Introduction: Prostheses radiolucent lines are currently used to evaluate the components fixation. The objective of this study is to determine concordance and reproducibility of humeral stem radiolucent lines evaluation. Material and method: Five observers evaluated 64 x-ray belonging to 32 pairs (1 antero-posterior view and 1 outlet view) obtained from 16 shoulder prostheses. 16 x-ray pairs were obtained immediately after surgery and 16 one year after surgery. Evaluation in four degrees of radiolucent width for each of the 7 zones that the humeral component was divided for. Evaluation of the component-cement interface and the cement-bone interface. Each observer made two evaluations of the 64 x-ray separated in 6 weeks. Statistics : index kappa with quadratic weighting. Results: Intra-observer results: mean kappa index for component-cement interface: 0,3274. mean kappa index for cement-bone interface: 0,5269. Inter-observer results: mean kappa index for component-cement interface: 0,1242. mean kappa index for cement-bone interface: 0,2478. Evaluation of 2 pairs of x-ray of the each prostheses taken in a period of 1 year: component-cement interface: mean of 91,67% of plausible results, cement-bone interface: mean of 80,2% of plausible Results:. Conclusions:. - low kappa index of reproducibility (0,3274–0,5269) of humeral component radiolucent lines evaluation for component-cement interface as well as for cement-bone interface. - low kappa index of concordance (0,1242–0,2478) of humeral component radiolucent lines evaluation for component-cement interface as well as for cement-bone interface. - High number of plausible observations when the same prostheses was evaluated immediately after surgery and at 1 year follow-up

Survivorship of unicondylar knee replacement (UKR) exceeds 85% at 10 years. During long term follow-up, progressive osteoarthritis (OA) and loosening are typical of UKR failure. The decision to revise UKR is complex as radiographic findings are not always consistent with clinical symptoms. This study of revised UKR compares intraoperative assessment of component fixation and progressive OA with prerevision radiographic evaluations. Twenty-seven UKR were retrieved from 22 female and 5 male patients. Patient age and time in situ averaged 76 (68–87) years and 79 (25–156) months, respectively. At index arthroplasty, all knees received a fixed-bearing medial UKR with cement fixation. Prior to revision, radiolucent lines and component alignment were assessed on radiographs according to Knee Society guidelines. Suspected revision reasons based on clinical and radiographic evaluation included aseptic loosening (63%), progressive OA (22%), and wear (15%). During revision surgery, component fixation was manually assessed and graded as well-fixed or loose, and progressive OA was graded using Outerbridge classification. Intraoperative and radiographic assessments were completed independently. Average Knee Society Scores declined > 30 points to 53+18 (pain) and 43+11 (function) before revision. During revision surgery, femoral and tibial component fixation were graded as loose in 19 (70%) and 9 (33%) knees, respectively. There was Grade III or IV progressive OA in the lateral or patellofemoral compartment of 15 (56%) and 16 (59%) knees, respectively. Radiolucent lines were evident in 8 of 19 loose femoral components and 5 of 9 loose tibial components. In contrast, 3 of 8 well-fixed femoral components and 6 of 18 well-fixed tibial components had radiolucent lines. There were 11 loose femoral components and 4 loose tibial components without radiolucent lines. Radiographic limb alignment averaged 3°+3° valgus immediately after index UKR. Change in limb alignment ranged from 0° to 17° at revision. Tibial or femoral component alignment changed 5° to 9° in 12 (44%) knees and > 10° in 5 (19%) knees. Eight of these 17 knees (47%) had malaligned components graded as loose. The prevalence of progressive OA at revision UKR was more than double occurrence suspected from radiographs. Interpreting radiographic indications for loosening was difficult. Radiolucent lines predicted loosening in 46% (13/28) of the components graded as loose and falsely predicted loosening in 35% (9/26) of the components graded as well-fixed. Radiolucent lines were absent in 15/28 (54%) of the loose components and changes in component alignment > 5° were associated with component loosening in < 50% of the knees. Rigorous attention to clinical symptoms and careful interpretation of radiographic phenomena are needed to determine indications for revision in UKR patients

Introduction. Various 2D and 3D surfaces are available for cementless fixation of acetabular cups. The goal of these surface modifications is to improve fixation between the metallic cups and surrounding bone. Radiographs have historically been used to evaluate the implant-to-bone fixation around the acetabular cups. In general, a well fixed cup shows no gaps or radiolucency around the cup's outer diameter. In post-operative radiographs, the presence of progressive radiolucent zones of 2mm or more around the implant in the three radiographic zones is indicative of aseptic loosening, as described by DeLee and Charnley [1]. In this cadaveric study, we investigated the X-ray image characteristics of two different types of acetabular shell surfaces (2D and 3D) to evaluate the implant-to-bone interface in the two designs. Methods. Six human cadavers were bilaterally implanted with acetabular cups by an orthopaedic surgeon. 2D surface cups (Trident, Stryker, Mahwah, NJ) and 3D surface cups (Tritanium, Stryker, Mahwah, NJ) were randomized between the left and right acetabula. The surgeon used his regular surgical technique (1 mm under reaming) to implant the acetabular cups. The cadavers were sent for X-ray imaging after the operation, Figure 1A. Following the X-ray imaging, the acetabular cups were carefully resected from the cadavers. Enough bone around the cups was retained for analysis of the implant-to-bone interface by contact X-ray. The acetabular cups with the surrounding bone were fixed in 70% isopropyl alcohol for about a week and subsequently embedded in polymethyl methacrylate. The embedded cups were sectioned at 30° intervals using a diamond saw in the coronal plane, as recommended by Engh et al [2], Figure 1B. The sectioning of the samples produced 6 slices of each cup where the implant-bone interface could easily be visualized for evaluation with contact X-ray. Results. The AP X-rays of the cadavers demonstrated radiolucent lines, as well as gap defects in some cases. The same phenomenon was observed on the contact X-rays of the embedded implant sections as well, where one could easily identify the gap between the metal cup and the surrounding bone. The most striking finding was that, in a few cases, the contact X-rays showed radiolucency around the metal cup whereas the physical section did not seem to have any gaps. This phenomenon is illustrated in Figure 2. Conclusions. The physical gap or radiolucent lines around the acetabular cups have been reported in literature; however, they seem to fill up with time as biological fixation progresses between the surrounding bone and the implant. In our study we found radiolucency that was not associated with the presence of a physical gap. In contrast, we found gaps on physical sections that were not correlated with radiolucencies. This phenomenon may be attributed to the interaction of X-rays with the cup surface modifications. The contact X-ray images demonstrated that radiolucency around cups may not always correlate with physical gaps. Further analysis is required to understand the implications of these findings

When Radiolucent lines (RLL) are observed around cemented acetabular components, they may progress and be associated with loosening. We reviewed the incidence and progression of RLLs around the Exeter Contemporary flanged acetabular component and compared our results with other published series. We reviewed a consecutive series of 203 sockets with a minimum 10-year follow-up. Up to date radiographs were reviewed by 2 independent assessors for the presence, location and thickness of RLL and an assessment for loosening/migration was made. Initial post-operative radiographs were examined for any case with RLLs at review. There were no revisions for aseptic loosening. 103 hips remained in situ with a minimum follow up of 10 years. Lucent lines were seen on 37/103 (36%) of hips with a mean follow up of 12.1 years (10.0–13.9 years). In these 37 hips, the lucency was present in one zone in 84%, two zones in 8% and all three zones in 8%. Of the 37 hips with a RLL at minimum 10 years follow up, five exhibited a RLL immediately post-operatively. All 5 of these lines were initially isolated to zone 1 and progressed over the 10 years around at least 1 more zone. Only one line became circumferential, although the cup did not migrate. Compared to previous papers (DeLee & Charnley, Hodgkinson and Garcia-Cimbrelo) the presence of RLL at 10 years is reduced in our series (table 2) and no cup migrated. All RLL seen in cups at both 10 years and immediate post-operatively in our series progressed (table 3), unlike in the previous studies. This reduction in lucent lines may be down to modern cementing techniques, cup design or a combination of both. For any figures or tables, please contact the authors directly by clicking on ‘Info & Metrics’ above to access author contact details

Abstract

OBJECTIVE OF THE STUDY. The objective of this study is to establish the medium-term clinical and radiological results with the cementless three-dimensional Vektor-Titan stem compared with conventional cementless stem, such as PerFix stem. The latter stem has a double-wedge design with a rounded distal portion for canal filling (Fig. 1). MATERIALS AND METHODS. From July, 2004, to May, 2010, fifty seven Vektor-Titan stems and 150 PerFix stems were implanted for the patients with osteoarthritis, avascular necrosis, femoral neck fracture, and rheumatoid arthritis in our hospital. The results were evaluated clinically using Japanese Orthopedic Association (JOA) scores and the Merle d’Aubigne and Postel (M&P) scores. Radiographs were analyzed retrospectively. The criteria used for determining loosening were migration or a total radiolucent zone between the prosthesis/bone cement and host bone, wherein the width increased progressively or change of position, i.e., migration or subsidence of the prosthesis. Migration of the socket seen on the radiograph was defined as either the presence of a ≥2-mm position change or rotation. Position changes of the stem seen on the radiograph were defined as the presence of a progressive subsidence of ≥2 mm or change of position, e.g., varus or valgus. The follow-up period was 9.2 ± 2.6 (range, 5.0–14.0) years. RESULTS. One patient had intraoperative femoral shaft fracture and healed by conservative treatment. The mean JOA and M&P scores improved from preoperative 39.3 and 6.8 points to postoperative 90.9 and 17.2 points, respectively. Thigh pain was less frequent for Vektor-Titan stems (Table 1). Radiolucent lines was far less likely to appear for Vektor-Titan stems evaluated by Gruen's zonal analyses (Table 2). On the other hand, there were radiolucent zones of more than 90% in zone 4 with cementless PerFix stems (Table 2). There was no cases of loosening or postoperative infection. Although signs of bone atrophy were found in the proximal femur and the trochanters in 66.7 % of all cases, bone structure was radiologically normal without stress shielding in most cases (Table 2). On the contrary, there was evidence of an even denser bone structure, such as trabeculae, at the tip of the stem and the lateral implant fixation within the greater trochanter in Vektor-Titan stem cases. These findings remained unchanged over observation periods. DISCUSSION AND CONCLUSIONS. The cementless Vektor-Titan stem is made of Ti6AI7Nb, has got the shape of a straight three-dimensional cone. It has a high proximal volume in the form of a three-dimensional taper with longitudinal ribs. This design achieves strong primary fixation in the proximal metaphysis. Radiologically, newly formed trabeculae toward to the stem were indicative of direct biological fixation at the bone-implant interface. Medium-term results with the cementless Vektor-Titan stem show no implant loosening with stable metaphyseal fixation and preservation of bone structure in the proximal femur and the absence of radiolucent zones around the stem compared with conventional cementless stem

Introduction. The clinical impact of radiolucent glenoid lines is controversial, where the presence of a radiolucent glenoid lines has been suggested to be an indicator of clinical glenoid loosening. The goal of this database analysis is to quantify and compare the pre- and post-operative outcomes of 427 patients who received a primary aTSA with one specific prosthesis and were sorted based upon the radiographic presence of a radiolucent glenoid line at latest clinical followup. Methods. 427 patients (mean age: 67.0yrs) with an average follow-up of 49.4 months was treated with aTSA for OA by 14 fellowship trained orthopaedic surgeons. Of these 427 patients, 293 had a cemented keel glenoids (avg follow-up = 50.8 months) and 134 had a cemented pegged glenoids (avg follow-up = 48.7 months). Cemented peg and keel glenoid patients were analyzed separately and also combined into 1 cohort: 288 patients (158 female, avg: 68.7 yrs; 130 male, avg: 64.9 yrs) did not have a radiolucent glenoid line (avg follow-up = 46.9 months); whereas, 139 patients (83 female, avg: 68.5 yrs; 56 male, avg: 64.6 yrs) had a radiolucent glenoid line (avg follow-up = 54.4 months). Outcomes were scored using SST, UCLA, ASES, Constant, and SPADI metrics; active ROM also measured. A two-tailed, unpaired t-test identified differences (p<0.05) in pre-operative, post-operative, and pre-to-post improvements. Results. The overall rate of radiolucent line formation in the glenoid for the combined peg and keel glenoid aTSA cohort was 32.6% (139 of 427 patients). The rate of radiolucent lines for the keel and peg glenoids was similar at nearly the same followup (∼50 months): 96 of 293 peg patients (32.8%) and 43 of 134 keel patients (32.1%) had a radiolucent glenoid line. Patients with cemented keeled glenoids had an average radiographic line score of 2.4 ± 1.3 which trended larger (p = 0.0875) than the average radiographic line score of 2.0 ± 1.1 of patients with cemented peg glenoids. Pre-operatively, no difference was noted between patients with and without radiolucent glenoid lines. (Figure 1) However post-operatively, patients with radiolucent glenoid lines were associated with significantly poorer clinical outcome scores according to all 5 clinical metrics and also had significantly less improvements in outcomes according to 4 of 5 outcome metrics; (Figure 2) poorer outcomes were observed for the combined cemented keeled and pegged glenoid cohorts and when each glenoid prosthesis type is analyzed separately. Additionally, patients with glenoid radiolucent lines were associated with significantly lower improvements in outcomes. (Figure 3) Finally, 24 complications were reported (5.6%), 14 for patients without radiolucent glenoid lines (4.9%) and 10 for patients with radiolucent glenoid lines (7.2%). Conclusions. This large-scale clinical outcome study demonstrated that aTSA patients with radiolucent glenoid lines were associated with significantly poorer clinical outcomes and a higher complication rate as compared to aTSA patients without radiolucent glenoid lines. The overall radiolucent line rate and the negative impact of radiolucent lines were no different between cemented keeled and cemented pegged glenoid components. Additional and longer-term follow-up is needed to confirm these conclusions. For figures/tables, please contact authors directly.

Introduction. Humeral radiolucent lines after anatomic TSA (aTSA) have been well described; however, little clinical consequences have been attributed to them. The recent emergence of shorter humeral stems has demonstrated higher incidences of humeral radiolucencies than has been reported historically with standard length components. This large scale database analysis quantifies and compares the clinical outcomes of aTSAs with and without radiolucent humeral lines using one specific prosthesis to determine their impact on clinical outcomes. Methodology. This is a multicenter, retrospective, case controlled radiographic and clinical review. Preoperative and postoperative data was analyzed from 671 aTSA patients with a minimum of 2 years followup. 538 of these 671 aTSA patients had full radiographic followup (80.2%) and were included in this study; these patients had an average followup of 45.3 months). 459 patients had noncemented humeral stems; whereas, 79 patients had cemented humeral stems. Radiographs were reviewed at latest follow up for humeral radiolucent lines based on the technique described by Gruen et al. Patients were evaluated and scored pre-operatively and at latest follow-up using the SST, UCLA, ASES, Constant, and SPADI scoring metrics; ROM was also recorded. A Student's two-tailed, unpaired t-test was used to identify differences in pre-operative, post-operative, and improvement in results, where p<0.05 denoted a significant difference. Results. All patients demonstrated significant improvements in pain and function following treatment with the primary shoulder arthroplasty. 14 patients (8 female, avg: 65.6 yrs; 6 male, avg: 61.7 yrs) were observed to have radiolucent lines around the humeral component (2.6%). The rate of humeral radiolucent lines was observed to be significantly higher in patients with cemented (7.6%) vs. noncemented (1.7%) humeral stems (p = 0.0025). Pre-operatively, no difference was noted in any clinical metric score between patients with or without radiolucent humeral lines. (Figure 1) However post-operatively, patients with radiolucent humeral lines had significantly worse ASES (p=0.0087), UCLA (p=0.0371), SST (p=0.0341), and SPADI (p=0.0051) scores (Figure 2) and significantly lower improvements in outcomes according to ASES (p=0.0120) and SPADI (p=0.0247) scores (Figure 3), relative to patients without radiolucent humeral lines. Additionally, radiolucent lines had a more profound effect on cemented stems (as compared to noncemented stems), where cemented stems with radiolucent humeral liners were associated with significantly lower post-operative outcomes and significantly lower improvements in outcomes. Finally, patients with humeral radiolucent lines had a significantly higher complication rate (21.4% vs 4.6%, p = 0.004) as compared to the complication rate of patients without radiolucent humeral lines. Conclusions. The study demonstrated a relatively low incidence of humeral radiolucent lines with anatomic TSA. Cemented stems were associated with a significantly higher rate of humeral radiolucent lines as compared to noncemented stems. Patients whose shoulders had radiolucent humeral lines were associated with significantly lower clinical outcomes and significantly less active ROM as compared to those without radiolucent lines. This diminished outcome was more pronounced with cemented humeral stems. Additional and longer term clinical followup is necessary to confirm the results of this study

Introduction: Early non progressive horizontal RLLs (< 2mm) under the tibial component following cemented TKR have been noted to be due to poor cement injection into cancellous bone. They may facilitate the entry of joint fluid and wear debris into the interface, which may proceed to ballooning osteolysis. At present, there is no consensus on the preferred cementing technique (single mix versus dual mix cementation) in TKR.

Purposes of the study: To assess RLLs in immediate postoperative radiographs in cemented TKRs at the cement-bone and cement-implant interface.

To compare the RLLs following single mix and dual mix cementation techniques.

Study Design: Prospective, consecutive radiographic analysis.

Material and Methods: 53 consecutive cemented TKRs in 39 patients (12: 27, F: M) with mean age of 72.5 years (range 50–90 y) who were operated on between 2001 to 2004 by the senior author (NMG). 27 had single mix and 26 had double mix cementation. Immediate postoperative radiographic assessment (AP and LAT standing view) was blinded for single mix versus dual mix cementation. All the radiographs were independently assessed by two of the authors for the presence of RLLs using the zonal pattern of the Knee Society scoring system. We have evaluated the RLLs in the cement-implant interface in a similar manner as described for the bone-cement interface.

Results: Most common TKR used was the Maxim (31) followed by the PFC (9). 29(54.7%) TKRs had RLLs (11in single mix : 18 in dual mix). There were more RLLs at the Cement-implant interface (29), than the bone-cement interface (10). In AP view, Zones 1(medial) and 4 (lateral) were the common sites for RLLs in both groups (< 2mm). In Lateral view, Zone 1 (Anterior) followed by Zone 2 (Posterior) were the common sites of RLLs (< 2mm). In AP view, there was no significant difference in the number of RLLs (Zone 4) between the two groups. The total number of RLLs in all zones (Zone 1–4) was significantly low in the single mix group (p< 0.05). There was no difference between the two groups in the lateral view.

Conclusions: Single mix cementation technique reduces the incidence of RLLs in the immediate postoperative radiographs following cemented TKRs.

Aims. Although the short stem concept in hip arthroplasty procedure shows acceptable clinical performance, we sometimes get unexplainable radiological findings. The aim of this retrospective study was to evaluate changes of radiological findings up to three years postoperatively, and to assess any potential contributing factors on such radiological change in a Japanese population. Methods. This is a retrospective radiological study conducted in Japan. Radiological assessment was done in accordance with predetermined radiological review protocol. A total of 241 hips were included in the study and 118 hips (49.0%) revealed radiological change from immediately after surgery to one year postoperatively; these 118 hips were eligible for further analyses. Each investigator screened whether either radiolucent lines (RLLs), cortical hypertrophy (CH), or atrophy (AT) appeared or not on the one-year radiograph. Further, three-year radiographs of eligible cases were reviewed to determine changes such as, disappeared (D), improved (I), stable (S), and progression (P). Additionally, bone condensation (BC) was assessed on the three-year radiograph. Results. CH was observed in 49 hips (21.1%), AT was observed in 63 hips (27.2%), and RLLs were observed in 34 hips (14.7%) at one year postoperatively. Among 34 hips with RLLs, 70.6% showed change of either D or I on the three-year radiograph. BC was observed in younger patients more frequently. Conclusion. The Fitmore stem works well in a Japanese population with favourable radiological change on hips with RLLs. Longer-term follow-up is required to determine clinical relevance. Cite this article: Bone Jt Open 2022;3(1):20–28

Aims. Varus-valgus constrained (VVC) devices are typically used in revision settings, often with stems to mitigate the risk of aseptic loosening. However, in at least one system, the VVC insert is compatible with the primary posterior-stabilized (PS) femoral component, which may be an option in complex primary situations. We sought to determine the implant survivorship, radiological and clinical outcomes, and complications when this VVC insert was coupled with a PS femur without stems in complex primary total knee arthroplasties (TKAs). Methods. Through our institution’s total joint registry, we identified 113 primary TKAs (103 patients) performed between 2007 and 2017 in which a VVC insert was coupled with a standard cemented PS femur without stems. Mean age was 68 years (SD 10), mean BMI was 32 kg/m. 2. (SD 7), and 59 patients (50%) were male. Mean follow-up was four years (2 to 10). Results. The five-year survivorship free from aseptic loosening was 100%. The five-year survivorship free from any revision was 99%, with the only revision performed for infection. The five-year survivorship free from reoperation was 93%. The most common reoperation was treatment for infection (n = 4; 4%), followed by manipulation under anaesthesia (MUA; n = 2; 2%). Survivorship free from any complication at five years was 90%, with superficial wound infection as the most frequent (n = 4; 4%). At most recent follow-up, two TKAs had non-progressive radiolucent lines about both the tibial and femoral components. Knee Society Scores improved from 53 preoperatively to 88 at latest follow-up (p < 0.001). Conclusion. For complex primary TKA in occasional situations, coupling a VVC insert with a standard PS femur without stems proved reliable and durable at five years. Longer-term follow-up is required before recommending this technique more broadly. Cite this article: Bone Jt Open 2021;2(11):921–925

Aims

There are concerns regarding complications and longevity of total elbow arthroplasty (TEA) in young patients, and the few previous publications are mainly limited to reports on linked elbow devices. We investigated the clinical outcome of unlinked TEA for patients aged less than 50 years with rheumatoid arthritis (RA).

Aims. The mean age of patients undergoing total knee arthroplasty (TKA) has reduced with time. Younger patients have increased expectations following TKA. Aseptic loosening of the tibial component is the most common cause of failure of TKA in the UK. Interest in cementless TKA has re-emerged due to its encouraging results in the younger patient population. We review a large series of tantalum trabecular metal cementless implants in patients who are at the highest risk of revision surgery. Methods. A total of 454 consecutive patients who underwent cementless TKA between August 2004 and December 2021 were reviewed. The mean follow-up was ten years. Plain radiographs were analyzed for radiolucent lines. Patients who underwent revision TKA were recorded, and the cause for revision was determined. Data from the National Joint Registry for England, Wales, Northern Island, the Isle of Man and the States of Guernsey (NJR) were compared with our series. Results. No patients in our series had evidence of radiolucent lines on their latest radiological assessment. Only eight patients out of 454 required revision arthroplasty, and none of these revisions were indicated for aseptic loosening of the tibial baseplate. When compared to data from the NJR annual report, Kaplan-Meier estimates from our series (2.94 (95% confidence interval (CI) 1.24 to 5.87)) show a significant reduction in cumulative estimates of revision compared to all cemented (4.82 (95% CI 4.69 to 4.96)) or cementless TKA (5.65 (95% CI 5.23 to 6.10)). Our data (2.94 (95% CI 1.24 to 5.87)) also show lower cumulative revision rates compared to the most popular implant (PFC Sigma Cemented Knee implant fixation, 4.03 (95% CI 3.75 to 4.33)). The prosthesis time revision rate (PTIR) estimates for our series (2.07 (95% CI 0.95 to 3.83)) were lower than those of cemented cases (4.53 (95% CI 4.49 to 4.57)) from NJR. Conclusion. The NexGen trabecular (tantalum) cementless implant has lower revision rates in our series compared to all cemented implants and other types of cementless implants, and its use in younger patients should be encouraged. Cite this article: Bone Jt Open 2024;5(4):277–285

Since 1977 we did implant ceramic on ceramic THR in younger and active population. In 1991 we published (JBJS B N°4) data's in a consecutive group of patients under 50 years of age. What about the same patients for more than 30 years? Eighty-six hips in 75 patients, 41 males 34 females, mean age 43 (18 to 50), mean weight 68 kg (36 to 100), Charnley class: 38 A, 28 (38 hips) B, 9 patients (10 hips) C. Sixty-six primary procedures, 20 revisions (18 failed arthroplasties: 6 THR, 5 resurfacing, four single cup, two hemiarthroplasty, one bipolar), one after acetabular fractures. Four hips previously infected. Eight Patients deceased (8 hips) prosthesis still in place, ten lost to follow-up before 2 years, eight hips in 8 patients were revised before the review, partially followed: from 2 to 20 years: 35, completely followed: 25 hips in 23 patients resuming in: No pain in 20, slight pain in 2, severe disability in 3 not related to the hip, no radiolucent lines in 22, radiolucent lines in 3, no osteolysis in 25. Revision for: early sepsis in one, socket loosening in 8 (3 revisions cases), femoral head fractures in 2: one extra small head (22mm) for Crowe 3 DDH, one fractured at 24 years. Inertness, stability related to fibrous tissue generation, no noise

The benefits of HXLPE in total knee arthroplasty (TKA) have not been as evident as total hip arthroplasty (THA). A systematic review and meta-analysis to assess the impact of highly-crosslinked polyethylene (HXLPE) on TKA outcomes compared to conventional polyethylene (CPE) is described. All studies comparing HXLPE with CPE for primary TKA were included for analysis. The minimum dataset included revision rates, indication for revision, aseptic component loosening and follow-up time. The primary outcome variables were all-cause revision, aseptic revision, revision for loosening, radiographic component loosening, osteolysis and incidence of radiolucent lines. Secondary outcome measures included postoperative functional knee scores. A random-effects meta-analysis allowing for all missing data was performed for all primary outcome variables. Six studies met the inclusion criteria. In total, there were 2,234 knees (1,105 HXLPE and 1,129 CPE). The combined mean follow-up for all studies was 6 years. The aseptic revision rate in the HXLPE group was 1.02% compared to 1.97% in the CPE group. There was no difference in the rate of all-cause revision (p = 0.131), aseptic revision (p = 0.298) or revision for component loosening (p = 0.206) between the two groups. Radiographic loosening (p = 0.200), radiolucent lines (p = 0.123) and osteolysis (p = 0.604) was similar between both groups. Functional outcomes were similar between groups. The use of HXLPE in TKA yields similar results for clinical and radiographic outcomes when compared to CPE at midterm follow-up. HXLPE does not confer the same advantages to TKA as seen in THA

Cup-cage constructs are one of several methods commonly used to treat severe acetabular bone loss during contemporary revision total hip arthroplasty. The purpose of this study was to provide a long-term results of the technique with emphasis on implant survivorship, radiographic results, and clinical outcomes for both full and half cup-cage reconstructions. We identified 57 patients treated with a cup-cage reconstruction for major acetabular bone loss between 2002–2012. All patients had Paprosky Type 2B through 3B bone loss, with 60% having an associated pelvic discontinuity. Thirty-one patients received a full cup-cage construct, and 26 a half cup-cage. Mean age at reconstruction was 66 years, 75% were female, and the mean BMI was 27 kg/m. 2. Mean follow-up was 10 years. The 10-year cumulative incidences of any revision were 14% and 12% for the full and half cup-cage construct groups, respectively. Of the 9 revisions, 3 were for dislocation, 2 for aseptic loosening and construct failure (both were pelvic discontinuities), 1 for adverse local tissue reaction, and 1 for infection with persistent pelvic discontinuity. The 10-year cumulative incidences of revision for aseptic loosening were 4.5% and 5% for the full and half cup-cage constructs, respectively. Of the unrevised cases, incomplete and non-progressive zone 3 radiolucent lines were observed in 10% of patients in each group. Three patients experienced partial motor and sensory sciatic nerve palsies (2 in the full and 1 in the half cup-cage group). Both the full and half cup-cage cohorts demonstrated significantly improved Harris hip scores. Full and half cup-cage reconstructions for major acetabular defects were successful at 10 years in regards to acetabular fixation without appreciable differences between the two techniques. However, zone 3 radiolucent lines were not uncommon in association with discontinuities, and dislocation continues to be a problem

Abstract. Introduction. Cementless fixation of Oxford Unicompartmental Knee Replacements (UKRs) is an alternative to cemented fixation, however, it is unknown whether cementless fixation is as good long-term. This study aimed to compare primary and long-term fixation of cemented and cementless Oxford UKRs using radiostereometric analysis (RSA). Methodology. Twenty-nine patients were randomised to receive cemented or cementless Oxford UKRs and followed for ten years. Differences in primary fixation and long-term fixation of the tibial components (inferred from 0/3/6-month and 6-month/1-year/2-year/5-year/10-year migration, respectively) were analysed using RSA and radiolucencies were assessed on radiographs. Migration rates were determined by linear regression and clinical outcomes measured using the Oxford Knee Score (OKS). Results. Preliminary analysis of Maximum Total Point Motion (MTPM) indicated cementless tibial components undergo significantly more migration than cemented components during the first 6 months (1.6mm/year, SD=0.92 versus 1.3mm/year, SD=1.1, p<0.001). Cementless migration was predominantly subsidence inferiorly (Mean=0.51mm/year, SD=0.29, p<0.001) and posteriorly (0.13mm/year, SD=0.21, p=0.03). Contrastingly, from 6 months to 10 years cemented components migrated significantly (MTPM=0.039mm/year, SD=0.11, p=0.04) whereas cementless components did not (MTPM=0.002mm/year, SD=0.02, p=0.744). Radiolucent lines occurred more frequently below cemented (10/13) than cementless (4/16) tibial components, but radiolucencies did not correlate with differences in migration or OKS. There was no significant difference in OKS between cemented and cementless. Conclusion. These results suggest that cementless tibial components migrate more than cemented before achieving primary fixation. However, long-term fixation of cementless tibial components appears to be as good, if not better, than cemented with the benefit of fewer radiolucent lines

Aim. Radiologic signs such as radiolucent lines around the implant, hardware fracture or displacement and periosteal reaction have been considered suggestive of implant-associated infection. The goal of this study is to assess the correlation of these signs with confirmed internal fixation-associated infection evaluated in a prospective cohort. Method. We evaluated the radiologic appearance of preoperative standard x-ray images in 421 surgeries performed in 380 patients with internal fixation device in place (56.8% male, mean age 53 ± 17 years). This prospective study was performed in a large single center for musculoskeletal surgery from 2013–2017. Infection was suspected preoperatively in only 23.8% of the surgeries. The most common indications for surgeries in which infection was not suspected were nonunion (84 cases) and symptomatic hardware (57 cases). All removed implants were sent to sonication for biofilm removal and detection. In addition, several peri-implant tissue samples were collected. Radiographs were analyzed in a blinded fashion for signs of radiolucent lines around the implant before removal, hardware fracture or displacement, and soft periosteal reactions suggestive of infection. Diagnosis was established according to the IDSA criteria for PJI. Contingency tables were constructed to determine sensitivity and specificity, and to perform Chi-square tests to compare the presence of infection with radiological signs of infection. Results. Radiologic signs suggestive for infection were uncommon, including radiolucent lines in 48 cases (11.4%); hardware breakage in 542cases (12.4%); hardware displacement in 45 cases (10.7%); periosteal reaction in 30 cases (7.1%). Infection was confirmed in 27.6% of the surgeries, and radiological signs of infection were only marginally more common in this group. Only the presence of radiolucent lines (p = 0.47; OR = 1.86 [95% CI 1.00 – 3.38]) and periosteal reaction (p = 0.15; OR = 2.48 [1.17 – 5.26]) were significantly associated with confirmed infection. Sensitivity of radiolucent lines and periosteal reaction were low (16,4% and 12,1%, respectively), while specificity remained acceptable (90.5%and 94.8%, respectively). Conclusions. Radiologic signs of infection are uncommon, even in the context of a confirmed infection. Radiolucency surrounding the implant and the presence of a soft periosteal reaction were significantly associated with the presence of infection, though sensitivity of the signs remained very low

Introduction. THA for patient's 50 years and younger is a procedure at high risk for complications and failure because of the high level of activity of this population. Highly cross linked polyethylene (HXLPE) has greatly improved the durability of the implant because of the improved wear characteristics. Few studies have followed this population into the second decade and therefore the purpose of this investigation was to evaluate the clinical outcome for the patients 5o years of age and younger at a minimum of 15 years. The second purpose was to evaluate the radiographic findings secondary to wear or mechanical failure of the implant. Methods. Between October 1999 and December 2005, 105 THAs were performed in 95 patients (53 female, 42 male) age 50 years and younger (mean 42 years; range 20–50). Ten patients (10 hips) were lost to follow-up or deceased. The remaining 95 hips and 85 patients were followed for a minimum of 15 years (mean of 16.8, range 15–20.5) for analysis. HXLPE (Longevity, Zimmer Biomet) was the acetabular bearing for all hips. Radiographs were evaluated for radiolucent lines and osteolysis. Results. Clinical outcomes showed excellent results in 80 hips, good results in 10 hips, fair in 3 hips and poor in 2 hips. One hip was revised for recurrent instability, one patient suffered a DVT and there were no infections. None of the hips were revised for mechanical loosening or osteolysis. Radiolucent lines were present in Zone I of the acetabulum in 23 hips and Zone II in 6 and Zone III 7. Osteolysis was not present in any of the hips. Conclusions. The use of HXLPE in THA for patients 50 years of age and younger has performed exceptionally well without evidence of wear causing mechanical loosening or necessitating revision. Radiographic evidence of osteolysis was not identified, but progressive radiolucent lines of the acetabular component were noted

Abstract. Objective. Up to 20% of patients can remain dissatisfied following TKR. A proportion of TKRs will need early revision with aseptic loosening the most common. The ATTUNE TKR was introduced in 2011 as successor to its predicate design The PFC Sigma (DePuy Synthes, Warsaw, In). However, following reports of early failures of the tibial component there have been ongoing concerns of increased loosening rates with the ATTUNE TKR. In 2017 a redesigned tibial baseplate (S+) was introduced, which included cement pockets and an increased surface roughness to improve cement bonding. Given the concerns of early tibial loosening with the ATTUNE knee system, this study aimed to compare revision rates and those specific to aseptic loosening of the ATTUNE implant in comparison to an established predicate as well as other implant designs used in a high-volume arthroplasty centre. Methods. The Attune TKR was introduced to our unit in December 2011. Prior to this we routinely used a predicate design with an excellent long-term track record (PFC Sigma) which remains in use. In addition, other designs were available and used as per surgeon preference. Using a prospectively maintained database, we identified 10,202 patients who underwent primary cemented TKR at our institution between 01/04/2003–31/03/2022 with a minimum of 1 year follow-up (Mean 8.4years, range 1–20years): 1) 2406 with ATTUNE TKR (of which 557 were S+) 2) 4652 with PFC TKR 3) 3154 with other cemented designs. All implants were cemented using high viscosity cement. The primary outcome measures were all-cause revision, revision for aseptic loosening, and revision for tibial loosening. Kaplan-Meier survival analysis and Cox regression models were used to compare the primary outcomes between groups. Matched cohorts were selected from the ATTUNE subsets (original and S+) and PFC groups using the nearest neighbor method for radiographic analysis. Radiographs were assessed to compare the presence of radiolucent lines in the Attune S+, standard Attune, and PFC implants. Results. At a mean of 8.4 years follow-up, 308 implants underwent revision equating to 3.58 revisions per 1000 implant-years. The lowest risk of revision was noted in the ATTUNE cohort with 2.98 per 1000-implant-years where the PFC and All Other Implant groups were 3.15 and 4.4 respectively. Aseptic loosing was the most common cause for revision across all cemented implants with 76% (65/88) of involving loosening of the tibia. Survival analysis comparing the ATTUNE cohort to the PFC and All Other Cemented Implant cohorts showed no significant differences for: all-cause revision, aseptic loosening, or tibial loosening (p=0.15,0.77,0.47). Radiolucent lines were detected in 4.6%, 5.8%, and 5.0% of the ATTUNE S+, standard ATTUNE, and PFC groups respectively. These differences were not significant. Conclusion. This study represents the largest non-registry review of the original and S+ ATTUNE TKR in comparison to its predicate design as well as other cemented implants. There appears to be no significant increased revision rate for all-cause revision or aseptic loosening. Radiographic analysis also showed no significant difference in peri-implant radiolucency. It appears that concerns of early loosening may be unfounded. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest