Journal Abstract Index

Introduction
This collection of abstracts from journal articles, scientific exhibits and additional reference materials has been brought
together using Medline, Embase and physical searches of available literature.
It is intended to list the references available relating to the Corail Hip System and to give a brief description of their
contents.
*

Full articles can be ordered within the Corail clinical folder (Cat No: 9072-74-000 version 2)

Table of Contents
Long Term Survivorship

Proven Features

Indication: Intracapsular Fractured Neck of Femur

Indication: Revision

Indication: Young Patients

12

Indication: Infection

13

Cost Effectiveness: Primary Cases

14

Cost Effectiveness: Intracapsular Fractured Neck of Femur

15

Long Term Survivorship

The following key papers highlight the excellent long-term stability and durability of the Corail stem as a result of its unique
design, full hydroxyapatite coating and simple but effective surgical technique. This section also includes the latest results from the
Norwegian Arthroplasty Register, which reports 97% survivorship at 15 years in 5456 cases.

Hallan G; Lie SA: Furnes O: Engesaeter LB; Vollset SE; Havelin LI*
Medium and long-term performance of 11,516 uncemented primary femoral stems from the Norwegian arthroplasty
register. Journal of Bone and Joint Surgery, 2007;89-B:1574-1580
Primary uncemented femoral stems reported to the Norwegian arthroplasty register between 1987 and 2005 were included in this
prospective observational study. There were 11,516 hips (9679 patients) and 14 different designs of stem. Kaplan-Meier survival
probabilities and Cox regression were used to analyse the data. With aseptic loosening as the end-point, all currently used designs
performed excellently with survival of 96% to 100% at ten years. With the end-point as stem revision for any cause, the long-term
results of the different designs varied from poor to excellent, with survival at 15 years ranging between 29% and 97%. Follow-up
for longer than seven years was needed to identify some of the poorly performing designs. There were differences between
the stems; the Corail used in 5456 hips, was the most frequently used stem with a survival of 97% at 15 years. Male gender
was associated with an increased risk of revision of X 1.3 (95% confidence interval 1.05 to 1.52), but age and diagnosis had no
influence on the results. Overall modern uncemented femoral stems performed well. Moderate differences in survival between
well-performing stems should be interpreted with caution since the differences may be caused by factors other than the stem
itself.

Boldt J
Femoral bone remodeling in HA coated stems with 20 years follow-up. Presented at EFORT Congress, May 29 June 2, 2008
Femoral stress shielding in cementless THA is a potential complication commonly observed in distally loading press-fit stems.
This prospective study describes long-term femoral bone remodeling in cementless THA at a mean of 17 years (range: 15 to 20)
in 208 consecutive fully HA-coated stems (Corail, DePuy Int. Ltd, Leeds, UK). All THA were performed by one group of surgeons
between 1986 and 1991. The concept of surgical technique included impaction of metaphyseal bone utilizing bland femoral
broaches until primary stability was achieved without distal press-fit. Radiographic evaluation revealed a total of five (2.4%) stems
with periprosthetic osteolysis, which were associated with eccentric polyethylene wear. They were either revised or awaiting revision
surgery. The remaining 97.6% stems revealed biologic load transfer in the metaphysis alone (52%) or in both metaphysis and
diaphysis (48%). Stem survival of 97.6% after 15 to 20 years without stress shielding were considered to be related to: impaction
of metaphyseal bone, bland broaches, HA coating, and unique prosthetic design.

Long Term Survivorship

Froimson MI; Garino J; Machenaud A; Vidalain JP*
Minimum 10 -year Results of a Tapered, Titanium, Hydroxyapatite-Coated Hip Stem, an independent review. Journal of
Arthroplasty, 2007;22(1):1-6
The performance of, and periprosthetic bone response to, a tapered, titanium (Ti6Al4V), hydroxyapatite-coated femoral hip
prosthesis was evaluated at minimum of 10 years of follow-up. Data were prospectively collected on 147 consecutive primary
hip arthroplasties performed in 133 patients by a single surgeon during a 2-year interval. Clinical and radiographic analyses
of 96 hips in 86 patients were independently performed by 2 surgeons who were not involved in the care of these patients.
There were no cases of aseptic loosening of the femoral component. Subsidence and stress shielding occurred in 5% and 2%
of cases, respectively, and was not clinically significant. In all 15 hips that required revision of the acetabular component, the
femoral component was found to be well fixed, without any occurrence of distal osteolysis. This femoral design provided reliable
osseointegration that was durable at a mean of 11.5 years of follow-up.

Vidalain JP*
Corail Stem Long-Term Results Based upon the 15-Years ARTRO Group Experience. In: Epinette JA, Manley MT, editors.
Fifteen Years of Clinical Experience with Hydroxyapatite Coatings in Joint Arthroplasty. Paris: Springer; 2004;217-224
This study continues to demonstrate that the benefits of HA should not be confined to an early but temporary role. Bioactive
coatings may contribute to the durability and stability by significantly reducing osteolysis and the risk of delayed aseptic loosening.
In the short run, Hydroxyapatite improves clinical results significantly in providing superior stability thanks to osteointegration. In
the intermediate term, the mechanical characteristics of the implant will likely play a critical role, although it becomes more and
more evident that the quality of the load transfer is also dependant on the nature of the bone between the implant and the host
site. In addition, a full coating does not increase the rate of proximal bone resorption in so far as the shape of the stem prevents
distal blockages and harmonizes strain distribution on the bone with a progressive rigidity gradient. In the long run preservation of
the long-term stability and excellent bone trophicity will further increase the durability of the implant. Let us hope that the 98.3%
survival rate of the Corail femoral stem will be maintained during the next decade.

Full articles can be ordered within the Corail clinical folder (Cat No: 9072-74-000 version 2)
3

Proven Features
The papers in this section discuss the design features of the Corail stem such as the thin distal tip, full HA coating, primary
fixation, macro and micro structure and tissue and bone sparing design. Those features have proven to deliver superior long term
survivorship and clinical outcomes.

Frayssinet P; Vidalain JP; Ranz X; Cartillier JC; Rouquet N

Hydroxyapatite particle migration. European Journal of Orthopaedic Surgery and Traumatology, 1999;9:95-98
HA coatings have a complex structure due to modification of the crystallographic structure of the HA and the appearance of other
calcium phosphate phases during spraying. These modifications are responsible for enhancing of the coating degradation rate by
cells and extracellular fluids. Calcium phosphate debris of different sizes and characteristics is released during the degradation and
phagocytosed by macrophages or integrated within the newly formed bone. The phagocytosed debris are dissolved in the low PH
compartment of the cells and do not trigger osteoclast activation. Some concerns have been raised about the hypothetical particle
migration to the surface of the polyethylene cup increasing the release of polymeric debris by a third body wear process. However,
the presence of calcium phosphate particles is observed at the surface of polyethylene cups even when implanted with non-coated
devices. Thus the fate of calcium phosphate debris differs to that of metal and polymer due to the characteristics and degradability
within the cells of this former.

Karachalios T; Tsatsaronis C; Efraimis G; Diakoumopoulos G; Papadelis P; Lyritis G*

The Long-Term clinical relevance of Calcar Atrophy caused by Stress Shielding in Total Hip Arthroplasty: A 10-year
prospective randomized study. Journal of Arthroplasty, 2004;19(4):469-75
Eighty osteoarthritic female patients were randomly allocated to 4 equal groups; the Zwey-Muller, the Corail, the Optifix, or
Autophor 900S cementless total hip arthroplasties (THAs) were implanted; and bone density changes, at different sites, were
prospectively studied. In zone 7, the greatest reduction of bone density values was observed at 2 years (group A: 24%, group
B: 8%, group C: 14.8%, and group D: 18.5%). In all groups, a similar pattern of slow but progressive recovery of bone mineral
density changes after the third year was observed, approaching baseline values at 10 years, during which all patients showed
satisfactory clinical results. We suggest that the clinical and theoretical relevance of the stress-shielding phenomenon in THA has
been overestimated in the literature.

Proven Features
Reikeras O; Gunderson RB*
Excellent Results of HA Coating on a Grit-Blasted Stem, 245 Patients Followed for 8-12 Years. Acta Orthopedica
Scandinavica, 2003;74(2):140-145
We report the outcome of a grit-blasted titanium stem designed for press-fit insertion and entirely plasma sprayed with HA.
During the years 1988-1993, we performed 323 primary total hip replacements in 276 patients (189 women) with a HA-coated
prosthesis. Their mean age was 48 (15-79) years. During the follow-up, 12 patients died. 19 other patients did not attend the
follow-up examination, but had no major symptoms according to telephone interviews and written replies. Thus, 245 patients
(291 hips) were followed for a mean of 10 (8-12) years with radiographic and clinical examinations. Only 1 stem was revised
due to mechanical failure. None were revised because of infection. Osteolysis was significantly associated with wear, and wear
was significantly associated with the size of the femoral head. We found a small amount of proximal bone loss (37/291) and
a low incidence of distal hypertrophy of the bone (23/291). These observations indicate an essentially physiological weight
distribution from the stem to the femoral bone. The changes in the bone confirmed that the femoral component was well fixed in
asymptomatic patients. To conclude, we found excellent 8-12-year results with a fully HA-coated femoral prosthesis designed for
press-fit insertion.

Rkkum M; Reigstad A*
Total Hip Replacement With an Entirely Hydroxyapatite-Coated Prosthesis. 5 Years Follow-Up of 94 Consecutive Hips.
Journal of Arthroplasty, 1999;14(6):689-700
The first 100 consecutive entirely hydroxyapatite (HA)-coated hip arthroplasties in 86 patients (mean age, 56.2 years [range,
32-73 years]; female-to-male ratio, 75:25) were followed with standardized radiographs annually up to 5 years. All components
developed 100% intimate bone-implant contact, being gradually reduced to 99.5%+/-3.8% by 2 partial periacetabular lines and
on the femoral side to 94.0%+/-6.1% and 96.5%+/-5.2% in the frontal and lateral planes by lines along 75 stems, mostly in zones
1 and 8. Bone formation took place adjacent to the prostheses regularly, with gap filling and comprehensive periprosthetic bone
remodeling, stabilizing at 3 years. No adverse stress shielding was found. The clinical results were excellent without thigh pain. We
believe that all components were bonded directly to bone, promoted by the reliable primary fixation and the osteoconductive effect
of HA.

Full articles can be ordered within the Corail clinical folder (Cat No: 9072-74-000 version 2)
5

Indication: Intracapsular Fractured Neck of Femur

The following papers compare the various treatment options available; internal fixation, hemiarthroplasty and total hip
replacement,. They conclude that total hip replacement should be seriously considered as a standard treatment option for healthy,
active and independent patients suffering from a fractured neck of femur.

Baker RP; Squires B; Gargan MF; Bannister GC*

Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of
the femoral neck. A randomized, controlled trial. Journal of Bone and Joint Surgery, 2006;88A:2583-2589
Hemiarthroplasty and total hip arthroplasty are commonly used to treat displaced intracapsular fractures of the femoral neck,
but each has disadvantages and the optimal treatment of these fractures remains controversial. In this prospectively randomized
study, eighty-one patients who had been mobile and lived independently before they had sustained a displaced fracture of the
femoral neck were randomized to receive either a total hip arthroplasty or a hemiarthroplasty. The mean age of the patients was
seventy-five years. Outcome was assessed with use of the Oxford hip score, and final radiographs were assessed. After a mean
duration of follow-up of three years, the mean walking distance was 1.17 mi (1.9 km) for the hemiarthroplasty group and 2.23 mi
(3.6 km) for the total hip arthroplasty group, and the mean Oxford hip score was 22.3 for the hemiarthroplasty group and 18.8
for the total hip arthroplasty group. Patients in the total hip arthroplasty group walked farther (p = 0.039) and had a lower (better)
Oxford hip score (p = 0.033) than those in the hemiarthroplasty group. Twenty of thirty-two living patients in the hemiarthroplasty
group had radiographic evidence of acetabular erosion at the time of the final follow-up. None of the hips in the hemiarthroplasty
group dislocated, whereas three hips in the total hip arthroplasty group dislocated. In the hemiarthroplasty group, two hips were
revised to total hip arthroplasty and three additional hips had acetabular erosion severe enough to indicate revision. In the total hip
arthroplasty group, one hip was revised because of subsidence of the femoral component. Total hip arthroplasty conferred superior
short-term clinical results and fewer complications when compared with hemiarthroplasty in this prospectively randomized study of
mobile, independent patients who had sustained a displaced fracture of the femoral neck.

Hardy D; Frayssinet P*
Hydroxyapatite-Coated Femoral Arthroplasties : Long Term Study Through 29 Corail Prostheses Explanted During Ten
Year Survey. Surgical Technology International X, 2003;237-245
In our department, all the patients over 65 years of age with a displaced intracapsular fracture of the upper femur (type III and IV
of the Gardens Classification) are treated with a femoral hemiarthroplasty. This practice is relatively universal among the European
traumatologic centres. Two prospective and randomized trails, published in 2000, reported a high rate of reoperation when treating
these fractures with osteosynthesis (36% and 38% of the cases), thus indicating arthroplasty may be preferred.

Indication: Intracapsular Fractured Neck of Femur

Blomfeldt R; Tornkvist H; Eriksson K; Soderqvist A; Ponzer S; Tidermark J
A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular
fractures of the femoral neck in elderly patients. Journal of Bone and Joint Surgery, 2007;89-B:160-165
The best treatment for the active and lucid elderly patient with a displaced intracapsular fracture of the femoral neck is still
controversial. Randomised controlled trials have shown that a primary total hip replacement is superior to internal fixation as
regards the need for secondary surgery, hip function and health-related quality of life. Despite good results achieved with total hip
replacement in this group, most orthopaedic surgeons still advocate hemiarthroplasty for this injury. We studied 120 patients with a
mean age of 81 years (70 to 90) with an acute displaced intracapsular fracture of the femoral neck. They were randomly allocated
to be treated with either a bipolar hemiarthroplasty or total hip replacement. Outcome measurements included peri-operative data,
general and hip-specific complications, hip function and health-related quality of life. The patients were reviewed at four and 12
months. The duration of surgery was longer in the total hip replacement group (102 minutes (70 to 151)) versus 78 minutes (43 to
131) (p < 0.001), and the intra-operative blood loss was increased 460 ml (100 to 1100) versus 320 ml (50 to 850) (p < 0.001), but
there were no differences between the groups regarding any complications or mortality. There were no dislocations in either group.
Hip function measured by the Harris hip score was significantly better in the total hip replacement group at both follow-up periods
(p = 0.011 and p < 0.001, respectively). The health-related quality of life measure was in favor of the total hip replacement group
but did not reach statistical significance (p = 0.818 at four months and p = 0.636 at 12 months). These results indicate that a total
hip replacement provides better function than a bipolar hemiarthroplasty as soon as one year post-operatively, without increasing
the complication rate. We recommend total hip replacement as the primary treatment for this group of patients.

Parker MJ; Gurusamy K

Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database of
Systematic Reviews, 2006;(4):CD001708
Fractures of the thigh bone (femur) near the hip joint (termed intracapsular) may be treated by fixing the fracture (with screws
or pins), or alternatively replacing the top of the femur at the hip joint (femoral head) with an artificial hip joint (arthroplasty).
This review found that each treatment has its own specific complications. Realigning the bones and fixing the fracture (reduction
and internal fixation) is a shorter operation with less blood loss, but is more likely to need a second operation (36% versus 11%).
The reason for this is mainly from a failure of the bone to heal in those cases treated with fixation. Final outcomes of mortality
are essentially similar for the two treatment methods. The degree of residual pain and functional activities related to using the hip
seemed to be better after a replacement with an artificial hip joint that is fixed in place with cement.

Full articles can be ordered within the Corail clinical folder (Cat No: 9072-74-000 version 2)
7

Indication: Intracapsular Fractured Neck of Femur

Ravikumar KJ; Marsh G
Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of the femur - 13
year results of a prospective randomised study. Injury, 2003;31(10):793-797
In this prospective randomised trial we compare the mortality, morbidity and functional results of patients following each of the
three principal methods of treatment for displaced subcapital fractures of the femur. Two hundred and ninety patients over the age
of 65 years were included and randomly allocated to undergo closed reduction and internal fixation with a sliding compression
screw plate or uncemented Austin Moore hemiarthroplasty or cemented Howse II total hip arthroplasty (THA). Nineteen patients
were subsequently excluded. The 13 year results show that there was no statistical difference in the mortality between the
three groups (81, 85 and 91% respectively). Internal fixation and hemiarthroplasty groups fared poorly with a revision rate of
33 and 24%, respectively, compared with 6.75% in the THA group. The dislocation rate was 13% following hemiarthroplasty
and 20% following THA. Average Harris hip scores were 62, 55 and 80, respectively, for the internal fixation, hemiarthroplasty
and THA groups. In the long term, both internal fixation and hemiarthroplasty resulted in a poor outcome with respect to pain
and mobility. Despite high early complications, THA resulted in least pain and most mobility both in the short and long-term and
was encouraging with a revision rate of only 6.25%. THA should be seriously considered in physiologically active patients with a
displaced subcapital fracture of the femur.

Rogmark C; Johnell O*
Primary arthroplasty is better than internal fixation of displaced femoral neck fractures: a meta-analysis of 14
randomized studies with 2,289 patients. Acta Orthopaedica, 2006;77(3):359-367
The treatment of displaced femoral neck fractures has long been debated. 14 randomized controlled studies (RCTs) comparing
internal fixation with primary arthroplasty may give material for evidence-based decision-making. Methods computerized databases
were searched for RCTs published between 1966 and 2004. 14 RCTs containing 2,289 patients were included in a meta-analysis
regarding complications, re-operations and mortality. The analysis was performed with software from the Cochrane collaboration.
Results were concluded as primary arthroplasty leads to significantly fewer major method-related hip complications and
re-operations, compared to internal fixation. There was no significant difference in mortality between the two groups at 30 days
and 1 year. Most of the studies found better function and less pain after primary arthroplasty. Primary arthroplasty should be used
in most patients with displaced femoral neck fracture. The healthy, lucid individual, 7080 years old, should be given a total hip
arthroplasty. The older, impaired or institutionalized patient would benefit from a hemiarthroplasty.

Indication: Revision
The Corail Hip System has proven its reliability and durability in both primary and revision total hip arthroplasty. Due to a
combination of good design and full HA coatings, the Corail family offers the potential to restore good periprosthetic bone
trophicity, increase bone ingrowth and minimize stress shielding after a revision procedure.

Reikeras O; Gunderson RB*

Excellent results with femoral revision surgery using an extensively hydroxyapatite-coated stem. 59 patients followed for
10-16 years. Acta Orthopaedica, 2006;77(1):98-103
This clinical paper prospectively reviewed a consecutive series of 66 femoral revisions in 65 patients performed between 1988
and 1993. 40 hips had revision of both the femoral and acetabular components and 26 hips had revision of the stem alone. In
36.5% the revised prosthesis was cemented and in 63.5% it was uncemented. The mean age at the time of revision was 58
years (range 28 to 86 years) and there were 49 female and 16 male. The diagnoses that led to revision were aseptic loosening
(87.9%), secondary stage of infection (6.1%), pain of unknown origin (4.5%) and periprosthetic femoral fracture (1.5%). Femoral
bone stock was classified according to Paprosky and Weeden: 7 type I, 41 type II, 11 type IIIA, 6 type IIIB and 1 type IV. The
stems used to revise were Corail in 48 cases and KAR in 18 cases. Of the 65 patients, 3 patients were deceased at the time
of the review without 10-year follow up, 4 did not come to the follow-up examination because they had no hip problem but
1 had been controlled previously at 10 years. As a result, this paper reports on the results of 60 hips (59 patients) available for
clinical and radiographical analysis for 10-16 years after femoral stem revision with a Corail or a KAR. In this study, no patient
had significant thigh pain and bone ingrowth was associated with a low change in bone density which indicate that the stress
distribution from those stems to the bone occur in a physiological way. Dr D Hardys post-mortem analyses also supported the
notion that the combination of a good design and a full HAC has the potential to increase bone ingrowth and minimize stress
shielding. The authors find the Corail to have excellent results in Paprosky type I and II femurs and the KAR in Paprosky type III
and IV femurs.

Chatelet JC; Setiey L*

Femoral Component Revision With Hydroxyapatite Coated Revision Stems. In: Epinette JA, Manley MT, editors.
Fifteen Years of Clinical Experience with Hydroxyapatite Coatings in Joint Arthroplasty. Paris: Springer; 2004;385-395
The present study of 252 revisions of failed THRs to HA-coated devices has confirmed the reliability of HA-coated prostheses in
revision arthroplasty. No one implant could cater to all the patients. The Corail system, with its long-stem version, the KAR,and
the Reef prosthesis, allow the overwhelming majority of problems in stem revision to be appropriately dealt with. We use
the KAR for the bulk of our revisions. Revision surgery is straightforward, without the need for windows or osteotomies.
Postoperative management is likewise straightforward. The femur heals around the implant. Cysts require only curetting, without
any need for grafting. Load transfer and stability are obtained in healthy bone stock in the metaphysis and diaphysis. If healthy
bone stock is encountered only distally, fixation is obtained distally with a screw-locked construct, and the femur is reconstructed
proximally. For such cases, the Reef prosthesis is used. The bone will heal around the HA-coated implant, similar to the way
in which fracture healing occurs. The advent of modular cementless prostheses has transformed the outlook for these difficult
revisions. This paper concludes that all-over HA-coated screwlocked modular stems allow us to cope with extremely difficult
patterns. Even in badly damaged femurs, the Reef stem will act as a stent that can be anchored in healthy diaphyseal bone stock,
and locked with screws. This provides very sound initial stability, and the stent can be adjusted to obtain the required length and
anteversion. Over the weeks, good-quality diaphyseal and metaphyseal bone stock will rebuild around the stent. This new bone
formation appears to proceed more rapidly thanks to the presence of HA on the implant; and the healthy look of the bone on the
radiographs suggests that the implant will have a long inservice life.

Full articles can be ordered within the Corail clinical folder (Cat No: 9072-74-000 version 2)
9

Indication: Revision
Petit R
Hydroxyapatite and revision of femoral hip prostheses. European Journal of Orthopaedic Surgery and Traumatology
1999;9:107-110
Implants coated with Hydroxyapatite (HA) are of very special importance in revisions of total hip prostheses. As far as the femur
is concerned, the rapid bony reconstruction due to the osteoconductive properties, which ensure in particular the filling of defects
of bony contact guarantee excellent secondary stabilization of the implants, provided that the mechanical assembly secured at
operation be stable. The results of a personal series of 46 patients confirm the efficacy of the HA coating by demonstrating the
quality of bony reconstruction and the long-term stability of the implants with satisfactory clinical results.

Vidalain JP
Advantages of a modular interlocked HA coated stem in revisions with major bone deficiencies. Presented at the
International Society for Technology in Arthroplasty, October 1-3, 1998
This papers review a modular interlocked and osteoconductive device to treat cases of major femoral deficiencies encountered in
revision surgeries. 35 patients suffering from severe femoral loosening corresponding to grade 3B and grade 4 of the Paproskys
classification were included in the study. Patients were treated with the REEF prostheses which is a modular femoral component
made up of two parts: 1) The trochanteric component providing for the adjustment of neck length, anteversion and offset. 2) The
metaphyseo-diaphyseal stem has a proximal tapered portion with horizontal macrotextures, and a distal cylindrical and curved
portion with longitudinal grooves and two distal holes for interlocking screws. This study concludes that preliminary data on revision
surgery with a modular HA coated and interlocked long stem have demonstrated that once implants have acquired bony stability,
the prospect for long term prosthesis survival is very favorable. Restoration of good periprosthetic bone trophicity is a reality. If long
term bone status is improved, any future surgery will be easier indeed.

Pinaroli A; Lavoie F; Cartillier JC, Neyret P; Ait Si Selmi T*

Conservative Femoral Stem Revision: Avoiding Therapeutic Escalation. Journal of Arthroplasty, 2008;24(3):365-373
A conservative approach to femoral revision is assessed. We report on 41 femoral revisions using an extensively coated
hydroxyapatite primary femoral stem. Clinical, operative, and radiological data were gathered. Harris hip scores increased from
65/100 to 90/100 at the minimal follow-up of 1 year (P b .05). All stems showed signs of osseous integration. No significant
migration was measured. No patient had to be reoperated because of problems related to the stem. Good results are reported for
femoral revision with Paprosky type I and II bone defects with no significant difference between the 2 subgroups, hereby proving
that conservative femoral revision is a reasonable treatment alternative. Reproducible results with such a technique may bring
surgeons to be more aggressive when noticing early signs of femoral loosening. Key words: revision hip arthroplasty, femoral stem
revision, primary intention stem, metaphyseal fixation, hydroxyapatite coating, bone loss.

10

Indication: Revision
Hernndez-Vaquero D, Suarez-Vazquez A, Cima-Suarez M, Garcia-Sandoval MA, Gava R
Extensively hydroxyapatite-coated stems in revision hip arthroplasty: A radiological mid-term follow-up study.
Hip International, 2005;15:38-45
Femoral revision surgery involves the placement of a stable stem and the regeneration of the damaged bone structure. We
retrospectively reviewed 36 cases of femoral revision surgery in which an extensively hydroxyapatite-coated porous stem was
implanted with a five-year minimum follow-up. Nine of the cases had type I defects, 12 had type II defects, six had III-A defects and
nine had III-B defects. The mean follow-up was 7.7 years (range 5-11). No cases of revision surgery, subsidence or displacement
were detected. In 35 cases the integration of the stem had been achieved, the bone structure had been restored and there was no
fibrous interface visible between the implant and the bone. The fully hydroxyapatite-coated stems thus proved a valuable alternative
for femoral revision surgery in mild and moderate bone defects.

Full articles can be ordered within the Corail clinical folder (Cat No: 9072-74-000 version 2)
11

Indication: Young Patients

The following papers emphasise further that the Corail is one stem, which can be used in multiple indications. As well as standard
and complex primary cases, fractured neck of femurs and revisions. Corail has proven to be successful in young, high demanding
patients.

Vidalain JP*
Can we propose a HA-THR to a patient younger than 50 years old? Retrospective study of a continuous series of 131
Corail prostheses (mean follow up 5 years). Presented at the European Hip Society, June 25-27, 1998, Beaune, France
Long life expectancy, specific pathologies, hard professional activities and sometimes still practicing sport are the main
characteristics of a population needing hip arthroplasty before 50 years of age. This study concerns a continuous series of 131
Corail prosthesis implanted between 1987 and 1993, the mean follow up was 5.02 years (SD 3.08). The different demographic
data concerning the patients were as follows: male 48%: mean age 42.1 years, the main aetiologies were: AON 30%: dysplasia
27%: primary arthrosis 23%: secondary arthrosis 12% and arthritis 5%. The quality of clinical results confirmed that we can really
propose HA coated implants to young patients needing THR. The survivorship rate of both components was identical to those
of the best cemented prosthesis at the time. The global F.U. is short, but the absence of specific complications, and of aseptic
loosening was noted. In addition, the biological junction, bone/implant, seemed to reduce PE debris migration.

Wangen H; Lerein P; Holm I; Gunderson R; Reikeras O

Hip Arthroplasty in patients younger than 30 years: excellent 10 to16 year follow-up results with a HA-coated stem.
International Orthopaedics (SICOT), 2008;32:203-208
It is well accepted that youth and high activity levels are among the factors that increase the risk of mechanical failure of total hip
prostheses. However, there are few reports of long-term results in very young patients. In this study, we evaluated the results of
total 49 hip replacements (THRs) using an uncemented total hip prosthesis (CORAIL) in 44 patients (28 females) who were 30 years
or younger (range: 15-30 years). The diagnosis was ostearthritis due to congenital dislocations in 28 patients, with the remaining
patients having diagnoses of sequelae of fracture, infection, Calve-Legg-Perthes disease, avascular necrosis, chondrodystrophia
and epiphyseal dysplasia. In all cases we used an uncemented straight stem fully coated with hydroxyapatite (HA). In 36 cases
we used a hemispherical cup inserted with press fit, and in seven cases we used a hemispherical screw cup. The patients were
evaluated ten to 16 years (mean: 13 years) after the operation by radiographic and clinical examinations, including the Harris Hip,
WOMAC and EuroQol-5D scores. In a sub-group of nine patients with a unilateral prosthesis, the muscle strength of the quadriceps
and hamstrings was tested using a Cybex 6000. None of the stems were revised at the follow-up examination, and all were
classified as well integrated, with no signs of radiological loosening. Twenty four hips had revision of the acetabular component
due to mechanical failure. The Harris Hip score was, on average, 88 (range: 62-100), the WOMAC score 80 (range: 37-100) and
the EuroQol score 0.68 (range: 0.14-1). Isokinetic muscle strength testing showed that seven of the nine tested patients were
weaker on the operated side. In conclusion, we found mechanical failures at the acetabular side, but excellent results with a fully
HA-coated femoral stem, with no revisions after ten to 16 years.

12

Indication: Infection
Corail can also be utilised for infection in revision cases.

Vidalain JP and the ARTRO Group*

Hydroxyapatite and Infection, Results of a Consecutive Series of 49 Infected Total Hip Replacements. In: Epinette JA,
Manley MT, editors. Fifteen Years of Clinical Experience with Hydroxyapatite Coatings in Joint Arthroplasty. Paris:
Springer; 2004;191-195
The present study was not performed to show that the risk of infection is less with HA-coated then with conventional prosthesis.
Septic complications are generally not very frequent following total hip replacement. This paper demonstrates that in the light of a
ten-year experience at many centres, HA coated stems in revision arthroplasty can be utilized for infection. Histological studies of
retrieved hips had shown that, at least in the presuppurative phase, the implant-bone interface had remained unaffected and was
still tight, and that the pattern of the adjoining bone marrow was that of a simple acute osteomyelitis. Under these conditions,
conservative management with appropriate systematic antibiotics could be envisaged. However, this paper concludes a more
aggressive approach with a single-component or preferably two-component exchange, would appear to hold greater promise
in terms of cure rates. In this respect, HA should be seen as an effective means of controlling infection; however, it cannot be
relied upon in isolation, and must be combined with medical treatment and sound technique. Hydroxyapatite is at least a credible
alternative to the use of antibiotic-laden cement.

Full articles can be ordered within the Corail clinical folder (Cat No: 9072-74-000 version 2)
13

Cost Effectiveness: Primary Cases

The following paper compares the cost of a cemented total hip replacement to a uncemented total hip replacement, and concludes
that the overall difference in cost is not significant when considering all materials and equipment needed for each procedure.

Yates P; Serjeant S; Rushforth G; Middleton R

The Relative Cost of Cemented and Uncemented Total Hip Arthroplasties. Journal of Arthroplasty, 2006;21(1):102-105
The use of uncemented femoral stems in primary total hip arthroplasty (THA) has been slow to develop in the UK because of the
lack of encouraging published long-term follow-up data, the continued success of the cemented primary THA, and the perceived
excessive relative cost of the uncemented THA. In this article, we argue that the total costs of 3 proven uncemented stems are
comparable with commonly used cemented femoral components, when all necessary materials are taken into consideration. In
addition, we will also discuss other potential benefits and drawbacks for considering the use of uncemented stems.

14

Cost Effectiveness: Intracapsular Fractured Neck of Femur

This section compares the relative cost of each treatment option for fractured neck of femur cases, when considering pre operative
management, equipment needed for each procedure, post operative management and secondary surgery. The results conclude that
there is no difference and even the potential for cost saving when using total hip replacement in comparison to internal fixation
and hemiarthroplasty.

Johansson T; Bachrach-Lindstrom M; Aspenberg P; Jonsson D; Wahlstrom O

The total costs of a displaced femoral neck fracture: Comparison of internal fixation and total hip replacement - A
randomized study of 146 hips. International Orthopaedics, 2006;30(1):1-6
We randomised 143 patients - age 75 years or older - with displaced femoral neck fracture to either internal fixation or total
hip replacement (THR) and compared the socio-economic consequences. In the internal fixation group, 34 of 78 hips underwent
secondary surgery. In the THR group, 12 of 68 hips dislocated, the majority in mentally impaired patients. We calculated the total
hospital costs for two years after operation. When secondary surgery was included, there was no difference in costs between
the internal fixation and THR groups, or between the mentally impaired and lucid subgroups. The costs to the community were
calculated comparing the baseline cost before surgery with the average cost per month during the first postoperative year. No
difference was found between the treatment groups. The Harris hip scores were higher in the THR group, and pain was more
common in the internal fixation group. In lucid patients, THR gives a better clinical result at the same cost.

Keating JF; Grant A; Masson M; Scott NW; Forbes JF*

Randomised comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty; treatment of
displaced intracapsular hip fractures in healthy older people. Journal of Bone and Joint Surgery, 2006;88A(2):249-260
Orthopaedic surgeons vary in their management of displaced intracapsular fractures of the hip in healthy older patients.
The aim of this investigation was to determine the functional, clinical, and resource consequences of three different types of
surgical treatment. The study was a multicenter randomized controlled trial. Reduction and fixation was compared with bipolar
hemiarthroplasty with cement and total hip replacement with cement. Participating surgeons elected to randomize their patients to
be treated with either one of the three types of procedures or with either fixation or bipolar hemiarthroplasty. Functional outcomes
were measured with a hip-rating questionnaire and the EuroQol health status measure. Clinical outcomes included mortality and
complications. The direct health service costs were compared. Participants were followed up for two years. Two hundred and seven
patients were randomized to be treated with one of the three operations, and ninety-one were randomized to be treated with
either fixation or bipolar hemiarthroplasty. There were no differences in the mortality rates among the treatment groups. The rate
of secondary surgery was highest in the fixation group (39% compared with 5% in the group treated with bipolar hemiarthroplasty
and 9% in the group treated with total hip replacement). The fixation group had the worst hip-rating-questionnaire and
EuroQol scores at four and twelve months. The total hip replacement group had significantly better functional outcome scores at
twenty-four months than the other two groups. Although fixation was initially the least costly procedure, this short-term advantage
was eroded by significantly higher costs for subsequent hip-related hospital admissions. Arthroplasty is more clinically effective and
cost-effective than reduction and fixation in healthy older patients with a displaced intracapsular fracture of the hip. The long-term
results of total hip replacement may be better than those of bipolar hemiarthroplasty.

Full articles can be ordered within the Corail clinical folder (Cat No: 9072-74-000 version 2)
15

Cost Effectiveness: Intracapsular Fractured Neck of Femur

Rogmark C; Carlsson A; Johnell O; Sernbo I
Costs of internal fixation and arthroplasty for displaced femoral neck fractures: A randomized study of 68 patients.
Acta Orthopaedica Scandinavica, 2003;74(3):293-298
We randomised 143 patients - age 75 years or older - with displaced femoral neck fracture to either internal fixation or total
hip replacement (THR) and compared the socio-economic consequences. In the internal fixation group, 34 of 78 hips underwent
secondary surgery. In the THR group, 12 of 68 hips dislocated, the majority in mentally impaired patients. We calculated the total
hospital costs for two years after operation. When secondary surgery was included, there was no difference in costs between
the internal fixation and THR groups, or between the mentally impaired and lucid subgroups. The costs to the community were
calculated comparing the baseline cost before surgery with the average cost per month during the first postoperative year. No
difference was found between the treatment groups. The Harris hip scores were higher in the THR group, and pain was more
common in the internal fixation group. In lucid patients, THR gives a better clinical result at the same cost.

16

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