The management of severe acetabular bone defects poses a complex challenge in revision hip arthroplasty. Although biological fixation materials are currently dominant, cage has played an important role in complex acetabular revision in the past decades, especially when a biological prosthesis is not available. The purpose of this study is to report the long-term clinical and radiographic results of Paprosky type Ⅲ acetabular bone defects revised with cage and morselized allografts. We retrospectively analyzed 45 patients who underwent revision hip arthroplasty with cage and morselized allografts between January 2007 and January 2019. Forty-three patients were followed up. There were 19 Paprosky type IIIA bone defect patients and 24 Paprosky type IIIB bone defect patients and 7 patients of the 24 were also with pelvic discontinuity. Clinical assessment included Harris Hip Score (HHS) and Short Form-12 (SF-12). Radiographic assessment included cage stability, allografts incorporation, and center of rotation. All patients were followed up with a mean follow-up of 10.6 years, HHS and SF-12 improved significantly at last follow-up in comparison to the preoperative. There were 2 re-revisions, one at 5 years after surgery, another at 13.6 years after surgery. Two patients had nonprogressive radiolucency in zone III and the junction of zone II and zone III at the bone implant interface. Allografts of 40 (93%) cases incorporated fully. The combination of cage and morselized allograft is an alternative option for acetabular revision with Paprosky type III bone defects with satisfactory long-term follow-up results

The periacetabular osteotomy (PAO) is a well-described procedure for symptomatic acetabular dysplasia. For severe acetabular deformities, the efficacy of acetabular reorientation remains controversial and the literature on mid to long-term outcomes is limited. The purpose of this study was to analyze average 10-year clinical and radiographic results of the PAO for severe acetabular dysplasia. We retrospectively analyzed a consecutive series of patients undergoing PAO for severe acetabular dysplasia as defined by LCEA < 5˚. Patient demographics, radiographic measurements, modified Harris Hip score (MHHS), UCLA activity, SF-12, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were assessed. Sixty-eight patients (82 hips; 54 females) with an average age 20.7 and BMI of 24.4 kg/m2 were included. Mean follow-up was follow up was 10.3 years. . The LCEA and ACEA improved a mean of 32.8˚ (8.4˚ to 24.4˚, p<0.0001) and 31.6˚ (−4.9˚ to 26.7˚, p< 0.0001), respectively. MHHS improved an average of 17.5 points (64.6 to 82.3, p<0.0001), WOMAC Pain subscore improved an average of 21.1 points (65.7 to 85.0, p = 0.004), and SF-12 physical improved 11.8 points (from 40.3 to 50.6, p = 0.006). Activity improved as indicated by a 1.5-point increase in the UCLA Activity score (6.4 to 7.9, p=0.005). Six hips (9.1%) converted to THA at average 6.8 years post-PAO. Kaplan-Meier survival analysis with THA as the endpoint was 92% at 15 years (95% confidence interval [CI] (81%–96%). Multivariable linear regression analysis revealed concurrent osteochondroplasty was associated with a decreased risk of PAO failure. PAO is an effective treatment for severe acetabular dysplasia. At average 10.3 years, clinical and radiographic outcomes demonstrate pain relief, improved hip function, and major deformity correction. We observed minimal clinical deterioration over time

Executing an extended retinacular flap containing the blood supply for the femoral head, reduction osteotomy (FHO) can be performed, increasing the potential of correction of complex hip morphologies. The aim of this study was to analyse the safety of the procedure and report the clinical and radiographic results in skeletally mature patients with a minimum follow up of two years. Twelve symptomatic patients (12 hips) with a mean age of 17 years underwent FHO using surgical hip dislocation and an extended soft tissue flap. Radiographs and magnetic resonance imaging producing radial cuts (MRI) were obtained before surgery and radiographs after surgery to evaluate articular congruency, cartilage damage and morphologic parameters. Clinical functional evaluation was done using the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score (HOS), and the modified Harris Hip Score (mHHS). After surgery, at the latest follow-up no symptomatic avascular necrosis was observed and all osteotomies healed without complications. Femoral head size index improved from 120 ± 10% to 100 ± 10% (p<0,05). Femoral head sphericity index improved from 71 ± 10% before surgery to 91 ± 7% after surgery (p<0,05). Femoral head extrusion index improved from 37 ± 17% to 5 ± 6% (p< 0,05). Twenty five percent of patients had an intact Shenton line before surgery. After surgery this percentage was 75% (p<0,05). The NAHS score improved from a mean of 41 ± 18 to 69 ± 9 points after surgery (p< 0,05). The HOS score improve from 56 ± 24 to 83 ± 17 points after surgery (p< 0,05) and the mHHS score improved from 46 ± 15 before surgery to 76 ± 13 points after surgery (p< 0,05). In this series, femoral head osteotomy could be considered as safe procedure with considerable potential to correct hip deformities and improve patients reported outcome measures (PROMS). Level of evidence - Level IV, therapeutic study. Keywords - Femoral head osteotomy, Perthes disease, acetabular dysplasia, coxa plana

Purpose. Long-term clinical and radiographic results and survival rates were compared between closed-wedge high tibial osteotomy (HTOs) and fixed-bearing unicompartmental knee arthroplasty (UKA) in patients with similar demographics. Methods. Sixty HTOs and 50 UKAs completed between 1992 and 1998 were retrospectively reviewed. There were no significant differences in preoperative demographics. The mean follow-up period was 10.7 ±5.7 years for HTO and 12.0 ±7.1 years for UKA (n.s.). The Knee Society knee and function scores, WOMAC, and range of motion (ROM) were investigated. The mechanical axis and femorotibial angle were evaluated. Kaplan–Meier survival analysis was performed (failure: revision to TKA), and the failure modes were investigated. Results. Most of the clinical and radiographic results were not different at the last follow-up, except ROM; ROM was 135.3 ±12.3° in HTO and 126.8 ±13.3° in UKA (p=0.005). The 5-, 10-, 15-, and 20-year survival rates were 100%, 91.0%, 63.4%, and 48.3% for closed-wedge HTO, respectively, and 90.5%, 87.1%, 70.8%, and 66.4% for UKA (n.s.). The survival rate was higher than that for UKA until 12 years postoperatively but was higher in UKAs thereafter, following a remarkable decrease in HTO. The most common failure mode was degenerative osteoarthritic progression of medial compartment in HTO and femoral component loosening in UKA. Conclusions. Long-term survival did not differ significantly between closed-wedge HTO and fixed-bearing UKA in patients with similar preoperative demographics and knee conditions. The difference in postoperative ROM and failure mode should be considered when selecting a procedure

Objective. The purpose of the present study was to compare the clinical and radiographic results after TKA using a patellofemoral design modified prosthesis and its predecessor. The other purpose was to investigate whether the use of the recent prosthesis increase the risk of posterior tibial cortex injury or patellar fracture. Materials and Methods. The clinical and radiographic results of 300 knees which underwent TKA using the Attune®prosthesis (group A) were compared with those in a paired match-control group who underwent TKA using the P.F.C. Sigma® prosthesis (group B). The preoperative demographic data between the 2 groups did not differ significantly. The WOMAC, Feller and Kujala scores, and range of motion (ROM) were compared. The minimal distance between the tibial component stem to posterior tibial cortex, and the remnant patella thickness were compared. Results. The postoperative WOMAC score was better in the group A than in the group B (17.7 vs. 18.8, p=0.004). The postoperative ROM was greater in the group A than in the group B (131.4° vs. 129.0°, p=0.008). The postoperative Feller score was not different, but postoperative Kujala score was better in the group A. The minimal distance between the tibial component stem and posterior tibial cortex was significantly shorter in group A than in the group B (6.3mm vs 7.0mm, p<0.001). The proportion of high risk group for posterior tibial cortical injury, which had the minimal distance less than 4mm, was higher in the group A (20.0% vs 10.7%, p=0.002). The remnant patella was thinner in the group A than in the group B (14.8mm vs 15.7mm, p<0.001). The proportion of high risk group for patella fracture with remnant thickness of <12mm was higher in the group A (7.5% vs 2.1%, p=0.003). Conclusion. When comparing the clinical and radiographic results after TKA using the two prostheses of a design modified prosthesis and its predecessor, TKA using the recent prosthesis provided better satisfactory results. However, the risk of injury in the posterior cortex of the tibial metaphysis or remnant patella should be considered in this design modified prosthesis. Level of Evidence. Level III

Trabecular metal (TM) augments are designed to support an uncemented socket in revision surgery when adequate rim fit is not possible. We have used TM augments in an alternative arrangement, to contain segmental defects to facilitate impaction bone grafting (IBG) and cementation of a cemented socket. However, there is a paucity of literature supporting the use of this technique. We present one of the largest studies to date, reporting early outcomes of patients from a tertiary centre. A single-centre retrospective analytical study of prospectively collected data was performed on patients who had undergone complex acetabular reconstruction using TM augments, IBG and a cemented cup. All patients operated between 2015 and 2019 were included. We identified 105 patients with a mean age of 74yrs. The mean follow-up was 2.3 years(1–5.5yrs). Our primary outcome measure was all-cause revision of the construct. The secondary outcome measures were, Oxford hip score (OHS), radiographic evidence of cup migration/loosening and post-op complications. Eighty-four out of 105 patients belonged to Paprosky grade IIb, IIc or IIIa. Kaplan-Meier survivorship for all-cause revision was 96.36% (CI, 90.58–100.00) at 2 years with 3 failures. Two were due to early infection which required two-stage re-revision. The third was due to post-operative acetabular fracture which was then re-revised with TM augment, bone graft and large uncemented cup. Pre-op and post-op matched OHS scores were available for 60 hips(57%) with a mean improvement of 13 points. Radiographic analysis showed graft incorporation in all cases with no evidence of cup loosening. The mean vertical cup migration was 0.5mm (Range −5 to 7mm). No other complications were recorded. This study shows that reconstruction of large acetabular defects during revision THA using a combination of TM augments to contain the acetabulum along with IBG to preserve the bone stock and a cemented socket is a reliable and safe technique with low revision rates and satisfactory clinical and radiographic results. Long term studies are needed to assess the possibility of preservation and regeneration of bone stock

INTRODUCTION. In patients presenting with significant ligamentous instability/insufficiency and/or significant varus/valgus deformity of the knee, reproduction of knee alignment and soft tissue stability continues to be a difficult task to achieve. These complex primary total knee arthroplasty (TKA) candidates generally require TKA systems incorporating increasing levels of constraint due to the soft-tissue and/or bone deficiencies. In addition, achievement of “normal” gap symmetry through physiologic kinematics is challenging due to the complexity of the overall correction. Advancements in TKA design have not fully addressed the negative consequences of the increased forces between the degree of component constraint, the femoral box, and the tibial post. The purpose of this early feasibility study was to introduce the design characteristics of a primary TKA system that incorporates progressive constraint kinematics using a low profile trapezoidal femoral box, and to assess the short-term clinical and radiographic results of this patient cohort. METHODS. We retrospectively evaluated 22 consecutive, non-selected, complex primary TKA patients with a minimum of 3-years follow-up and varus deformity of > 20 degrees or valgus deformity of >15 degrees. The Progressive Constraint Kinematics® Knee System (PCK, MAXX Orthopedics, Norristown, PA) was used and provides a variable constraint profile, from high constraint in extension to less constraint in flexion through a novel trapezoidal femoral box. We evaluated patient demographics, pre- and post-operative serial radiography, range of motion (ROM), and total Knee Society Score (KSS – total score). General descriptive statistics and paired t-Test to assess the difference between means at p <0.05 level of significance. RESULTS. The average time to most recent follow-up was 40.5 ±3.5 months (range: 36.0 to 44.0 months). The PCK knee system had 100% survival rate at the most recent follow-up, with no reports of adverse events, subsequent corrective surgery, or revision. The average total KSS improved from 72.7 ±3.2 (range: 68 to 81) pre-operatively to 92.3 ±2.1 (range: 88 to 96) post-operatively (p < 0.001). Full post-operative arc of motion was 0 – 130° and there was no radiographic evidence of composite degradation, aseptic loosening or component malalignment. DISCUSSION/CONCLUSION. The PCK Knee System utilizes a trapezoidal shaped femoral box, where the narrower end is located anteriorly, allowing a valgus/varus tilt of 1–4 degrees and internal/external rotation of 2–7 degrees during flexion, while maintaining necessary soft-tissue constraint during extension. This variable constraint profile allows for fully tensed collaterals in extension, with a slight reduction in collateral tension through flexion. Furthermore, the combination of the condylar anatomy, trapezoidal femoral box and tibial post allows for adequate clearance through full flexion, while facilitating slightly progressive increases in tilt and rotation, thereby maintaining knee kinematics while dampening forces transmitted through the prosthetic composite. From this feasibility study we report promising short-term clinical and radiographic results in the absence of biomechanical failure in complex primary TKA cases. We recommend continuation of the use and further research of the PCK Knee System for complex primary TKA with the ultimate goal of further determining cost effectiveness and intermediate to long-term clinical relevance

Introduction. Long term results of Total Hip Arthroplasty (THA) are affected by wear of articulation. Ceramic on ceramic articulation have been used especially for young patients because of its low wear and bio-inert property. However, because of its hardness, it is concerned that ceramic fracture, chipping, or squeaking might happen with ceramic on ceramic articulation. Objective. The purpose of this study was to investigate over 10-years clinical and radiographic results of ceramic bearing cementless THA. Methods. Evaluation was performed in 60 patients (68 joints) who underwent primary cementless THA from May 2003 to April 2007. Mean age at surgery was 59 years. Mean follow up period was 11.2 years. Forty-nine patients were female. Mean BMI at surgery was 24.0 kg/m. 2. Fifty-one patients had osteoarthrosis, 6 patients had osteonecrosis, 2 patients had rheumatoid arthraitis, and 1 patient had PSS. A 28mm-size femoral head was used in all patients. Clinical evaluation was performed with Japanese Orthopaedic Association Hip Score (JOA score). Radiographic results were evaluated with standard bilateral hip radiograph in supine position. Results. Mean clinical score at surgery was 45 (pain: 13/40, ROM: 12/20, gait: 9/20, ADL: 12/20). Mean clinical score at final follow up was 92 (pain: 39/40, ROM: 17/20, gait: 17/20, ADL: 18/20). Pain score was dramatically improved from 13 to 39 (maximum pain score: 40). One stem was revised because of recurrent dislocation. Two other patients experienced one time dislocation during follow up. One stem showed 5mm of subsidence. ALL cups and stems showed bone ingrowth at final follow up. Cortical hypertrophy was seen in 17 joints. However, there was no patient complained thigh pain. Stress shielding was seen in 55 joints (81%). First, second and third degree of stress shielding were seen in 12, 40, and 3 joints, respectively. Most of the female patients who had surgery at the age over 60 years showed second and third degree of stress shielding. There was no measurable wear. No osteolysis was found around the implants. There were no ceramic fracture, chipping, and squeaking. Conclusion. This study demonstrated excellent clinical and radiographic results of ceramic bearing cementless THA. Excellent long term results will be expected with this system

Introduction. Female gender, old age (men >60y and women > 55y), severe acetabular dysplasia, poor proximal femoral bone geometry, large (>1cm) femoral head cysts, limb-length discrepancy (> 2cm) and small prosthetic head size (less than 50mm for men and less than 46mm for women) are risk factors for hip resurfacing arthroplasty (HRA). Purpose. To present clinical and radiographic results of HRA in patients having risk factors. Patients and methods: A total of 39 HRA was inserted in 33 patients (11 men and 22 women). Birmingham hip resurfacing (Smith & Nephew, UK) was used in 9 hips and Adept (Finsbury, UK) was used in 30 hips. Among the 30 hips inserted Adept, 11 cups were fixed with rim screws. The mean age of the patients at the time of operation was 52 years. The mean weight and height of the male and female patients were 70.4kg and 167cm, 58.5kg and 154.4cm, respectively. The median head size of the male and female patients was 50mm and 42mm, respectively. Preoperative diagnosis was primary osteoarthritis in 6 hips and secondary osteoarthritis due to aceatbular dysplasia (DDH) in 33 hips. Risk factors of HRA were listed for each patient. The Harris hip score and visual analogue pain scale (VAS) were measures of clinical outcome. Radiographic review was performed retrospectively. MRI and CT images were acquired in 29 hips and 2 hips, respectively, at a mean of 4.8 years after HRA to find periprosthetic soft tissue abnormality such as a psedotumor. Kaplan-Meier method was used to calculate implant survivorship. Results. Two hips had no risk factor, whereas 37 hips had at least one risk factor. Risk factors were listed as follows: female gender in 27, old age in nine, severe acetabular dysplasia in 25, poor proximal femoral bone geometry in 11, head cysts in 13, limb-length discrepancy in three and small head size in 21. There were two revisions in two men. One hip was revised because of acute infection. The patient had a risk factor (old age). Another hip was revised because of cup loosening. The patient had two risk factors (severe acetabular dysplasia and small head size). The mean follow-up period for unrevised hips was 5 years (range, 2 to 8 years). The Harris hip score improved from 47.3 points preoperatively to 96.5 points at the latest follow-up (p<0.001). VAS improved from 65 preoperatively to 5 at the latest follow-up (p<0.001). Using revision for any reason as the endpoint, the Kaplan-Meier survivorship was 94.9% at 5years. No implant was loose at the latest radiographic examination. MRI and CT of the hip revealed no pseudotumor. Discussion. In this series, only two patients had no risk factor for HRA. Although majority of our patients were women with acetabular dysplasia and small head size, clinical and radiographic results of HRA were good up to five years (Figs 1 and 2: pre- and post-operative X-ray of 49y women having five risk factors). Conclusion. Clinical and radiographic results of HRA were good in patients who have risk factors

Introduction. We sought to determine the 10-year survivorship of single-radius, posterior-stabilized total knee arthroplasty (TKA) in Asian patients. We also aimed to determine whether the long-term clinical and radiographic results differed between patients with and without patellar resurfacing. Materials and Methods. This retrospective study included 148 (115 patients) consecutive single-radius, posterior-stabilized TKAs. Ten-year survivorship analysis was performed using the Kaplan-Meier method with additional surgery for any reason as the end-point. Furthermore, long-term clinical and radiographic results of 109 knees (74%; 84 patients) with more than a 10-year follow-up were analyzed. Ten-year survivorship and long-term outcomes after surgery were determined, and outcomes were compared between patients with and without patellar resurfacing. Results. Cumulative survival rate of the single-radius posterior-stabilized TKA of 148 knees was 97.7% (95% confidence interval, 93.1%–99.3%) at 10 years after surgery. Three knees had additional surgery during the 10-year follow-up because of one case of instability and two periprosthetic infections. Mean postoperative Knee Society knee score and function score were 97 and 75, respectively. There was no aseptic loosening of the prosthesis, even though a non-progressive radiolucent line was found in 10 (9%) knees. There were no differences in postoperative scores and degree of patellar tilt and displacement between patients with and without patellar resurfacing. Conclusions. Single-radius, posterior-stabilized TKA showed satisfactory long-term clinical and radiographic outcomes in Asian patients regardless of patellar resurfacing, with comparable survivorship to that reported in westerners

Background. The short stem prosthesis showed good results in patients with primary osteoarthritis. However, there were a few studies about the short stem THA in patients with osteonecrosis of the femoral head (ONFH). Objective. To evaluate the clinical and radiographic results of the short stem THA in patients with ONFH. The authors hypothesized that the short stem THA would be a promising procedure for patients with ONFH. Material and Method. The authors reviewed 120 osteonecrotic hips in 93 patients who underwent THA with Metha® short stem from November 2010 to February 2013. The appearance of bone trabeculae development and radiolucent line was reviewed using Gruen's classification. The Harris hip score (HHS) was recorded at 6, 12, 24 and 36 months postoperative for evaluating the clinical results. Results. The mean age of patients was 44.4 years (18–68) with the mean BMI of 22.7 (15.1–32.5, SD 3.5). The average follow-up period was 29.2 months (20–47). The mean HHS was significantly improved from 43.9 (22.7–74, SD 7.7) preoperatively to 97.7 (85.9–100, SD 2.7) at 6 months postoperatively (p<0.01). The radiographic change around the stems showed bone trabeculae development at zone 1 (77 cases)(64.2%), 2 (27 cases)(22.5%), 3 (106 cases)(88.3%), 6 (120 cases)(100%) and 7 (115 cases)(95.8%). There was 1 case (0.8%) of 5 mm subsidence and the radiolucent line was observed in zone 1. There were 6 cases (5%) of intraoperative femoral fractures and were treated with cerclage wires, no further subsidence was observed. There was 1 case (0.8%) of distal stem perforation which had stable bone ingrowth. No revision was required. Conclusion. The clinical and radiographic results of the short stem THA in patients with ONFH are generally satisfactory. Its design enables preservation of the bone stock and the bone trabeculae appear to confirm the assumption of proximal force transmission. The authors believe that the short stem THA is a promising procedure for patients with ONFH

Introduction. The decreased bone mass or local osteoporosis at the proximal femur is often recognized in patients of rheumatoid arthritis (RA). In total hip arthroplasty (THA), the cancellous bone will be lost when rasping technique is applied for the preparation of stem insertion. In addition, cutting or elongation for contracted muscles around the hip joint can be required to insert the stem. To avoid these problems, the non-broaching, non-rasping impaction technique for the stems was applied in THA for the patients with RA. We report clinical and radiographic results of this method. Materials and Methods. In surgery, the femoral neck was cut and prepared without using a box chisel, reamer or broaches, instead, a series of trial stems were used with the method of impaction technique. After impaction of cancellous bone with the final size of the trial stem, the stem is fixed by bone cement without taking any cement mantle. Full weight bearing was allowed for all patients from the next day of the surgery. We investigated short-term clinical and radiographic results and the incidence of complication that was related to this technique. Post-operative radiological results with the minimum follow-up of 12 months after surgery were analyzed in 31 joints (25 cases) with this technique. The mean age at the time of surgery was 66.3 years (46∼82). The mean duration after surgery was 62 months (14∼108). Results. No case showed hypotension, decrease of saturation of oxygen concentration during this technique in surgery. Neither pulmonary embolism nor venous thrombosis of the leg was recognized in those cases. All cases showed good walking performance and did not show any hip and thigh pain at the time of follow up. The preoperative mean HHS score was 32.7 (±12.1) and improved to 79.4 (±11.7) at the time of follow up. Although two cases showed slight subsidence of the stem, no case showed the development of the loosening or any adverse effect such as radiolucent line, breakage of the bone cement, and any migration around the stem at the time of follow up. Conclusion. Although the number of our cases is small and also the follow up period is short, the non-broaching, non-rasping impaction method for stem in THA is thought to be better technique to preserve cancellous bone of the proximal femur, to avoid cutting or elongation of muscles around the hip joint, and to obtain good implant fixation for the patients with osteoporotic proximal femur

Total hip arthroplasty (THA) is frequently performed as a salvage procedure for the acetabular fracture when posttraumatic osteoarthritis, posttraumatic avascular necrosis, or fixation failure with subluxation develop. Special considerations for this situation include previous surgical exposure with dense scar tissue, the type and location of implants, the location and amount of heterotopic ossification, indolent infection, previous sciatic nerve palsy, and the pathoanatomy of existing acetabular defect. These factors can influence the choice of surgical exposure and the reconstructive method. The outcomes of THA after acetabular fracture are generally less favorable than those of the nontraumatic degenerative arthritis. Reason for this high failure is the low mean age and the high activity level of the patient. Other important reasons for failure include the problem of acetabular bone deficiency and compromised bone quality. We evaluated the results of cementless THA in patient who had previous acetabular fracture. We also compared this result with those of patients with posttraumatic avascular necrosis of the femoral head. Forty-five consecutive cementless THAs were performed for the treatment of post-traumatic osteoarthritis after acetabular fracture between December 1993 and December 2008. Of these patients, 15 patients were died or lost to follow-up monitoring before the end of the minimum one year follow-up period. This left 30 patients (30 hips) as the subjects of our retrospective review. We evaluated the clinical and radiographic results of these patients and compared with the results of THA in patients with post-traumatic AVN of the femoral head which had without acetabular damage. Two hips required revision of the cup secondary to early migration of the acetabular cup (1 hip) and postoperative deep infection (1 hip). There was no significant difference in clinical and radiographic results between two groups except implanted acetabular component size and required bone graft (p<0.05). The Kaplan-Meier ten-year survival rate, with revision as the end-point, was 90% and 96.7% with loosening of acetabular component as the end-point. Our series suggested that compared with cemented components, uncemented sockets may improve the results of arthroplasty after previous acetabular fracture. In conclusion, cementless THA following acetabular fracture presents unique challenge to the surgeon, careful preoperative assessment and secure component fixation with proper bone grafting is essential to minimize problems

Introduction. Tibial component loosening is a frequent cause of failure in primary total knee arthroplasty (TKA). Management options include isolated tibial component revision or full component revision. A full component revision is frequently selected by surgeons who are unfamiliar with the existing implant or have a “let's just start over attitude.” This option adds morbidity versus isolated tibial exchange. While isolated tibial exchange has lower morbidity, it is technically more challenging with regard to exposure and maintaining prosthetic stability. This study was designed to compare these two reconstructive options. Methods. Patients revised for isolated aseptic tibial loosening were identified from 2012–2017. Patients with revision implants, or those revised for infection, instability, osteolysis, or femoral component loosening were excluded. 161 patients met these criteria, 85 patients had an isolated tibial revision and 76 had revision of both components despite having only a loose tibial component. Patient demographics as well as clinical and radiographic outcomes were recorded for each cohort. Results. Patient demographical information, including age, gender, and BMI were statistically similar between the two cohorts. Median follow-up was 3.5 years. Supplemental metaphyseal fixation was used in 22 patients in the isolated tibial cohort and 19 of the full revision cohort. There was a higher incidence of radiographic loosening in the full component revision cohort (10.5% vs. 6.0%; p=0.28). There were five failures requiring revision in the isolated tibial cohort, two for sepsis, one for repeat isolated tibial loosening, one for femoral aseptic loosening, and one for an extensor mechanism disruption. There were eight failures in the full component cohort, three for patellar avascular necrosis, two for sepsis, one for repeat tibial loosening, one for arthrofibrosis, and one for a postoperative wound dehiscence. Conclusion. Isolated tibial revision for aseptic tibial loosening has similar clinical and radiographic results when compared to full component revision. Although no intraoperative complications were identified when revising the femur, there is the potential for complications unique to femoral revision. Femoral component revision for isolated tibial loosening is unnecessary and should be avoided provided adequate ligamentous stability can be obtained. Keywords: Aseptic loosening, Tibial loosening, revision total knee replacement, total knee replacement. For figures, tables, or references, please contact authors directly

Aims: Evaluation of: 1/ early clinical and radiographic results of total hip arthroplasty (THA) made by standard lateral direct approach, 2/ early clinical and radiographic results of THA made by minimal lateral approach, 3/ comparison of results of THA in these two groups. Material and methods: Prospective study of 120 THAs (60 cementless and 60 cement) done in 120 patients due to degenerative changes was made. 60 THAs made by minimal lateral approach consist study group. 60 THAs made by direct lateral approach consist of control group. Mean age of 120 patients (98 women and 22 men) was 45 y.o. (range: 32–61 y.o.). Follow-up time in study group was from 6 to 12 months (mean: 8,5 months). Follow-up time in control group was from 10 to 16 months (mean: 10,5 months). Mean preoperative functional status of the study group was 44,5p in Harris hip score. Radiographic evaluation of the results was made according to criteria of Joined Committee of The Hip Society, AAOS and SICOT. Results: Clinical results in 6 months after THA were: 92p. in study group and 88p. in control group. In all 120 cases in both groups radiographic results were very good – there were no differences between control and study group. Incidence of complications were similar in both groups. Conclusions: THA with minimal invasive approach has proved its value in the treatment of hip degenerative changes as regarding short-time results. Clinical and radiographic results of THA made by standard or minimal invasive approaches are comparable. Successful THA with minimal invasive approach is a matter of excellent operative technique and experience with standard hip approaches, and not special instruments

Introduction. Total knee arthroplasty is a highly effective procedure to improve the quality of life in patients with advanced osteoarthritis. The number of these procedures are expected to grow 174% by 2030. This growth rate is expected to economically strain the health care system. A potential solution to alleviate this problem is the utilization of single use instruments (SUI). Potential advantages of SUI include: improved operating room efficiencies, decreased costs associated with traditional instrument management (sterile processing, shipping), and decreased infection risk. The present study examines the clinical results of SUI compared to standard instrumentation. Furthermore, economic modeling is performed to examine the cost savings that is potentially realized with their use. Materials and Methods. 51 patients receiving a TKA with use of SUI were prospectively compared to 49 patients utilizing standard instrumentation. Knee Society Scores and Radiographic alignment will be evaluated. Adverse events will be recorded. Economic modeling of SUI will be performed in 4 different areas: 1. Decreased infection burden; 2. Operating room logistics; 3. Sterile processing savings; and 4. Instrument logistical savings. Results. The average Pre-operative KSS (Objective/Functional) scores were 48.7/41.6 for the SIU patients compared to 50.2/38.7 for the standard instrumentation patients. Post-operative improvements measured 84.0/72.8 and 83.9/76.4 for the 2 groups respectively. The Pre-operative Hip-Knee-Ankle Angle was 176.2 and 177.0 for the 2 groups. The SUI HKA improved to 179.3 while the standard improved to 178.9. There were no statistical differences between the 2 groups. Furthermore, there were no cases of subsidence, migration, loosening, or infection in either group. There were no SUI procedure abandonments. Economic analysis revealed a decreased risk of Infection burden of $28.08/case. Operating room efficiencies include reduced set-up/take-down time and case efficiency savings/case. This averages $348.14/case. Instrument sterilization savings occur by bypassing the central sterile-processing department completely and models to $700/case. Finally, instrument logistics savings include time and money spent organizing/turning over/shipping instrument sets for cases. This estimate is $112.88/case for a total economic value of $1, 189.10/case. Discussion. In summary, the present study confirms that SUI provides similar clinical and radiographic results to standard instrumentation for TKA. Furthermore, SUI offers significant cost savings/case via potential benefits of reduced risk of infection, increased operating room productivity, and significant tray sterilization and loaner instrumentation cost savings

Introduction. Cementless Total Knee Replacement (TKR) was introduced to improve the longevity of implant; but has yet to be widely adopted because of reports of higher earlier failures in some series. The cementless TKR design has evolved recently and we have been using cementless component – both femoral and tibial on our patients. The long follow-up for fully TKR has been scarce in the literature. The purpose of this study isto investigate the minimum of ten years clinical and radiographic result of cementless titanium component and cementless tantalum component in primary TKR. Material & method. From 2008 to 2010 317 TKR underwent primary total knee with cementless femoral component titanium based (Zimmer Nexgen) and cementless tantalum component monoblock tibial component, The surgery was performed mainly on younger patients - average age was 48 yrs old ranging from 26 yrs old to 62 yrs old. All surgeries were performed by single surgeon. All patients were followed clinically and radiographically for a minimum of 8 yrs. Mean 7.8 years and range from 7 to 9 years. The underlying diagnosis for majority of the cases were degenerative arthritis in 97 of the cases and rheumatoid arthritis on the 3%. Result. We have revised 6 cases − 3 cases were for sepsis. They were revised in 2 stages. And we also revised 5 cases for loosening of femoral component. The tibial component revision for aseptic loosening or osteolysis for an end point for survivorship was a 100% for the tibia monoblock design. There was no radiographic evidence of tibial component loosening or subsidence, or migration at the time of the latest follow-up for tibia monoblock. On the femoral part we documented 16 cases other than those 4 revision for osteolysis, where limited osteolysis happened in some area of the tibial component but it did not affect stability and those has been followed up for a longer term. There was interesting phenomena in some of those cases where bone growth happened around the anterior cortex where it sealed the component entirely. Knee society scores improved from 51 pre-operatively to 94 pre-operatively on the last clinical visit. We had 32 cases where the patientswere able to regain their full mobility flexion of over 150 degrees. Conclusion. Our data clearly shows that the cementless TKR has excellent result as compared to the cemented with a good survival ship at 10 years. The tantalum tibial component shows an excellent survivorship. The femoral component also present reasonably good result but we still faced a few cases of loosening. The functional outcome for the implant with the surgery was satisfactory. With this result we strongly recommend using the cementless implant in young patients. We believe that cementless tibial is totally safe at this point as well as the femoral cementless prosthesis. However, we expect some improvement with the outcome with the femoral component when using the tantalum

Introduction. Patients under the age of 50 who undergo a total hip arthroplasty (THA) are at high risk for wear-related complications due to their higher activity level. Previous studies have shown that highly crosslinked polyethylene (HXLPE) is more durable with no evidence of loosening compared to conventional polyethylene due to its improved wear characteristics. Unfortunately, there are few studies with long term follow-up of HXLPE in this patient population. The purpose of this study was to evaluate two questions related to this population of patients undergoing THA. First, what were the clinical outcomes for HXLPE in patients 50 years or younger at an average follow-up of 15 years? Second, was osteolysis observed in any of these hips?. Methods. Between November 1999 and April 2005, 105 THAs were performed for 90 patients 50 years of age or younger (mean, 42 years; range, 20–50 years). The mean body mass index (BMI) was 30 kg/m2 (range, 17–51 kg/m2). The mean follow-up was 15.25 years (range, 12–19 years). Eight patients (two bilateral) were lost to follow-up, which left 82 patients with 95 hips for analysis. HXLPE was the acetabular bearing for all hips. Harris Hip Scores were collected from all patients. Radiographs were obtained on all patients to evaluate for wear and osteolysis. Results. Clinical outcomes show excellent results in 81 hips, good results in ten, fair results in three, and a poor result in one hip using the Harris Hip Score. There have been no revisions, infections, or dislocations in this cohort of patients. Fourteen hips developed radiolucent lines in zone I, II, or III of the acetabulum, but none were circumferential. Two hips developed radiolucent lines in zones I and VII in the femur. None of the hips in our study developed osteolysis. Conclusions. The use of HXLPE in patients under the age of 50 who undergo THA shows excellent clinical and radiographic results at an average of 15 years follow-up

Purpose. Two-stage revision with the removal of all prosthesis has been considered to be the gold standard for treatment of periprosthetic joint infection. However, removal of well-fixed femoral stem is technically challenging and may cause excessive bone loss. The aim of this study was to compare the results between retention and removal of femoral stem when performing two-stage revision total hip arthroplasty for periprosthetic joint infection. Materials & Methods. From 2007 to 2014, ninety-four patients with infection after hip arthroplasty were treated by using two-stage exchange protocol with temporary articulating spacers. Among them, 38 patients completed the planned second stage reimplantation. Stem was exchanged in 15 patients (group I) and retained in 23 patients (group II). We retrospectively investigated the clinical and radiographic results after an average 39.9 months follow up. Results. The rate of infection control was 86.6% (13/15) in group I, 86.9% (20/23) in group II. There were no statistical differences between the two groups in term of demographics or presence of resistant organism. Conclusion. Retention of well-fixed cementless stem during two-stage revision total hip arthroplasty could be alternative treatment option for the treatment of periprosthetic joint infection

Background. No study compared the clinical results of the posterior-stabilized mobile-bearing knee with those of nonposterior-stabilized mobile-bearing knee in the same patients. The purpose of this study was to examine whether the clinical and radiographic results, range of motion, patients satisfaction, and complication rates would be better in the knees with a posterior-stabilized mobile-bearing knee than in the knees with a nonposterior-stabilized mobile-bearing knee. Methods. One hundred and fourteen patients (mean age, 67.9 years) received a nonposterior-stabilized mobile-bearing knee prosthesis in one knee and a posterior-stabilized mobile-bearing knee prosthesis in the contralateral knee. Seven patients were men, and 107 were women. At the time of each follow-up (mean, 7.3 years; range, seven to 7.6 years), the patients were assessed clinically and radiographically. Results. The mean postoperative Knee Society knee score (95 points versus 96 points, p=0.176), Hospital for Special Surgery knee score (92 points versus 93 points, p=0.077), and Western Ontario and McMaster University Osteoarthritis score (21 versus 20 points, p=0.785) were similar between the two group. At the final follow-up, the average range of motion was 27.7° (range, 70° to 150°) in the knees with a nonposterior stabilized mobile-bearing prosthesis and it was 132° (range, 90 to 150 °) in the knees with a posterior-stabilized mobile-bearing prosthesis. Complication rates (2.6% versus 1.8%) were similar between the two groups. The estimated survival rate was 97.4% at eight years with an overall revision rate of 2.6% (three of 114 knees) in the nonposterior-stabilized mobile-bearing prosthesis group and 98.2% at eight years with an overall revision rate of 1.8% (two of 114 knees) in the posterior-stabilized mobile-bearing prosthesis group. Conclusions. After a minimum duration of follow-up of seven years, we found no significant differences between the two groups with regard to the clinical and radiographic results, or patient satisfaction, or complication rate. However, the posterior-stabilized mobile-bearing prosthesis group had a greater range of knee motion than the nonposterior-stabilized mobile-bearing prosthesis group