To date, the literature has not yet revealed superiority of Minimally Invasive (MI) approaches over conventional techniques. We performed a systematic review to determine whether minimally invasive approaches are superior to conventional approaches in total hip arthroplasty for (1) clinical and (2) functional outcomes. We performed a meta-analysis of level 1 evidence to determine whether (3) minimally invasive approaches are superior to conventional approaches for clinical outcomes.

All studies comparing MI approaches to conventional approaches were eligible for analysis. The PRISMA guidelines were adhered to throughout this study. Registries were searched using the following MeSH terms: ‘minimally invasive’, ‘muscle-sparing’, ‘THA’, ‘THR’, ‘hip arthroplasty’ and ‘hip replacement’. Locations searched included PubMed, the Cochrane Library, ClinicalTrials.gov, the EU clinical trials register and the International Clinical Trials Registry Platform (World Health Organisation).

Twenty studies were identified. There were 1,282 MI THAs and 1,351 conventional THAs performed.

Intermuscular MI approaches are equivalent to conventional THA approaches when considering all-cause revision, aseptic revision, infection, dislocation, fracture rates and functional outcomes. Meta-analysis of level 1 evidence supports this claim.

High complication rates and poor outcomes have been widely reported in patients undergoing revision of large head metal-on-metal arthroplasty. A previous study from our centre showed high rates of dislocation, nerve injury, early cup loosening and pseudotumor recurrence. After noting these issues, we implemented the following changes in surgical protocol in all large head MOM revisions: One: Use of highly porous shells in all cases. Two: Use of largest femoral head possible. Three: Low threshold for use of dual mobility and constrained liners when abductors affected or absent posterior capsule. Four: Use of ceramic head with titanium sleeve in all cases. Five: Partial resection of pseudotumor adjacent to sciatic and femoral nerves.

The purpose of the present study is to compare the new surgical protocol above to our previously reported early complications in this group of patients

We specifically looked at (1) complications including reoperations, (2) radiologic outcomes, and (3) functional outcomes. Complication rates after (Group 1), and before (Group 2) modified surgical protocol were compared using Chi-square test, assuming statistical significance p < 0 .05.

Major complications occurred in 4 (8.3%) of 48 patients who had modified surgical technique, compared to 12 (38%) of 32 revisions prior to modification (p < 0 .05). Two hips of 48 (4.17%) endured dislocations in Group 1, compared to 9 of 32 (28%) in Group 2 (p < 0 .05). Four patients of 48 had repeat revision in Group 1: 2 for recurrence of pseudotumor, 1 for dislocation, and 1 for infection, compared to 6 patients who had 7 repeat revisions of 32 patients in Group 2: 3 for acetabular loosening, 3 for dislocation, and 1 for recurrence of pseudotumor (p=0.1). None of 48 revisions in Group 1 had acetabular loosening, compared to 4 of 32 in Group 2 (p=0.02). Two patients had nerve injury in Group 2, compared to none in Group 1 (p=0.16). The mean WOMAC pain score was 87.1 of 100 and the function score was 88.4 of 100 in Group 1, compared to a mean WOMAC pain score of 78 of 100 (p=0.6) and a function score of 83 of 100 in Group 2 (p=0.8).

Modification of the surgical techniques described in the introduction has resulted in a significant decrease in complications in revision of large head MOM total hips. We continue to use this protocol and recommend it for these difficult cases.

Introduction

The practice of overlapping surgery has been increasing in the delivery of orthopaedic care, aiming to provide efficient, high-quality care. However, there have been concerns about the safety of this practice. The purpose of this study is to examine safety and efficacy of a model of partially overlapping surgery that we termed “the swing room” in practice in primary hip and knee arthroplasty.

Background

Fully constrained liners are used to treat recurrent dislocations or patients at high risk after total hip replacements. However, they can cause significant morbidities including recurrent dislocations, infections, aseptic loosening and fractures. We examine long term results of 111 patients with tripolar constrained components to assess their redislocation and failure rate.

Background

High complication rates and poor outcomes have been widely reported in patients undergoing revision of large head metal-on-metal arthroplasty. A previous study from our center showed high rates of dislocation, nerve injury, early cup loosening and pseudotumor recurrence. After noting these issues, we implemented the following changes in surgical protocol in all large head MOM revisions: 1. Use of highly porous shells in all cases 2. Use of largest femoral head possible 3. Low threshold for use of dual mobility and constrained liners when abductors affected or absent posterior capsule 4. Use of ceramic head with titanium sleeve in all cases 5. Partial resection of pseudotumor adjacent to sciatic and femoral nerves.

Purpose

Dislocation after revision total hip is a common complication. The purpose of this study was to assess whether a large femoral head (36/40mm) would result in a decreased dislocation rate compared to a standard head (32mm).

Purpose

There is a postulated association between increased serum metal ions and pseudotumour formation in patients with metal-on-metal hip replacements. The primary aim of this study was to assess the prevalence of pseudotumour in 31 asymptomatic patients with a large femoral head (LFH) metal-on-metal hip implant. This was compared to the prevalence of pseudotumour in 20 matched asymptomatic patients with a hip resurfacing (HRA) and 24 matched asymptomatic patients with a standard metal-on-polyethylene (MOP) total hip. A secondary objective was to assess possible correlation between increased serum metal ions and pseudotumour formation

Purpose

The purpose of this study was to compare and evaluate the cost-effectiveness of the MIS Anterolateral Approach to that of the MIS Posterolateral and MIS Direct Lateral Approach.

Purpose: The purpose of this study was to evaluate the clinical effectiveness and outcomes of the ‘abductor sparing’ MIS Anterolateral approach (MIS Watson Jones/G3) in comparison to the MIS Direct Lateral and MIS Posterolateral approaches in primary total hip arthroplasty.

Method: A multicentre, prospective, randomized controlled trial was designed to evaluate for the superiority of the new MIS Anterolateral approach (MIS Watson Jones/ G3). The sample size calculation was performed for alpha .05, power .90, to evaluate for effect size 0.5 in WOMAC using repeated measures analyses with baseline WOMAC as covariate. A total of 156 patients consented to participate in the trial and patients were assigned to MIS Antero-lateral approach or alternate MIS approach (MIS Direct Lateral or MIS Posterolateral). Patients were subjected to standardized anaesthetic and perioperative management protocols and were evaluated at standardized intervals to evaluate endpoints of early recovery (3 months) as well as endpoints of 12 and 24 months respectively. The primary outcome of interest was WOMAC, however secondary outcomes included SF-36, as well as parameters of health resource utilization and complications. Univariate and multivariate analyses were perfomed.

Results: Patient groups were found to be similar at baseline with regards to demographics and baseline quality of life outcomes (p> .05). Multivariate and repeated measures analyses demonstrated no superiority of the MIS Anterolateral approach on outcomes of WOMAC and other quality of life measures in comparison to MIS Direct Lateral and MIS Posterolateral approaches (p> .05). Health care resource utlization was also similar with length of stay, blood transfusion requirements and complications (p> .05).

Conclusion: Our multicentre, prospective, randomized clinical trial demonstrates that the MIS Anterolateral approach is not superior to alternate MIS surgical approaches when evaluating outcomes of quality of life, complications, and health resource utilization. Surgeons should consider these outcomes, complications, and other relevant advantages and disadvantages of select surgical approaches when deciding on a technique for use in their orthopaedic practice.

Purpose: This study investigates the synergistic use of fusidic acid with vancomycin, and linezolid in poly-methylmethacrylate (PMMA) cement for the treatment of orthopedic MRSA and MRSE infections. Alone, Vancomycin is typically eluted in limited quantities from cement. The purpose of this study was to

combine FA and Vancomycin, and Linezolid alone in PMMA cement and characterize antibiotic elution, and

Method: Standardized 1g pellets of Palacos cement were manufactured containing Vancomycin and FA or Linezolid at increasing concentrations in three batches: without additive, with increasing concentrations of PEG, and with increasing concentrations of NaCl. The pellets were incubated in phosphate buffered saline and sampled at regular intervals. Drug analysis was performed with high pressure liquid chromatograpy.

Results: Total drug release at 2.5% loading of Vancomycin alone was 0.84% and of FA was 2.35%. Linezolid showed comparable release profiles. Vancomycin and FA combined yeilded Vancomycin release of 6.2% and FA of 8.4%. The addition of 30% PEG increased release of Vancomycin and Fusidic Acid by six-fold. The addition of 18% NaCl increased total Vancomycin release by 11-fold but had no effect on FA release.

Conclusion: Linezolid, Vancomycin and FA can be combined in PMMA and have favorable release profiles. The addition of PEG and NaCl dramatically increases the release of antibiotics, with the exception of FA and NaCl. These strategies may be useful in the management of MRSA/MRSE infections.

Purpose: The purpose of this study was to prospectively evaluate a consecutive series of patients receiving metal on metal hip resurfacing arthroplasty with regards to outcomes and complications at minimum of 2 years follow-up.

Method: A prospective evaluation of all patients receiving hip resurfacing was performed including baseline evaluation (demographics, WOMAC, SF12, Oxford Hip Score) and minimum 2 year follow-up assessment (WOMAC, SF12, Oxford Hip Score, UCLA activity score, Patient Satisfaction, Complications). No patients were lost to follow-up.

Results: 143 hips in 127 patients received metal-on-metal hip resurfacing arthroplasty. The mean age was 52 years and the primary diagnosis was osteoarthritis or avascular necrosis, Significant improvements were noticed across all baseline quality of life instruments (p< .05) with final mean WOMAC and Oxford Scores 95 (normalized 0–100). Final post-op satisfaction was mean 95 out of 100. Two patient sustained post-operative femoral neck fractures and required revision. An additional two patients required revision for ongoing hip pain. One patient sustained a sciatic nerve palsty and one additional patient required acetabular component repositioning on the same day as the index procedure. Revision procedures involved conversion of resurfacing femoral component to cementless total hip stem with large diameter metal head and preservation of acetabular component. Acetabular component survivorship is 99% and femoral component survivorship is 97% at 2 year follow-up.

Conclusion: Our short to midterm data, from an independant center, suggests excellent improvement in quality of life with high levels of patient satisfaction and postop acitivity level. Our comprehensive post-operative quality of life assessment demonstrates restoration of the hip to rival that of the normal non-arthritic hip joint. Complications unique to resurfacing arthroplasty occur and were not predictable based on pre-operative or intra-operative patient-specific features.

Purpose: Porous tantalum has been shown to be very effective in achieving bone ingrowth. However, in some circumstances, bone quality or quantity is insufficient to allow adequate bone ingrowth. We hypothesized that the addition of alendronate to porous tantalum would enhance the ability of porous tantalum to achieve bone ingrowth in these challenging situations, such as when a gap exists between the implant and bone. We evaluated the effect of alendronate coated porous tantalum on new bone formation in an animal model incorporating a gap between implant and bone.

Method: Thirty-six cylindrical porous tantalum implants were bilaterally implanted into the distal femur of 18 rabbits for 4 weeks. There were 3 groups of implants inserted; a control group of porous tantalum with no coatings, porous tantalum with micro-porous calcium phosphate coating, and porous tantalum coated with micro-porous calcium phosphate and alendronate. Subcutaneous fluorescent labeling was used to track new bone formation. Bone formation was analyzed by backscattered electron microscopy and fluorescent microscopy on undecalcified samples.

Results: The relative increase in mean volume of gap filling, bone ingrowth and total bone formation was 143% (p< 0.001), 259% (p< 0.001) and 193% (p< 0.001) respectively in the alendronate coated porous tantalum compared with the uncoated porous tantalum controls. The relative increase in the percentage of new bone-implant contact length was increased by 804% on average in the alendronate coated porous tantalum compared with the uncoated tantalum controls.

Conclusion: This study demonstrated the significant enhancement of bone-implant gap filling and bone ingrowth which can be achieved by coating porous tantalum with alendronate. It is proposed that, when faced with the clinical problem of revision joint replacement in the face of bone loss (at the hip, knee or elsewhere), the addition of an alendronate-delivery surface coating would enhance biological fixation of the implant and promote the healing of bone defects.

Introduction: Achieving durable implant–host bone fixation is the major challenge in uncemented revision hip arthroplasty when significant bone stock deficiencies are encountered. The purpose of this study was 1) to develop an experimental model which would simulate the clinical revision hip scenario and 2) determine the effects of alendronate coating on porous tantalum on gap filling and bone ingrowth in the experimental model.

Methods: Thirty-six porous tantalum plugs were implanted into the distal femur, bilaterally of 18 rabbits for four weeks. There were 3 groups of plugs inserted; control groups of porous tantalum plugs (Ta) with no coating, a 2^nd control group of porous tantalum plugs with micro-porous calcium phosphate coating, (Ta-CaP) and porous tantalum plugs coated with alendronate (Ta-CaP-ALN). Subcutaneous fluorochrome labelling was used to track new bone formation. Bone formation was analysed by backscattered electron microscopy and fluorescence microscopy on undecalcified histological sections.

Results: The relative increase in mean volume of gap filling, bone ingrowth and total bone formation was 124 %, 232 % and 170 % respectively in Ta-CaP-ALN compared with the uncoated porous tantalum (Ta) controls, which was statistically significant. The contact length of new bone formation on porous tantalum implants in Ta-CaP-ALN was increased by 700% (8-fold) on average compared with the uncoated porous tantalum (Ta) controls.

Discussion: Alendronate coated porous tantalum significantly modulated implant bioactivity compared with controls. This study has demonstrated the significant enhancement of bone-implant gap filling and bone ingrowth, which can be achieved by coating porous tantalum with alendronate. It is proposed that, when faced with the clinical problem of revision joint replacement in the face of bone loss, the addition of alendronate as a surface coating would enhance biological fixation of the implant and promote the healing of bone defects.

Introduction: Deep infection in total hip replacement can be devastating. We report the outcomes 10–15 years after two stage revision for hip infection in 103 patients using the PROSTALAC (prosthesis of antibiotic-loaded acrylic cement) hip.

Methods: All patients or their next of kin were contacted to determine their current functional status and whether they had required repeat surgery or had recurrent infection. The Oxford-12, SF-12, and WOMAC questionnaires were administered. A comprehensive chart review was undertaken to review the infective organisms, surgery, approach, complications, and need for further revision surgery.

Results: 11 patients had re-infection, 7 of whom responded to repeat surgery with no further sequelae. Two patients required resection arthroplasty, one patient underwent hip disarticulation after eventual failure of treatment and bone loss, and one immuno-compromised patient developed osteomyelitis and was subsequently lost to follow-up. Long-term success rate for two stage-revision is thus 89%, or 96% with additional surgery. Since then, 3 patients required revisions for aseptic loosening, 1 for recurrent dislocation. We were able to follow up 45 patients, 75 % of whom provided health-related quality of life outcome scores. 39 patients were deceased, with their outcome confirmed via their last follow-up or with family members, for a total follow-up rate of 85 %. 15 patients were lost to follow-up, but did not undergo further surgery or have reinfections treated at our centre.

Discussion: Two-stage revision for hip infection, which includes an interim prosthesis of antibiotic loaded cement, offers a predictable and lasting solution for patients with this difficult problem.

Introduction: The aims of this study were to

determine predictors of pain, function and activity level 1–2 years after revision hip arthroplasty and

Methods: A prospective cohort of 222 patients who underwent revision hip arthroplasty were evaluated. Predictive models were developed and proportional odds regression analyses were performed to identify factors that predict quality of life outcomes at 1 and 2 years post surgery. The dependent outcome variables were WOMAC function, pain and UCLA activity. The independent variables included patient demographic, surgery specific and objective parameters including baseline Western Ontario McMaster Universities (WOMAC) osteoarthritis index, and the Short Form-12 mental component. The Loess method was used to plot the change of WOMAC and SF-12 scores over time.

Results: There was a significant improvement (p< 0.001) in all patient quality of life scores from baseline with results plateauing at 1 year. UCLA activity remained static between 1 and 2 years. In the predictive model, higher baseline WOMAC function (p < 0.001), age between 60–70 (p< 0.037), male gender (0.017), lower Charnley class (p < 0.001) and diagnosis of aseptic loosening (p < 0.003) were significant predictors of improved function.

When considering WOMAC pain as an outcome variable, factors predictive of improving category outcome included baseline WOMAC function (p= 0.001), age between 60–70 (p< 0.004), male gender (p= 0.005), lower Charnley class (p< 0.001) and no previous revisions (p < 0.023). Baseline WOMAC pain did not predict final pain outcome. Baseline WOMAC function (p=0.001), the indication for the operation (p=0.007), and the operating surgeon were significant predictors of UCLA activity at follow up. Peri or post-operative complications were not an adverse predictor of physical function, pain or activity.

Conclusions: Predictors of quality of life outcomes after revision hip replacement-showed that although some patient specific and surgical specific variables were important, age, gender, Charnley class and baseline WOMAC function had the most robust associations with outcomes.

Revision of a failed acetabular reconstruction in total hip arthroplasty (THA) can be challenging when associated with significant bone loss. In cementless revision THA, achieving initial implant stability and maximising host bone contact is key to the success of reconstruction. Porous tantalum acetabular shells may represent an improvement from conventional porous coated uncemented cups in revision acetabular reconstruction associated with severe acetabular bone defects.

Methods: We reviewed the clinical and radiographic results of 46 acetabular revisions with Paprosky 2 and 3 acetabular bone defects done with a hemispheric, tantalum acetabular shell (Trabecular Metal Revision Shell, Zimmer, Warsaw, USA) and multiple supplementary screws for fixation.

Results: At a mean follow-up of 40 (24–51) months, one acetabular shell had been revised in a patient with a Paprosky 3B defect. Two liner revisions were performed for recurrent instability, without porous tantalum shell revision. The clinical outcome showed significant postoperative improvement in all measured sub-scales, compared with baseline pre-operative scores (mean improvement in Oxford Hip Score of 40.0, p < 0.001, in WOMAC of 36.7, p < 0.001, Physical component SF-12 of 12.3, p =0.0003, mental component of SF-12 of 6.8, p = 0.006). Radiographic evidence of osseointegration using validated criteria (Moore’s criteria) was demonstrated in 39 of the 40 hips available for radiographic analysis at a mean of 30.9 months, by two independent observers. Of the remaining six hips, five hips were lost to follow-up and one radiograph demonstrated failure of the hip reconstruction secondary to loss of fixation and superior migration of the component.

Discussion: Cementless acetabular revision with the porous tantalum acetabular shell demonstrated excellent early clinical and radiographic results in a series of complex revision acetabular reconstruction associated with severe bone defects. The evidence of radiographic osseointegration suggests that outcome should remain favourable, however, further longer-term evaluation is warranted.

Introduction: This single incision, anterolateral intermuscular approach (AL-IM) utilizes the interval between gluteus medius and tensor fascia lata. The aims of the study were to compare the quality of life, satisfaction and complications of this approach with two of the most commonly used limited incision transmuscular (TM) approaches, namely the mini-posterior (P-TM) and the mini-direct lateral (L-TM).

Methods: 199 patients receiving MIS THA surgical procedures were evaluated prospectively (63 AL-IM, 68 P-TM and 68 L-TM). The outcome variables were WOMAC function, pain, stiffness, SF-12 (physical & mental), Oxford-12, satisfaction and radiological outcome. Parametric and non-parametric analyses were performed.

Results: There were no significant differences between groups in baseline characteristics including age, sex, BMI, co-morbidity, or pre-op WOMAC, SF-12, Oxford-12 (p> .05). However, the AL-IM group was associated with superior outcomes (p< .05) in WOMAC function, WOMAC pain, global WOMAC, Oxford-12 and SF-12 physical component.

Conclusion: In the short term the AL-IM approach provides significant improvements in quality of life scores over other limited incision approaches. It provides minimal soft tissue disruption and maintains the abductor musculature and posterior soft tissue envelope, with similar complications and radiological outcomes.