Bearing surfaces in Total Hip Arthroplasty (THA) may affect implant longevity and hence patient outcomes. This randomised clinical trial (RCT) determined how ceramic-on-ceramic bearing (CERAMIC) THA affected joint-specific pain, function and stiffness, and prosthesis fixation/longevity over 10 postoperative years compared with ceramic-on-highly-crosslinked-polyethylene bearing (POLYETHYLENE) THA. This is a follow-up to previously reported five year outcomes. Subjects aged less than 61 years were randomised to CERAMIC [n=48] or POLYETHYLENE [n=44] THA. Subjects were assessed using the Western Ontario McMaster Osteoarthritis Index (WOMAC) and the RAND 12-Item Health Survey (RAND-12) preoperatively, and at one, five and 10 years postoperatively. Plain radiographs were evaluated at 10 years for fixation and medical records were reviewed for revisions. Of 92 subjects, six (7%) died within 10 years; 68 (79%) survivors provided radiographic and/or clinical follow-up at 10 years postoperatively. Improvements seen at five years in both the WOMAC and RAND-12 were retained at 10 years with no group differences (p>0.48). There were no failures/loss of fixation related to bearing surfaces/wear in either group. Over 10 years, three subjects in the POLYETHYLENE group had revisions that were related to recurrent dislocation; two revisions were performed within two years of surgery and one further subject underwent revision at 7 years postoperatively. This is one of the first RCTs to examine 10 year outcomes between ceramic-on-ceramic and ceramic-on-highly-crosslinked-polyethylene bearing THA. Both bearing surfaces performed well out to 10 years in subjects who were less than 61 years at time of surgery

Dislocation following revision THA remains a leading cause of failure. Integrity of the abductor muscles is a major contributor to stability. Large diameter heads (LDH), Dual Mobility (DM) and Constrained Acetabular Liners (CAL) are enhanced stability options but the indication for these choices remains unclear. We assessed an algorithm based on Gluteus Medius (GM) deficiency to determine bearing selection. Default choice with no GM damage was a LDH. GM deficiency with posterior muscle intact received DM and CAL for GM complete deficiency with loss of posterior muscle. Consecutive revision THA series followed to determine dislocation, all-cause re-revision and Oxford Hip Score (OHS). 311 revision THA with mean age 70 years (32–95). At a mean follow-up of 4.8 years overall dislocation rate 4.1% (95%CI 2.4–7.0) and survivorship free of re-revision 94.2% (95%CI 96.3–91.0). Outcomes:. Group 1 - LDH (36 & 40mm) n=164 / 4 dislocations / 7 re-revisions. Group 2 - DM n=73 / 3 dislocations / 4 re-revisions. Group 3 - CAL n=58 / 5 dislocations / 7 re-revisions. Group 4 - Other (28 & 32mm) n=16 / 1 dislocation / no re-revisions. Mean pre-op OHS: 19.6 (2–47) and mean post-op OHS: 33.9 (4–48). Kaplan-Meier analysis at 60 months dislocation-free survival was 96.1% (95% CI: 93.0–97.8). There was no difference between survival distributions comparing bearing choice (p=0.46). Decision making tools to guide selection are limited and in addition soft tissue deficiency has been poorly defined. The posterior vertical fibres of GM have the greatest lateral stabiliser effect on the hip. The algorithm we have used clearly defined indication & implant selection. We believe our outcomes support the use of an enhanced stability bearing selection algorithm

Polyimide (MP-1, MMATech, Haifa, Israel), is a high performance aerospace thermoplastic used for its lubricity, stability, inertness and radiation resistance. A wear resistant thin robust bearing is needed for total hip arthroplasty (THR). After independent laboratory testing, in 2006, the author used the material as a bearing in two Reflection (Smith and Nephew, USA) hip surgeries. The first, a revision for polyethylene wear, survives with no evidence of wear, noise, new osteolysis or complications related to the MP-1 bearing after 16 yrs. The second donated his asymptomatic MP-1 hip at 6.5yrs for post-mortem examination. There were no osteoclasts, cellular reaction bland in contrast to that of polyethylene. In 2013 a clinical study with ethical committee approval was started using a Biolox Delta (Ceramtec, Germany) head against a polyimide liner in 97 patients. MMATech sold all liners, irradiated: steam 52:45. Sixteen were re-machined in New Zealand. Acetabular shells were Delta PF (LIMA, Italy). The liner locked by taper. The cohort consisted of 46:51 M:F, and ages 43 to 85, mean 65. Ten received cemented stems. For contralateral surgery, a ceramic or polyethylene liner was used. Initial patients were lower demand, later, more active patients, mountain-biking and running. All patients have on-going follow up, including MP-1 liner revision cases. There has been no measurable wear, or osteolysis around the acetabular components using weight-bearing radiographs. Squeaking within the first 6 weeks was noted in 39 number of cases and subtle increase in palpable friction, (passive rotation at 50 degrees flexion), but then disappeared. There were 6 revisions, four of which were related to cementless Stemsys implants (Evolutis, Italy) fixed distally with proximal linear lucencies in Gruen zones 1 and 7, and 2 and 6. No shells were revised and MP-1 liners were routinely changed to ceramic or polyethylene. The liners showed no head contact at the apex, with highly polished contact areas. There were no deep or superficial infections, but one traumatic anterior dislocation at 7 years associated with 5 mm subsidence of a non-collared stem. The initial squeaking and increased friction was due to the engineering of the liner / shell composite as implanted, not allowing adequate clearance for fluid film lubrication and contributed to by shell distortion during impaction. The revised bearings were “equatorial” rather than polar, and with lack of wear or creep this never fully resolved. Where the clearance was better, function was normal. The “slow” utilization was due to my ongoing concern with clearances not being correct. The revision of 4 Stemsys stems, tribology issues may have contributed, but non “MP-1” / Stemsys combinations outside this study have shown the same response, thought to be due to de-bonding of the hydroxyapatite coating. With correct engineering and clearances, a 3.6 mm thick MP-1 bearing, a surface Ra<0.5, steam sterilized, shows no appreciable wear, and with confidence, can be used as a high performance THR bearing

Ceramic bearing fracture is a rare complication following implantation using modern day ceramic bearing materials. Revision bearing options in such cases is debated, with the choice between ceramic-on-ceramic and ceramic-on-polyethylene bearings. Revision to a hard on soft bearing raises concerns about potential catastrophic wear secondary to a third-body reaction caused by the fractured ceramic particles. Data was collected retrospectively from the NJR, electronic patient records, revision database and picture archiving and communication system. Templating software was used to determine linear wear between first post-operative radiograph and the latest available follow up. Univariate analysis was used to examine patient demographics and the wear rates for revision of ceramic bearing fractures to ceramic on polyethylene components. The intra and inter-rater reliability of wear measurements was calculated. There were twelve patients identified as meeting the inclusion criteria. The average age at revision was 62 years (54–72). There were 6 liner and 6 head fractures revised to delta ceramic heads and cross-linked polyethylene acetabular components. The most frequently used head size was 32mm. At mean follow up of 3.8 years (0.5 6.1 years), median 4.4 years, linear wear rate was calculated at 0.08± 0.06 mm/year. Both intra-rater and inter-rater reliability was excellent with ICC scores of 0.99 at all timepoints. Revision to ceramic on polyethylene (CoP) bearings following ceramic fracture does not cause early catastrophic wear at early follow up. It appears safe to use this hard on soft bearing combination, given that wear rates are comparable to what is expected in a primary hip replacement setting. Longer follow up is required to establish if this trend persists

Burroughs et al showed that frictional torque increases with increasing head size in a simple in vitro model and showed differences in frictional torque with different polyethylene materials [1]. Therefore, the purpose of this study was to evaluate the influence of bearing material and bearing size on the frictional torque of hip bearings utilizing a more physiologically relevant hip simulator model. A total of four hip bearing combinations (Crosslinked PE/CoCr, Conventional PE/CoCr, Crosslinked PE/Delta and Alumina /Alumina) with various bearing sizes were evaluated. The sizes tested in this study range from 22 mm to 44 mm; it is important to note that the study only evaluated bearing combinations (size and material combination) currently commercially available. A total of three samples per bearing combination were tested, with the exception of conventional PE, which included a total of 4 samples. A MTS hip joint simulator was used. All components were oriented anatomically with the femoral head mounted below on a rotating angled block which imparts a 23° biaxial rocking motion onto the head. Loading was held constant at each load level (500N, 1000N, 1500N, 2000N, 2450N) for at least two rotational cycles while all 3 axes of load and all 3 axes of moments were measured at 10 khz. Fresh Alpha Calf Fraction serum was utilized as a lubricant. Results show that frictional torque increases with the increase of head size regardless of head material for all polyethylene combinations (p > 0.05), as shown in Figure 1 and 2. However, results showed no change in frictional behavior for the Alumina/Alumina combination regardless of the bearing size. The results of this test did not show any significant difference between crosslinked PE and conventional PE materials for sizes 28 mm and 32 mm when paired against a CoCr head (p > 0.05) (Figure 3). The Alumina/Alumina bearing combination had the lowest frictional torque among all the bearing material combinations evaluated in this study. This data suggests that there is a strong correlation between increased head size and increased frictional torque (R. 2. = 0.6906, 0.8847) for the polyethylenes evaluated here regardless of head material. No correlation can be concluded for the Alumina /Alumina bearing combination (R. 2. = 0.0217). The combination of Alumina /Alumina seems to have the most favorable frictional properties. This data also suggests no effect on frictional properties regardless of the polyethylene material (crosslinked and conventional) for sizes 28 mm and 32 mm. The frictional torque values recorded in this study are different than those published by Burroughs et al [1]. This difference may be attributed to the testing methodology. The current study utilizes a hip simulator, which closely mimics the natural joint providing a more physiologically relevant model whereas the Burroughs et al study utilizes a single axis machine. It is important to understand that frictional behavior in hip bearings may be highly sensitive to bearing clearance, cup thickness, and stiffness, which may outweight the effect of head diameter. Further evaluation is necessary to isolate and investigate those parameters

Introduction: Mobile bearing TKRs may allow some axial rotation and also compensate for a slight tibiofemoral rotational mismatch. This is thought to provide better kinematics and a more natural patellar movement. This theoretical advantage has not been verified in clinical studies for the tibiofemoral kinematics. However, little is known about the patellofemoral kinematics of mobile bearing TKRs. The aim was to compare patellar kinematics among the anatomic knee, fixed bearing TKR and mobile bearing TKR. Methods: Optical computer navigation marker arrays (Brainlab) were attached to the femur, tibia and patella of 9 whole lower extremities (5 fresh cadavers). The trial components of a fixed bearing posterior stabilised TKR (FB) (Sigma PFC, Depuy) were implanted using a tibia first technique. Then the tibia component was changed to a posterior stabilised mobile bearing tibia component (MB) (Sigma RP Stabilised). The patellae were not resurfaced. The knees were moved through a cycle of flexion and extension on a CPM machine. Medial/lateral shift and tilt was measured relative to the patella position in the natural knee at full extension always with soft tissue closure. The path of the trochlea and patellar groove of the femoral component was registered. Values are expressed as mean+/−one standard deviation. Statistical analysis: two tailed paired Student’s T-test. Results: M/L shift: There was a tendency for the patella to track 2mm more laterally throughout the flexion range with a FB or MB TKR compared to the natural knee, but this did not reach significance. Tilt: The patella in the natural knee tilted progressively laterally from extension to flexion, plateauing at 50° of flexion (20°: 1.9+/−2.7°, 40°: 5.6+/−5.4°, 60°: 6.2+/−6.4°, 80°:6.5+/−7.3°, 90°: 6.4+/−7.7°). With a FB or MB TKR the patellae also tilted laterally up to 50 degree of flexion, but then started to tilt back medially, reaching the neutral position again at 90°. The patellae of the FB and MB TKRs were significantly more medially tilted at 50° to 90° of flexion compared to the natural knee. But there was no difference between the FB and MB TKRs. (Fixed bearing: 20°: 2.5+/−7.2° p=0.30, 40°: 3.7°+/−6.5° p=0.15, 60°: 3.1+/−5.8° p=0.02, 80°:1.2+/−6.5° p=0.001, 90°: 0.3+/−7.2° p=0.001, Mobile bearing: 20°: 0.3+/−5.5° p=0.27, 40°: 3.6+/−5.2° p=0.08, 60°: 2.1°+/−5.8 p=0.01, 80°: 0.2+/−6.8 p=0.003, 90°: −0.6+/−7.3 p=0.002; vs. natural). Trochlea position: The centre of the patellar groove of the femur component was more lateral than the trochlea by 2–5mm, it also extended 10mm further proximally. Conclusion: There are kinematic differences in patellar tracking between the natural and a FB/MB TKR. This may be due to a slightly different position of the patellar groove. The patellar kinematics of the MB TKR is not more natural compared to the FB TKR

Introduction and Aims: Fixed bearing and mobile bearing knee designs are currently used in clinical practice with little evidence based research available to determine superiority of one system. The purpose of this study was to compare the results between a cruciate retaining mobile bearing and two cruciate retaining fixed bearing total knee prostheses. Method: We performed a prospective, randomised, blinded clinical trial to compare a mobile bearing to two standard fixed-bearing implants. We evaluated the short- and long-term outcomes of the SAL. ®. (Sulzer) mobile bearing versus the AMK. ®. (Depuy) and Genesis II. ®. (Smith & Nephew) fixed bearing, total knee joint replacements. Ninety patients were randomised to receive one of the three prostheses. Patients were evaluated pre-operatively, at three, 12 months and annually thereafter. Patient demographics, radiographs, and multiple outcome measures (WOMAC, SF-12 and the Knee Society Clinical Rating System) were evaluated. A single observer was used to measure range of motion scores. Results and Discussion: No patients were lost to follow-up. One patient was withdrawn due to dementia before three months, one patient died prior to the two-year follow-up, and one patient was revised for infection at six months, leaving 87 patients at an average follow-up of 3.37 years (range 2.91–4.44 years). There were no significant differences in any outcome measures or radiographic findings. There were no differences in KSCRS at two years (SAL – 167, AMK – 158, GenesisII – 166 ). There were no differences in WOMAC scores or SF-12 survey scores. There were no differences in knee flexion at two years (SAL – 117. °. , AMK – 115. °. , GenesisII – 118. °. ). Therefore, no differences in multiple outcome measures were seen between a cruciate retaining mobile bearing and two cruciate retaining fixed bearing total knee prostheses. Conclusion: In this prospective randomised clinical trial no differences could be seen between a mobile bearing and two fixed bearing designs at a minimum of two years follow-up. Long-term evaluation will be required to comment on differences in polyethylene wear and implant longevity

Abstract. Introduction. The Oxford Unicompartmental Knee Replacement's (OUKR's) fully-congruent design minimises polyethylene wear. Consequently, wear is a rare failure mechanism. Phase-3 OUKR linear wear at 5 years was higher than previous OUKR phases, but very low compared to fixed-bearing UKRs. This study aimed to measure OUKR bearing wear at 10 years and investigate factors that may affect wear. Methodology. Bearing thickness for 39 OUKRs from a randomised study was calculated using radiostereometric analysis at regular intervals up to 10 years. Data for 39 and 29 OUKRs was available at 5 and 10 years, respectively. As creep occurs early, wear rate was calculated using linear regression between 6 months and 10 years. Relationships between wear and patient factors, fixation method, Oxford Knee Score (OKS), bearing position, and component position were analysed. Results. The mean wear rate was 0.06mm/year. Fixation method, age, OKS, component size, and bearing size had no correlation with wear. A higher BMI was associated with lower wear (p=0.01). Bearings more than 4mm from the wall had significantly more wear (p=0.04) than those less than 4mm from the wall. There was a linear correlation between the femoral component contact area on the bearing and wear (p=0.04). Conclusions. Phase-3 bearing wear rate is constant, significantly higher than previous OUKR phases at 10 years, and may increase the risk of long-term bearing failure. To minimise complications associated with wear, size 4 bearings should be used in young patients and manufacturing bearings from more durable, highly crosslinked polyethylene should be studied

Introduction/Aim. Thromboembolism is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. It was therefore, our aim to identify a difference in symptomatic thromboembolism by treating acute Achilles tendon rupture patients with conventional non- weight bearing plaster versus functional weight bearing mobilisation. Methodology. The notes of 91 consecutive patients with acute Achilles tendon rupture were reviewed. The patients' demographics, treatment modality (non- weight bearing plaster versus weight bearing boot), and predisposing risk factors were analysed. From the 91 patients, 50 patients with acute Achilles tendon rupture were treated conservatively in a non- weight bearing immobilisation cast. From these 50 patients, 3 then underwent surgery and were therefore excluded from the results. 41 patients were treated with functional weight bearing mobilisation. Patients who did have a symptomatic thromboembolic event had an ultrasound scan to confirm a deep vein thrombosis of the lower limb, or a CT-scan to confirm pulmonary embolism. Results. Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9 patients (19.1 %) had a thromboembolic event. Out of the 41 patients who were treated with functional weight bearing mobilisation, 2 patients (4.8%) had a thromboembolic event. Thus, patients who were treated in a non-weight bearing plaster had a significantly higher risk of developing thromboembolism (p value of <0.05) and an increased risk ratio of 24% compared to those who were treated with functional weight bearing mobilisation. Conclusion. There is a significant decrease in the clinical incidence of thromboembolic events in patients treated conservatively with early mobilisation in the functional weight bearing boot compared to those treated in a non- weight bearing cast

Introduction: Metal-on-metal (MM) bearing wear releases soluble metal ions which enter the systemic circulation and insoluble metal particles which collect in the periprosthetic tissues and disseminate through the lymphoreticular system. Disseminated particles also release ions through corrosion. The rate of metal ion level reduction following revision of a MM bearing offers insights into the relative contribution of metal ions from the bearing and from disseminated particles. Methods: Whole blood concentrations and daily output of metal ions were studied, prospectively over a period of one year, in seven patients whose MM resurfacings were revised to metal–polythylene THRs. None of the patients had other metal devices or compromised renal function. Results: Preoperative levels in these patients were highly elevated as expected from a failing device. Thereafter there is a trend of reducing metal levels in whole blood and urine in a biphasic manner. Over the first four weeks there is a rapid decline, followed by a period of slow decrease over the next twelve months (figure). Discussion: The steep reduction of cobalt release immediately following revision supports the reported short half-life of cobalt ions. The later protracted trend can only be accounted for through progressive corrosion from previously worn particles. However this trend is also not sustained indefinitely and tends to approach control levels eventually. Some authors have suggested that metal wear in patients with well-functioning MM bearings occurs only during the run-in wear phase and that continued corrosion of metal particles released during that period is responsible for metal level elevation later on. However the reducing trend in the later phase following revision in this study suggests that metal ion elevation from corrosion is not sustained indefinitely and therefore cannot by itself account for the persistent elevation of systemic metal levels throughout. Bearing wear continues to occur throughout bearing life

The purpose of this randomized controlled trial was to evaluate serum metal levels in patients undergoing total hip arthroplasty (THA) with a conventional compared to a modular dual-mobility bearing. Patients undergoing primary THA for osteoarthritis were randomized to receive either a modular dual-mobility or conventional polyethylene bearing. All patients received the same titanium acetabular and femoral component and a ceramic femoral head. Serum metal levels were drawn pre-operatively then annually for a minimum of two years postoperatively. An a priori power analysis determined that 40 patients (20 per cohort) were needed to identify a clinically relevant difference in serum cobalt of 0.35 ng/ml (ppb) at 90% power. Forty-six patients were randomized to a modular dual-mobility (n=25) or conventional bearing (n=21) with 40 at a minimum follow-up of two years. No differences in serum cobalt (mean 0.14 ppb [range, 0.075–0.29] vs. 0.20 ppb [range, 0.075–0.57], p=0.39) or chromium levels (mean 0.14 ppb [range, 0.05–0.50] vs. 0.12 ppb [range, 0.05–0.35], p=0.65) were identified between the modular dual-mobility and conventional cohorts, respectively. There was no statistically significant difference in serum Co or Cr at two years postoperatively in subjects implanted with a ceramic head and this particular dual mobility bearing in comparison to a ceramic head and a conventional acetabular component. While modest expected elevations in serum Co and Cr were observed in the dual mobility group, in no case did the Co level exceed the laboratory reference range nor the threshold of one part per billion that has been associated with adverse local tissue reactions to mechanically-assisted crevice corrosion

Abstract. Background. Multiple devices can stabilise the MTP joint for arthrodesis. The ideal implant should be easy to use, provide reproducible and high quality results, and ideally enable early rehabilitation to enable faster return to function, whilst lessening soft tissue irritation. We prospectively evaluated the combination of the IO-Fix (Extremity Medical, NJ, USA) device which consists of an intra-osseous post and lag screw that offers these features with full bearing of weight after surgery. Methods. 67 feet in 65 patients were treated over 31 months. After excluding patients lost to follow-up, undergoing revision arthrodesis, or concomitant first ray procedures, there were 54 feet in 52 patients available with a minimum 12 month follow-up with clinical and radiographic outcomes. All patients were treated using a similar operative technique with immediate bearing of weight in a rigid soled shoe. Results. The mean MOXFQ score improved from 46.4 (range 18 – 64) before surgery to 30.2 (range 0 – 54) at 6 months after surgery (p=0.02), and 18.4 (range 0 – 36) (p< 0.001) at latest follow-up. Arthrodesis across the MTP joint was achieved in 52 feet (96%), at a mean of 61 days (range 39–201). Non-union was observed in two feet; superficial wound infections in two feet; and metalwork impingement in three feet. Conclusions. In the largest reported series to date, the IO-Fix device achieved a union rate of 96% across the MTP joint when coupled with immediate bearing of weight. Significant improvements were seen in patient reported outcomes with low complication rates

Introduction/Aim. Thromboembolism is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. It was therefore, our aim to identify a difference in symptomatic thromboembolism by treating acute Achilles tendon rupture patients with conventional non-weight bearing plaster versus functional weight bearing mobilisation. Methodology. The notes of 91 consecutive patients with acute Achilles tendon rupture were reviewed. The patients demographics, treatment modality (non-weight bearing plaster versus weight bearing boot), and predisposing risk factors were analysed. From the 91 patients, 50 patients with acute Achilles tendon rupture were treated conservatively in a non-weight bearing immobilisation cast. From these 50 patients, 3 then underwent surgery and were therefore excluded from the results. 41 patients were treated with functional weight bearing mobilisation. Patients who did have a symptomatic thromboembolic event had an ultrasound scan to confirm a deep vein thrombosis of the lower limb, or a CT-scan to confirm pulmonary embolism. Results. Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9 patients (19.1 %) had a thromboembolic event. Out of the 41 patients who were treated with functional weight bearing mobilisation, 2 patients (4.8%) had a thromboembolic event. Thus, patients who were treated in a non-weight bearing plaster had a significantly higher risk of developing thromboembolism (p value of <0.05) and an increased risk ratio of 24% compared to those who were treated with functional weight bearing mobilisation. Conclusion. There is a significant decrease in the clinical incidence of thromboembolic events in patients treated conservatively with early mobilisation in the functional weight bearing boot compared to those treated in a non-weight bearing cast

The Profix knee replacement arthroplasty manufactured by Smith and Nephew has been in use for the past five years however there are few published outcome data for this prosthesis. The purpose of this study was to provide clinical outcome data for a cohort of patients with a Profix TKR at a minimum 3 years follow up. There were 65 joint replacements in 58 patients all performed by or under the direct supervision of one of two senior consultant Orthopaedic surgeons. There were 34 right and 31 left knees replaced in 31 male and 27 female patients. Mean age of the patients was 69 years (51–84 years) and mean body mass 89Kg (45–140Kg). The femoral component was uncemented in 49 knees and cemented in 16 knees. The tibial component was cemented in all 65 cases. There were 53 mobile bearing polyethylene inserts and 12 fixed bearing knees. The patella was resurfaced primarily in 32 cases. Using the Oxford Knee score, the mean knee score was 20.7 (Range 12–42) where a perfect score is 12 and the worst possible score 60. Mean clinical range of movement was 111 degrees (Range 90–130 degrees). Of the 65 joints, 13 have required or are awaiting some form of re-operation. These included 3 for patellae that were not resurfaced at the index arthroplasty, 6 for secondary insertion or revision of mobile bearing locking-screws and one femoral revision for failure of on-growth of an uncemented femoral component. The finding of loosening of the mobile bearing locking screw in three well functioning knees highlights the importance of Xray follow-up of patients even if their knee scores are entirely satisfactory. Overall, the clinical results of this prosthesis are satisfactory, however these data would support routine patellar resurfacing and use of the cemented fixed bearing option for the Profix arthroplasty

Introduction. The identification of biological markers associated to implant failure in THA (total hip arthroplasty) patients remains a challenge in orthopedic surgery. In this search, previous studies have been mainly focused on typical mediators associated to bone metabolism and inflammation. Our group has evaluated changes in serum levels of insulin-like growth factor binding protein-1 (IGFBP-1), a protein which is not directly related to bone homeostasis, in patients undergoing THA. Method. We assessed IGFBP-1 levels in serum obtained from 131 patients (58% female, 42 % male; age: 68 ± 13 years) who underwent THA in the Orthopedic Surgery and Traumatology Department of our institution. In this cohort, 57% of patients had metal on polyethylene (MoP) as hip-bearing surface combination, 17 % had ceramic on ceramic (CoC) and 26% of them did not have any prosthesis. A test based on an enzyme-linked immunosorbent assay (ELISA) was used to determine IGFBP-1 levels in serum obtained from these patients. Result. Our results showed a significant increase in IGFBP- 1 levels in MoP group as compared to CoC and control groups, in which no differences in quantified levels were detected. Further analysis revealed no significant differences in IGFBP-1 between cemented and non-cemented MoP bearings. We performed a ROC curve to evaluate the accuracy of serum IGFBP-1 in discriminating MoP from the rest of patients (area under the curve: 0.7; 95% confidence interval: 0,6-0.8; p<0.05) and established a cut-off value of 10.2 ng/ml, according to the Youden´s Index. Logistic regression analysis showed that patients with MoP bearing surfaces had a higher risk of increased IGFBP- 1 levels in serum (p<0.05, Odds Ratio: 6.7, 95% Confidence Interval 3.1 to 14.8). Conclusion. IGFBP- 1 levels are significantly elevated in THA patients with MoP bearing surfaces, suggesting that this protein might be a reliable biomarker for the outcome of patients implanted with MoP

Background: The osteolysis in revision total knee arthroplasty was observed. The purpose of this study was to compare the prevalence and characteristics of osteolysis recognized in revision total knee arthroplasties between the failed mobile bearing and fixed bearing knees. Methods: Eighty revision total knee arthroplasties were done between 1995 and 1998. The primary prosthesis that failed included thirty-four mobile bearing (Low Contact Stress) knees and forty-six fixed bearing knees of vary prostheses. At the time of revision surgery, all the interfaces between bone and prosthesis or cement were routinely checked and recorded for evidence of osteolytic resorption of bone. Preoperative radiographs were assessed independently by two authors for evidence of focal or severe periprosthetic osteolysis. The presence of the lesion was recorded. The demographic data included age and body weight was reviewed. The interval between the primary and revision surgery was recorded. The revision technique was reviewed. A statistical technique of chi-square test was applied in this study. Results: Osteolysis was recognized in sixteen of thirty-four mobile bearing knees (47 per cent) with thirteen knees involved distal femur and in six of forty- six fixed bearing knees (13 per cent) with four knees involved distal femur. The incidence of osteolysis was statistically significant difference between the mobile bearing and fixed bearing knees (p< 0.05). An overall 28 per cent (twenty-two knees) incidence of osteolysis was identified intraoperatively. The overall incidence of osteolysis in distal femur was 21 per cent (seventeen knees). The average time interval from the primary surgery to revision was 108 months. All the knees were affected by osteoarthritis. The most common site of osteolytic bone resorption was the posterior femoral condyle. Conclusions: Comparing to the fixed bearing knees, the mobile bearing (Low Contact Stress) knees were at increased risk for osteolysis in our series. Osteolysis occurred predominantly on the femoral side, especially adjacent to the prostheses in posterior condyle. Radiographic evaluation of osteolysis in distal femur is unreliable

The search for the ideal bearing surface in Total Hip Replacements continues. The current ‘best’ materials are felt to be combinations of metal, ceramics and cross-linked polyethylene. Laboratory studies suggest that ceramic-on-metal articulations may provide distinct advantages. This study aims to identify the best bearing surface combination with the lowest adverse side effect profile. Between February 2004 and September 2007, 164 hips were replaced in 142 patients. 39% were male and 69% were female. The average age at surgery was 53 years (17-72 years). Follow-up assessment included radiographs, the Harris Hip Score and whole blood samples for metal ion levels. Complications to date included 3 hips which needed femoral revision because of surgery related factors, and 3 cases of sepsis of which 1 settled and 2 needed revision. One hip needed revision of head and liner to a larger bearing size for recurrent dislocations, and is no longer being followed up for blood metal ions. Post-operative whole blood metal ion levels were compared to pre-operative levels to determine the increase or decrease in metal ion levels. There were no changes in those patients with ceramic-on-ceramic and ceramic-on-polyethylene articulations. Moderately raised whole blood metal ion levels were noted at 3 months in the ceramic-on-metal group, while the metal-on-metal group show the greatest increase. This study agrees with laboratory bearing surface wear studies demonstrating lower wear rates in the ceramic-on-metal group compared to the metal-on-metal group. With concerns related to high blood metal ion levels in metal-on-metal articulations, ceramic-on-metal bearing surfaces may well become a bearing surface of choice in the future, but progress needs to be monitored in the longer term

Is Non-Weight-Bearing Necessary? (INWN) is a pragmatic multicentre randomised controlled trial comparing immediate protected weight-bearing (IWB) with non-weight-bearing cast immobilisation (NWB) following ankle fracture fixation (ORIF). This trial compares; functional outcomes, complication rates and performs an economic analysis to estimate cost-utility.

IWB within 24hrs was compared to NWB, following ORIF of all types of unstable ankle fractures. Skeletally immature patients and tibial plafond fractures were excluded. Functional outcomes were assessed by the Olerud-Molander Ankle Score (OMAS) and RAND-36 Item Short Form Survey (SF-36) taken at regular follow-up intervals up to one year. A cost-utility analysis via decision tree modelling was performed to derive an incremental cost effectiveness ratio (ICER). A standard gamble health state valuation model utilising SF-36 scores was used to calculate Quality Adjusted Life Years (QALYs) for each arm.

We recruited 160 patients (80 per arm), aged 15 to 94 years (M = 45.5), 54% female. Complication rates were similar in both groups. IWB demonstrated a consistently higher OMAS score, with significant values at 6 weeks (MD=10.4, p=0.005) and 3 months (MD 12.0, p=0.003). Standard gamble utility values demonstrated consistently higher values (a score of 1 equals perfect health) with IWB, significant at 3 months (Ẋ = 0.75 [IWB] / 0.69 [NWB], p=0.018). Cost-utility analysis demonstrated NWB is €798.02 more expensive and results in 0.04 fewer QALYs over 1 year. This results in an ICER of −€21,682.42/QALY. This negative ICER indicates cost savings of €21,682.42 for every QALY (25 patients = 1 QALY gain) gained implementing an IWB regime.

IWB demonstrates a superior functional outcome, greater cost savings and similar complication rates, compared to NWB following ankle fracture fixation.

Ceramic bearing fractures are rare events, but mandate revision and implantation of new bearings. Revisions using metal heads have been reported to lead to gross volumetric head wear (due to abrasive retained ceramic micro-debris), cobalt toxicity, multi-organ failure and death. Such complications are widely published (50+ reports), yet we know that patients continue to be put at risk. Using data from the NJR and AOANJRR, this study seeks to compare the risk of re-revision and death by revision bearing combination following a ceramic bearing fracture. Data were extracted from the NJR and AOANJRR, identifying revisions for ceramic bearing fracture. Subsequent outcomes of survival, re-revision and death were compared between revision bearing combinations (ceramic-on-ceramic, ceramic-on-polyethylene, and metal-on-polyethylene). 366 cases were available for analysis from the NJR dataset (MoP=34, CoP=112, CoC=221) and 174 from the AOANJRR dataset (MoP=17, CoP=44, CoC=113). The overall incidence rate of adverse outcome (revision or death) was 0.65 for metal heads and 0.23 for ceramic head articulations (p=0.0012) across the whole time period (NJR). Kaplan-Meir survival estimates demonstrate an increased risk of both re-revision and death where a metal head has been used vs a ceramic head following revision for ceramic fracture. There are few decisions in arthroplasty surgery that can lead to serious harm or death for our patients, but revision using a metal head following ceramic bearing fracture is one of them. This study enhances the signal of what is already known but previously only reported as inherently low-level evidence (case reports and small series) due to event rarity. Use of a metal head in revision for ceramic fracture represents an avoidable patient safety issue, which revision guidelines should seek to address

Purpose. We aimed to investigate whether the anterior superior iliac spine could provide consistent rotational landmark of the tibial component during mobile-bearing medial unicompartmental knee arthroplasty (UKA) using computed tomography (CT). Methods. During sagittal tibial resection, we utilized the ASIS as a rotational landmark. In 47 knees that underwent postoperative CT scans after medial UKA, the tibial component position was assessed by drawing a line tangential to the lateral wall of the tibial component. Rotation of the tibial component was measured using two reference lines: a line perpendicular to the posterior cortical rim of the tibia (angle α) and Akagi's line (angle β). Instant bearing position and posterior cruciate ligament fossa involvement were also evaluated. External rotation of the tibial component relative to each reference line and external rotation of the bearing relative to the lateral wall of the tibial component were considered positive values. Results. The mean angle α and β were 8.0 ± 6.1° (range, −4.0 – 24.3) and 8.7 ± 4.8° (range, 1.9 – 25.2), respectively. The mean instant bearing position was 4.3 ± 28.6° (range, −52.9 – 179.7). One bearing showed complete 180° rotation at 2 weeks postoperatively. Fourteen knees (29.8%) showed posterior cruciate ligament fossa involvement of the tibial resection margin. Conclusions. Due to the wide variation in, and inherent difficulty in identification of, the ASIS during the operation, it is not recommended for guidance of sagittal tibial resection during mobile-bearing medial UKA. Level of Evidence: Level IV