Aims. The purpose of this study was to compare the clinical outcomes, mortalities, implant survival rates, and complications of total knee arthroplasty (TKA) in patients with or without hepatitis B virus (HBV) infection over at least ten years of follow-up. Methods. From January 2008 to December 2010, 266 TKAs were performed in 169 patients with HBV (HBV group). A total of 169 propensity score–matched patients without HBV were chosen for the control group in a one-to-one ratio. Then, the clinical outcomes, mortalities, implant survival rates, and complications of TKA in the two groups were compared. The mean follow-up periods were 11.7 years (10.5 to 13.4) in the HBV group and 11.8 years (11.5 to 12.4) in the control group. Results. The mean Knee Society scores in the HBV and control groups improved from 37.1 (SD 5.6) and 38.4 (SD 5.4) points preoperatively to 78.1 (SD 10.8) and 81.7 (SD 10.2) points at final follow-up (p = 0.314), while the mean function scores in the HBV and control groups improved from 36.2 and 37.3 points preoperatively to 77.8 and 83.2 points at final follow-up (p = 0.137). Nine knees in the HBV group required revision surgery, including seven due to septic loosening and two due to aseptic loosening. Four knees in the control group required revision surgery, including three due to septic loosening and one due to aseptic loosening. Kaplan–Meier survivorship analysis with the revision of either component as an endpoint in the HBV and control groups estimated 96.6% and 98.5% chances of survival for ten years, respectively (p = 0.160). Conclusion. TKA in patients with HBV infection resulted in good clinical outcomes and survivorship. However, there was a higher revision rate over a minimum ten-year follow-up period compared to TKA in patients without HBV infection. Cite this article: Bone Jt Open 2022;3(6):470–474

Although data on uncemented short stems are available, studies on cemented short-stemmed THAs are limited. These cemented short stems may have inferior long-term outcomes and higher femoral component fracture rates. Hence, we examined the long-term follow-up of cemented short Exeter stems used in primary THA. Within the Exeter stem range, 7 stems have a stem length of 125 mm or less. These stems are often used in small patients, in young patients with a narrow femoral canal or patients with anatomical abnormalities. Based on our local database, we included 394 consecutive cemented stems used in primary THA (n=333 patients) with a stem length ≤125 mm implanted in our tertiary referral center between 1993 and December 2021. We used the Dutch Arthroplasty Registry (LROI) to complete and cross-check the data. Kaplan-Meier survival analyses were performed to determine 20-year survival rates with stem revision for any reason, for septic loosening, for aseptic loosening and for femoral component fracture as endpoints. The proportion of male patients was 21% (n=83). Median age at surgery was 42 years (interquartile range: 30–55). The main indication for primary THA was childhood hip diseases (51%). The 20-year stem survival rate of the short stem was 85.4% (95% CI: 73.9–92.0) for revision for any reason and 96.2% (95%CI: 90.5–98.5) for revision for septic loosening. No stems were revised for aseptic femoral loosening. However, there were 4 stem fractures at 6.6, 11.6, 16.5 and 18.2 years of follow-up. The stem survival with femoral component fracture as endpoint was 92.7% (CI: 78.5–97.6) at 20 years. Cemented short Exeter stems in primary THA show acceptable survival rates at long-term follow-up. Although femoral component fracture is a rare complication of a cemented short Exeter stem, orthopaedic surgeons should be aware of its incidence and possible risk factors

Aims. The aim of this meta-analysis was to compare the outcome of total elbow arthroplasty (TEA) undertaken for rheumatoid arthritis (RA) with TEA performed for post-traumatic conditions with regard to implant failure, functional outcome, and perioperative complications. Materials and Methods. We completed a comprehensive literature search on PubMed, Web of Science, Embase, and the Cochrane Library and conducted a systematic review and meta-analysis. Nine cohort studies investigated the outcome of TEA between RA and post-traumatic conditions. The preferred reporting items for systematic reviews and meta-analysis (Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)) guidelines and Newcastle-Ottawa scale were applied to assess the quality of the included studies. We assessed three major outcome domains: implant failures (including aseptic loosening, septic loosening, bushing wear, axle failure, component disassembly, or component fracture); functional outcomes (including arc of range of movement, Mayo Elbow Performance Score (MEPS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), and perioperative complications (including deep infection, intraoperative fracture, postoperative fracture, and ulnar neuropathy). Results. This study included a total of 679 TEAs for RA (n = 482) or post-traumatic conditions (n = 197). After exclusion, all of the TEAs included in this meta-analysis were cemented with linked components. Our analysis demonstrated that the RA group was associated with a higher risk of septic loosening after TEA (odds ratio (OR) 3.96, 95% confidence interval (CI) 1.11 to 14.12), while there was an increased risk of bushing wear, axle failure, component disassembly, or component fracture in the post-traumatic group (OR 4.72, 95% CI 2.37 to 9.35). A higher MEPS (standardized mean difference 0.634, 95% CI 0.379 to 0.890) was found in the RA group. There were no significant differences in arc of range of movement, DASH questionnaire, and risk of aseptic loosening, deep infection, perioperative fracture, or ulnar neuropathy. Conclusion. The aetiology of TEA surgery appears to have an impact on the outcome in terms of specific modes of implant failures. RA patients might have a better functional outcome after TEA surgery. Cite this article: Bone Joint J 2019;101-B:1489–1497

Aims. The purpose of this study is to report our updated results at a minimum follow-up of 30 years using a first generation uncemented tapered femoral component in primary total hip arthroplasty (THA). Methods. The original cohort consisted of 145 consecutive THAs performed by a single surgeon in 138 patients. A total of 37 patients (40 hips) survived a minimum of 30 years, and are the focus of this review. The femoral component used in all cases was a first-generation Taperloc with a non-modular 28 mm femoral head. Clinical follow-up at a minimum of 30 years was obtained on every living patient. Radiological follow-up at 30 years was obtained on all but four. Results. Seven femoral components (18%) required revision, and none for septic loosening. Four well fixed stems were removed during acetabular revision and three were revised for late infection. One femoral component (3%) was loose by radiological criteria. The mean Harris Hip Score improved from 47 points (SD 4.62) preoperatively to 83 points (SD 9.27) at final follow-up. With revision for any reason as the endpoint, survival of the femoral component was 80% (95% confidence interval (CI) 61% to 90%) at 32 years. With revision for aseptic loosing femoral component, survival was 99% (95% CI 93% to 99%). Conclusion. With regards to aseptic loosening, the Taperloc femoral component provides excellent fixation at a mean follow-up of 32 years. Cite this article: Bone Jt Open 2023;4(2):79–86

THA in patients with acetabular bone defects is associated with a high risk of dislocation. Dual mobility (DM) cups are known to prevent and treat chronic instability. The aim of this study was to evaluate the dislocation rate and survival of jumbo DM cups. This was a retrospective, continuous, multicenter study of all the cases of jumbo DM cup implantation between 2010 and 2017 in patients with acetabular bone loss (Paprosky 2A: 46%, 2B: 32%, 2C: 15% and 3A: 6%). The indications for implantation were revisions for aseptic loosening of the cup (n=45), aseptic loosening of the femoral stem (n=3), bipolar loosening (n=11), septic loosening (n=10), periprosthetic fracture (n=5), chronic dislocation (n=4), intraprosthetic dislocation (n=2), cup impingement (n=1), primary posttraumatic arthroplasty (n=8), and acetabular dysplasia (n=4). The jumbo cups used were COPTOS TH (SERF), which combines press-fit fixation with supplemental fixation (acetabular hook, two superior flanges with one to four screws, two acetabular pegs). A bone graft was added in 74 cases (80%). The clinical assessment consisted of the Harris hip score. The primary endpoint was surgical revision for aseptic acetabular loosening or the occurrence of a dislocation episode. In all, 93 patients were reviewed at a mean follow-up of 5.3 ± 2.3 years [0, 10]. As of the last follow-up, the acetabular cup had been changed in five cases: three due to aseptic loosening (3.2%) and two due to infection (2.1%). The survivorship free of aseptic loosening was 96.8%. Three patients (3%) suffered a dislocation. At the last follow-up visit, the mean HSS scores were 72.15, (p < 0.05). Use of a jumbo DM cup in cases of acetabular bone defects leads to satisfactory medium-term results with low dislocation and loosening rates

The reconstruction of peri-acetabular defects after severe bone loss or pelvic resection for tumor is among the most challenging surgical intervention. The Lumic® prosthesis (Implantcast, Buxtehude, Germany) was first introduced in 2008 in an effort to reduce the mechanical complications encountered with the classic peri-acetabular reconstruction techniques and to improve functional outcomes. Few have evaluated the results associated with the use of this recent implant. A retrospective study from five Orthopedic Oncology Canadian centers was conducted. Every patient in whom a Lumic® endoprosthesis was used for reconstruction after peri-acetabular resection or severe bone loss with a minimal follow-up of three months was included. The charts were reviewed and data concerning patients’ demographics, peri-operative characteristics and post-operative complications was collected. Surgical and functional outcomes were also assessed. Sixteen patients, 11 males and five females, were included and were followed for 28 months [3 – 60]. Mean age was 55 [17–86], and mean BMI reached 28 [19.6 – 44]. Twelve patients (75%) had a Lumic® after a resection of a primary sarcoma, two following pelvic metastasis, one for a benign tumor and one after a comminuted acetabular fracture with bone loss. Twelve patients (75%) had their surgery performed in one stage whereas four had a planned two-stage procedure. Mean surgical time was 555 minutes [173-1230] and blood loss averaged 2100 mL [500-5000]. MSTS score mean was 60.3 preoperatively [37.1 – 97] and 54.3 postoperatively [17.1-88.6]. Five patients (31.3%) had a cemented Lumic® stem. All patients got the dual mobility bearing, and 10 patients (62.5%) had the largest acetabular cup implanted (60 mm). In seven of these 10 patients the silver coated implant was used to minimize risk of infection. Five patients (31.3%) underwent capsular reconstruction using a synthetic fabric aiming to reduce the dislocation risk. Five patients had per-operative complications (31.3%), four were minor and one was serious (comminuted iliac bone fracture requiring internal fixation). Four patients dislocated within a month post-operatively and one additional patient sustained a dislocation one year post-operatively. Eight patients (50%) had a post-operative surgical site infection. All four patients who had a two-stage surgery had an infection. Ten patients (62.5%) needed a reoperation (two for fabric insertion, five for wash-outs, and three for implant exchange/removal). One patient (6.3%) had a septic loosening three years after surgery. At the time of data collection, 13 patients (81.3%) were alive with nine free of disease. Silver coating was not found to reduce infection risk (p=0.2) and capsuloplasty did not prevent dislocation (p=1). These results are comparable to the sparse data published. Lumic® endoprosthesis is therefore shown to provide good functional outcomes and low rates of loosening on short to medium term follow-up. Infection and dislocation are common complications but we were unable to show benefits of capsuloplasty and of the use of silver coated implants. Larger series and longer follow-ups are needed

The reconstruction of peri-acetabular defects after severe bone loss or pelvic resection for tumor is among the most challenging surgical intervention. The Lumic® prosthesis (Implantcast, Buxtehude, Germany) was first introduced in 2008 in an effort to reduce the mechanical complications encountered with the classic peri-acetabular reconstruction techniques and to improve functional outcomes. Few have evaluated the results associated with the use of this recent implant. A retrospective study from five Orthopedic Oncology Canadian centers was conducted. Every patient in whom a Lumic® endoprosthesis was used for reconstruction after peri-acetabular resection or severe bone loss with a minimal follow-up of three months was included. The charts were reviewed and data concerning patients’ demographics, peri-operative characteristics and post-operative complications was collected. Surgical and functional outcomes were also assessed. Sixteen patients, 11 males and five females, were included and were followed for 28 months [3 – 60]. Mean age was 55 [17-86], and mean BMI reached 28 [19.6 – 44]. Twelve patients (75%) had a Lumic® after a resection of a primary sarcoma, two following pelvic metastasis, one for a benign tumor and one after a comminuted acetabular fracture with bone loss. Twelve patients (75%) had their surgery performed in one stage whereas four had a planned two-stage procedure. Mean surgical time was 555 minutes [173-1230] and blood loss averaged 2100 mL [500-5000]. MSTS score mean was 60.3 preoperatively [37.1 – 97] and 54.3 postoperatively [17.1-88.6]. Five patients (31.3%) had a cemented Lumic® stem. All patients got the dual mobility bearing, and 10 patients (62.5%) had the largest acetabular cup implanted (60 mm). In seven of these 10 patients the silver coated implant was used to minimize risk of infection. Five patients (31.3%) underwent capsular reconstruction using a synthetic fabric aiming to reduce the dislocation risk. Five patients had per-operative complications (31.3%), four were minor and one was serious (comminuted iliac bone fracture requiring internal fixation). Four patients dislocated within a month post-operatively and one additional patient sustained a dislocation one year post-operatively. Eight patients (50%) had a post-operative surgical site infection. All four patients who had a two-stage surgery had an infection. Ten patients (62.5%) needed a reoperation (two for fabric insertion, five for wash-outs, and three for implant exchange/removal). One patient (6.3%) had a septic loosening three years after surgery. At the time of data collection, 13 patients (81.3%) were alive with nine free of disease. Silver coating was not found to reduce infection risk (p=0.2) and capsuloplasty did not prevent dislocation (p=1). These results are comparable to the sparse data published. Lumic® endoprosthesis is therefore shown to provide good functional outcomes and low rates of loosening on short to medium term follow-up. Infection and dislocation are common complications but we were unable to show benefits of capsuloplasty and of the use of silver coated implants. Larger series and longer follow-ups are needed

The aim of the study to analyze the circulating white blood cells including the intensity expression of surface receptors and cytoplasmic molecules in patients underwent total hip replacement, with either aseptic or septic loosening of hip prostheses in order to identify cell-surface and cytoplasmic markers that could be indicative of early loosening. Flow cytometry was performed in whole peripheral blood samples of 20 patients with loosening (10 septic and 10 aseptic). Ten healthy individuals served a control group. The CD62L, CD18, CD11a, CD11b and CD11c expressions were evaluated. The mean fluorescence intensity (MFI) of CD 18 was decreased on all leukocytes subsets compared to control group. For patients with aseptic loosening we demonstrated an increase of MFI for CD11b in granulocytes and for CD11c in monocytes and granulocytes compared to control group. In patients with septic loosening an increase of MFI for CD 11c was observed in monocytes compared to control group. The comparison between aseptic and septic loosening showed a statistically significant lower CD18 MFI value in granulocytes for aseptic loosening. A trend towards lower MFI values of CD 62L in lymphocytes and granulocytes were observed in aseptic but not in septic loosening patients compared to control group. The present study is the first study in published literature to demonstrate cell surface and cytoplasmic markers in peripheral blood indicative of loosening of THAs by means of flow cytometry

Aims: The symptoms of aseptic and septic prosthetic joint loosening may be similar, and identification of low-grade prosthetic infection based only on clinical history and physical examination has a reported low sensitivity. In a prospective study we explored to what extent a thorough examination of the patient’s history of sickness and a standardized preoperative clinical examination could help the surgeon to identify cases of septic loosening. Methods: We included 54 patients undergoing revision surgery due to loosening of a total hip or knee prosthesis. Preoperatively a standardized form which included data regarding the patient’s history of sickness was obtained and a physical examination was performed. Postoperatively a final diagnose was made based on microbiological testing, which in addition to routine culture, included sonication of the prosthesis and nucleic acid based diagnostics (PCR). Data from the preoperative examination was evaluated in relation to the final diagnose (chi-square test and Student’s t-test), and the sensitivity and specificity for diagnosing a septic loosening was calculated for each preoperative finding. Results: According to the final diagnose, 21 patients had a septic loosening and 33 patients had an aseptic loosening. In the septic group and aseptic group the following anamnestic data was registered: Pain during rest: 16/21 vs. 7/33 (p < 0.001). Prior history of soft tissue debridement: 11/21 vs. 4/33 (p = 0.001). Prior prosthetic revision surgery: 13/21 vs. 8/33 (p = 0.006). Time from index operation to revision: 45 (5 – 144) moths vs. 159 (22–390) moths, (p = 0.02). Time from index operation to debut of prosthetic assosiated dyscomfort: 10 (0–110) moths vs. 120 (0–240) moths, (p < 0.001). The calculated sensitivity (se) and spesifisity (sp) for the pre-operative findings were: Existence of prosthetic related pain during rest: 79% se, 79% sp; history of soft tissue revision in the affected joint 52% se, 88% sp; history of prior exchange prosthetic revision in the affected joint 62% se, 76% sp, respectively. Conclusion: We advise a carefully obtained history from every patient presenting with loosening of implanted prosthetic components for identification of a potential low grade infection. In particular, pain during rest has a notable sensitivity and specificity. A prior history of soft tissue revision also strongly indicates a septic prosthetic loosening

INTRODUCTION. Conventional surgical exposures are usually inadequate for 2-stage revision knee replacement ofinfected implants. Reduced range of motion, extensor mechanism stiffness, peripatellar contracture and soft tissue scarring make patellar eversion difficult and forced eversion places the integrity of the extensor mechanism at risk. On the contrary, a wide exposure is fundamental to allow complete cement spacer removal, soft tissue balancing, management of bone loss and reimplantation without damaging periarticular soft tissues. OBJECTIVES. To compare the long-term clinical, functional and radiographic results and the reinfection rate of the quadriceps snip approach and the tibial tubercle osteotomy in 2-stage revision knee replacement performed for septic loosening of the primary implant. METHODS. In our department, 87 patients had a 2 stage revision knee replacement for septic loosening of the primary implant between 1996 and 2008. In all patients, first stage consisted of primary implant removal, extensive soft tissue debridement and positioning of a static antibiotic loaded cement spacer. The timing for reimplantation was decided basing on negative clinical and laboratory (ESR, CRP) signs and negative Leukoscan results. For reimplantation, a quadriceps snip was used in patients with an intraoperative flexion >90° (Group A) while a tibial tubercle osteotomy (Group B) was used in patients with an intraoperative flexion <90°. RESULTS. At observation point, 4 patients died for reasons unrelated to surgery, leaving 42 patients in Group A and 41 in Group B. We had a total amount of 10 recurrent infections (11%) after reimplantation, 7 patients in Group A and 3 patients in Group B (p<0.005). Patients with a reinfection in Group A were treated with a knee fusion in 4 cases, a rerevision in 2 cases and an amputation above the knee in 1 case, while all those with a reinfection in Group B had a knee fusion. According to HSS score, 11 patients were rated as Excelent/Good in Group A and 9 patients in Group B (p=n.s.). Three patients had a major complication in Group A and 0 patients in Group B (p=0.005). No differences were found between the two groups regarding range of motion and subjective satisfaction. CONCLUSION. Tibial tubercle osteotomy is a safe procedure to obtain a wide exposure in 2-stage revision knee replacement performed for septic loosening of the primary implant and it is effective in reducing reinfection rate without compromising clinical results and range of motion

Introduction. Revision TKA can be a difficult and complex procedure. Bone quality is commonly compromised and stem fixation is required in many cases to provide stability of the prosthetic construct. However, utilization of diaphyseal engaging stems adds complexity to the case and can present technical challenges to the surgeon. Press fit metaphyseal sleeves can provide stable fixation of the construct without the need for stems and allows for biologic ingrowth of the prosthesis. Metaphyseal sleeves simplify the revision procedure by avoiding the need to prepare the diaphysis for stems, alleviating the need for offset stems and decreasing the risk of intra-operative complications. The ability to obtain biologic fixation in the young patient is also appealing. This study reports on the author's mid-term experience with this novel technique. Methods. Between May 2007 and June 2009 the author performed 17 revisions TKA that utilized press-fit metaphyseal sleeves without stems on either the tibial side of the joint, the femoral side of the joint or both. Twenty six sleeves were implanted altogether (13 tibial, 13 femoral). Patients were limited to touch down weight bearing for 6 weeks post-operatively. The patients were followed prospectively with clinical and radiographic follow-up at routine intervals. Results. Average clinical and radiographic F/U for the cohort was 57 months (range 30 – 77). Fourteen of seventeen patients had a minimum of 4 years F/U. Average age at the time of surgery was 58 years (range 46–72) and average BMI was 32.4. Indications for the index revision included nine knees with aseptic loosening and / or osteolysis, two knees for septic loosening, two knees for instability and 4 knees for pain / stiffness or other causes. ROM at pre-op and latest F/U averaged 2–108 deg and 0–117 deg respectively. Knee Society Scores at pre-op and latest F/U averaged 35 and 86 respectively (range 57–100). Survivorship analysis revealed 25 of 26 sleeves (96%) to still be in situ at latest F/U. One tibial sleeve was revised at 30 months for septic loosening. Radiographic analysis revealed 22 of the remaining 25 sleeves (88%) to be ingrown. Two tibial sleeves and one femoral sleeve exhibit stable fibrous fixation and are asymptomatic. Conclusions. Press-fit metaphyseal sleeves utilized without stems appear to provide excellent stability of the revision TKA construct at mid-term F/U. Biologic fixation appears to be present in the majority of cases. This ability to obtain reliable osseointegration of the revision construct is appealing, especially in the younger revision patient. The sleeves have proven easy to use and there have been no intra-operative complications. This technique appears to provide a simple, but robust alternative when compared to revision TKA with stems in appropriate cases. Further F/U of this cohort is necessary to evaluate long term results

At our institution between 1994 and 2003 a total of 36 revision total elbow Arthroplasties were performed in 34 patients. We clinically reviewed 25 patients and reviewed the notes and x-rays of all of them. Of eleven who were not reviewed clinically seven had died from an unrelated cause and four were unable to attend because of illness but we were able to include them as sufficient data were available in the notes. There were 24 female and 12 male, Average age was 67 years and twelve had elbow Arthroplasty in a non-dominant side. The average follow up was 6 years (range 5–13 years). The mean period between the primary and revision surgery was sixty three months (range 3–240 months). The indication for surgery was mainly for aseptic loosening in 15 cases, followed by septic loosening in twelve. All cases of septic loosening had two stage revisions. Other reasons for revision in this series include unstable elbows, implant fracture and peri-prosthetic fractures. Twelve of these revisions had a further revision for a variety of reasons at an average period of twenty eight months. Seven patients had thirteen complications in this series, two radial nerve palsies (one recovered), one distal humeral fracture, five cortical perforations and five triceps weakness. Most of the patients are satisfied with their elbows. The mean Mayo elbow Performance Score was 79 points. We conclude that revision Elbow Arthroplasty is a specialized surgery which is technically demanding, with high risk of complications and high re-revision rate and therefore, should be done in a specialised centres

Girdlestone’s arthroplasty is often used to treat septic loosening of hip prostheses. Although this operation provides goodresults with regards to pain and loosening, it causes instability and in the hip and limb shortening that force the patient to use walking aids. From 1990 to 1999 we treated ten cases of revisionhip arthroplasty after Girdlestone’s arthroplasty. Girdleston e’sarthroplasty was carried out in all cases due to sepsis in the previousimplant. Preoperatively all patients underwent granulocyte-labeledscintigraphy. For clinical evaluation we used the Merle D’Aubignè score. From 1990 to 1999 we treated ten cases of revisionhip arthroplasty after Girdlestone’s arthroplasty. Girdleston e’sarthroplasty was carried out in all cases due to sepsis in the previousimplant. Preoperatively all patients underwent granulocyte-labeledscintigraphy. For clinical evaluation we used the Merle D’Aubignè score. Girdlestone’s arthroplasty is very effective for treating septic loosening of hip prostheses, but it causes severe walking impediment. Revision surgery restores limb length and walking. Patients that undergo this treatment should be checked for residual sepsis, which may jeopardize the operation. Currently we are experimenting with spacers with antibiotics and our initial results are promising

Introduction: Hip replacement prosthesis infection is a severe complication of ever increasing incidence. Currently there is controversy as to whether prosthetic revision surgery should be carried out in one or two stages and whether cemented or uncemented prostheses should be used. Materials and methods: This is a retrospective study of 17 cases of chronic infections of hip replacements that were revised in one-stage procedures between 1996 and 2005 in our center. Mean follow-up is 3.4 years. We analyzed the functional status of the hips before and after revision using the Merle D’Aubigne scale, x-rays, and supplementary tests for diagnosis and decisions on treatment. Results: The functional score at the end of the follow-up was 16.17 (Merle D’Aubigne scale). The most common pathogen is coagulase-negative staphylococci. Acute phase reactive elements reached normal levels. X-ray control does not show any alterations or signs of loosening. No subsequent revisions have been performed. Conclusions: The diagnosis and treatment of prosthetic revision requires correct preoperative assessment and planning. Differential diagnosis of aseptic versus septic loosening in chronic infections is complex; in some cases it is necessary to wait for definite culture results for a surefire diagnosis. We think that in selected chronic cases of septic loosening of the hip due no non-multi-resistant organisms, one-stage revision using a Wagner osteotomy for diaphyseal cleaning combined with a hydoxyapatite-coated stem makes it possible to achieve good functional results and control infection, decreasing the morbidity and cost of a two-stage revision

Numerous techniques are used for the fusion of failed TAR. We wish to report our results of the revision of failed TAR to fusion. Between July 2005 and February 2011 the senior author had performed 20 arthrodeses in 19 patients (13 male and 6 female) who had failed total ankle arthroplasty (TAR). Their mean age was 63.5 years. All of them had the AES total ankle replacement. (Biomet UK). The mean period from the original TAR to fusion was 51 months (6 to72). The indication for revision of TAR to fusion was septic loosening in 4 patients and osteolysis and or aseptic loosening in 16 cases. Three types of fusion techniques were used. The mean follow-up was 15 months. All 3 tibiotalar arthrodeses with screws alone fused successfully. Of the 13 patients where the fusion was augmented with an Ilizarov frame, 4 were done for septic loosening. There were 2 non unions of which one was stable without pain and the other required a further revision fusion with a frame and subsequently fused. Of the 9 patients who had a fusion with a frame for osteolysis and or aseptic loosening, there was one non union which was revised to a tibiotalocalacaneal fusion with a hind foot nail. The nail fractured at the level of the posterior oblique screw hole. The patient subsequently developed a relatively pain free non-union of the tibiotalar joint and not required further surgical intervention. The remaining 8 ankles fused at a mean of 5 months. The average time of frame removal was 17 weeks. There was four pin-site infection all of which settled with oral antibiotics. 5 patients had tibiotalocalacaneal fusion with a hind foot nail. The indication for the hind foot nail was significant osteolysis and loss of talar bone stock. The average shortening as a result of the fusion for the failed TAR was 1.5cms. Our results were comparable to the previous reports of arthrodesis for failed total ankle replacement. We recommend the use of tibiotalocalcaneal fusion with a hind foot nail in the presence of severe osteolysis or accompanying subtalar arthritis. In the presence of good bone stock an ankle fusion supplemented with a circular frame gives a good predictable outcome

Aims: To test the outcome of acetabular revisons with impacted morsellized bone grafts and a cemented cup at a minimum follow-up of 15 years. Methods: Between 1979–1986 62 acetabular revisions (58 patients) were performed with impacted bone grafts and a cemented cup. Two cases (2 hips) were lost to FU. The average age at operation was 59.1 years. The indication was aseptic in 56 and septic loosening in 4 hips. Defects were AAOS-classiþed as ñcavitaryñ in 37 and ñcombinedñ 23 cases. Femoral-head allografts were used. Acetabular re-revisions were determined, the HHS obtained and radiographs analyzed. Results: Nineteen cases (20 hips) died within þfteen years after the operation, none had a re-revision. Eleven acetabular re-revisions were performed: 2 septic loosenings (3 and 6 years p.o.), 7 aseptic loosenings (6, 9, 11, 12, 13, 14, 14 year p.o.) and two for cup wear (12 and 17 yrs p.o.). The average HHS at follow-up was 86 (50–100). There were no additional radiographic failures. Using Kaplan-Meier analysis the survival with endpoint revision for any reason was 79% at 15 years and 71% at 20 years; for aseptic loosening of the cup 84% at 15 years and 84% at 20 years. Conclusions: This technique is attractive to reconstruct acetabular bone stock loss

Introduction: In case of massive bone defect, femoral stem revision may cause significant problems to the orthopaedic surgeons. The periprosthetic infection introduces a further element of complication which often leads to complex surgical strategies. The aim of this study was to assess the preliminary results of femoral revision with modular resection femoral stems in a selected group of patients with infected total hip arthroplasty and extensive bone defect. Materials and Methods: The study group included five patients (three women – two men) with an average age of 72 years (range 62–81 years). From 2006 to 2008 the patients underwent a prosthetic femoral revision with resection modular stems to treat a septic loosened primary hip prosthesis (one case) or revision hip prosthesis (four cases). The bacteria responsible for the infection were MRSE in three cases, MSSE and Str. Agalactie in one case, Proteus Mirabilis in one case. Three patients were treated in election for septic loosening of hip implant and two were admitted in our Department as emergency for a periproshtetic femoral fracture (Duncan type B3). In all the patients the femoral bone defect was grade III-B according to Paprosky classification of femoral bone deficiency. One patient with periproshtetic femoral fracture underwent a one-stage prosthetic revision and four patients sustained a two-stage prosthetic revision. In one patient a local flap was performed and Vaacum Assisted Therapy was applied in order to treat an associated loss of substance. The patients underwent periodical clinical controls in which the result has been evaluated by means of Merle-d’Aubigné hip score. Results: The follow-up period ranged from 10 to 28 months. We observed one case of recurrence of infection in the patient treated with a one-stage revision. At present, we did not observe signs of infection in the remaining four patients who underwent a two-stage revision. As for functional result, four patients walked with supports and one without them. No patient referred moderate or severe residual pain. Discussion: The preservation of bone stock is one of the most important goals in prosthetic revision procedures. In some circumstances the amount of femoral bone loss can be so wide to prevent the application of conventional or modular uncemented femoral stems. In these selected cases cemented modular resection femoral stems may represent the only available option for femoral reconstruction. In our clinical experience this solution offered altogether successful outcomes. In our opinion two-stage revision is the preferable surgical choice

Purpose: We report a series of 78 total hip arthroplasty revisions using a locked femoral stem, Ultime. Material and methods: These patients presented aseptic loosening (88%) and septic loosening (12%). Fracture was associated in 17%. The preoperative Postel Merle d’Aubligné (PMA) score was 10.2 points. Using the Vives-SOFCOT classification, 29% of the loosenings were stage I, 37% stage II, 24% stage III, and 10% stage IV. All fractures were associated with lossening. We used a femoral window in 57% and trochanterotomy in 14 cases. The first eight patients in this series had an allograft (impacted piecemeal). Most of the patients resumed weight bearing the first week. The PMA score was used to assess outcome. AP and lateral views were used to evaluate stem-bone contact and cortical thickness at three levels. Results: Early complications were phlebitis (n=1) and superficial haematoma (n=5). Late complications were dislocation (n=6), stem fracture (n=2), deep infection (n=3). At last follow-up, 81% of the aseptic loosenings, 77% of the septic loosenings, and 70% of the fractures on stem had a good or excellent PMA score with a mean gain of 4, 5, and 1 points respectively. Bone reconstruction showed an increase in internal cortical (2 to 4.4 mm) and stem-bone contact increased in the lower two-thirds of the stem. Allografts did not improve results. Furthermore, 28% of the patients had hip pain which could not be related to clinical findings or implant characteristics. Half of the patients were reoperated. Conclusion: In this series, functional improvement was similar to that in published series. The femoral window facilitated the procedure and decreased intraoperative complications. The Ultime prosthesis met the objectives set by the manufacturer, i.e. primary stability and bone reconstruction authorising subsequent revision

Aim. In two-stage replacements for septic loosening, some studies have suggested that associate bacterial colonization of spacers had a worse result in relation to the control of the infection and a higher rate of complications after the implantation of the definitive prosthesis. The aim of our study was to determine the reoperation rate of patients undergoing two-stage revision surgery according to the results of spacer sonication. Method. A retrospective observational study was conducted in which 56 hip or knee spacers implanted at our center from 2010 to 2017 were analysed. Patients were grouped into three categories:. Patients with positive spacer sonication fluid culture, with or without positive cultures from the rest of the samples. Patients with negative spacer sonication culture and negative second-stage intraoperative cultures. Patients with negative spacer sonication culture but positive cultures of the rest of intraoperative samples. Results. Of the 56 patients analysed, 11 were included in group A, 32 in group B and 13 in group C. The reoperation rate was 36%, 34% and 54% respectively. Reoperation rate due to infection was 9%, 25% and 46% respectively. In only two cases (both in group C), the reoperation was caused by infection by a previously isolated microorganism. Spacers were colonized in all cases by low virulence microorganisms (coagulase negative staphylococci, P. acnes or Candida). Within group A, six patients also had other positive cultures. Conclusions. In our study, bacterial colonization of the spacer is not associated with a higher rate of reoperations in the short-medium term. The group of patients with positive cultures in the second stage surgery was the one with the highest rate of reoperations

Purpose: The aim of this work was to assess retrospectively osteofixation and survival of a long custom-made femoral stem with complete hydroxyapatite coating and without locking for replacement of the femoral implant. Material and methods: From 1990 to 1999, 89 stems were implanted for revision total hip arthroplasty. Seventy-five hips were reviewed at one to ten years (mean four years). Radiographic analysis searched for bone damage, osteofixation and implant migration. All measures were taken on the AP views postoperatively and at last follow-up. Results: Revision was performed for aseptic loosening in 75%, for septic loosening in 12%, for fracture in 11% and for instability in 2%. Destruction was SOFCOT stage I in 36%, stage II in 44%, stage III in 17% and could not be assessed in 3%. The femorotomy approach was used in 60% and trochanterotomy in 32% and endofemoral assess in 8%. There were 18% intraoperative fractures, 4.8% postoperative infections and 2.4% dislocations. At last follow-up, the Postel Merle d’Aubigné score was 15.3 and the Harris Hip Score was 77.9. Thigh pain was present in 4%. Bone fixation was considered good in 48%, partial but better than 50% contact in 36% and could not be interpreted in 16%. Complete metaphyseal reconstruction was present in 8%. A piecemeal allograft was used in 89%. Between the postoperative and last follow-up films, 16% of the stems descended a mean 11 mm. Five percent of the stems were removed for infection and one (1.3%) for non-fixation. At five years, 95% of the stems was still in place and 80% at ten years, including removals for infection. All revisions for septic loosening had comparable clinical and radiological results in this series and did not develop secondary infection. Discussion: These results demonstrate the usefulness of the uncemented stems for replacement compared with cemented stems which have a 10% revision rate at five years (SOFCOT 1999). The complete hydroxyapatite coating improves distal fixation of the stem in a healthy zone without compromising secondary proximal fixation and authorising spontaneous metaphyseal bone reconstructions. This may explain the low rate of painful thighs. Modularity and locking could improve the primary fixation and limit descent