Despite considerable legacy issues, Girdlestone's Resection Arthroplasty (GRA) remains a valuable tool in the armoury of the arthroplasty surgeon. When reserved for massive lysis in the context of extensive medical comorbidities which preclude staged or significant surgical interventions, and / or the presence of pelvic discontinuity, GRA as a salvage procedure can have satisfactory outcomes. These outcomes include infection control, pain control and post-op function. We describe a case series of 13 cases of GRA and comment of the indications, peri, and post-operative outcomes.

We reviewed all cases of GRA performed in our unit during an 8 year period, reviewing the demographics, indications, and information pertaining to previous surgeries, and post op outcome for each. Satisfaction was based on a binary summation (happy/unhappy) of the patients’ sentiments at the post-operative outpatient consultations.

13 cases were reviewed. They had a mean age of 75. The most common indication was PJI, with 10 cases having this indication. The other three cases were performed for avascular necrosis, pelvic osteonecrosis secondary to radiation therapy and end stage arthritis on a background of profound learning disability in a non-ambulatory patient. The average number of previous operations was 5 (1-10). All 13 patients were still alive post girdlestone. 7 (54%) were satisfied, 6 were not. 3 patients were diabetic. 5 patients developed a sinus tract following surgery.

With sufficient pre-op patient education, early intensive physiotherapy, and timely orthotic input, we feel this procedure remains an important and underrated and even compassionate option in the context of massive lysis and / or the presence of pelvic discontinuity / refractory PJI. GRA should be considered not a marker of failure but as a definitive procedure that gives predictability to patients and surgeon in challenging situations.

Resurfacing arthroplasty of the hip is a relatively new procedure. This paper reports the technical and clinical problems one surgeon encountered in the first 50 consecutive resurfacing arthroplasties of the hip. The mean age of the 14 women and 32 men at the time of surgery was 44.8 years (20 to 65). Four patients underwent bilateral arthroplasty. Technical problems included failure of the acetabular component to seat fully in six hips and failure of the femoral component to seat fully in four. There was varus malalignment of the femoral component in three cases, retention of the alignment pin in one, and retention of a cable fragment in one. Surgical complications included one case of intra-operative femoral neck fracture, one transection of the psoas tendon during capsulotomy, and a femoral nerve palsy, which recovered after six months. Postoperative problems included superficial wound inflammation in five hips and one dislocation. There were radiological signs of impingement of the femoral neck on the acetabular rim in four cases and clinical symptoms of impingement in one. An undisplaced fracture of the femoral neck that occurred eight weeks after surgery was successfully managed conservatively by keeping the limb non-weight-bearing. Despite these problems, only one patient retains any noteworthy symptoms, apparently due to impingement of the femoral neck on the acetabular rim. Modest malalignment or seating failure appears to be of minimal clinical consequence. Patients typically mobilise rapidly and are able to return to a high level of physical activity. It is possible to avoid most technical problems by taking specific precautions

Fourteen hips with osteoarthritis had femoral head blood flow measured with laser Doppler flowmeter while undergoing during total hip replacement through a modified lateral approach. Mean age sixty-five years (48–77); eight males & six females. Two measurements were taken within the femoral head one after anterior hip dislocation and one after simulated notching of the femoral neck. All hips had a significant decrease in blood flow with a median percentage decrease of 76% (range 4.4–90.4). During surface arthroplasty of the hip, notching of the femoral neck may not only mechanically weaken the bone but also put the femoral head at risk of osteonecrosis. To evaluate femoral head blood supply in patients with osteoarthrtis of the hip undergoing simulated notching of the femoral neck during total hip replacement and its potential implications in hip resurfacing. During surface arthroplasty of the hip, notching of the femoral neck may not only mechanically weaken the femoral neck but also put the femoral head at risk of osteonecrosis and subsequent femoral loosening. It would appear that the retinacular vessels (extraosseous blood supply) are as important in the arthritic femoral head as they are in the nonarthritic state, contradicting the notion that arthritic femoral heads in humans rely mainly on an intraosseous blood supply. Fourteen hips with a diagnosis of degenerative arthritis had femoral head blood flow measured with laser Doppler flowmeter while undergoing during total hip replacement through a modified lateral approach. With the femoral head exposed and leg in neutral position, a 3.5mm drill hole was made into the anterior lateral quadrant and the fiber optic probe of the laser Doppler flowmeter (Moor Instruments, Wilmington Delaware, 20mW laser, wavelength 780nm) was inserted. Mean age was sixty-five years (48–77). Eight males and six females. Two measurements were taken one after anterior hip dislocation and one after simulated notching of the femoral neck. All but four hips had a significant decrease of more than 50% in blood flow after neck notching with a median percentage change of 76% (range 4.4–90.4), p< 0.001

Introduction: ‘Revisability’ has been touted as one of the major advantages of resurfacing arthroplasty of the hip. However, this theoretical advantage has never been clearly demonstrated. The objective of the present study was to test the hypothesis that a failed, modern generation metal-on-metal resurfacing arthroplasty (MMRA) can be converted to a total hip (THA) as easily and with comparable results as a primary (THA). Methods: Twenty-two failed MMRA’s in 21 patients with an average age of 49.5 years (23 – 72 years) were converted to a THA. In 18 hips, the acetabular component was retained, and in 4 hips both components were revised. The control group of primary THA’s, implanted during the same time period by the same surgeon, consisted of 64 patients with an average age of 50.8 years (27 – 64 years). Results: There was no significant difference in operative time, blood loss and complication rates between the conversions and the controls. The average follow-up was 47 months (12 – 113 months) for the conversions and 57 months (24 – 105 months) for the controls. Clinical outcomes measures were comparable with average Harris Hip Scores of 92.7 and 90.3 for the MMRA conversions and primary THA’s, respectively. The UCLA activity scores were 6.6 and 6.4 in the conversion group and THA group, respectively. There have been no cases of aseptic loosening of the femoral or acetabular components in either group, and there have been no dislocations after MMRA conversion. Conclusion: Conversion of failed MMRA to a THA appears to be as safe and effective as a primary THA

Aim

Analysis of microbiological spectrum and resistance patterns as well as the clinical outcome of patients who underwent a Debridement, antibiotics and implant retention (DAIR) procedure in the early phase following failed two-stage exchange arthroplasty of the knee and hip.

We report a surgical technique for arthroplasty of the deformed hip after poliomyelitis. A fifty three year old man presented to our unit with a long-standing history of hip problems since contracting poliomyelitis at the age of two. Unusually, both of his hips were affected. He had been operated on twice for his right hip. This had left him with a deformed upper femur with significant shortening. The right hip was sub-luxed on presentation; this was due to a markedly dysplastic acetabulum. The polio and subluxation meant his muscles were weak and stretched. Like other authors, we were keen to achieve a stable hip. The senior author felt that a fully constrained socket would carry the following disadvantages:. Reduced range of movement. It would be difficult to fit a constrained socket into the small amount of pelvic bone available. Constrained sockets are more likely to loosen. An alternative approach, using a large diameter unconstrained metal on metal articulation, was employed; stability was achieved with the large head and the relatively small socket still preserved bone stock. The components chosen were a 52mm MMT, Birmingham acetabular resurfacing prosthetic, articulating with a 46mm chromium cobalt head. A fluted stem CAD CAM (computer aided design, computer aided manufacture) femoral prosthesis was used, as he needed to fully weight-bear from the outset, because of the weakness in his left leg. He has a good, pain-free range of movement. This represents a novel solution for arthroplasty in hips surrounded by weakened musculature. It avoids dramatic limitation of movement whilst minimising the bone stock loss and risk of dislocation. The patient is delighted with the medium term results

Ninety-four hips with a mean patient age 34.2 (range 15– 40) with a metal/metal surface arthroplasty (SA) were reviewed with 71% men and 14% with previous surgery. The Chandler risk index was calculated as well as the SA risk index (SARI). At a mean follow-up three years, three hips were converted at a mean of twenty-seven months (two to fifty), and ten patients had significant radiological changes. Mean SARI for the thirteen problematic hips versus remaining hips was significantly higher, 4.7 and 2.6, respectively (p=0.00). If SARI > 3 the relative risk of early problems is twelve times greater than if SARI ≤3. The purpose of this study was to evaluate the early outcome of a hybrid metal on metal surface arthroplasty of the hip in patients forty years and younger and identify potential risk factors. Surface Arthroplasty Risk Index can help identify patients who may be at increased risk of early failure following metal on metal surface arthroplasty. Proper patient selection and careful surgical technique may minimize early failures with the re-introduction of surface arthroplasty of the hip. Ninety-four hips mean age 34.2 (range 15– 40) with metal/metal surface arthroplasty (SA) were reviewed with 71% men and 14% with previous surgery. The Chandler risk index was calculated and SA risk index (SARI). Mean follow-up three years (range 2–5), three hips were converted at a mean of twenty-seven months (2–50), and ten patients had significant radiological changes. Mean SARI for these thirteen problematic hips versus remaining hips was significantly higher, 4.7 and 2.6, respectively (p=0.00). The mean angle between the prosthesis stem and femoral shaft in the problematic group was significantly smaller than the remaining hips (p=0.03): 133° and 139°, respectively. If SARI > 3 the relative risk of early problems is twelve times greater than if SARI ≤3

Aims. Cementing in arthroplasty for hip fracture is associated with improved postoperative function, but may have an increased risk of early mortality compared to uncemented fixation. Quantifying this mortality risk is important in providing safe patient care. This study investigated the association between cement use in arthroplasty and mortality at 30 days and one year in patients aged 50 years and over with hip fracture. Methods. This retrospective cohort study used linked data from the Australian Hip Fracture Registry and the National Death Index. Descriptive analysis and Kaplan-Meier survival curves tested the unadjusted association of mortality between cemented and uncemented procedures. Multilevel logistic regression, adjusted for covariates, tested the association between cement use and 30-day mortality following arthroplasty. Given the known institutional variation in preference for cemented fixation, an instrumental variable analysis was also performed to minimize the effect of unknown confounders. Adjusted Cox modelling analyzed the association between cement use and mortality at 30 days and one year following surgery. Results. The 30-day mortality was 6.9% for cemented and 4.9% for uncemented groups (p = 0.003). Cement use was significantly associated with 30-day mortality in the Kaplan-Meier survival curve (p = 0.003). After adjusting for covariates, no significant association between cement use and 30-day mortality was shown in the adjusted multilevel logistic regression (odd rati0 (OR) 1.1, 95% confidence interval (CI) 0.9 to 1.5; p = 0.366), or in the instrumental variable analysis (OR 1.0, 95% CI 0.9 to 1.0, p=0.524). There was no significant between-group difference in mortality within 30days (hazard ratio (HR) 0.9, 95% CI 0.7to 1.1; p = 0.355) or one year (HR 0.9 95% CI 0.8 to 1.1; p = 0.328) in the Cox modelling. Conclusion. No statistically significant difference in patient mortality with cement use in arthroplasty was demonstrated in this population, once adjusted for covariates. This study concludes that cementing in arthroplasty for hip fracture is a safe means of surgical fixation. Cite this article: Bone Jt Open 2023;4(3):198–204

In the last months of 2007 we started to retrospectively review 60 patients who had undergone Girdlestone resection arthroplasty of the hip between 1994 to 2006. The most frequent indications for this procedure were sepsis around prosthesis, aseptic loosening, pseudoartrhosis after femoral neck fractures or medical compromised patients who had an high risk of hip reimplantation procedure. The evaluation of patient’s satisfaction ranges a lot in literature and no valid guidelines have been publicated. All our patients were submitted to limb shortening measurement and functional evaluation according to SF-36 score and Harris Hip Score. There were 20 men and 40 women with an average age of 70 years old (range 96-43 years old on operation time), the mean follow up was 133 months (range 14–167 months). Some patients were lost at the follow-up, the main reason was death for related and unrelated causes (overall mortality of 30%). The aim of this study was to analyze patient’s satisfaction and functional outcomes after Girdlestone arthroplasty which appears in our experience, despite the limits, a valid surgical option in order to improve hip function, decrease or cancel pain and control infections when implantation or reimplantation is not possible

This study examines patient characteristics, indications for conversion, surgical and anaesthetic technique, peri-operative management and complications of surgery in this small and challenging group of patients. In the six years from 1994 to 1999, 33 conversion arthroplasties were performed for failed femoral hemiarthroplasty. The average age at conversion surgery was 75.5 years (range 65–90). The female to male ratio was 6:1. Primary hemiarthroplasties comprised 24 Austin-Moore, 6 Thompson & 3 Bipolar prostheses. The average interval from primary to conversion surgery was 50 months (6 months to 17 years). The average age at primary surgery was 71.2 years (62–88) – AMP:71.4 years, Thompson’s: 74.2 years, Bipolar: 63.5 years. All hemiarthroplasties were performed for fractured femoral necks. 62% of patients came from the Eastern Health Board area, while 38% were tertiary are referrals from other Health Boards. The average length of stay was 17.5 days (3–24). Indications for conversion included gross loosening/acetabular erosion in 9 cases, suspected infection in 4 cases and abscess/septicaemia in 1 case. All but 3 patients had significant pain (night pain etc.) and/or severely impaired mobility.

We also looked at anaesthetic and analgesic practice, surgical technique and prostheses used.

Post-operatively, mean total blood loss was 1430 ml (420–2280) with an average of 1.4 units of blood transfused (0–5). Intraoperative complications included acetabular & femoral perforation, periprosthetic fracture and cement reactions. Complications post-op (in hospital) included cardiac arrhythmia’s, cerebrovascular accidents, pulmonary embolus, myocardial infarct, respiratory & urinary tract infections, constipation, nausea & vomiting.

The elderly nature of these patients and the physiological stress of what is major surgery allied with multiple co-morbidities make their care especially challenging. A conversion arthroplasty is a procedure with a significant risk of considerable morbidity. Primary total hip replacement or bipolar hemiarthroplasty are options which, therefore, should be seriously considered in the case of fractured femoral necks to minimise the need for further surgery in the future, with all its attendant risks.

In addition to “conventional” total hip replacement with cemented or cementless stems more recently different implant designs have been proposed by Orthopaedic Surgeons in Europe and US. Especially surface replacement and short stem prosthesis are believed to overcome the disadvantages of conventional THR in younger patients.

The symposium “MINIMAL DEVICE OR REPLACEMENT FOR THE HIP” is trying to summarize current implant philosophies and to review critically the available data of functional as well as radiographic outcome.

In a study of 76 consecutive hip resurfacing arthroplasty procedures, the reasons for choosing this procedure rather than total hip arthroplasty (THA) were reviewed. Patient age, preoperative diagnosis, presence of bone deficiency and other technical factors were considered.

The mean age of patients, 79% of whom were men, was 44 years (20 to 76). The preoperative diagnosis in 59% of patients was osteoarthritis and in 37% avascular necrosis. The decision to resurface the hip rather than to perform THA was influenced primarily by the patient’s choice. In 43 cases (57%), the patient had prior knowledge of the procedure and specifically that it be considered. Other important considerations were the patient’s level of physical activity, the expectation of non-compliance with mobilisation and rehabilitation, the expectation of instability of the hip, the quality of bone and the surgeon’s experience with the surgical technique.

As experience of the procedure grew, the mean age of patients who underwent resurfacing arthroplasty increased. The early clinical results of resurfacing indicate that the range of motion is less than in hip replacement, that the resurfaced hip demands less care against dislocation or wear, and that the patient mobilises and rehabilitates more rapidly and reaches a higher level of physical ability than with THA. As mid-term and long-term results become available, the indications for and prevalence of hip resurfacing arthroplasty are likely to increase.

Administration of perioperative antibiotic prophylaxis (AP) reduces the risk of prosthetic joint infection (PJI) following primary total hip (THA) and knee (TKA) arthroplasty. The optimal type of antibiotic used, and duration of prophylaxis are subject to debate. We compared the risk of revision surgery for PJI in the first year following THA and TKA by AP regimen. A national survey collecting information on hospital-level AP regimen policy was conducted across the Netherlands and linked to data from the LROI arthroplasty registry for 2011–2015. PJI status was defined using the surgical indication reported at revision by surgeons in the registry form. Restricted cubic splines Poisson model adjusted for hospital clustering were used to conduct the comparisons on 130,712 THAs and 111,467 TKAs performed across 99 institutions. These included 399 THAs and 303 TKAs revised for an indication of PJI. Multiple shot of Cefazolin (MCZ), of cefuroxime (MCX) and single shot of Cefazolin (SCZ) were respectively administrated to 87%, 4% and 9% of patients. For THA, the rates of revision for PJI were respectively 31/10,000 person-years 95%CI[28, 35], 39[25, 59] and 23[15, 34] in the groups which received MCZ, MCX and SCZ; respectively, the rates for TKA were 27[24, 31], 40[24, 62] and 24[16, 36]. No evidence of difference between AP regimens was found in the unadjusted and adjusted model (age, gender, BMI and ASA grade). Further work is advocated to confirm whether there is an association between AP regimen collected at patient-level and the risk of subsequent revision for PJI.

The purpose of the present study was to analyze the-clinical and radiographic factors which determine the enduring fixation of metal on metal hybrid surface arthroplasty. The first 500 hips (in 436 patients) of a consecutive series of over 700 Conserve® plus were reviewed clinically and radiographically. The patients were 48.6 years-old in average, 74% were male and the dominant etiology was idiopathic osteoarthritis (64.6%). All femoral components were cemented but the femoral metaphyseal stem was cemented in 112 hips and press-fit in the remaining 388. Average follow-up was 4.8 years (range, 2.7 to 7.8 years). Eighteen hips were converted to a THR, 11 of them for aseptic loosening of the femoral component at an average follow-up of 40.5 months. Put in positives mention fx and loose incidence, survor ship details of loose and fx for other At last review, 14 hips presented metaphyseal stem radiolucencies and 16 hips (3.2%) showed a narrowing of the neck of 10% or more at the interface with the femoral component. None of the components with cemented stems showed femoral radiolucencies, neck narrowing, or were revised for aseptic loosening. Cementing the femoral stem significantly (p = 0.013) reduces the chances of early femoral failure or appearance of a metaphyseal stem radiolucency. Risk factors for loosening or radioluciences included cysts > 1 cm, small femoral head size, female gender, early cases (before improved acrylic fixation including femoral suctioning measures were instituted) and reduced stem shaft angle. Metal-on-metal surface arthroplasty provides a stable, bone conserving, low morbidity and wear resistant prosthetic solution well suited for young and highly active patients

Introduction and Aims: The purpose of this study was to validate in a clinical series a method to measure femoral component migration in surface arthroplasty based on the principles of EBRA-FCA.

Method: The first 400 hybrid MMSA in 355 patients have an average of 3.5 years follow-up (range two to six years). The average age was 48 years, 73% were men and 35% had secondary osteoarthritis. All patients were evaluated prospectively at three months and then yearly. We reviewed the x-rays of 26 hips that had undergone metal-on-metal resurfacing using EBRA-FCA. Minimum follow-up was 3.5 years. Group 1was free of any clinical or radiographic signs of loosening (17 hips); group 2 had failed from femoral component aseptic loosening (nine hips). Mean age for the whole group was 50.7 years (28–67). Sixty-six percent were male and 63% were operated for osteoarthritis. We recorded migrations of 2mm or greater and the time to initiation of migration.

Results: Group 2 showed significantly greater migration than group 1, respectively: 4.57 mm versus 1.62mm for centre of the head (p=0.005), 4.51mm versus 1.05mm for stem tip (p=0.001). Initial migration was significantly sooner in group 2 versus group 1: 19 months versus 29.2 months (p=0.030). In group 2, the average time to first migration detected with EBRA-FCA was significantly less than time to first clinical symptoms: 19 months versus 29.5 months (p=0.003). More importantly, the time to detection of significant migration was shorter than the time to detection of the first metaphyseal stem radiolucency: 19 months versus 24.3 months (p=0.028).

Conclusion: EBRA-FCA represents a reliable tool to measure migration of femoral component, which may become essential in the assessment of the clinical performance of MMSA. It is best used in large clinical series with standardised x-ray technique and limiting the number of observers.

Introduction

It was the purpose to evaluate the biomechanical changes that occur after optimal and non-optimal component placement of a hip resurfacing (SRA) by using a subject specific musculoskeletal model based on CT-scan data.

Minimally invasive approaches to the hip may be divided into two categories: single mini-incisions derived from standard approaches and two-incision approaches designed specifically for minimally invasive total hip replacement. The authors have a number of specific concerns about the latter based on its apparent transgression of basic surgical principles and favour a mini-lateral approach to the hip which they describe and review.

The two-incision approach requires two short (2–5cm) incisions from two different directions. Unlike other minimally invasive techniques, these incisions run close to the major neurovascular structures, which have been damaged. Visibility is limited as demonstrated by the need for navigation systems and illuminated retractors by some groups. Accurate resection of the femoral neck is obscured by the presence of the femoral head. Precise siting of the socket may be compromised by poor visibility. Most series accomodate only the use of uncemented components. Claims for more rapid mobilisation appear to depend more on anaesthetic rather than surgical technique.

We have developed the mini-lateral approach to the hip, in parallel with others, over the last five years. It is a scaled-down version (< 10cm) of the Hardinge approach which has been used successfully for 25 years. It relies on a precise appreciation of the regional anatomy requires no additional equipment and avoids the problems posed by the two-incision approach. A short video presentation will be given.

We present a consecutive retrospective series of 99 patients having 103 cemented C-stem THA for OA over a three-year period. Patients were assessed for duration of surgery, blood loss and length of postoperative stay. At follow-up (mean 18/12) they were assessed using the Oxford Hip Score, radiographic analysis and their incisions were measured. No hips have been revised and none are considered to be at risk. No nerve or vascular injuries have been reported.

The ultimate goal for treatment of osteonecrosis of femoral head (ONFH) is preserving the femoral head. We have tried to manage the patient who received failed joint preserving procedures with resurfacing arthroplasty if they fit the indicati385on. In this brief review, we wanted to clarify the role and technical concern of resurfacing arthroplasty as a salvage procedure after failed joint preserving operations for ONFH. Among 556 hips underwent resurfacing arthroplasty from September 1998 to October 2007, sixteen resurfacing arthroplasties (13 patients) were performed after failed joint preserving procedures for ONFH. Mean age at the operation was 39 years old. Seven vascularized fibular grafts, 3 multiple drillings, 3 core decompressions and 3 combined procedures were performed as initial operations. Mean duration from the index operation and resurfacing was 95 months. Mean follow up was 14 months. The patients were clinically evaluated with the Harris hip score, hip or thigh pain, and range of motion. As a radiological evaluation, we measured positions of the acetabular cup and femoral stem, radiographic changes at the neck and complications. The Harris hip score increased from 69.2 preoperatively to 89.5 at the final visit. Hip range of motions other than sagittal directions significantly improved after the operation. No patient complained of limb length discrepancy. One patient complained of unexplained hip pain, and another patient had trochanteric pain. Other than those two cases, all patients regained their pre-morbid activity level uneventfully. Radiologically, eleven femoral stems in anteroposteior and lateral radiographs were exactly aligned along the previous operative tracts. However, there were no clinical complications related to the position of femoral component. The only case that the acetabular cup was implanted in high inclination (60 degrees) experienced sustained unexplained hip pain. There was no another complications. Our experience suggests that even for the case of failed hip preserving procedures in ONFH, resurfacing arthroplasty can play a successful role as a salvage operation. Furthermore, this can be an excellent alternative between joint preserving procedures and conventional THA

The 3D interplay between femoral component placement on contact stresses and range of motion of hip resurfacing was investigated with a hip model. Pre- and post-operative contours of the bone geometry and the gluteus medius were obtained from grey-value CT-segmentations. The joint contact forces and stresses were simulated for variations in component placement during a normal gait. The effect of component placement on range of motion was determined with a collision model. The contact forces were not increased with optimal component placement due to the compensatory effect of the medialisation of the center of rotation. However, the total range of motion decreased by 33%. Accumulative displacements of the femoral and acetabular center of rotation could increase the contact stresses between 5–24%. Inclining and anteverting the socket further increased the contact stresses between 6–11%. Increased socket inclination and anteversion in combination with shortening of the neck were associated with extremely high contact stresses. The effect of femoral offset restoration on range of motion was significantly higher than the effect of socket positioning. In conclusion, displacement of the femoral center of rotation in the lateral direction is at least as important for failure of hip resurfacings as socket malpositioning.

Introduction

Wear of the ultra high molecular weight polyethylene (UHMWPE) cup and the resulting loosening has been shown to limit the long-term results of the Charnley low-frictional torque arthroplasty (LFA). Factors affecting wear rates have been studied: level of patient activity, effective roughness of the stainless steel head, impingement and the possible variations in wear characteristics of UHMWPE. Since patients' activity level cannot be predicted or modified, alternative materials were examined.