the stem caused by wear when performing an exchange of head and liner[16]. The results of this study group are comparable to to previous published cohorts as shown by Delauny, giving survival rates of 99% for aseptic loosening after a timespan of 7 to 8 years[1]. The study group of Pieringer et al. presented 98.4% surviving cups after 157 months for the endpoint of aseptic loosening in 2006[29]. The cohort of Busch et al. gave results of 89% survival rate (revision for any reason; including cup and stem) after 17 years in 2012[4]. Schröder et al. gave a report on their cohort of revision cases with a survival rate of 95% percent for the cup after 6.1 years[2]. Within the czech arthroplasty register, 2677 evaluated stems showed a survival rate of 99.81% after 1 to 11 years[30]. Other stems with excellent long term results in younger patients such as CLS Spotorno (72.8 any reason after 23.8 years)[10,12,11], Bicontact (93.57% at 12 years)[6,5] and Corail (95% at 12 years)[8,9] show good results up to 24 years of follow-up, but none of the mentioned cohorts give results for a period up to the end of the third decade as we do. Published data does sometimes not focus on the long-term problems such as wear of early polyethylene liners, therefore the reason for aseptic loosenings stays unclear in most cases. We observed a high number of worn-out liners, so we assume that the reason for our aseptic loosenings may be the result of wear after a long timespan. It has to be stated, that the criteria ‚revision for any reason’ increases with the years and usage because of progressive wear and the need for replacing head and liner[31]. Comparison with data from our previous publications shows, that all of the patients, who needed an exchange of head and liner, were not older than 60 years at primary surgery. Knowing the excellent results for aseptic loosening of the discussed system a successing arthroplasty system needs further benchmarks to prove superiority. Criteria such as bone loss in revision surgery and reproducibility of surgical results are arguments to pursue the development and evaluation of bone sparing, and more anatomically shaped arthroplasty systems[32-34]. Our evaluation is limited by the small number of patients being alive after 30 years. Furthermore, most of the surviving patients are in a bad general medical condition or have moved far away from our institution, which leads to a very small number of clinical evaluations. Nevertheless, our primary aim was not the collection of clinical scores, but the survival rate of the implant and the resulting complications during a 30-year-timespan in younger, more demanding patients. This objective was achieved satisfactorily. The evaluated system is very reliable in primary and secondary THA, as shown in previous studies as well as in this one. In our institution, it has been the basic implant for many years. It has been our backup-system in cases of failure of anatomically shaped stems and spherical pressfit cups for a long period of time. Conclusion The current study is the first one to show a 30-year follow-up for the described straight stem in combination with the threaded cup in patients younger than 60 years of age at implantation. The combination of the discussed total hip arthroplasty system shows excellent results in young patients under the age of 60 at ultra-longterm follow up at 30 years and sets the benchmark for successing total hip arthroplasty systems such as anatomically shaped stems and spherical cups. Revisions due to wear of the polyethylene liner are more likely than in the older patients. Declarations Informed consent: IRB approval was obtained (number K-125-16), informed consent not applicable in retrospective research with existing data Human rights statement: This study was carried out respecting the Declaration of Helsinki Consent for publication: All Authors have read the manuscript and give consent for publication. Availability of data and materials: Access to published data will be granted on reasonable request. Competing interests: Author HG states to have a consulting relationship with Zimmer-Biomet. All other authors: Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg. consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Funding: This research didn't receive grants from any funding agency in the public, commercial or not-for-profit sectors Author contributions: NB, SB, GT, KMC and HG planned the study; PL, SB and AJ collected data, PL and AJ did statistics and wrote the manuscript; KMC and GT did quality control of data and proofreading of the manuscript Acknowledgements: not applicable Abbreviations CI confidence Interval CLS cementless stem CSF conical self-tapping fixation NICE National Institute of Clinical Excellence ODEP Orthopaedic Data Evaluation Panel PE polyethylene SD standard deviation SL stepless THA total hip arthroplasty T-TAP threaded hemispheric titanium shell UHMWPE ultra high molecular weight polyethylene References Delaunay C, Cazeau C, Kapandji AI (1998) Cementless primary total hip replacement. Four to eight year results with the Zweymuller-Alloclassic prosthesis. 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Surg Technol Int 27:279-286 Mert M, Ermutlu C, Kovalak E, Unkar E, Okur SC (2019) Long term survival analysis of cementless Spotorno femoral stem in young patients. Acta Orthop Traumatol Turc 53 (1):19-23. doi:10.1016/j.aott.2018.11.004 Valkering LJJ, Biemond JE, van Hellemondt GG (2018) A Wedge-Shaped Uncemented Femoral Component: Survivorship in Patients Younger Than 50 Years at a Mean Follow-Up of 22 Years. J Arthroplasty 33 (10):3226-3230. doi:10.1016/j.arth.2018.06.009 Smeekes C, de Witte PB, Ongkiehong BF, van der Wal BCH, Barnaart AFW (2017) Long-term results of total hip arthroplasty with the CementLess Spotorno (CLS) system. Hip Int 27 (5):465-471. doi:10.5301/hipint.5000492 McLaughlin JR, Lee KR (2010) Cementless total hip replacement using second-generation components: a 12- to 16-year follow-up. J Bone Joint Surg Br 92 (12):1636-1641. doi:10.1302/0301-620X.92B12.24582 van Oldenrijk J, Molleman J, Klaver M, Poolman RW, Haverkamp D (2014) Revision rate after short-stem total hip arthroplasty: a systematic review of 49 studies. Acta Orthop 85 (3):250-258. doi:10.3109/17453674.2014.908343 . http://www.odep.org.uk/products.aspx . Accessed October 3rd 2019 Pisecky L, Hipmair G, Schauer B, Bohler N (2017) Osteolysis in total hip arthroplasty after head and inlay revision surgery. J Orthop 14 (1):192-194. doi:10.1016/j.jor.2016.12.004 DeLee JG, Charnley J (1976) Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res (121):20-32 Gruen TA, McNeice GM, Amstutz HC (1979) "Modes of failure" of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res (141):17-27 Pisecky L, Hipmair G, Schauer B, Bohler N (2018) 30-years of experience with the cementless implanted Alloclassic total hip arthroplasty system-An ultra-long-term follow-up. J Orthop 15 (1):18-23. doi:10.1016/j.jor.2017.11.003 Pisecky L, Hipmair G, Schauer B, Bohler N (2019) 30-Years of experience with the cementless implanted Alloclassic CSF screw cup total hip arthroplasty system - An ultra-long-term follow-up. J Orthop 16 (2):182-186. doi:10.1016/j.jor.2019.02.019 Wangen H, Lereim P, Holm I, Gunderson R, Reikeras O (2008) Hip arthroplasty in patients younger than 30 years: excellent ten to 16-year follow-up results with a HA-coated stem. Int Orthop 32 (2):203-208. doi:10.1007/s00264-006-0309-2 Reigstad O, Siewers P, Rokkum M, Espehaug B (2008) Excellent long-term survival of an uncemented press-fit stem and screw cup in young patients: follow-up of 75 hips for 15-18 years. 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J Bone Joint Surg Br 86 (8):1108-1114. doi:10.1302/0301-620x.86b8.14732 Pieringer H, Auersperg V, Bohler N (2006) Long-term results of the cementless ALLOCLASSIC hip arthroplasty system using a 28-mm ceramic head: with a retrospective comparison to a 32-mm head. J Arthroplasty 21 (7):967-974. doi:10.1016/j.arth.2005.08.027 Vavrik P, Landor I, Popelka S, Fialka R, Hach J (2014) The National Register of Joint Replacements of the Czech Republic. Acta Chir Orthop Traumatol Cech 81 Suppl:3-68 Schmalzried TP, Shepherd EF, Dorey FJ, Jackson WO, dela Rosa M, Fa'vae F, McKellop HA, McClung CD, Martell J, Moreland JR, Amstutz HC (2000) The John Charnley Award. Wear is a function of use, not time. Clin Orthop Relat Res (381):36-46. doi:10.1097/00003086-200012000-00005 Ries C, Schopf W, Dietrich F, Franke S, Jakubowitz E, Sobau C, Heisel C (2015) [Anatomic reconstruction of hip joint biomechanics: conventional vs. short-stem prosthesis]. Z Orthop Unfall 153 (1):46-50. doi:10.1055/s-0034-1396230 Choi YW, Kim SG (2016) The Short-term Clinical Outcome of Total Hip Arthroplasty Using Short Metaphyseal Loading Femoral Stem. Hip Pelvis 28 (2):82-89. doi:10.5371/hp.2016.28.2.82 Rajakulendran K, Field RE (2012) Neck-preserving femoral stems. HSS J 8 (3):295-303. doi:10.1007/s11420-012-9302-z Tables Indication Absolute number Percentage Primary osteoarthritis 55 73.3% Necrosis of the femoral head 7 9.3% Dysplasia 5 6.7% St.p. loosening of cup 5 6.7% St.p. Girdlestone procedure 3 4% Trauma 1 1.3% Perthes 1 1,3% Tab. 1; Indications for implantation of the cementless Alloclassic/CSF THA-system Type of failure Absolute number Absolute risk Wear 11 14.67% Septic loosening 3 4% Asepic loosening of stem 2 2.67% Periprosthetic fracture 2 2.67% Aseptic loosening of cup 2; 1 with loose stem; 1 with worn-out liner 2.67% Major calcification 2 2.67% Implant fracture (stem) 1 1.33% Totally worn-out liner 1 1.33% Overall patients needing revision surgery 22 29.3% Tab. 2; Reasons for revision surgery Cite Share Download PDF Status: Published Journal Publication published 26 Nov, 2020 Read the published version in Journal of Orthopaedic Surgery and Research → Version 2 posted Editorial decision: Accept 17 Nov, 2020 Editor assigned by journal 12 Oct, 2020 Submission checks completed at journal 11 Oct, 2020 Editor invited by journal 11 Oct, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-16774","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":3406849,"identity":"48182ad3-59ad-4b77-b3d2-651ebd9d4fcf","order_by":0,"name":"Lorenz 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GmbH","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jakob","middleName":"","lastName":"Allerstorfer","suffix":""},{"id":3406851,"identity":"8df3ec1e-5c2d-459b-886d-5d02febd90f6","order_by":2,"name":"Bernhard Schauer","email":"","orcid":"","institution":"Kepler Universitatsklinikum GmbH","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bernhard","middleName":"","lastName":"Schauer","suffix":""},{"id":3406852,"identity":"eab393d2-2528-4ba1-9020-c8f960bbb93a","order_by":3,"name":"Günter Hipmair","email":"","orcid":"","institution":"Kepler Universitatsklinikum GmbH","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Günter","middleName":"","lastName":"Hipmair","suffix":""},{"id":3406853,"identity":"c5328360-341d-4c6c-9344-3cc287a0161c","order_by":4,"name":"Rainer Hochgatterer","email":"","orcid":"","institution":"Kepler Universitatsklinikum GmbH","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rainer","middleName":"","lastName":"Hochgatterer","suffix":""},{"id":3406854,"identity":"f22abee9-f0aa-4226-8399-f7ee9c30d1c7","order_by":5,"name":"Nikolaus Böhler","email":"","orcid":"","institution":"Kepler Universitatsklinikum GmbH","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nikolaus","middleName":"","lastName":"Böhler","suffix":""},{"id":3406855,"identity":"781edeaa-4090-45e3-b378-8e4463b89151","order_by":6,"name":"Tobias Gotterbarm","email":"","orcid":"","institution":"Kepler Universitatsklinikum GmbH","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tobias","middleName":"","lastName":"Gotterbarm","suffix":""},{"id":3406856,"identity":"e6e58dbc-4d87-489c-a66c-f06f3bce5855","order_by":7,"name":"Matthias Klotz","email":"","orcid":"","institution":"Kepler Universitatsklinikum GmbH","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Matthias","middleName":"","lastName":"Klotz","suffix":""}],"badges":[],"createdAt":"2020-03-06 14:53:49","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.3.rs-16774/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-16774/v2","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13018-020-02102-w","type":"published","date":"2020-11-26T15:01:59+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":3160081,"identity":"74550aed-ad00-43a7-b54e-a3d16e92969e","added_by":"auto","created_at":"2020-10-23 16:08:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":84670,"visible":true,"origin":"","legend":"Algorithm leading to revision surgery for any reason","description":"","filename":"F1.png","url":"https://assets-eu.researchsquare.com/files/rs-16774/v2/1c1d789d1f607e2787997843.png"},{"id":3160082,"identity":"2e58cc83-fa8e-450b-9791-d8910d54e0eb","added_by":"auto","created_at":"2020-10-23 16:08:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":24525,"visible":true,"origin":"","legend":"Kaplan-Meier survival curve with 95% CI for the endpoint ‚aseptic loosening of the stem or cup’","description":"","filename":"F2.png","url":"https://assets-eu.researchsquare.com/files/rs-16774/v2/8b8846bce0219c2560e5d2ed.png"},{"id":3160083,"identity":"c8e97f5f-7d4c-420c-ae2b-179de15b2a5c","added_by":"auto","created_at":"2020-10-23 16:08:51","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":36546,"visible":true,"origin":"","legend":"Kaplan-Meier survival curve with 95% CI for the endpoint ‚revision for any reason’","description":"","filename":"F3.png","url":"https://assets-eu.researchsquare.com/files/rs-16774/v2/8e6e5c3125b5662d8ec5e450.png"},{"id":3160084,"identity":"a3c5fae8-272f-42db-af0e-34a839af760c","added_by":"auto","created_at":"2020-10-23 16:08:51","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":746681,"visible":true,"origin":"","legend":"Radiograph showing excellent results after 30 years in a highly active 73-year old male (l)","description":"","filename":"F4.png","url":"https://assets-eu.researchsquare.com/files/rs-16774/v2/bcf5fafa8779ec61146ce13d.png"},{"id":3160085,"identity":"307df0c2-301a-4b05-af20-ac3a34ab0144","added_by":"auto","created_at":"2020-10-23 16:08:52","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":647937,"visible":true,"origin":"","legend":"Radiograph showing totally worn-out liner after 25 years","description":"","filename":"F5.png","url":"https://assets-eu.researchsquare.com/files/rs-16774/v2/f0cb13d47029b000f5ede87c.png"},{"id":3160086,"identity":"f819ae13-3887-46e8-9e07-98c7d492860f","added_by":"auto","created_at":"2020-10-23 16:08:52","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1019453,"visible":true,"origin":"","legend":"intraoperative picture showing totally worn-out liner and affected cup","description":"","filename":"F6.png","url":"https://assets-eu.researchsquare.com/files/rs-16774/v2/b9ea1b557d5ca00170c37992.png"},{"id":3160087,"identity":"51289753-6b0d-4629-9b01-b78ff85bd65e","added_by":"auto","created_at":"2020-10-23 16:08:52","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":526644,"visible":true,"origin":"","legend":"Radiograph showing implant fracture after 20 years","description":"","filename":"F7.png","url":"https://assets-eu.researchsquare.com/files/rs-16774/v2/61740a1e1b8e9c52c1e77956.png"},{"id":13605626,"identity":"eec60f80-62c9-4ce8-99c3-8daabe180bc8","added_by":"auto","created_at":"2021-09-17 06:04:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3252332,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-16774/v2/87576533-f76f-46af-bf47-da221dd8ae28.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eStraight stem and threaded cup in patients under 60 years of age. 28.8-30.2 years of follow-up\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVarious studies and registry data deal with short and midterm results of the cementless implanted Alloclassic Zweym\u0026uuml;ller hochgezogen, the Alloclassic\u0026nbsp; SL and the Alloclassic CSF screw cup system[1-3]. These implants have excellent results in older patients[3]. Some studies describe long-term results up to 20 years[4]. Other well established stem systems are reported to have excellent long term results such as Bicontact[5,6], \u0026nbsp;Taperloc[7], Corail[8,9], CLS[10-12] as well as threaded cups such as T-TAP ST[13].\u003c/p\u003e\n\u003cp\u003eRecent trends lead to bone and muscle preserving implants such as spherical press-fit cups and bone preserving, metaphyseal fixed short stems, especially in younger and more active patients. According to some authors, available data does not show satisfying evidence regarding the benchmark of 90% survivorship after 10 years, set by the National Institute of Clinical Excellence, NICE[14]. Up to now, only straight stems have an ODEP 13A* rating[http://www.odep.org.uk/products.aspx 15].\u003c/p\u003e\n\u003cp\u003eThreaded cups and conventional straights stems have proven excellent overall long term-results in various cohorts.\u003c/p\u003e\n\u003cp\u003eNevertheless, there is only limited published data for the combination of a straight stem with a screw cup in younger patients, who are mostly more physically active and demanding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe already published first results of our cohort 15 years ago with excellent outcome[3]. Up to now, there is no published data reporting clinical and radiological results for a screw cup in combination with a straight stem in patients less than 60 years of age at time of implantation with an ultra-longterm follow-up of up to 30 years.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eWe established a retrospective observational study of one cohort. Between 1986 and 1987 seventyfive hips in 75 consecutive patients 60 years of age or younger at time of surgery were treated in our institution with a cementless total hip arthoplasty system. All patients received a straight uncemented stem (n=46, Alloclassic Zweymueller/ n=29, Alloclassic SL) and a uncemented threaded cup (n=75; Alloclassic CSF (AlloPro/Sulzer Medica; Centerpulse; Winterthur, Switzerland). In all cases, a standard non highly cross-linked PE liner was used with 28mm ceramic heads with 12/14 trunnion (Cerasul, AlloPro/SulzerMedica). The group included 38 women and 37 men. Mean age at surgery was 53.35 years (32.5 \u0026ndash; 60.5; standard-deviation 6.17; 95%-Confidence Interval 51.9 \u0026ndash; 54.7).\u003c/p\u003e\n\u003cp\u003e44 patients (44 hips) had died over the past 30 years. Using data from a previous study, we know for 42 of them if the arthroplasty system was in situ at death or revised for any reason.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFour patients being still alive were lost to follow-up. The remaining 27 (Figure 1) patients (12 male, 15 female; 27 hips) were available and had a mean age of 82.9 years at follow-up (72.4 \u0026ndash; 90.5; SD 6.4; 95%-CI 80.5 \u0026ndash; 85.5).\u003c/p\u003e\n\u003cp\u003eThe patients were interviewed by telephone if the prostheses were still in situ and if there was any revision surgery or any problems over the past years, concerning the prostheses. If feasible, the patients were invited to come to our outpatient clinic for a routine clinical and radiological check-up. We were able to assess 16 patients clinically and radiologically. All other 11 patients refused to come to the hospital but data from a structured telephone-interview was available.\u003c/p\u003e\n\u003cp\u003eThe surgical indication (Table 1) for total hip arthroplasty was primary osteoarthritis in 55 cases (73 percent) and secondary osteoarthritis in 8 cases (16 percent). Others were revision surgeries in 12 cases (10.6 percent).\u003c/p\u003e\n\u003cp\u003eFor analyzing the osteolytic zones on biplanar x-rays,\u0026nbsp;the image editing software GIMP, version 2.8, was used. In detail, using histograms made it possible to analyze the amount of colored pixels which was needed to cover the ball head and the radiolucent zones. With this measurements the size of the osteolysis could be calculated.\u0026nbsp;The technique was described in 2017 by the authors.[16]\u003c/p\u003e\n\u003cp\u003eWe calculated the survival rate of the implanted system including graphs for survival curves according to Kaplan-Meier, the adverse events correlating with the implants over the past 30 years, the occurrence of radiolucent lines and osteolytic zones in the recent weight bearing x-rays according to the classification of DeLee and Charnley[17] and Gruen[18] on the a-p view and the patients\u0026rsquo; satisfaction with the result after 30 years. Confidence-intervals are given for calculated values, if applicable. Patients without follow-up were excluded from further analysis.\u003c/p\u003e\n\u003cp\u003eSurvival curves were calculated for all implanted stems for aseptic loosening as well as revision for any reason. The software used was Microsoft Excel 12.2.6 and jamovi 0.9.5.12 for detailed statistical analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eSurvival rate and adverse events (Table 2):\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe had two cases of aseptic loosening as well as three cases of septic loosening.\u003c/p\u003e\n\u003cp\u003eIf the endpoint is defined as the removal of the stem or cup for aseptic loosening (2 cases), the overall calculated survival rate is 97.33% (Figure 2). If the endpoint is revision for any reason (22 cases), the calculated survival rate is 70.6% (Figure 3). Eleven patients needed revision surgery for exchange of head and liner, one of them was operated twice on one hip due to wear. The mean time from implantation until change of head and liner was 21.44 years (SD 5.92).\u003c/p\u003e\n\u003cp\u003eOne totally worn-out liner leaded to revision surgery of the acetabular component due to destruction of the acetabular component (Figures 5, 6 and 7).\u003c/p\u003e\n\u003cp\u003eThose patients, who died over the last 30 years, have lived with the arthroplasty system for an average of 17.68 years (3.7 \u0026ndash; 28.3; SD 7.3; 95%-CI 15.9 \u0026ndash; 19.9).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRadiological:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the biplanar measurement of the x-rays using the technique as described by the studygroup in 2017, most of the radiolucent lines and osteolytic zones were found in the proximal Gruen-zones 1 (19 hips) and 7 (5 hips), in only 2 hips in zone 6. Osteolytic zones around the cup were seen in the lateral DeLee and Charnley zone 1 in 8 hips.\u003c/p\u003e\n\u003cp\u003eBeing aware of the mode of stress-shielding around components, none of the implanted stems and cups were considered to be at risk.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOverall satisfaction of our patients with the implanted total hip arthoplasty system was very good (Figure 4). None of the 27 patients described pain.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFrom 1986 on, our institution has been implanting the described Alloclassic SL and CSF screw cup total hip arthroplasty system in primary and secondary hip surgery.\u003c/p\u003e\n\u003cp\u003eThis is the first study to provide a 30-year follow-up for young patients under 60 years of age treated with an uncemented total hip arthroplasty system consisting of a porous coated straight stem and threaded.\u003c/p\u003e\n\u003cp\u003ePursuing our published data for the Alloclassic stem system after 30 years of follow-up, our evaluation in combination with the cementless implanted Alloclassic CSF cup system is the first ultra-longterm-study in young and demanding patients with a mean follow up of 29.5 years[19,20]. During this timespan, a broad variety of complications occurred in our cohort. Reasons for revisions were various and represented the known modes of failure of total hip arthroplasty systems.\u003c/p\u003e\n\u003cp\u003eNevertheless, for a majority of 70.6%, the implantation of the evaluated THA-system was the last surgery needed involving the replaced joint.\u003c/p\u003e\n\u003cp\u003ePrevious data shows, that youth as well as higher activity levels may increase the incidence of mechanical failure of total hip prostheses. Wangen et al. showed a failure rate of 49 percent for the acetabular components (press fit and screw cups) due to mechanical failure in patients younger than 30 years after a mean follow-up of 16 years[21]. The main type of failure in our study did not occur in the interface between cup and bone, but wear of the polyethylene liner was the main reason for revision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eReigstad et al. presented a longterm follow-up (15-18 years) for a tapered stem (Zweym\u0026uuml;ller SL) and a threaded cup (Endler) in 75 hips. Averaging 52 years of age at surgery, the cohort is comparable to the one of this study group. The survival analysis for the implanted system showed a Kaplan-Meier survival rate of 88%, whereof 6 cups had to be revised due to polyethylene wear. The prefixed polyethylene was stated to be a serious drawback, because in case of progression of wear, the explantation of the whole cup-system is required.[22]\u003c/p\u003e\n\u003cp\u003eIn our population group 29.6% needed revision surgery for any reason, which seems to be on a high level compared to other published cohorts with a long-term follow-up in the third decade. It has to be noted, that in those cases, which needed revision surgery to exchange head and liner, a regular PE-liner had been implanted in primary surgery. As soon as ultra-high cross-linked UHMWPE liners have entered the market in 1998, secondary surgery was performed using this long material, which has proven about 10-times less wear in long-term follow-up cohorts. As a result, a far smaller revision rate due to wear can be expected.[23-25].\u003c/p\u003e\n\u003cp\u003eIt can be assumed, that the known cost-effectiveness of THA gets stronger when the revision rate decreases[26,27].\u003c/p\u003e\n\u003cp\u003eRegarding the low wear rates of modern materials, the fear of wear-associated complications in younger individual over decades does not seem to be justified.\u003c/p\u003e\n\u003cp\u003eMost of the radiolucent lines and osteolytic zones were seen in the lateral zone I according to DeLee and Charnley describing changes at the cup. Radiolucent lines around the stem were commonly seen in Gruen-zones 1 and 7, but none of the implanted systems was considered to be at risk[3,28]. The authors were able to show in a previous study, that there may be a positive effect for the reduction of osteolytic zones around the stem caused by wear when performing an exchange of head and liner[16].\u003c/p\u003e\n\u003cp\u003eThe results of this study group are comparable to to previous published cohorts as shown by Delauny, giving survival rates of 99% for aseptic loosening after a timespan of 7 to 8 years[1].\u003c/p\u003e\n\u003cp\u003eThe study group of Pieringer et al. presented 98.4% surviving cups after 157 months for the endpoint of aseptic loosening in 2006[29]. The cohort of Busch et al. gave results of 89% survival rate (revision for any reason; including cup and stem) after 17 years in 2012[4]. Schr\u0026ouml;der et al. gave a report on their cohort of revision cases with a survival rate of 95% percent for the cup after 6.1 years[2]. Within the czech arthroplasty register, 2677 evaluated stems showed a survival rate of 99.81% after 1 to 11 years[30].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther stems with excellent long term results in younger patients such as CLS Spotorno (72.8 any reason after 23.8 years)[10,12,11], Bicontact (93.57% at 12 years)[6,5] and Corail (95% at 12 years)[8,9] show good results up to 24 years of follow-up, but none of the mentioned cohorts give results for a period up to the end of the third decade as we do. Published data does sometimes not focus on the long-term problems such as wear of early polyethylene liners, therefore the reason for aseptic loosenings stays unclear in most cases. We observed a high number of worn-out liners, so we assume that the reason for our aseptic loosenings may be the result of wear after a long timespan.\u003c/p\u003e\n\u003cp\u003eIt has to be stated, that the criteria \u0026sbquo;revision for any reason\u0026rsquo; increases with the years and usage because of progressive wear and the need for replacing head and liner[31]. Comparison with data from our previous publications shows, that all of the patients, who needed an exchange of head and liner, were not older than 60 years at primary surgery.\u003c/p\u003e\n\u003cp\u003eKnowing the excellent results for aseptic loosening of the discussed system a successing arthroplasty system needs further benchmarks to prove superiority. Criteria such as bone loss in revision surgery and reproducibility of surgical results are arguments to pursue the development and evaluation of bone sparing, and more anatomically shaped arthroplasty systems[32-34].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur evaluation is limited by the small number of patients being alive after 30 years. Furthermore, most of the surviving patients are in a bad general medical condition or have moved far away from our institution, which leads to a very small number of clinical evaluations. Nevertheless, our primary aim was not the collection of clinical scores, but the survival rate of the implant and the resulting complications during a 30-year-timespan in younger, more demanding patients. This objective was achieved satisfactorily.\u003c/p\u003e\n\u003cp\u003eThe evaluated system is very reliable in primary and secondary THA, as shown in previous studies as well as in this one. In our institution, it has been the basic implant for many years. It has been our backup-system in cases of failure of anatomically shaped stems and spherical pressfit cups for a long period of time.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe current study is the first one to show a 30-year follow-up for the described straight stem in combination with the threaded cup in patients younger than 60 years of age at implantation. The combination of the discussed total hip arthroplasty system shows excellent results in young patients under the age of 60 at ultra-longterm follow up at 30 years and sets the benchmark for successing total hip arthroplasty systems such as anatomically shaped stems and spherical cups. Revisions due to wear of the polyethylene liner are more likely than in the older patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eInformed consent:\u003c/strong\u003e IRB approval was obtained (number K-125-16), informed consent not applicable in retrospective research with existing data\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman rights statement:\u003c/strong\u003e This study was carried out respecting the Declaration of Helsinki\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e All Authors have read the manuscript and give consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials: \u003c/strong\u003eAccess to published data will be granted on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e Author HG\u0026nbsp; states to have a consulting relationship with Zimmer-Biomet. All other authors: Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg. consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research didn't receive grants from any funding agency in the public, commercial or not-for-profit sectors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e NB, SB, GT, KMC and HG planned the study; PL, SB and AJ collected data, PL and AJ did statistics and wrote the manuscript; KMC and GT did quality control of data and proofreading of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e not applicable\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCI\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; confidence Interval\u003c/p\u003e\n\u003cp\u003eCLS\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; cementless stem\u003c/p\u003e\n\u003cp\u003eCSF\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; conical self-tapping fixation\u003c/p\u003e\n\u003cp\u003eNICE\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; National Institute of Clinical Excellence\u003c/p\u003e\n\u003cp\u003eODEP\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Orthopaedic Data Evaluation Panel\u003c/p\u003e\n\u003cp\u003ePE\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; polyethylene\u003c/p\u003e\n\u003cp\u003eSD\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; standard deviation\u003c/p\u003e\n\u003cp\u003eSL\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; stepless\u003c/p\u003e\n\u003cp\u003eTHA\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; total hip arthroplasty\u003c/p\u003e\n\u003cp\u003eT-TAP\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; threaded hemispheric titanium shell\u003c/p\u003e\n\u003cp\u003eUHMWPE\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; ultra high molecular weight polyethylene\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eDelaunay C, Cazeau C, Kapandji AI (1998) Cementless primary total hip replacement. Four to eight year results with the Zweymuller-Alloclassic prosthesis. Int Orthop 22 (1):1-5. doi:10.1007/s002640050198\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eSchroder JH, Matziolis G, Tuischer J, Leutloff D, Duda GN, Perka C (2006) The Zweymuller threaded cup: a choice in revision? Migration analysis and follow-up after 6 years. J Arthroplasty 21 (4):497-502. doi:10.1016/j.arth.2005.05.029\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003ePieringer H, Auersperg V, Griessler W, Bohler N (2003) Long-term results with the cementless Alloclassic brand hip arthroplasty system. J Arthroplasty 18 (3):321-328. doi:10.1054/arth.2003.50045\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eBusch VJ, Pouw MH, Laumen AM, van Susante JL, Vervest AM (2012) Long-term outcome of 73 Zweymuller total hip prostheses with a screw cup in patients under 50 years of age. Hip Int 22 (3):292-295. doi:10.5301/HIP.2012.9239\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eAteschrang A, Weise K, Weller S, Stockle U, de Zwart P, Ochs BG (2014) Long-term results using the straight tapered femoral cementless hip stem in total hip arthroplasty: a minimum of twenty-year follow-up. J Arthroplasty 29 (8):1559-1565. doi:10.1016/j.arth.2014.02.015\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eSwamy G, Pace A, Quah C, Howard P (2012) The Bicontact cementless primary total hip arthroplasty: long-term results. Int Orthop 36 (5):915-920. doi:10.1007/s00264-010-1123-4\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eParvizi J, Keisu KS, Hozack WJ, Sharkey PF, Rothman RH (2004) Primary total hip arthroplasty with an uncemented femoral component: a long-term study of the Taperloc stem. J Arthroplasty 19 (2):151-156. doi:10.1016/j.arth.2003.10.003\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eLouboutin L, Viste A, Desmarchelier R, Fessy MH (2017) Long-term survivorship of the Corail standard stem. Orthop Traumatol Surg Res 103 (7):987-992. doi:10.1016/j.otsr.2017.06.010\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eBoldt JG, Cartillier JC, Machenaud A, Vidalain JP (2015) Long-term Bone Remodeling in HA-coated Stems: A Radiographic Review of 208 Total Hip Arthroplasties (THAs) with 15 to 20 Years Follow-up. Surg Technol Int 27:279-286\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eMert M, Ermutlu C, Kovalak E, Unkar E, Okur SC (2019) Long term survival analysis of cementless Spotorno femoral stem in young patients. Acta Orthop Traumatol Turc 53 (1):19-23. doi:10.1016/j.aott.2018.11.004\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eValkering LJJ, Biemond JE, van Hellemondt GG (2018) A Wedge-Shaped Uncemented Femoral Component: Survivorship in Patients Younger Than 50 Years at a Mean Follow-Up of 22 Years. J Arthroplasty 33 (10):3226-3230. doi:10.1016/j.arth.2018.06.009\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eSmeekes C, de Witte PB, Ongkiehong BF, van der Wal BCH, Barnaart AFW (2017) Long-term results of total hip arthroplasty with the CementLess Spotorno (CLS) system. Hip Int 27 (5):465-471. doi:10.5301/hipint.5000492\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eMcLaughlin JR, Lee KR (2010) Cementless total hip replacement using second-generation components: a 12- to 16-year follow-up. J Bone Joint Surg Br 92 (12):1636-1641. doi:10.1302/0301-620X.92B12.24582\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003evan Oldenrijk J, Molleman J, Klaver M, Poolman RW, Haverkamp D (2014) Revision rate after short-stem total hip arthroplasty: a systematic review of 49 studies. Acta Orthop 85 (3):250-258. doi:10.3109/17453674.2014.908343\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003e. \u003ca style=\"color: #000000;\" href=\"http://www.odep.org.uk/products.aspx\"\u003ehttp://www.odep.org.uk/products.aspx\u003c/a\u003e. Accessed October 3rd 2019\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003ePisecky L, Hipmair G, Schauer B, Bohler N (2017) Osteolysis in total hip arthroplasty after head and inlay revision surgery. J Orthop 14 (1):192-194. doi:10.1016/j.jor.2016.12.004\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eDeLee JG, Charnley J (1976) Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res (121):20-32\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eGruen TA, McNeice GM, Amstutz HC (1979) \"Modes of failure\" of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res (141):17-27\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003ePisecky L, Hipmair G, Schauer B, Bohler N (2018) 30-years of experience with the cementless implanted Alloclassic total hip arthroplasty system-An ultra-long-term follow-up. J Orthop 15 (1):18-23. doi:10.1016/j.jor.2017.11.003\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003ePisecky L, Hipmair G, Schauer B, Bohler N (2019) 30-Years of experience with the cementless implanted Alloclassic CSF screw cup total hip arthroplasty system - An ultra-long-term follow-up. J Orthop 16 (2):182-186. doi:10.1016/j.jor.2019.02.019\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eWangen H, Lereim P, Holm I, Gunderson R, Reikeras O (2008) Hip arthroplasty in patients younger than 30 years: excellent ten to 16-year follow-up results with a HA-coated stem. Int Orthop 32 (2):203-208. doi:10.1007/s00264-006-0309-2\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eReigstad O, Siewers P, Rokkum M, Espehaug B (2008) Excellent long-term survival of an uncemented press-fit stem and screw cup in young patients: follow-up of 75 hips for 15-18 years. Acta Orthop 79 (2):194-202. doi:10.1080/17453670710014978\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eAmstutz HC, Takamura KM, Ebramzadeh E, Le Duff MJ (2015) Highly cross-linked polyethylene in hip resurfacing arthroplasty: long-term follow-up. Hip Int 25 (1):39-43. doi:10.5301/hipint.5000190\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eNebergall AK, Greene ME, Rubash H, Malchau H, Troelsen A, Rolfson O (2016) Thirteen-Year Evaluation of Highly Cross-Linked Polyethylene Articulating With Either 28-mm or 36-mm Femoral Heads Using Radiostereometric Analysis and Computerized Tomography. J Arthroplasty 31 (9 Suppl):269-276. doi:10.1016/j.arth.2016.02.076\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eGlyn-Jones S, Thomas GE, Garfjeld-Roberts P, Gundle R, Taylor A, McLardy-Smith P, Murray DW (2015) The John Charnley Award: Highly crosslinked polyethylene in total hip arthroplasty decreases long-term wear: a double-blind randomized trial. Clin Orthop Relat Res 473 (2):432-438. doi:10.1007/s11999-014-3735-2\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eElmallah RK, Chughtai M, Khlopas A, Bhowmik-Stoker M, Bozic KJ, Kurtz SM, Mont MA (2017) Determining Cost-Effectiveness of Total Hip and Knee Arthroplasty Using the Short Form-6D Utility Measure. J Arthroplasty 32 (2):351-354. doi:10.1016/j.arth.2016.08.006\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eKoenig L, Zhang Q, Austin MS, Demiralp B, Fehring TK, Feng C, Mather RC, 3rd, Nguyen JT, Saavoss A, Springer BD, Yates AJ, Jr. (2016) Estimating the Societal Benefits of THA After Accounting for Work Status and Productivity: A Markov Model Approach. Clin Orthop Relat Res 474 (12):2645-2654. doi:10.1007/s11999-016-5084-9\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eWick M, Lester DK (2004) Radiological changes in second- and third-generation Zweymuller stems. J Bone Joint Surg Br 86 (8):1108-1114. doi:10.1302/0301-620x.86b8.14732\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003ePieringer H, Auersperg V, Bohler N (2006) Long-term results of the cementless ALLOCLASSIC hip arthroplasty system using a 28-mm ceramic head: with a retrospective comparison to a 32-mm head. J Arthroplasty 21 (7):967-974. doi:10.1016/j.arth.2005.08.027\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eVavrik P, Landor I, Popelka S, Fialka R, Hach J (2014) The National Register of Joint Replacements of the Czech Republic. Acta Chir Orthop Traumatol Cech 81 Suppl:3-68\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eSchmalzried TP, Shepherd EF, Dorey FJ, Jackson WO, dela Rosa M, Fa'vae F, McKellop HA, McClung CD, Martell J, Moreland JR, Amstutz HC (2000) The John Charnley Award. Wear is a function of use, not time. Clin Orthop Relat Res (381):36-46. doi:10.1097/00003086-200012000-00005\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eRies C, Schopf W, Dietrich F, Franke S, Jakubowitz E, Sobau C, Heisel C (2015) [Anatomic reconstruction of hip joint biomechanics: conventional vs. short-stem prosthesis]. Z Orthop Unfall 153 (1):46-50. doi:10.1055/s-0034-1396230\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eChoi YW, Kim SG (2016) The Short-term Clinical Outcome of Total Hip Arthroplasty Using Short Metaphyseal Loading Femoral Stem. Hip Pelvis 28 (2):82-89. doi:10.5371/hp.2016.28.2.82\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eRajakulendran K, Field RE (2012) Neck-preserving femoral stems. HSS J 8 (3):295-303. doi:10.1007/s11420-012-9302-z\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eIndication\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eAbsolute number\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003ePercentage\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003ePrimary osteoarthritis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e73.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eNecrosis of the femoral head\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e9.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eDysplasia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e6.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eSt.p. loosening of cup\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e6.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eSt.p. Girdlestone procedure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eTrauma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e1.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003ePerthes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e1,3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTab. 1; Indications for implantation of the cementless Alloclassic/CSF THA-system\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eType of failure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eAbsolute number\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eAbsolute risk\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eWear\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e14.67%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eSeptic loosening\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eAsepic loosening of stem\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e2.67%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003ePeriprosthetic fracture\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e2.67%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eAseptic loosening of cup\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e2; 1 with loose stem; 1 with worn-out liner\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e2.67%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eMajor calcification\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e2.67%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eImplant fracture (stem)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e1.33%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eTotally worn-out liner\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e1.33%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003eOverall patients needing revision surgery\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"205\"\u003e\n\u003cp\u003e29.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTab. 2; Reasons for revision surgery\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"total hip arthroplasty, threaded cup CSF, straight stem Alloclassic SL, long-term follow-up, young patients","lastPublishedDoi":"10.21203/rs.3.rs-16774/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-16774/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eThe aim of this retrospective observational study of one cohort was to evaluate the long-term outcome in patients younger than 60 years after total hip arthroplasty using a straight uncemented stem and an uncemented threaded cup.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eBetween 1986 and 1987, 75 hips of 75 patients (mean age: 53.35±6.17 years) were consecutively implanted with an Alloclassic Zweymüller/Alloclassic SL stem and an Alloclassic CSF cup. 44 patients had died over the last 30 years. The remaining 31 patients (mean age: 82.9±6.4years) were reinvited for follow-up examinations. Clinical and radiographic evaluations were carried out.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAt a mean follow-up of 29.5 (28.8-30.2), 4 patients (5.3%) were lost to follow up.\u003c/p\u003e\u003cp\u003eFor the endpoint aseptic loosening (defined as the removal of stem or the cup for 2 cases), the overall survival rate is 97.3%. For the endpoint revision for any reason (22 patients), the survival rate is 70.6%. Eleven patients needed an exchange of head and liner, caused by wear. The average time from implantation until change of head and liner was 21.44 years (SD 5.92). Other reasons for revison surgery were septic loosening (3 cases), aseptic loosening of stem and cup (1 case), aseptic loosening of stem (1 case), periprosthetic calcification (2 cases), implant fracture (1 case), periprosthetic fracture (1 case), intraoperative fissure of stem (1 case), total wear of liner including cup (1 case).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe combination of a straight stem (Alloclassic) and a screw cup (CSF) shows excellent results in young patients under the age of 60 at ultra-longterm follow up at 30 years. Revisions due to wear of the polyethylene liner are more likely than in the older patients.\u003c/p\u003e","manuscriptTitle":"Straight stem and threaded cup in patients under 60 years of age. 28.8-30.2 years of follow-up","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2020-10-23 16:05:51","doi":"10.21203/rs.3.rs-16774/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-11-18T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-10-12T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-10-11T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-10-11T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-03-11 15:22:28","doi":"10.21203/rs.3.rs-16774/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2020-08-17T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-06T12:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"reviewersInvited","content":"","date":"2020-07-30T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-07-30T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-03-12T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-03-11T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-03-06T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-03-03T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c7b0641c-9afd-4bcd-a497-a18fc165c011","owner":[],"postedDate":"October 23rd, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":869503,"name":"Orthopedic Surgery"}],"tags":[],"updatedAt":"2020-11-29T15:03:55+00:00","versionOfRecord":{"articleIdentity":"rs-16774","link":"https://doi.org/10.1186/s13018-020-02102-w","journal":{"identity":"journal-of-orthopaedic-surgery-and-research","isVorOnly":false,"title":"Journal of Orthopaedic Surgery and Research"},"publishedOn":"2020-11-26 15:01:59","publishedOnDateReadable":"November 26th, 2020"},"versionCreatedAt":"2020-10-23 16:05:51","video":"","vorDoi":"10.1186/s13018-020-02102-w","vorDoiUrl":"https://doi.org/10.1186/s13018-020-02102-w","workflowStages":[]},"version":"v2","identity":"rs-16774","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-16774","identity":"rs-16774","version":["v2"]},"buildId":"369fNeqWncA4NS6XSWjrt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}