Background. The knowledge about the common mode of failure and each period in primary and revision TKAs offers useful information to prevent those kinds of failure in each surgery. However, there has been limited report that simultaneously compared the mode of failure between primary and revision TKAs using single prosthesis. We compared the survival rate, mode of failure, and periods of each mode of failure between primary and revision TKAs. Methods. A consecutive cohort of 1606 knees (1174 patients) of primary TKA and 258 knees (224 patients) of revision TKA using P.F.C® prosthesis was retrospectively reviewed. The mean follow-up periods of primary and revision TKAs were 10.2 and 10.8 years, respectively. We compared the above variables between primary and revision TKAs. Results. The average 5-, 10-, 15-year survivor rate of primary TKA were 99.1% (CI 95%, ±0.3%), 96.7% (CI 95%, ±0.7%), and 85.4% (CI 95%, ±2.0%). They were 97.8% (CI 95%, ±1.0%), 91.4% (CI 95%, ±2.5%), and 80.5% (CI 95%, ±4.5%) in revision TKA. The common mode of failure included polyethylene wear, loosening, and infection in both primary and revision TKAs. The most common mode of failure was polyethylene wear in primary TKAs and infection in revision TKAs. The mean periods of polyethylene wear and loosening were not significantly different between primary and revision TKAs, but the mean period of infection was significantly long in revision TKA (4.8 years vs. 1.2 years, p=0.003). Conclusions. The survival rate decreased with time, especially after 10 years in both primary and revision TKAs. The continuous efforts are required to prevent and detect various modes of failure during the long-term follow-up after primary and revision TKAs. More careful attention is necessary to detect the late infection as a mode of failure after revision TKA. Level of Evidence. Level III, Therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence

Unicompartmental knee replacements (UKRs) have inconsistent and variable survivorships reported in the literature. It has been suggested that many are revised for ongoing pain with no other mode of failure identified. Using a medial UKR with an all-polyethylene non-congruent tibial component from 2004–7, we noted a revision rate of 9/98 cases (9.2%) at a mean of 39 months. Subchondral sclerosis was noted under the tibial component in 3/9 revisions with well fixed implants, and the aim of this study was to investigate this as a mode of failure. 89 UKRs in 77 patients were investigated radiographically (at mean 50 months) and with SF-12 and Oxford Knee scores at mean follow up 55 months. Subjectively 23/89 cases (25%) had sclerosis under the tibial component. We describe a method of quantifying this sclerosis as a greyscale ratio (GSR), which was significantly correlated with presence/absence of sclerosis (p<0.001). Significant predictors of elevated GSR (increasing sclerosis) were female sex (p<0.001) and elevated BMI (P=0.010) on both univariate and multivariate analysis. In turn, elevated GSR was significantly associated with poorer improvement in OKS (p<0.05) at the time of final follow up. We hypothesise that this sclerosis results from repetitive microfracture and adaptive remodelling in the proximal tibia due to increased strain. Finite element analysis is required to investigate this further, but we suggest caution should be employed when considering all polyethylene UKR implants in older women and in those with BMI >35

Introduction. In the early 2000s hip resurfacing became an established bone conserving hip arthroplasty option particularly for the fit and active patient cohort. The performance of second-generation metal-on-metal bearings had led to the reintroduction of hip resurfacing. The Birmingham Hip resurfacing (BHR) was introduced in 1997. This was followed by a number of different designs of the hip resurfacing. The Durom hip resurfacing was introduced in 2001. These two designs had different metallurgical properties, design parameters particularly clearance and different implantation techniques. Data from joint registries show that both prosthesis perform well. Objectives. Our objective was to perform a retrospective survival analysis comparing the Birmingham to the Durom hip resurfacing and analyse the mode of failures of the cases revised. Methods. Data was collected prospectively but analysed retrospectively. The two cohorts comprised patients treated by two senior surgeons at different units. The follow up range was 1 to 14 years with a mean of 10 years. The end-point was revision for any cause. However this was further substratified. Results. The outcome of all patients was known. The two cohorts exhibited no significant difference in demographics. No failures in either cohort were attributed to adverse reaction to metal debris. Revision for any cause was analysed by plotting Kaplan-Meier Survival curves. The Durom cohort (n=273) had 5 deaths and 9 revisions. The Birmingham cohort (n=567) had 5 deaths and 22 revisions. The Kaplan-Meier survival curves for the two resurfacing designs were different. The Durom cohort demonstrated a concave curve with more early failures. This was contrary to the BHR's convex curve with higher incidence of late failures. We analysed the data by substratifying into failure of femoral or acetabular component and neck fractures. Conclusions. The Kaplan-Meier survival analysis demonstrates that the Durom hip resurfacings had a higher rate of early failure. However extrapolation of the curves suggests that the Durom may have a superior long term survival compared to the BHR. We postulate that this may be due to the femoral implantation technique with less late failures in Duroms and an apparent acceleration of failures in BHR cohort around the ten year stage. Joint registry data also reflect this pattern

Aim. Cementless prosthesis is one of the major bone-implant interface fixation methods in total joint replacement. Grit blasted surface, hydroxyapatite coated surface and plasma sprayed metallic porous coating have been popularly used. The latter has demonstrated higher bone implant mechanical stability in previous laboratory study in early and middle stages. However, question remains what the mechanism is to make it performing better and how to improve them further. This study is designed to examine the mode of failure in bone-implant interface in a sheep model. Method. Plasma sprayed porous coated (TiPL); hydroxyapatite (HA) coated and and grit blasted (TiGB) titanium implants were examined in the study. Each type has 36 specimens. Implants were inserted into cortical bones in a press-fit fashion in a total of 22 sheep bilateral hind limbs. Specimens were retrieved at 4 weeks and 12 weeks. Push- out testing was performed to just reach ultimate failure. Failed bone-implant interface were investigated by histology and BSEM. The percentage of failure at bone-coating interface, bone itself fracture, coating itself failure, and coating-substrate dissociation were measured by BSEM. Results. In TiPL group, failure occurred mainly at new bone itself on ingrowing new bone and adjacent bone, with 74% at 4 weeks, and 82% at 12 weeks. The percentages were significantly higher than that of the failure at bone-porous coating dissociation. Furthermore, the percentage of failure occurred at bone was also higher in TiPS group than in the other groups at both time points. In HA group, the main proportion of failure, 69%, occurred at bone-HA dissociation at 4 weeks, higher than the 25% at bone itself fracture. 57% of failure occurred at HA-substrate dissociation at 12 weeks, which was followed by HA coating itself breakage (Figure 1). Bone itself fracture has the lowest proportion of only 4% breakage at 12 weeks. HA coating revealed micro cracks at some area although not all of them were failed. In TiGB group, failure mainly occurred at bone-implant surface dissociation at both time points. Conclusion. The failure mode at the HA and TiGB groups demonstrate that new bone was less likely to break, or stronger, than bone-implant surface interface at early stage, and new bone at middle stage was stronger than the other interfaces. The bone ingrowth to metallic porous coating results in that major proportion failure has to occur at bone anchorage, either at the entry level or at adjacent bone. The anchorage is the reason why TiPS has higher mechanical shear strength in previous study. Improving bone itself remodelling or maturing process may increase the porous coated implant in vivo mechanical strength; improving HA quality and HA-substrate adhesion may enhance HA coated implant performance; and improving bone implant surface bonding may strengthen grit blasted implant mechanical stability

Early failure of metal-on-metal (MoM) total hip replacements (THR) is now well established. We review 93 consecutive patients with CPT¯ stems MoM THR. Our series demonstrates a new mechanism of failure, which may be implant combination specific.

Between January 2005 and June 2009, 93 consecutive MoM total hip replacements were preformed using CPT stems by 3 surgeons at our unit. 73 CPT¯ stems, Metasul¯ Large Diameter Heads (LDH) with Durom¯ acetabulae and 20 CPT¯ stems, Metasul¯ 28mm diameter heads in Allofit¯ shells (zimmer). Clinical outcomes were collected prospectively before surgery, at 3 months, 1 year, 2 years, 3 years, and at 5 years post surgery. Revision for any cause was taken as the primary endpoint and the roentgenograms and explanted prostheses were analyzed for failure patterns.

In the LDH/Durom¯ group a total of 13 (18%) patients required revision (figs. 1) at a median of 35 months (range 6-44). 6 (8%) for periprosthetic fracture. All 6 periprostethic fractures were associated with minimal or no trauma and all had ALVAL identified histologically.

To date there have been no failures in the CPT¯/28mm head Allofit¯ group. Several failures demonstrated bone loss in Gruen zones 8 ± 9 ± 10 (fig. 2).

We demonstrate an unacceptably high rate of failure in CPT¯ MoM LDH hip replacements, with a high failure secondary to periprosthetic fracture and postulate a mechanism associated with local toxicity to metal ions. We strongly advise against this combination of prosthesis.

Aims. Retrospective review of a consecutive series of 1,168 total ankle replacements (TAR) performed at Wrightington, to analyse modes of failure and clinical outcomes following TAR failure. Methods. All patients undergoing TAR between November 1993 – June 2019 were collated (4–25 year follow-up; mean 13.7 years). 6 implants were used (300 STAR, 100 Buechal Pappas, 509 Mobility, 118 Zenith, 41 Salto and 100 Infinity). 5 surgeons, all trained in TAR, performed the surgery. Modes of failure were collated and clinical and radiological outcomes recorded for the revisional surgery following failure of the TAR. Results. 156 (13.4%) TARs failed (47STAR 15.6%, 16BP 16%, 77Mobility 15.1%, 6Salto 14.6%, 10Zenith 8.5% and 0Infinity 0%). Mean time to failure 5.8 years (0.1- 21.4 years). The 4 most common modes of failure were 44.9% aseptic loosening, 11.5% gutter pain, 10.9% infection and 10.3% recurrent edge loading. 50 underwent conversion to tibiotalocalcaneal (TTC) fusion with nail with 9 (18%) failing to fuse. 31 underwent revision TAR with 2 (6.5%) subsequently failed. 22 underwent ankle fusion with 10 (45%) failing to fuse. 21 underwent polyethylene exchange of which 8 (38%) had further poly failure. 20 (12.8%) were managed conservatively, 2 (1.3%) required below knee amputation and 6 were listed but lost to follow-up. 81 of the 1168 (7%) consecutive cohort were lost to follow-up. Conclusions. 13.4% of the TAR cohort have failed at average follow-up 13.7 years. There was no difference in failure modes across the implant designs. Whilst the fixed bearing has the shortest follow-up, it may be performing better as there have been no failures so far. Prior to October 2016, most revisions were to fusion (TTC 18% failure rate, ankle 45% failure rate), whereas post 2016, 57% patients elected for revision TAR (6.5% failure)

Aims. The aims of this study were to validate the outcome of total elbow arthroplasty (TEA) in patients with rheumatoid arthritis (RA), and to identify factors that affect the outcome. Methods. We searched PubMed, MEDLINE, Cochrane Reviews, and Embase from between January 2003 and March 2019. The primary aim was to determine the implant failure rate, the mode of failure, and risk factors predisposing to failure. A secondary aim was to identify the overall complication rate, associated risk factors, and clinical performance. A meta-regression analysis was completed to identify the association between each parameter with the outcome. Results. A total of 38 studies including 2,118 TEAs were included in the study. The mean follow-up was 80.9 months (8.2 to 156). The implant failure and complication rates were 16.1% (95% confidence interval (CI) 0.128 to 0.200) and 24.5% (95% CI 0.203 to 0.293), respectively. Aseptic loosening was the most common mode of failure (9.5%; 95% CI 0.071 to 0.124). The mean postoperative ranges of motion (ROMs) were: flexion 131.5° (124.2° to 138.8°), extension 29.3° (26.8° to 31.9°), pronation 74.0° (67.8° to 80.2°), and supination 72.5° (69.5° to 75.5°), and the mean postoperative Mayo Elbow Performance Score (MEPS) was 89.3 (95% CI 86.9 to 91.6). The meta-regression analysis identified that younger patients and implants with an unlinked design correlated with higher failure rates. Younger patients were associated with increased complications, while female patients and an unlinked prosthesis were associated with aseptic loosening. Conclusion. TEA continues to provide satisfactory results for patients with RA. However, it is associated with a substantially higher implant failure and complication rates compared with hip and knee arthroplasties. The patient’s age, sex, and whether cemented fixation and unlinked prosthesis were used can influence the outcome. Level of Evidence: Therapeutic Level IV. Cite this article: Bone Joint J 2020;102-B(8):967–980

Aims. The primary aim of this study was to determine the ten-year outcome following surgical treatment for femoroacetabular impingement (FAI). We assessed whether the evolution of practice from open to arthroscopic techniques influenced outcomes and tested whether any patient, radiological, or surgical factors were associated with outcome. Methods. Prospectively collected data of a consecutive single-surgeon cohort, operated for FAI between January 2005 and January 2015, were retrospectively studied. The cohort comprised 393 hips (365 patients; 71% male (n = 278)), with a mean age of 34.5 years (SD 10.0). Over the study period, techniques evolved from open surgical dislocation (n = 94) to a combined arthroscopy-Hueter technique (HA + Hueter; n = 61) to a pure arthroscopic technique (HA; n = 238). Outcome measures of interest included modes of failures, complications, reoperation, and patient-reported outcome measures (PROMs). Demographic, radiological, and surgical factors were tested for possible association with outcome. Results. At a mean follow-up of 7.5 years (SD 2.5), there were 43 failures in 38 hips (9.7%), with 35 hips (8.9%) having one failure mode, one hip (0.25%) having two failure modes, and two hips (0.5%) having three failure modes. The five- and ten-year hip joint preservation rates were 94.1% (SD 1.2%; 95% confidence interval (CI) 91.8 to 96.4) and 90.4% (SD 1.7%; 95% CI 87.1 to 93.7), respectively. Inferior survivorship was detected in the surgical dislocation group. Age at surgery, Tönnis grade, cartilage damage, and absence of rim-trimming were associated with improved preservation rates. Only Tönnis grade was an independent predictor of hip preservation. All PROMs improved postoperatively. Factors associated with improvement in PROMs included higher lateral centre-edge and α angles, and lower retroversion index and BMI. Conclusion. FAI surgery provides lasting improvement in function and a joint preservation rate of 90.4% at ten years. The evolution of practice was not associated with inferior outcome. Since degree of arthritis is the primary predictor of outcome, improved awareness and screening may lead to prompt intervention and better outcomes. Cite this article: Bone Jt Open 2022;3(10):804–814

Total hip arthroplasty (THA) has proved to be an effective treatment modality for sickle-cell hip arthropathy (mosaic-like dense bone due to infarcts). However, mode of failure, survival rates and challenges associated with revision hip arthroplasty in sickle-cell disease patients are mostly unknown. We retrospectively evaluated prospectively collected data from all patients with sickle-cell disease who underwent revision hip arthroplasty from 2016. Patient, surgery, medical and surgical complications related data were collected. The pinnacle and reclaim revision system with gription augments (JJ) was used in all patients. Pre-op and post-op clinical outcome data (both objective and subjective, HOOS Jr and OHS) were recorded. Cumulative success rates were recorded with re-revision surgery as an end point. We performed fifteen revision THAs on 13 patients (mean follow up of 6.6 years). The mean age of the patients was 48 years (range, 30–59). At final follow-up, a statistically significant improvement of mean OHS and HOOS JR scores eas found in all patients. reported (OHS: 34.0 and HOOS JR: 77.7). Cumulative success rate was 100% for re-revision for all reasons at 6 years. Five intensive care unit (ITU) admissions, two vaso-occlusive sickle cell crises, one transfusion-related complication and one acute chest syndrome (ACS) were recorded. On admission, the mean percentage of HbS was 75.25% (64.6–86.4%). Revision arthroplasty in sickle-cell disease patients poses increased risks, with medical and surgical challenges. However, with careful preparation, planning and a multi-disciplinary team approach, revision arthroplasty can result in excellent clinical outcomes and excellent functional scores in the majority of patients in the short and mid-term

Aim of this study was to identify reoperation rates in patients with short oblique and transverse fractures around a well fixed cemented polished taper slip stem and to determine any associations with treatment failure. Retrospective cohort study of 31 patients with AO transverse or short oblique Vancouver B1 PFFs around THA (total hip arthroplasty) cemented taper slip stems: 12 male (39%); mean age 74±11.9 (range 44–91); mean BMI 28.5±1.4 (range 16–48); and median ASA 3. Patient journeys were assessed, re-interventions reviewed. The primary outcome measure was reoperation. Time from primary THA to fracture was 11.3±7.8yrs (0.5–26yrs). Primary surgical management was fixation in 27/31 and rTHA (revision total hip arthroplasty) in 4/31. 10 of 31 (32%) patients required reoperation, 9 within 2 years of fracture: 1 following rTHA and 8 following ORIF. The commonest mode of failure was non-union (n=6). No significant associations with reoperation requirement were identified. Kaplan-Meier free from reoperation was 67.4% (49.8–85.0 95% CI) at 2 years and this was unaffected by initial management with ORIF or rTHA (Log rank 0.898). Of those reoperated, 6/10 required multiple reoperations to obtain either bony union or a stable revision construct and 13% ultimately required proximal femoral endoprostheses. The relative risk of 1 year mortality was 1.6 (0.25 to 10.1 95%CI) among patients who required reoperation compared to those who did not. These are difficult fractures to manage, should not be underestimated and patients should be counselled that there is a 30% risk of reoperation and 20% of requiring multiple reoperations

Background. Dynamic Hip Screw (DHS) is the most frequently used implant in management of intertrochanteric femoral fractures. There is a known statistical relationship between a tip-apex distance (TAD) >25mm and higher rate of implant failure. Our aim was to analyse all DHS procedures performed in our trust from seventeen months and compare their TAD values to the acceptable standard of ≤25mm. Methods. All patients undergoing DHS between April 2020-August 2021 were identified from our theatre system. Additionally, those presenting to hospital with implant failures were included. Patient demographics, date of surgery, fracture classification (AO) and date/mode of failure were recorded. Intraoperative fluoroscopy images were reviewed to calculate TAD, screw location and neck shaft angles by two independent observers. Results. 215 patients were identified, five of which were excluded due to inadequate fluoroscopy. Failure was seen in 3.3% of the cohort (n=7), of which 71.4% had an unacceptable TAD. In total, 21 patients (10%) had TAD >25mm, of whom 12 had superiorly and 15 had posteriorly placed screws. There were no failures in patients with a TAD of <20mm whereas a TAD >30mm had 50% failure rate. Conclusion. This audit reinforces the importance of aiming for a low TAD (preferably <20mm) intraoperatively. It is also desirable to avoid superiorly and significantly posteriorly placed screws. Implications. Complex hip revision surgery in the elderly bears substantial financial implications to the NHS and, more importantly, causes prolonged morbidity to the patient. Adhering to established standards will ensure reduced implant failure and best patient care

Rates of prosthetic joint infection in megaprostheses are high. The application of silver ion coating to implants serves as a deterrent to infection and biofilm formation. A retrospective review was performed of all silver-coated MUTARS endoprosthetic reconstructions (SC-EPR) by a single Orthopaedic Oncology Surgeon. We examined the rate of component revision due to infection and the rate of infection successfully treated with antibiotic therapy. We reviewed overall revision rates, sub-categorised into the Henderson groupings for endoprosthesis modes of failure (Type 1 soft tissue failure, Type 2 aseptic loosening, Type 3 Structural failure, Type 4 Infection, Type 5 tumour progression). 283 silver-coated MUTARS endoprosthetic reconstructions were performed for 229 patients from October 2012 to July 2022. The average age at time of surgery was 58.9 years and 53% of our cohort were males. 154 (71.3%) patients underwent SC-EPR for oncological reconstruction and 32 (14.8%) for reconstruction for bone loss following prosthetic joint infection(s). Proximal femur SC-EPR (82) and distal femur (90) were the most common procedures. This cohort had an overall revision rate of 21.2% (60/283 cases). Component revisions were most commonly due to Type 4 infection (19 cases), Type 2 aseptic loosening/culture negative disease (15 cases), and Type 1 dislocation/soft tissue (12 cases). Component revision rate for infection was 6.7% (19 cases). 15 underwent exchange of implants and 4 underwent transfemoral amputation due to recalcitrant infection and failure of soft tissue coverage. This equates to a limb salvage rate of 98.3%. The most common causative organisms remain staphylococcus species (47%) and polymicrobial infections (40%). We expand on the existing literature advocating for the use of silver-coated endoprosthetic reconstructions. We provide insights from the vast experience of a single surgeon when addressing patients with oncological and bone loss-related complex reconstruction problems

Neer Type-IIB lateral clavicle fractures are inherently unstable fractures with associated disruption of the coracoclavicular (CC) ligaments. A novel plating technique using a superior lateral locking plate with antero-posterior (AP) locking screws, resulting in orthogonal fixation in the lateral fragment has been designed to enhance stability. The purpose of this study was to biomechanically compare three different clavicle plating constructs. 24 fresh-frozen cadaveric shoulders were randomised into three groups (n=8 specimens). Group 1: lateral locking plate only (Medartis Aptus Superior Lateral Plate); Group 2: lateral locking plate with CC stabilisation (Nr. 2 FiberWire); and Group 3: lateral locking plate with two AP locking screws stabilising the lateral fragment. Data was analysed for gap formation after cyclic loading, construct stiffness and ultimate load to failure, defined by a marked decrease in the load displacement curve. After 500 cycles, there was no statistically significant difference between the three groups in gap-formation (p = 0.179). Ultimate load to failure was significantly higher in Group 3 compared to Group 1 (286N vs. 167N; p = 0.022), but not to Group 2 (286N vs. 246N; p = 0.604). There were no statistically significant differences in stiffness (Group 1: 504N/mm; Group 2: 564N/mm; Group 3: 512N/mm; p = 0.712). Peri-implant fracture was the primary mode of failure for all three groups, with Group 3 demonstrating the lowest rate of peri-implant fractures (Group 1: 6/8; Group 2: 7/8, Group 3: 4/8; p = 0.243). The lateral locking plate with orthogonal AP locking screw fixation in the lateral fragment demonstrated the greatest ultimate failure load, followed by the lateral locking plate with CC stabilization. The use of orthogonal screw fixation in the distal fragment may negate against the need for CC stabilization in these types of fractures, thus minimizing surgical dissection around the coracoid and potential complications

Reverse shoulder arthroplasty (RSA) is commonly used to treat patients with rotator cuff tear arthropathy. Loosening of the glenoid component remains one of the principal modes of failure and is the main complication leading to revision. For optimal RSA implant osseointegration to occur, the micromotion between the baseplate and the bone must not exceed a threshold of 150 µm. Excess micromotion contributes to glenoid loosening. This study assessed the effects of various factors on glenoid baseplate micromotion for primary fixation of RSA. A half-fractional factorial experiment design (2k-1) was used to assess four factors: central element type (central peg or screw), central element cortical engagement according to length (13.5 or 23.5 mm), anterior-posterior (A-P) peripheral screw type (nonlocking or locking), and bone surrogate density (10 or 25 pounds per cubic foot [pcf]). This created eight unique conditions, each repeated five times for 40 total runs. Glenoid baseplates were implanted into high- or low-density Sawbones™ rigid polyurethane (PU) foam blocks and cyclically loaded at 60 degrees for 1000 cycles (500 N compressive force range) using a custom designed loading apparatus. Micromotion at the four peripheral screw positions was recorded using linear variable displacement transducers (LVDTs). Maximum micromotion was quantified as the displacement range at the implant-PU interface, averaged over the last 10 cycles of loading. Baseplates with short central elements that lacked cortical bone engagement generated 373% greater maximum micromotion at all peripheral screw positions compared to those with long central elements (p < 0.001). Central peg fixation generated 360% greater maximum micromotion than central screw fixation (p < 0.001). No significant effects were observed when varying A-P peripheral screw type or bone surrogate density. There were significant interactions between central element length and type (p < 0.001). An interaction existed between central element type and level of cortical engagement. A central screw and a long central element that engaged cortical bone reduced RSA baseplate micromotion. These findings serve to inform surgical decision-making regarding baseplate fixation elements to minimize the risk of glenoid loosening and thus, the need for revision surgery

The Adams-Berger reconstruction is an effective technique for treating distal radioulnar joint (DRUJ) instability. Graft preparation techniques vary amongst surgeons with insufficient evidence to support one technique over another. Our study evaluated the biomechanical properties of four graft preparation techniques. Extensor tendons were harvested from fresh frozen porcine trotters obtained from a local butcher shop and prepared in one of three configurations (n=5 per group): tendon only; tendon prepared with non-locking, running suture (2-0 FiberLoop, Arthrex, Naples, FL) spaced at 6 mm intervals; and tendon prepared with suture spaced at 12 mm intervals. A fourth configuration of suture alone was also tested. Tendons were allocated in a manner to ensure comparable average diameters amongst groups. Biomechanical testing occurred using custom jigs simulating radial and ulnar tunnels attached to a Bose Electroforce 3510 mechanical testing machine (TA Instruments). After being woven through the jigs, all tendons were sutured end-to-end with 2-0 PROLENE suture (Ethicon). Tendons then underwent a staircase cyclic loading protocol (5-25 Newtons [N] at 1 hertz [Hz] for 1000 cycles, then 5-50 N at 1 Hz for 1000 cycles, then 5-75 N at 1 Hz for 1000 cycles) until graft failure; if samples did not fail during the protocol, they were then loaded to failure. Samples were visually inspected for mode of failure after the protocol. A one-way analysis of variance was used to compare average tendon diameter; post-hac Tuhey tests were used to compare elongation and elongation rate. Survival to cyclic loading was analyzed using Kaplan-Meier survival curves with log rank. Statistical significance was set at a = 0.05. The average tendon diameter of each group was not statistically different [4.17 mm (tendon only), 4.33 mm (FiberLoop spaced 6 mm), and 4.30 mm (FiberLoop spaced 12 mm)]. The average survival of tendon augmented with FiberLoop was significantly higher than tendon only, and all groups had significantly improved survival compared to suture only. There was no difference in survival between FiberLoop spaced 6 mm and 12 mm. Elongation was significantly lower with suture compared to tendon augmented with FiberLoop spaced 6 mm. Elongation rate was significantly lower with suture compared to all groups. Modes of failure included rupture of the tendon, suture, or both at the simulated bone and suture and/or tendon interface, and elongation of the entire construct without rupture. In this biomechanical study, augmentation of porcine tendons with FiberLoop suture spaced at either 6 or 12 mm for DRUJ reconstruction significantly increased survival to a staircase cyclic loading protocol, as suture material was significantly stiffer than any of the tendon graft configurations

Purpose. To identify the modes of failure after total knee arthroplasty (TKA) in patients ≤ 55 years of age and to compare with those ≥ 56 years of age in patients who underwent revision TKA. Materials and Methods. We retrospectively reviewed 256 revision TKAs among patients who underwent TKA for knee osteoarthritis between January 1992 and December 2012. The causes of TKA failure were analyzed and compared between those ≤ 55 years of age and those ≥ 56 years of age. The age at the time of primary surgery was ≤ 55 years in 30 patients (31 knees) and ≥ 56 years in 210 patients (225 knees). Results. A total of 453 TKAs were performed in ≤ 55-year-old patients between 1992 and 2012. Of these, 31 cases (7%) were revised. Their mean age was 50.6 years (range, 40 to 55 years) at primary surgery and the interval from primary TKA to revision was 8.6 years (range, 1 to 17 years). In the ≤ 55 years of age group, the most common modes of TKA failure was polyethylene wear in 14 cases (45%) followed by infection in 8 cases (26%) and component loosening in 5 cases (17%). The other conditions led to TKA failure were stiffness, periprosthetic fracture, malalignment, and osteolysis in one case each (3%). Of the 11,363 TKAs that were performed in ≥ 56-year-old patients, 225 cases (2%) required a revision. The mean interval between the operations was 5.3 years (range, 0.1 to 18 years). The major modes of failure of primary TKA include polyethylene wear in 99 cases (44%), infection in 91 cases (40%), and component loosening in 26 cases (12%). In both groups, the most common cause of failure was polyethylene wear, which was followed by infection and component loosening. There were relatively lower infection rate and higher loosening rate in patients ≤ 55 years of age, but the difference was not statistically significant (p > 0.05). The mean interval between the operations was shorter in the ≥ 56 years of age group (5.3 years; range, 0.1 to 18 years) than in the younger patient group (8.6 years; range, 1 to 17 years), but there was no notable intergroup difference (p > 0.05). Conclusion. The main modes of failure after TKA in patients ≤ 55 years of age were polyethylene wear, infection and loosening, and there was no significant difference in the modes of failure after TKA between the two groups

Revision total hip arthroplasty (rTHA) can be complex and associated with significant cost, with an increasing burden within the UK and globally. Regional rTHA networks have been proposed aiming to improve outcomes, reduce re-revisions and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for the rTHA service and to assess the financial impact of case complexity at a tertiary referral centre within the NHS. A retrospective analysis of all revision hip procedures was performed over two consecutive financial years (2018–2020). Cases were classified according to the Revision Hip Complexity Classification (RHCC) and by mode of failure; infected or non-infected. Patients of ASA grade of 3 or greater or BMI over 40 are considered “high-risk” by the RHCC. Costs were calculated using PLICS and remuneration based on the HRG data. The primary outcome was the financial difference between tariff and cost per episode per patient. Comparisons between groups were analysed using analysis of variance and two-tailed unpaired t-test. 199 revision episodes were identified in 168 patients: 25 (13%) least complex revisions (H1), 110 (55%) complex revisions (H2) and 64 (32%) most complex revisions (H3). 76 (38%) cases were due to infection. 78 (39%) of patients were in the “high-risk” group. Median length of stay increased with case complexity from 4, to 6 to 8 days (p=0.17) and significantly for revisions performed for infection (9 vs 5 days; p=0.01). Cost per episode increased significantly between complexity groups (p=0.0002) and for infected revisions (p=0.003). All groups demonstrated a mean deficit, but this significantly increased with revision complexity (£301, £1,820 and £4,757 per case; p=0.02) and for infected failure (£4,023 vs £1,679; p=0.02). The total deficit to the trust for the two-years was £512,202. Current NHS reimbursement for rTHA is inadequate and should be more closely aligned to complexity. An increase in the most complex rTHA at major revision centres (MRC) will likely place a greater financial burden on these units

Management of highly displaced acromioclavicular joint (ACJ) injuries remain contentious. It is unclear if delayed versus acute reconstruction has an increased risk of fixation failure and complications. The primary aim of this was to compare complications of early versus delayed reconstruction. The secondary aim was to determine modes of failure of ACJ reconstruction requiring revision surgery. A retrospective study was performed of all patients who underwent operative reconstruction of ACJ injuries over a 10-year period (Rockwood III-V). Reconstruction was classed as early (<12 weeks from injury) or delayed (≥12 weeks). Patient demographics, fixation method and post-operative complications were noted, with one-year follow-up a minimum requirement for inclusion. Fixation failure was defined as loss of reduction requiring revision surgery. 104 patients were analysed (n=60 early and n=44 delayed). Mean age was 42.0 (SD 11.2, 17–70 years), 84.6% male and 16/104 were smokers. No difference was observed between fixation failure (p=0.39) or deep infection (p=0.13) with regards to acute versus delayed reconstruction. No patient demographic or timing of surgery was predictive of fixation failure on regression modelling. Overall, eleven patients underwent revision surgery for loss of reduction and implant failure (n=5 suture fatigue, n=2 endo-button escape, n=2 coracoid stress fracture and n=2 deep infection). This study suggests that delayed ACJ reconstruction does not have a higher incidence of fixation failure or major complications compared to acute reconstruction. For those patients with ongoing pain and instability following a trial of non-operative treatment, delayed reconstruction would appear to be a safe treatment approach

As the numbers of revision total knee arthroplasty (RTKA) rise, we continually need current information regarding the etiology/modes of failure and functional disability of patients presenting for RTKA. We used a prospective cohort study to assess these fundamental aspects of RTKA. 290 consecutive subjects presenting for RTKA had relevant clinical information, including modes of failure, collected from surgeon-completed documents. Patients themselves also completed quality of life and functional questionnaires, including the SF-36 and WOMAC Osteoarthritis Index. Mean patient age was 68.6 years (55 to 79 years). Mean SF-36 and WOMAC score at baseline indicated significant functional disability. The mean time from primary procedure to RTKA was 7.9 years (6 months to 27 years). Our series included 31 percent ‘early’ (under 2 years) revisions and 69 percent ‘late’ revisions. Sepsis was the cause of 10.4 percent revisions. The tibia needed revision in 78 percent, femur in 71 percent and patella in 31 percent of cases. The predominant modes of failure (non-exclusive frequency values as patients could have more than one cause) were (in percentages): instability (28.9), malalignment (27.5), tibial osteolysis (27.5), polyethylene wear (24.5), femoral osteolysis (22.5) and tibial loosening (22.2). These patients are relatively young, and considerably disabled by their failed primary procedure. Many modes of failure are within surgical control and direct us toward improved techniques and approaches. Other modes confirm the need for continued development of implants and materials. Information gained here will allow better formulation of measures and resource allocation that may prevent RTKAs

The aim of this study is to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter). This is a retrospective cohort study of 152 operatively managed consecutive unilateral Vancouver B fractures involving Exeter stems. 130 were managed with open reduction and internal fixation (ORIF) and 22 with revision arthroplasty. Radiographs were assessed and classified by 3 observers. The primary outcome measure was revision of ≥1 component. Kaplan Meier survival analysis was performed. Logistic regression was used to identify risk factors for revision following ORIF. Secondary outcomes included any reoperation, complications, blood transfusion, length of hospital stay and mortality. Fractures (B1 n=74 (49%); B2 n=50 (33%); and B3 n=28 (18%)) occurred at mean 6.7±10.4 years after primary THA (n=143) or hemiarthroplasty (n=15). Mean follow up was 6.5 ±2.6 years (3.2 to 12.1). Rates of revision and reoperation were significantly higher following revision arthroplasty compared to ORIF for B2 (p=0.001) fractures and B3 fractures (p=0.05). Five-year survival was significantly better following ORIF: 92% (86.4 to 97.4 95%CI) Vs 63% (41.7 to 83.3), p<0.001. No independent predictors of revision following ORIF were identified: fixation of B2 or B3 fractures was not associated with an increased risk of revision. Dislocation was the commonest mode of failure after revision arthroplasty. ORIF was associated with reduced blood transfusion requirement and reoperations, but there were no differences in medical complications, hospital stay or mortality between surgical groups. When the bone-cement interface was intact and the fracture was anatomically reducible, Vancouver B2 fractures around Exeter stems can be treated with fixation as opposed to revision arthroplasty. Fixation of Vancouver B3 fractures can be performed in frail elderly patients without increasing revision risk