Introduction: Studies about the influence of patient characteristics on mechanical socket failure in THA apply different methodologies and reveal inconclusive results. In addition the fixation mode has rarely been in the focus of investigation.

Methods: We conducted a two-arm matched pairs case-control study assessing the influence of patient characteristics sex, age, weight, BMI, diagnosis, and activity level (Charnley classification) on the odds for mechanical socket loosening. The cemented and uncemented fixation mode was analyzed separately.

Results: 299 cases and 986 controls were included in the cemented study arm and 510 cases and 3000 controls in the uncemented arm. Women had reduced loosening odds for the cemented (OR=0.59, p=0.0024) and uncemented (OR=0.63, p=0.0001) fixation compared to men (OR=1). Each additional year the intervention was postponed reduced the loosening odds by about 2 % for cemented (OR=0.98, p=0.017) and uncemented (OR=0.98, p=0.0002) sockets. In cemented sockets the weight group of 73–82 kg had lower loosening odds (OR=0.63, p=0.017) than the lighter (OR> 0.92) and heavier (OR> 1.1) weight groups. There were no significant effects of weight in the uncemented group. In contrast, obese patients (BMI> 30) with uncemented sockets displayed elevated loosening odds (OR=1.41, p=0.034) compared to an insignificant effect in the cemented arm. Osteonecrosis was the only main pathology revealing elevated loosening odds (OR=1.27, p=0.049) but only in cemented sockets. The Charnley classification as an indirect proxy of activity revealed changing and insignificant effects.

Conclusions: Female sex and a delayed intervention have similarly protective effects on the odds for cemented and uncemented socket loosening. Whilst a certain body weight range has a significantly protective effect in cemented sockets the more important finding is the significantly increased risk for uncemented socket loosening in obese patients. Patients with osteonecrosis are the only etiologic group at a significantly increase risk for socket loosening, but only with a cemented fixation. The Charnley classification as a surrogate for activity level had no influence on loosening risks in either socket fixation mode. Level of Evidence: Level III (case-control study)

Aims: The study was carried out to describe the long-term development of relevant clinical parameters after total hip arthroplasty (THA). Methods: Primary and follow-up data from 26‘019 THA from 9‘801 men and 11‘144 women were monitored across a postoperative period of 15 years. The population was described as one group and according to Charnley. Results: Patients experienced significant pain relief and major improvements in mobility and hip motion. The 5% of patients with preoperatively no or mild hip pain grew to 90–95% postoperatively and was 85% 15 years later. The 8% patients with a preoperatively free walking time greater 30 min. increased to 60% postoperatively. 15 years after the THA 60% managed free walking times up to 30 minutes. A hip flexion greater 90 degrees was preoperatively possible for 22% of the patients, postoperatively for 78%. Up to 94% judged the outcome as excellent or good after one year and 84% after fifteen years. The prevalence of radiographically loose stems increased from 0.87% to 14.44% 14 years postoperatively. Simultaneously, the prevalence of radiographically loose cups increased from 0.8% to 16.67%. Conclusions: A THA delivers significant gain in mobility, hip motion and pain relief and a high number of satisfied patients. A constant deterioration of abilities and satisfaction could be observed beginning three to five years after the primary operation. However, 15 years postoperatively, these abilities were still superior to the preoperative levels. A steady increase in radiographically loose components was noted. It took patients three to five years to reach their maximum outcome.

Aims: New threshold levels for a classification of Harris hip score (HHS) with respect to patient satisfaction after total hip arthroplasty (THA) were calculated. Methods: Registry data from four follow-up intervals (< =3, 3–6, 6–9, > 9 years) from 3824 female and 4002 male patients were analyzed and optimal agreements between patient satisfaction and HHS classes were calculated using kappa values (κ). Patients were classified into Charnley classes A and B/C. HHS outcome was transformed into a binary format (positive, negative). Results: Associations between outcomes of the complete patient group using the normal HHS-classification (100, 90, 80,< 70) were weak (κ≤ 0.42). For a binary outcome classification with positive (excellent, good) and negative (fair, poor) results, associations improved especially for Charnley A patients (κ=0.46). Using the recalibrated HHS, the separation of patients in Charnley A vs. B/C and a binary outcome classification resulted in clear associations between HHS results and patient evaluation in both groups A (κ=0.527) and B/C (κ=0.424). The new thresholds were 95 (good), 75 (fair) and 65 (poor) for Charnley A and 95, 75 and 60 for Charnley B/C respectively. Conclusions: The newly calibrated HHS can differentiate between a patient perceived positive and a negative outcome in Charnley A and B/C patients. The differentiation between these two groups is essential since Charnley B and C patients have, by definition, an inferior mobility compared to Charnley A patients which can render a successful THA as fair and poor in many of those patients if the traditional HHS classification is applied.

We assessed differences in the incidence and appearance of the radiological signs of loosening of the cup for various types of design. This was an observational study based on hip registry data of 15 340 patients with 17 951 total hip arthroplasties collected over a period of 33 years in 49 hospitals in Central Europe.

The threaded and the press-fit titanium cups showed significantly less aseptic loosening than the other systems. The direction of migration and the frequency of the radiological signs of loosening differed between the cup systems and were time-dependent.

Our findings indicate the superiority of uncemented threaded cups and press-fit titanium cups over other designs of cup.

We analysed follow-up data from 18 486 primary total hip arthroplasties performed between 1967 and 2001 to assess the validity of clinical procedures in diagnosing loosening of prosthetic components. Sensitivity, specificity and predictive values were estimated with the radiological definition of loose or not loose as the ‘gold standard’.

The prevalence of acetabular loosening increased from 0.6% to 13.9% during the period of the study and that of femoral loosening from 0.9% to 12.1%. Sensitivities and positive predictive values were low, suggesting that clinical procedures could not replace radiological assessment in the identification of loose prostheses. Specificities and negative predictive values were constantly above 0.86. The possibility of there being a prosthesis which is not loose in asymptomatic patients was consequently very high, particularly during the first five to six years after operation.

The necessity of periodic clinical and radiological follow-up examinations of asymptomatic patients during the first five to six years after operation remains questionable. Symptomatic patients, however, require radiological assessment.