Outcomes using wedge stem with full hydroxiapatite coverage with a minimum of 5 years’ follow-up | Revista Española de Cirugía Ortopédica y Traumatología (English Edition)

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Godoy-Monzon, M. Buttaro, F. Comba, G. Zanotti, F. Piccaluga, I. Neira-Borrajo" "autores" => array:6 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Godoy-Monzon" "email" => array:1 [ 0 => "daniel.godoy@hospitalitaliano.org.ar" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Buttaro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "F." "apellidos" => "Comba" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "G." "apellidos" => "Zanotti" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "F." "apellidos" => "Piccaluga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "I." "apellidos" => "Neira-Borrajo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Centro de Cadera Sir John Charnley, Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Santa Cristina, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resultados de un vástago con cobertura completa de hidroxiapatita con un seguimiento mínimo de 5 años" ] ] "textoCompleto" => "IntroductionTotal hip arthroplasty (THA) has greatly evolved since its introduction by Sir John Charnley in 1959, and has become the most successful procedure of orthopaedic surgery. At present each year a million patients receive a THA.<a class="elsevierStyleCrossRef" href="#bib0215">1</a>Throughout this time stem designs and cementation techniques have changed and as a result there has been an improvement in surgical outcomes of primary surgery at 10 years, with a drop in revision of the initial technique from 19% to under 1% with polished stems and the modern cementation technique being a mixture of using vacuum, gun cementation, pulsed lavage pistol and centralisers.<a class="elsevierStyleCrossRef" href="#bib0220">2</a>The concept of cementless fixation arose from an attempt to reduce the rate of loosening (Morscher)<a class="elsevierStyleCrossRef" href="#bib0225">3</a> with the appeal of obtaining a direct union of the bone implant (biological attachment) and long-lasting stability.Depending on the design and elastic properties of an implant pressures will be transmitted. The concept of a wedged stem is intended as fixation in a metaphysary area and the reduction of the possibility of stress shielding with loss of bone stock. Full coverage with a hydroxiapatite (HA) with osteoinductive properties and with new trabecular bone formation<a class="elsevierStyleCrossRefs" href="#bib0230">4,5</a> compensates for the possible imperfect femoral canal fill, achieving a stable fixation even in the presence of initial micromovements and good clinical and radiological outcomes.<a class="elsevierStyleCrossRefs" href="#bib0240">6–9</a>The survival of an implant is critical, and guidelines published in the United Kingdom recommend a revision rate of 10% at 10 years as the limit to their acceptance and production.<a class="elsevierStyleCrossRef" href="#bib0255">9</a> In accordance with these criteria, national registers in other countries (Scandinavia, Australia, FDA) carry out the follow-up of implants and their performance.We must remember that new implants are constantly being produced, at the rate of approximately 5 new designs per year. Surgeons are faced with a wide range of stems without sufficient clinical results and follow-up to be able to take an evidence-based decision on them.<a class="elsevierStyleCrossRefs" href="#bib0215">1,9–11</a>ObjectivesThe aim of our study was to analyse the clinicoradiological results of an uncemented hydroxiapatite covered wedge stem with a 5-year minimum follow-up.Material and methodsA prospective study of hip prosthesis from operations performed in our hospital using an uncemented wedge stem with full HA coverage, of Novation Element® (Exactech, Inc, U.S.A.) type, with a minimum 5-year follow-up.Inclusion criteria were patients aged between 21 and75 years with primary arthrosis, osteo/avascular necrosis and with no previous hip operations. Exclusion criteria were: patients aged over 75, patients with fractures, tumour disease or metastasis and patients who did not wish or could not attend follow-up sessions (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>During the study period, we carried out 114 THA on 104 patients: 54 women and 50 men (52%/48%), with a follow-up of 5.7 years (range: 5–6.2 years). Mean age was 56.8 (range: 42–75years).Initial diagnoses were arthrosis, avascular necrosis, dysplasia of the hip and rheumatoid arthritis (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The operations were performed in a single institution by surgeons exclusively dedicated to hip surgery and with a common approach.All patients agreed to participate in the study and signed specific consent form for the procedure and study.With regard to antibiotic prophylaxis, all patients received 1g of cefazolin, which was administered every 8h for 24h. In patients allergic to this drug vancomycin was administered, 1g every 12h from 24h after surgery. A posterolateral approach was used with piriformis retention and reinsertion of the cup and short external rotators (complete flap) using the Pellicci<a class="elsevierStyleCrossRef" href="#bib0270">12</a> technique during closure. The acetabular component chosen was uncemented, modular, line to line, and with highly crosslinked polyethylene with 10 posterior rim. 32mm cobalt chromium heads were used.All the patients received prophylaxis for thromboembolic disease. 220mg of dabigatran was administered for 30 days after surgery.Excepting contraindication, physiotherapy began on the first day after surgery, with sitting and walking exercises with a frame or sticks, depending on the functional ability of each patient, and following a protocol of accelerated rehabilitation.Check-ups with X-rays were programmed 15 and 45 days after hospital discharge and subsequently at 3 and 6 months and then annually.Intraoperative, hospital stay and follow-up complications were recorded.Clinical and radiographic study methodsClinical assessments according to the Merle d’Aubigné Postel scale modified by Charnley<a class="elsevierStyleCrossRef" href="#bib0275">13</a> and Harris Hip Score,<a class="elsevierStyleCrossRef" href="#bib0280">14</a> for pre and postoperative assessments.A subjective assessment was also carried out on personal patient satisfaction, referring to their overall appreciation of the procedure and their expectations of it, on a scale of 1–10, where a score of 1–3 was a poor outcome, 4–5 was satisfactory, 6.8 good and 9–10 excellent.Radiographic evaluationAssessment of the acetabular cup was made but was not the main aim of this study. The pre and postoperative X-rays were digital and standardised for magnification in 1.2 corresponding to the preoperative planning templates used. The focus was on the pubic bone. We proceeded with a serried radiographic assessment with measurement of the following parameters:On an acetabular level:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Acetabular inclination angle.</li><li class="elsevierStyleListItem" id="lsti0010">•Appearance of radiolucent lines (DeLee and Charnley areas).<a class="elsevierStyleCrossRef" href="#bib0285">15</a></li><li class="elsevierStyleListItem" id="lsti0015">•Cup migration (defined by the variation of over 5 degrees).<a class="elsevierStyleCrossRef" href="#bib0290">16</a></li><li class="elsevierStyleListItem" id="lsti0020">•Screw breakages.</li></ul>The acetabular component was considered integrated in accordance with the non appearance of signs of loosening, progressive radiolucent lines, screw breakage and migration.<a class="elsevierStyleCrossRef" href="#bib0290">16</a>On stem level:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">•Osteolisis (progressive localised reabsorption or endostal erosion).<a class="elsevierStyleCrossRef" href="#bib0295">17</a></li><li class="elsevierStyleListItem" id="lsti0030">•Calcar reabsorption.<a class="elsevierStyleCrossRef" href="#bib0295">17</a></li><li class="elsevierStyleListItem" id="lsti0035">•Presence of radiolucent lines.<a class="elsevierStyleCrossRef" href="#bib0300">18</a></li><li class="elsevierStyleListItem" id="lsti0040">•Cortical hypertrophy.<a class="elsevierStyleCrossRefs" href="#bib0295">17,18</a></li><li class="elsevierStyleListItem" id="lsti0045">•Subsidence (comparing the distance from the stem shoulder to the lesser trochanter).<a class="elsevierStyleCrossRefs" href="#bib0305">19,20</a></li><li class="elsevierStyleListItem" id="lsti0050">•Pedestal formation l and appearance of heterotopic ossifications.</li><li class="elsevierStyleListItem" id="lsti0055">•Subsidence was considered to have taken place with progression after its detection in 3 serial X-rays. For definition of fixation Engh<a class="elsevierStyleCrossRef" href="#bib0315">21</a> criteria were used.</li></ul>ResultsComparative radiographic assessment based on X-ray obtained in the immediate postoperative period showed osteointegration of stems in all follow-up periods. Subsidence was detected in 6 cases (5.3%) within the first 3 months after surgery, with an average of 1.4mm (range from 0.1 to 2.6mm) with no clinical repercussions to date and patients are continuing with periodic reviews. In 3 cases where subsidence presented intraoperative fractures were detected: one due to a greater trochanter injury (wire “back-pack” type cerclage was performed) and two due to a proximal fracture in the calcar area (treated with circular cerclage). In 3 cases a reduction of weight-bearing during the rehabilitation period was made up to 4 weeks after surgery (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Subjective assessment results were as follows: 86 cases (82.6%) excellent, 9 good (8.6%), satisfactory (5.9%) and 3 poor (.29%). The poor results coincided with the patients who had the before-mentioned associated complications (one greater trochanter fracture and two proximal calcar fractures) (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The Harris Hip Score and Merle d’Aubigné Postel scale results are contained in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>No anterior femoral pain was detected. There were no luxations or septic loosening in any components. No patients were lost to follow-up. All implants were in place at the last follow-up review.DiscussionProsthesis designs have improved in shape and coating and as a result the use of uncemented materials in THA is increasingly greater for a larger number of patients.<a class="elsevierStyleCrossRefs" href="#bib0215">1,9–11</a> Not all uncemented stem designs are optimal or achieve similar outcomes. There is great interest in determining early markers of failure to rapidly limit the use of designs offering poor results.In the case of the wedge stem we present, primary fixation is in the metaphysic due to shape and self-blocking properties. As a result the axial load becomes radial and the compressive strength transfers the load in a more balanced manner in the proximal metaphysic. Stress shielding is thus limited, as is anterior femoral pain secondarily.<a class="elsevierStyleCrossRefs" href="#bib0320">22,23</a> The joint space is also sealed, blocking the migration of particles and preventing proximal osteolisis.Wedge-shaped designs are associated with high long-term rates of success. Good function and clinical tolerance have been recorded with a varied degree of subsidence.<a class="elsevierStyleCrossRefs" href="#bib0260">10,15,16,24,25</a>Coating the uncemented stems with HA was proposed in order to take advantage of the oseinductor ability and ensure rapid osteointegration with the generation of bone joining the femoral stem without the formation of fibrous tissue and thereby providing stability and duration in the long term.<a class="elsevierStyleCrossRefs" href="#bib0325">23–25</a> Several studies have shown that bone union occurs during the first 3 months and persists over time, even with the disappearance of the HA coating or the inclusion of it in the newly formed bone.<a class="elsevierStyleCrossRef" href="#bib0325">23</a>Survival rates with complete HA coating are excellent. In the Norwegian Arthroplasty Register 1987–2004<a class="elsevierStyleCrossRef" href="#bib0260">10</a> the rate was <1% of revisions at 4.5 years and 2.4% revisions at 10 years achieving a result of 4.9% revisions at 15 years out of a total of 5130 implanted stems.This result of a survival rate of 95.1% at 15 years is comparable to the best of cemented stems examined to date.<a class="elsevierStyleCrossRef" href="#bib0260">10</a>In wedge-shaped stem design with full hydroxiapatite coverage, Pellegrini et al.<a class="elsevierStyleCrossRef" href="#bib0340">26</a> achieved 2% revisions at 6.5 years and Hozack et al.<a class="elsevierStyleCrossRef" href="#bib0345">27</a> obtained 100% fixation, with 98% of patients pain free. In the case of the Bicontact® stems and the modified Zweymuller® design, 97.6% and 96% survivorship were reported respectively at 10 years.<a class="elsevierStyleCrossRefs" href="#bib0350">28,29</a>Radiographic assessment may reveal osseous radiographic signs of re-adaptation and failure following the implant of an uncemented femoral stem. On observation of these signs and above all, with the comparison of periodic studies it may be defined whether a prosthesis is stable with bone growth, stable with fibrous growth or unstable. Engh et al.<a class="elsevierStyleCrossRef" href="#bib0315">21</a> described the signs of osteo integration classifying them into greater or lesser. The absence of radiolucency around the implant, atrophy or rounding of femoral calcar and the presence of welding area or bony bridges between the stem and the endosteum mark good osteointegration but these criteria were described for full coverage, cylindrical stems. To define the case of the stem which we used we would have to add the finding of progressive demarcation of the implant-bone interphase, subsidence of the implant with progression over time and the re-absorption of the femoral calcar area. The design has an excellent correlation with surgical findings and the presence of visible signs of failure from an X-ray concurred with the real situation of the implant.Furthermore, the observation of these signs has predictive value if they early enough. Khalily et al.<a class="elsevierStyleCrossRef" href="#bib0355">29</a> have demonstrated the presence of radiolucency around the porous area of the stem provide 100% sensitivity and 55% specificity in prediction of future revision surgery for the next 8 years.Systematic follow-up and control mean that information may be acquired regarding the behaviour of implants and provide information for making decisions about use, and for early detection of failure.<a class="elsevierStyleCrossRefs" href="#bib0355">29,30</a>Since fixation design and method of THA determines stability which consequently has an influence on implant survival, the problem currently existing is that many new implants are introduced onto the market without having proven good performance (Sheth et al.<a class="elsevierStyleCrossRef" href="#bib0365">31</a>). This has led to the suspension in usage of implants with extremely high levels of failure, such as the Charnley Elite Plus®, or the metal-on-metal surface prosthesis (Hauptfleisch et al.<a class="elsevierStyleCrossRef" href="#bib0370">32</a>).In order to prevent disasters of this type of situation occurring, national guidelines and registers for patient protection have been developed.<a class="elsevierStyleCrossRefs" href="#bib0215">1,9–11</a> An analysis also needs to be made regarding the practice of phased introduction into the pharmaceutical sector, with small controlled groups to detect early indications of failure, as suggested by McCulloch et al.<a class="elsevierStyleCrossRef" href="#bib0375">33</a> and Schemitsch et al.<a class="elsevierStyleCrossRef" href="#bib0380">34</a>Stem subsidence has been suggested as an early prognostic factor of loosening,<a class="elsevierStyleCrossRefs" href="#bib0385">35,36</a> with 1.2mm in Roentgen steriophotogrammetric analysis (RSA)studies and ≤1.5mm measured with EBRA<a class="elsevierStyleCrossRef" href="#bib0395">37</a> or ≤2mm with digital radiographies and ad hoc software.<a class="elsevierStyleCrossRefs" href="#bib0390">36,37</a> The results obtained in our series, with a mean subsidence of 1.4mm, are within the expected and acceptable range according to the literature, to prevent late aseptic loosening. Furthermore, the detection of subsidence in only 5.5% of cases, without progression in follow-up 3 months after surgery, suggests that the prostheses are self-stabilising due to their wedge shape and the implant-bone union induced. Also, initial fixation in the other patients was not affected.<a class="elsevierStyleCrossRefs" href="#bib0390">36–39</a>In a review of the literature regarding stem subsidence at 2 years follow-up, White et al. reported values of 0.29 to 4.5mm±1.5mm.<a class="elsevierStyleCrossRef" href="#bib0410">40</a>Campbell et al.<a class="elsevierStyleCrossRef" href="#bib0330">24</a> reported subsidence values of 0.58mm at 2 years with the use of the Corail® (DePuy, U.S.A.) stem during the first 6 months of implantation. We should point out that a similar pattern was found in our cases during the first 3 months after surgery, but without any progression or appearance of new cases. These data appear to be linked to the low incidence of initial subsidence with a good rate of long-term implant survival. It is important to add that 2 out of 6 cases which presented with subsidence had fractures during implantation which were successfully treated with cerclage. Partial weight-bearing entailed during the 45 days of physiotherapy after surgery. To date none of the patients have reported any pain or any reduction in their everyday activities.This review of the outcome of a specific femoral implant underlines the need to provide series offering this type of information to contrast with the data only available from today's arthroplasty registers.<a class="elsevierStyleCrossRefs" href="#bib0330">24,33,34</a>The guidelines from the United Kingdom<a class="elsevierStyleCrossRef" href="#bib0255">9</a> recommend a revision rate of ≤10% at 10 years for uncemented stems as the cut-off number for not using a particular stem. In our series there was no revision surgery at 5 years of follow-up and this is consistent with that suggested by international guidelines.<a class="elsevierStyleCrossRefs" href="#bib0255">9–11</a>The survival mean obtained in our series is comparable with other high survival stems,<a class="elsevierStyleCrossRef" href="#bib0400">38</a> such as CLS Spotorno®<a class="elsevierStyleCrossRefs" href="#bib0265">11,17,41,42</a> and Corail®<a class="elsevierStyleCrossRefs" href="#bib0260">10,11,40–42</a> and even better than the 8% reported with LCU Link.®<a class="elsevierStyleCrossRefs" href="#bib0265">11,38,42</a>Clinical outcomes are promising, with 91% excellent or good satisfaction in subjective evaluation. There was a considerable improvement in function, reflected in the scores evaluated and non patients stated they suffered from pain in the femoral diaphysis as have been reported in similar designs, such as Corail® or LCU Link.®<a class="elsevierStyleCrossRefs" href="#bib0410">40–42</a>With regard to modification of Harris<a class="elsevierStyleCrossRef" href="#bib0280">14</a> and Merle d’Aubigné Postel<a class="elsevierStyleCrossRef" href="#bib0275">13</a> pre and postoperative function scores, statistically significant improvements were observed.At the date of the last follow-up revision, no patients had been lost to the series, nor had there been any revised implants.LimitationsThis study is a prospective, non comparative work and follow-up is mid-term. Our advantage was that the operations were performed by a team solely dedicated to hip replacement surgery.Conclusions<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060">1.Evaluation and radiographic follow-up confirmed the benefits of this type of uncemented stem design with good osteointegration.</li><li class="elsevierStyleListItem" id="lsti0065">2.Clinical and subjective results of patients with excellent and good scores are promising.</li></ul>Level of evidenceEvidence level IV.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this investigation.Confidentiality of dataThe authors declare that no patient data appears in this article.Right to privacy and informed consentThe authors declare that no patient data appear in this article.Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres941121" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Material and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec914339" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres941122" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Material y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec914338" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objectives" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Material and methods" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0020" "titulo" => "Clinical and radiographic study methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Radiographic evaluation" ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 8 => array:3 [ "identificador" => "sec0035" "titulo" => "Discussion" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Limitations" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Level of evidence" ] 11 => array:3 [ "identificador" => "sec0060" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0075" "titulo" => "Right to privacy and informed consent" ] ] ] 12 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interests" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-09-14" "fechaAceptado" => "2017-06-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec914339" "palabras" => array:2 [ 0 => "Uncemented stem" 1 => "Hidroxiapatite covered" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec914338" "palabras" => array:2 [ 0 => "Vástago no cementado" 1 => "Cobertura de hidroxiapatita" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionTotal hip arthroplasty (THA) using uncemented stems is a popular practice in the last decades.The implant survivorship is critical and a less than 10% revision at 10 years is been proposed for commercialisation and use. ObjectiveTo analyse the clinicoradiological results of an uncemented hydroxiapatite covered wedge stem with a 5 years minimum follow up. Material and methodsProspective study, patients aged from 21 to 75 years were included. All patients received an Element stem (Exactech) and uncemented cup with crosslink poly and 32mm metal head, and posterior approach with piriformis retention was used.Scheduled clinical and radiographic evaluation at 3 weeks, 3–6 month, year and subsequent years using Harris Hip Score and Merle d’Aubigné Postel. Intraoperative and during follow up complications were recorded. ResultsOne hundred and fourteen total hip replacements in 104 patients: 54 females and 50 males (52%/48%). Follow-up of 5.7 years (range, 5–6.2years). Average age 56.8years (range, 42–75years).Clinical evaluation the Merle d’Aubigné score improved 6.8 points and from the initial Harris Hip Score 47.3–93.1 points at last follow up.Radiographic evaluation shows osteointegration in all stems. And in 6 cases (5.3%) at 3 months subsidence was detected, average 1.4mm (range 0–2.6mm) with no clinical manifestation, 3 cases of subsidence were associated to intraoperative fractures (1 greater trochanter and 2 in the calcar area, all resolved with wire cerclaje).Subjective evaluation: 86 cases (82.6%) excellent, 9 patients (8.6%) good, 6 cases (5.9%) satisfactory and 3 cases (2.9%) poor. All poor results linked to the intraoperative complications.No patient lost during follow up period.No femoral pain dislocation or aseptic or loosening detected. All implants were in situ at last follow up. ConclusionsThe radiological results confirm the benefits of this type of stem with good osteointegration.The clinical and subjective results are promising.With good surgical technical and without complications the risk of aseptic loosening should be absent or minimal." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Material and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa artroplastia total de cadera (ATC) con vástagos no cementados es popular en las últimas décadas.La supervivencia de un implante es crítica, con una tasa de revisión menor al 10% a 10años como límite para su aceptación y comercialización. ObjetivosAnalizar los resultados clínico-radiográficos con un vástago en forma de cuña no cementado con recubrimiento completo de hidroxiapatita (HA) y con seguimiento mínimo de 5 años. Material y métodosEstudio prospectivo. Utilización de vástago Element (Exactech) y copa no cementada con inserto crosslink pared posterior elevada y cabeza metálica de 32mm. Se realizó un abordaje posterolateral con retención del músculo piriforme.Seguimiento clínico a las 3 semanas, a los 3 y 6 meses, al año y años subsiguientes.Evaluación radiográfica base en el postoperatorio inmediato y comparación con los controles. Se registraron las complicaciones intraoperatorias y en los seguimientos. ResultadosCiento catorce ATC en 104 pacientes: 54 mujeres y 50 hombres (52/48%), con seguimiento de 5,7 años (rango, 5-6,2 años) y con 56,8 años de promedio de edad (rango, 42-75 años).Evaluación inicial score Merle d’Aubigné pobre con mejora postoperatoria de 6,8 puntos. Score de Harris inicial de 47,3 puntos y, a la última consulta, de 93,1 puntos.Evaluación radiográfica: osteointegración de todos los vástagos. Hundimiento: 6 casos (5,3%) a 3meses de cirugía, promedio de 1,4mm (rango, 0-2,6mm) sin repercusión clínica hasta la actualidad.En 3 casos de hundimiento hubo fracturas intraoperatorias: una del trocánter mayor (se realizó un cerclaje tipo mochila) y 2 por fractura proximal en el área del calcar (tratadas con cerclaje circular).Evaluación subjetiva: 86 casos (82,6%) excelente, 9 pacientes (8,6%) buena, 6 casos (5,9%) satisfactoria y 3 casos (2,9%) pobre. Los resultados pobres coincidieron con pacientes que tuvieron las complicaciones mencionadas.No se detectó dolor femoral anterior. No se produjeron luxaciones o aflojamientos sépticos. No hubo pérdida de pacientes en el período de seguimiento. Todos los implantes se encuentran in situ al momento del último seguimiento. ConclusionesLa evaluación y el seguimiento radiográfico confirman buena osteointegración del vástago. Los resultados clínicos y subjetivos son prometedores. Con una buena técnica quirúrgica y sin complicaciones, el riesgo de aflojamiento aséptico impresiona ser mínimo o ausente." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Material y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Godoy-Monzon D, Buttaro M, Comba F, Zanotti G, Piccaluga F, Neira-Borrajo I. Resultados de un vástago con cobertura completa de hidroxiapatita con un seguimiento mínimo de 5 años. Rev Esp Cir Ortop Traumatol. 2017;61:390–396." ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Received \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">187 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Excluded \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Over 75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fractures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Refuse to participate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pathological fractures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Included in the study \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">104 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lost to follow-up \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1592754.png" ] ] ] ] "descripcion" => array:1 [ "en" => "patient flow-diagram." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cases \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osteoarthrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Avascular necrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Congenital hip dysplasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rheumatoid arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1592755.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Preoperative diagnoses." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acetabular \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Angle of inclination, 43.3 degrees average (range, 39–50 degrees) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Radiolucent lines, 4 cases, without progression \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Migration of acetabular cup, 0 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Screw rupture, 0 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Femoral \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osteolisis, 0 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calcar re-absorption, 0 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Radiolucent lines, 0 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cortical hypertrophy, 0 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Subsidence, 6 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pedestal formation, 5 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Heterotopic ossifications, 2 cases (Brooker type 1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1592753.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Radiographic evaluation." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with 114 prostheses \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">86 cases (82.6%) excellent \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9 cases (8.6%) good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 cases (5.9%) satisfactory \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 cases (2.9%) poor \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1592757.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Results of subjective satisfaction." ] ] 4 => array:6 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Harris Hip Score \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preoperative score, 45.7 points (range: 28–65) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postoperative score, 89.1 points (range: 61–96) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">p=.0002 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Score Merle d’Aubigné Postel \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preoperative, 10 points (range: 4–12) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postoperative, 16.8 points (range: 8–18) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">p=.0353 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1592756.png" ] ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:42 [ 0 => array:3 [ "identificador" => "bib0215" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Total hip arthroplasty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "U. 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Outcomes using wedge stem with full hydroxiapatite coverage with a minimum of 5 years’ follow-up

Resultados de un vástago con cobertura completa de hidroxiapatita con un seguimiento mínimo de 5 años

D. Godoy-Monzona,

Corresponding author

daniel.godoy@hospitalitaliano.org.ar

Corresponding author.

, M. Buttaroa, F. Combaa, G. Zanottia, F. Piccalugaa, I. Neira-Borrajob

a Centro de Cadera Sir John Charnley, Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

b Hospital Santa Cristina, Madrid, Spain

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gun cementation&#44; pulsed lavage pistol and centralisers&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The concept of cementless fixation arose from an attempt to reduce the rate of loosening &#40;Morscher&#41;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">3</span></a> with the appeal of obtaining a direct union of the bone implant &#40;biological attachment&#41; and long-lasting stability&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Depending on the design and elastic properties of an implant pressures will be transmitted&#46; The concept of a wedged stem is intended as fixation in a metaphysary area and the reduction of the possibility of stress shielding with loss of bone stock&#46; Full coverage with a hydroxiapatite &#40;HA&#41; with osteoinductive properties and with new trabecular bone formation<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">4&#44;5</span></a> compensates for the possible imperfect femoral canal fill&#44; 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of Novation Element<span class="elsevierStyleSup">&#174;</span> &#40;Exactech&#44; Inc&#44; U&#46;S&#46;A&#46;&#41; type&#44; with a minimum 5-year follow-up&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Inclusion criteria were patients aged between 21 and75 years with primary arthrosis&#44; osteo&#47;avascular necrosis and with no previous hip operations&#46; Exclusion criteria were&#58; patients aged over 75&#44; patients with fractures&#44; tumour disease or metastasis and patients who did not wish or could not attend follow-up sessions &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">During the study period&#44; we carried out 114 THA on 104 patients&#58; 54 women and 50 men &#40;52&#37;&#47;48&#37;&#41;&#44; with a follow-up of 5&#46;7 years &#40;range&#58; 5&#8211;6&#46;2 years&#41;&#46; Mean age was 56&#46;8 &#40;range&#58; 42&#8211;75years&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Initial diagnoses were arthrosis&#44; avascular necrosis&#44; dysplasia of the hip and rheumatoid arthritis &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The operations were performed in a single institution by surgeons exclusively dedicated to hip surgery and with a common approach&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">All patients agreed to participate in the study and signed specific consent form for the procedure and study&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">With regard to antibiotic prophylaxis&#44; all patients received 1<span class="elsevierStyleHsp" style=""></span>g of cefazolin&#44; which was administered every 8<span class="elsevierStyleHsp" style=""></span>h for 24<span class="elsevierStyleHsp" style=""></span>h&#46; In patients allergic to this drug vancomycin was administered&#44; 1<span class="elsevierStyleHsp" style=""></span>g every 12<span class="elsevierStyleHsp" style=""></span>h from 24<span class="elsevierStyleHsp" style=""></span>h after surgery&#46; A posterolateral approach was used with piriformis retention and reinsertion of the cup and short external rotators &#40;complete flap&#41; using the Pellicci<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">12</span></a> technique during closure&#46; The acetabular component chosen was uncemented&#44; modular&#44; line to line&#44; and with highly crosslinked polyethylene with 10 posterior rim&#46; 32<span class="elsevierStyleHsp" style=""></span>mm cobalt chromium heads were used&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">All the patients received prophylaxis for thromboembolic disease&#46; 220<span class="elsevierStyleHsp" style=""></span>mg of dabigatran was administered for 30 days after surgery&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Excepting contraindication&#44; physiotherapy began on the first day after surgery&#44; with sitting and walking exercises with a frame or sticks&#44; depending on the functional ability of each patient&#44; and following a protocol of accelerated rehabilitation&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Check-ups with X-rays were programmed 15 and 45 days after hospital discharge and subsequently at 3 and 6 months and then annually&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Intraoperative&#44; hospital stay and follow-up complications were recorded&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Clinical and radiographic study methods</span><p id="par0095" class="elsevierStylePara elsevierViewall">Clinical assessments according to the Merle d&#8217;Aubign&#233; Postel scale modified by Charnley<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">13</span></a> and Harris Hip Score&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">14</span></a> for pre and postoperative assessments&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">A subjective assessment was also carried out on personal patient satisfaction&#44; referring to their overall appreciation of the procedure and their expectations of it&#44; on a scale of 1&#8211;10&#44; where a score of 1&#8211;3 was a poor outcome&#44; 4&#8211;5 was satisfactory&#44; 6&#46;8 good and 9&#8211;10 excellent&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Radiographic evaluation</span><p id="par0105" class="elsevierStylePara elsevierViewall">Assessment of the acetabular cup was made but was not the main aim of this study&#46; The pre and postoperative X-rays were digital and standardised for magnification in 1&#46;2 corresponding to the preoperative planning templates used&#46; The focus was on the pubic bone&#46; We proceeded with a serried radiographic assessment with measurement of the following parameters&#58;</p><p id="par0110" class="elsevierStylePara elsevierViewall">On an acetabular level&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Acetabular inclination angle&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Appearance of radiolucent lines &#40;DeLee and Charnley areas&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Cup migration &#40;defined by the variation of over 5 degrees&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Screw breakages&#46;</p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">The acetabular component was considered integrated in accordance with the non appearance of signs of loosening&#44; progressive radiolucent lines&#44; screw breakage and migration&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">16</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">On stem level&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Osteolisis &#40;progressive localised reabsorption or endostal erosion&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">17</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Calcar reabsorption&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">17</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Presence of radiolucent lines&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Cortical hypertrophy&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">17&#44;18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Subsidence &#40;comparing the distance from the stem shoulder to the lesser trochanter&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">19&#44;20</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Pedestal formation l and appearance of heterotopic ossifications&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Subsidence was considered to have taken place with progression after its detection in 3 serial X-rays&#46; For definition of fixation Engh<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">21</span></a> criteria were used&#46;</p></li></ul></p></span></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0180" class="elsevierStylePara elsevierViewall">Comparative radiographic assessment based on X-ray obtained in the immediate postoperative period showed osteointegration of stems in all follow-up periods&#46; Subsidence was detected in 6 cases &#40;5&#46;3&#37;&#41; within the first 3 months after surgery&#44; with an average of 1&#46;4<span class="elsevierStyleHsp" style=""></span>mm &#40;range from 0&#46;1 to 2&#46;6<span class="elsevierStyleHsp" style=""></span>mm&#41; with no clinical repercussions to date and patients are continuing with periodic reviews&#46; In 3 cases where subsidence presented intraoperative fractures were detected&#58; one due to a greater trochanter injury &#40;wire &#8220;back-pack&#8221; type cerclage was performed&#41; and two due to a proximal fracture in the calcar area &#40;treated with circular cerclage&#41;&#46; In 3 cases a reduction of weight-bearing during the rehabilitation period was made up to 4 weeks after surgery &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">Subjective assessment results were as follows&#58; 86 cases &#40;82&#46;6&#37;&#41; excellent&#44; 9 good &#40;8&#46;6&#37;&#41;&#44; satisfactory &#40;5&#46;9&#37;&#41; and 3 poor &#40;&#46;29&#37;&#41;&#46; The poor results coincided with the patients who had the before-mentioned associated complications &#40;one greater trochanter fracture and two proximal calcar fractures&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">The Harris Hip Score and Merle d&#8217;Aubign&#233; Postel scale results are contained in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">No anterior femoral pain was detected&#46; There were no luxations or septic loosening in any components&#46; No patients were lost to follow-up&#46; All implants were in place at the last follow-up review&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0200" class="elsevierStylePara elsevierViewall">Prosthesis designs have improved in shape and coating and as a result the use of uncemented materials in THA is increasingly greater for a larger number of patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;9&#8211;11</span></a> Not all uncemented stem designs are optimal or achieve similar outcomes&#46; There is great interest in determining early markers of failure to rapidly limit the use of designs offering poor results&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">In the case of the wedge stem we present&#44; primary fixation is in the metaphysic due to shape and self-blocking properties&#46; As a result the axial load becomes radial and the compressive strength transfers the load in a more balanced manner in the proximal metaphysic&#46; Stress shielding is thus limited&#44; as is anterior femoral pain secondarily&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">22&#44;23</span></a> The joint space is also sealed&#44; blocking the migration of particles and preventing proximal osteolisis&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Wedge-shaped designs are associated with high long-term rates of success&#46; Good function and clinical tolerance have been recorded with a varied degree of subsidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">10&#44;15&#44;16&#44;24&#44;25</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Coating the uncemented stems with HA was proposed in order to take advantage of the oseinductor ability and ensure rapid osteointegration with the generation of bone joining the femoral stem without the formation of fibrous tissue and thereby providing stability and duration in the long term&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">23&#8211;25</span></a> Several studies have shown that bone union occurs during the first 3 months and persists over time&#44; even with the disappearance of the HA coating or the inclusion of it in the newly formed bone&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">23</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Survival rates with complete HA coating are excellent&#46; In the Norwegian Arthroplasty Register 1987&#8211;2004<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">10</span></a> the rate was &#60;1&#37; of revisions at 4&#46;5 years and 2&#46;4&#37; revisions at 10 years achieving a result of 4&#46;9&#37; revisions at 15 years out of a total of 5130 implanted stems&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">This result of a survival rate of 95&#46;1&#37; at 15 years is comparable to the best of cemented stems examined to date&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">10</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">In wedge-shaped stem design with full hydroxiapatite coverage&#44; Pellegrini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">26</span></a> achieved 2&#37; revisions at 6&#46;5 years and Hozack et al&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">27</span></a> obtained 100&#37; fixation&#44; with 98&#37; of patients pain free&#46; In the case of the Bicontact<span class="elsevierStyleSup">&#174;</span> stems and the modified Zweymuller<span class="elsevierStyleSup">&#174;</span> design&#44; 97&#46;6&#37; and 96&#37; survivorship were reported respectively at 10 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">28&#44;29</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Radiographic assessment may reveal osseous radiographic signs of re-adaptation and failure following the implant of an uncemented femoral stem&#46; On observation of these signs and above all&#44; with the comparison of periodic studies it may be defined whether a prosthesis is stable with bone growth&#44; stable with fibrous growth or unstable&#46; Engh et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">21</span></a> described the signs of osteo integration classifying them into greater or lesser&#46; The absence of radiolucency around the implant&#44; atrophy or rounding of femoral calcar and the presence of welding area or bony bridges between the stem and the endosteum mark good osteointegration but these criteria were described for full coverage&#44; cylindrical stems&#46; To define the case of the stem which we used we would have to add the finding of progressive demarcation of the implant-bone interphase&#44; subsidence of the implant with progression over time and the re-absorption of the femoral calcar area&#46; The design has an excellent correlation with surgical findings and the presence of visible signs of failure from an X-ray concurred with the real situation of the implant&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Furthermore&#44; the observation of these signs has predictive value if they early enough&#46; Khalily et al&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">29</span></a> have demonstrated the presence of radiolucency around the porous area of the stem provide 100&#37; sensitivity and 55&#37; specificity in prediction of future revision surgery for the next 8 years&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Systematic follow-up and control mean that information may be acquired regarding the behaviour of implants and provide information for making decisions about use&#44; and for early detection of failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">29&#44;30</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Since fixation design and method of THA determines stability which consequently has an influence on implant survival&#44; the problem currently existing is that many new implants are introduced onto the market without having proven good performance &#40;Sheth et al&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">31</span></a>&#41;&#46; This has led to the suspension in usage of implants with extremely high levels of failure&#44; such as the Charnley Elite Plus<span class="elsevierStyleSup">&#174;</span>&#44; or the metal-on-metal surface prosthesis &#40;Hauptfleisch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">32</span></a>&#41;&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">In order to prevent disasters of this type of situation occurring&#44; national guidelines and registers for patient protection have been developed&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;9&#8211;11</span></a> An analysis also needs to be made regarding the practice of phased introduction into the pharmaceutical sector&#44; with small controlled groups to detect early indications of failure&#44; as suggested by McCulloch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">33</span></a> and Schemitsch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">34</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Stem subsidence has been suggested as an early prognostic factor of loosening&#44;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">35&#44;36</span></a> with 1&#46;2<span class="elsevierStyleHsp" style=""></span>mm in <span class="elsevierStyleItalic">Roentgen steriophotogrammetric analysis</span> &#40;RSA&#41;studies and &#8804;1&#46;5<span class="elsevierStyleHsp" style=""></span>mm measured with EBRA<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">37</span></a> or &#8804;2<span class="elsevierStyleHsp" style=""></span>mm with digital radiographies and ad hoc software&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">36&#44;37</span></a> The results obtained in our series&#44; with a mean subsidence of 1&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#44; are within the expected and acceptable range according to the literature&#44; to prevent late aseptic loosening&#46; Furthermore&#44; the detection of subsidence in only 5&#46;5&#37; of cases&#44; without progression in follow-up 3 months after surgery&#44; suggests that the prostheses are self-stabilising due to their wedge shape and the implant-bone union induced&#46; Also&#44; initial fixation in the other patients was not affected&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">36&#8211;39</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">In a review of the literature regarding stem subsidence at 2 years follow-up&#44; White et al&#46; reported values of 0&#46;29 to 4&#46;5<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">40</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">Campbell et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a> reported subsidence values of 0&#46;58<span class="elsevierStyleHsp" style=""></span>mm at 2 years with the use of the Corail<span class="elsevierStyleSup">&#174;</span> &#40;DePuy&#44; U&#46;S&#46;A&#46;&#41; stem during the first 6 months of implantation&#46; We should point out that a similar pattern was found in our cases during the first 3 months after surgery&#44; but without any progression or appearance of new cases&#46; These data appear to be linked to the low incidence of initial subsidence with a good rate of long-term implant survival&#46; It is important to add that 2 out of 6 cases which presented with subsidence had fractures during implantation which were successfully treated with cerclage&#46; Partial weight-bearing entailed during the 45 days of physiotherapy after surgery&#46; To date none of the patients have reported any pain or any reduction in their everyday activities&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">This review of the outcome of a specific femoral implant underlines the need to provide series offering this type of information to contrast with the data only available from today&#39;s arthroplasty registers&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">24&#44;33&#44;34</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">The guidelines from the United Kingdom<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">9</span></a> recommend a revision rate of &#8804;10&#37; at 10 years for uncemented stems as the cut-off number for not using a particular stem&#46; In our series there was no revision surgery at 5 years of follow-up and this is consistent with that suggested by international guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">9&#8211;11</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">The survival mean obtained in our series is comparable with other high survival stems&#44;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">38</span></a> such as CLS Spotorno<span class="elsevierStyleSup">&#174;</span><a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">11&#44;17&#44;41&#44;42</span></a> and Corail<span class="elsevierStyleSup">&#174;</span><a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">10&#44;11&#44;40&#8211;42</span></a> and even better than the 8&#37; reported with LCU Link&#46;<span class="elsevierStyleSup">&#174;</span><a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">11&#44;38&#44;42</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">Clinical outcomes are promising&#44; with 91&#37; excellent or good satisfaction in subjective evaluation&#46; There was a considerable improvement in function&#44; reflected in the scores evaluated and non patients stated they suffered from pain in the femoral diaphysis as have been reported in similar designs&#44; such as Corail<span class="elsevierStyleSup">&#174;</span> or LCU Link&#46;<span class="elsevierStyleSup">&#174;</span><a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">40&#8211;42</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">With regard to modification of Harris<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">14</span></a> and Merle d&#8217;Aubign&#233; Postel<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">13</span></a> pre and postoperative function scores&#44; statistically significant improvements were observed&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">At the date of the last follow-up revision&#44; no patients had been lost to the series&#44; nor had there been any revised implants&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Limitations</span><p id="par0305" class="elsevierStylePara elsevierViewall">This study is a prospective&#44; non comparative work and follow-up is mid-term&#46; Our advantage was that the operations were performed by a team solely dedicated to hip replacement surgery&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0310" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">1&#46;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Evaluation and radiographic follow-up confirmed the benefits of this type of uncemented stem design with good osteointegration&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">2&#46;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Clinical and subjective results of patients with excellent and good scores are promising&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Level of evidence</span><p id="par0325" class="elsevierStylePara elsevierViewall">Evidence level IV&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Ethical disclosures</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Protection of human and animal subjects</span><p id="par0335" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Confidentiality of data</span><p id="par0340" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Right to privacy and informed consent</span><p id="par0345" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflict of interests</span><p id="par0330" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2016-09-14"
    "fechaAceptado" => "2017-06-27"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec914339"
          "palabras" => array:2 [
            0 => "Uncemented stem"
            1 => "Hidroxiapatite covered"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec914338"
          "palabras" => array:2 [
            0 => "V&#225;stago no cementado"
            1 => "Cobertura de hidroxiapatita"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Total hip arthroplasty &#40;THA&#41; using uncemented stems is a popular practice in the last decades&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The implant survivorship is critical and a less than 10&#37; revision at 10 years is been proposed for commercialisation and use&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">To analyse the clinicoradiological results of an uncemented hydroxiapatite covered wedge stem with a 5 years minimum follow up&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and methods</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Prospective study&#44; patients aged from 21 to 75 years were included&#46; All patients received an Element stem &#40;Exactech&#41; and uncemented cup with crosslink poly and 32<span class="elsevierStyleHsp" style=""></span>mm metal head&#44; and posterior approach with piriformis retention was used&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Scheduled clinical and radiographic evaluation at 3 weeks&#44; 3&#8211;6 month&#44; year and subsequent years using Harris Hip Score and Merle d&#8217;Aubign&#233; Postel&#46; Intraoperative and during follow up complications were recorded&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">One hundred and fourteen total hip replacements in 104 patients&#58; 54 females and 50 males &#40;52&#37;&#47;48&#37;&#41;&#46; Follow-up of 5&#46;7 years &#40;range&#44; 5&#8211;6&#46;2<span class="elsevierStyleHsp" style=""></span>years&#41;&#46; Average age 56&#46;8<span class="elsevierStyleHsp" style=""></span>years &#40;range&#44; 42&#8211;75<span class="elsevierStyleHsp" style=""></span>years&#41;&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Clinical evaluation the Merle d&#8217;Aubign&#233; score improved 6&#46;8 points and from the initial Harris Hip Score 47&#46;3&#8211;93&#46;1 points at last follow up&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Radiographic evaluation shows osteointegration in all stems&#46; And in 6 cases &#40;5&#46;3&#37;&#41; at 3 months subsidence was detected&#44; average 1&#46;4<span class="elsevierStyleHsp" style=""></span>mm &#40;range 0&#8211;2&#46;6<span class="elsevierStyleHsp" style=""></span>mm&#41; with no clinical manifestation&#44; 3 cases of subsidence were associated to intraoperative fractures &#40;1 greater trochanter and 2 in the calcar area&#44; all resolved with wire cerclaje&#41;&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Subjective evaluation&#58; 86 cases &#40;82&#46;6&#37;&#41; excellent&#44; 9 patients &#40;8&#46;6&#37;&#41; good&#44; 6 cases &#40;5&#46;9&#37;&#41; satisfactory and 3 cases &#40;2&#46;9&#37;&#41; poor&#46; All poor results linked to the intraoperative complications&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">No patient lost during follow up period&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">No femoral pain dislocation or aseptic or loosening detected&#46; All implants were in situ at last follow up&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The radiological results confirm the benefits of this type of stem with good osteointegration&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">The clinical and subjective results are promising&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">With good surgical technical and without complications the risk of aseptic loosening should be absent or minimal&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objective"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Material and methods"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
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          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La artroplastia total de cadera &#40;ATC&#41; con v&#225;stagos no cementados es popular en las &#250;ltimas d&#233;cadas&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La supervivencia de un implante es cr&#237;tica&#44; con una tasa de revisi&#243;n menor al 10&#37; a 10<span class="elsevierStyleHsp" style=""></span>a&#241;os como l&#237;mite para su aceptaci&#243;n y comercializaci&#243;n&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Analizar los resultados cl&#237;nico-radiogr&#225;ficos con un v&#225;stago en forma de cu&#241;a no cementado con recubrimiento completo de hidroxiapatita &#40;HA&#41; y con seguimiento m&#237;nimo de 5 a&#241;os&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Material y m&#233;todos</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo&#46; Utilizaci&#243;n de v&#225;stago Element &#40;Exactech&#41; y copa no cementada con inserto <span class="elsevierStyleItalic">crosslink</span> pared posterior elevada y cabeza met&#225;lica de 32<span class="elsevierStyleHsp" style=""></span>mm&#46; Se realiz&#243; un abordaje posterolateral con retenci&#243;n del m&#250;sculo piriforme&#46;</p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Seguimiento cl&#237;nico a las 3 semanas&#44; a los 3 y 6 meses&#44; al a&#241;o y a&#241;os subsiguientes&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Evaluaci&#243;n radiogr&#225;fica base en el postoperatorio inmediato y comparaci&#243;n con los controles&#46; Se registraron las complicaciones intraoperatorias y en los seguimientos&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Ciento catorce ATC en 104 pacientes&#58; 54 mujeres y 50 hombres &#40;52&#47;48&#37;&#41;&#44; con seguimiento de 5&#44;7 a&#241;os &#40;rango&#44; 5-6&#44;2 a&#241;os&#41; y con 56&#44;8 a&#241;os de promedio de edad &#40;rango&#44; 42-75 a&#241;os&#41;&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Evaluaci&#243;n inicial score Merle d&#8217;Aubign&#233; pobre con mejora postoperatoria de 6&#44;8 puntos&#46; Score de Harris inicial de 47&#44;3 puntos y&#44; a la &#250;ltima consulta&#44; de 93&#44;1 puntos&#46;</p><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Evaluaci&#243;n radiogr&#225;fica&#58; osteointegraci&#243;n de todos los v&#225;stagos&#46; Hundimiento&#58; 6 casos &#40;5&#44;3&#37;&#41; a 3<span class="elsevierStyleHsp" style=""></span>meses de cirug&#237;a&#44; promedio de 1&#44;4<span class="elsevierStyleHsp" style=""></span>mm &#40;rango&#44; 0-2&#44;6<span class="elsevierStyleHsp" style=""></span>mm&#41; sin repercusi&#243;n cl&#237;nica hasta la actualidad&#46;</p><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">En 3 casos de hundimiento hubo fracturas intraoperatorias&#58; una del troc&#225;nter mayor &#40;se realiz&#243; un cerclaje tipo mochila&#41; y 2 por fractura proximal en el &#225;rea del calcar &#40;tratadas con cerclaje circular&#41;&#46;</p><p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Evaluaci&#243;n subjetiva&#58; 86 casos &#40;82&#44;6&#37;&#41; excelente&#44; 9 pacientes &#40;8&#44;6&#37;&#41; buena&#44; 6 casos &#40;5&#44;9&#37;&#41; satisfactoria y 3 casos &#40;2&#44;9&#37;&#41; pobre&#46; Los resultados pobres coincidieron con pacientes que tuvieron las complicaciones mencionadas&#46;</p><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">No se detect&#243; dolor femoral anterior&#46; No se produjeron luxaciones o aflojamientos s&#233;pticos&#46; No hubo p&#233;rdida de pacientes en el per&#237;odo de seguimiento&#46; Todos los implantes se encuentran in situ al momento del &#250;ltimo seguimiento&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">La evaluaci&#243;n y el seguimiento radiogr&#225;fico confirman buena osteointegraci&#243;n del v&#225;stago&#46; Los resultados cl&#237;nicos y subjetivos son prometedores&#46; Con una buena t&#233;cnica quir&#250;rgica y sin complicaciones&#44; el riesgo de aflojamiento as&#233;ptico impresiona ser m&#237;nimo o ausente&#46;</p></span>"
        "secciones" => array:5 [
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            "identificador" => "abst0030"
            "titulo" => "Introducci&#243;n"
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            "titulo" => "Objetivos"
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          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Material y m&#233;todos"
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          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
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          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
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      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Godoy-Monzon D&#44; Buttaro M&#44; Comba F&#44; Zanotti G&#44; Piccaluga F&#44; Neira-Borrajo I&#46; Resultados de un v&#225;stago con cobertura completa de hidroxiapatita con un seguimiento m&#237;nimo de 5 a&#241;os&#46; Rev Esp Cir Ortop Traumatol&#46; 2017&#59;61&#58;390&#8211;396&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Received&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">187&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Excluded&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Over 75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fractures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Refuse to participate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pathological fractures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Included in the study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">104&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lost to follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0140" class="elsevierStyleSimplePara elsevierViewall">patient flow-diagram&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osteoarthrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Avascular necrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Congenital hip dysplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rheumatoid arthritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">Preoperative diagnoses&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Acetabular</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Angle of inclination&#44; 43&#46;3 degrees average &#40;range&#44; 39&#8211;50 degrees&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Radiolucent lines&#44; 4 cases&#44; without progression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Migration of acetabular cup&#44; 0 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Screw rupture&#44; 0 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Femoral</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Osteolisis&#44; 0 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Calcar re-absorption&#44; 0 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Radiolucent lines&#44; 0 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cortical hypertrophy&#44; 0 cases&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Preoperative&#44; 10 points &#40;range&#58; 4&#8211;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Postoperative&#44; 16&#46;8 points &#40;range&#58; 8&#8211;18&#41;&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 19888856
Original language: English

DOI:10.1016/j.recote.2017.10.004

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Year/Month	Html	Pdf	Total

2024 November	1	0	1
2024 October	13	8	21
2024 September	16	9	25
2024 August	20	2	22
2024 July	32	5	37
2024 June	26	3	29
2024 May	16	6	22
2024 April	52	8	60
2024 March	123	4	127
2024 February	26	11	37
2024 January	16	3	19
2023 December	23	9	32
2023 November	24	10	34
2023 October	19	15	34
2023 September	13	7	20
2023 August	16	2	18
2023 July	11	9	20
2023 June	25	4	29
2023 May	50	2	52
2023 April	44	1	45
2023 March	45	2	47
2023 February	28	4	32
2023 January	17	1	18
2022 December	37	9	46
2022 November	28	10	38
2022 October	25	7	32
2022 September	33	15	48
2022 August	34	13	47
2022 July	28	9	37
2022 June	50	9	59
2022 May	51	7	58
2022 April	71	9	80
2022 March	110	10	120
2022 February	112	5	117
2022 January	71	13	84
2021 December	39	12	51
2021 November	64	6	70
2021 October	45	11	56
2021 September	31	781	812
2021 August	40	7	47
2021 July	14	8	22
2021 June	17	12	29
2021 May	21	4	25
2021 April	31	9	40
2021 March	17	9	26
2021 February	17	17	34
2021 January	23	9	32

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