Aims

Transfusion after primary total hip arthroplasty (THA) has become rare, and identification of causative factors allows preventive measures. The aim of this study was to determine patient-specific factors that increase the risk of needing a blood transfusion.

Aims. Registry studies on modified acetabular polyethylene (PE) liner designs are limited. We investigated the influence of standard and modified PE acetabular liner designs on the revision rate for mechanical complications in primary cementless total hip arthroplasty (THA). Methods. We analyzed 151,096 primary cementless THAs from the German Arthroplasty Registry (EPRD) between November 2012 and November 2020. Cumulative incidence of revision for mechanical complications for standard and four modified PE liners (lipped, offset, angulated/offset, and angulated) was determined using competing risk analysis at one and seven years. Confounders were investigated with a Cox proportional-hazards model. Results. Median follow-up was 868 days (interquartile range 418 to 1,364). The offset liner design reduced the risk of revision (hazard ratio (HR) 0.68 (95% confidence interval (CI) 0.50 to 0.92)), while the angulated/offset liner increased the risk of revision for mechanical failure (HR 1.81 (95% CI 1.38 to 2.36)). The cumulative incidence of revision was lowest for the offset liner at one and seven years (1.0% (95% CI 0.7 to 1.3) and 1.8% (95% CI 1.0 to 3.0)). No difference was found between standard, lipped, and angulated liner designs. Higher age at index primary THA and an Elixhauser Comorbidity Index greater than 0 increased the revision risk in the first year after surgery. Implantation of a higher proportion of a single design of liner in a hospital reduced revision risk slightly but significantly (p = 0.001). Conclusion. The use of standard acetabular component liners remains a good choice in primary uncemented THA, as most modified liner designs were not associated with a reduced risk of revision for mechanical failure. Offset liner designs were found to be beneficial and angulated/offset liner designs were associated with higher risks of revision. Cite this article: Bone Joint J 2022;104-B(7):801–810

Aims. Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA. Methods. A retrospective analysis was conducted of 91 cementless THAs (57 male and 34 female) performed between 2008 and 2017 in patients who had history of hip infection during childhood. Clinical outcome was measured using Harris Hip Score (HHS) and Modified Merle d’Aubigne and Postel (MAP) score, and quality of life (QOL) using 12-Item Short Form Health Survey Questionnaire (SF-12) components: Physical Component Score (PCS) and Mental Component Score (MCS); limb length discrepancy (LLD) and radiological assessment of the prosthesis was performed at the latest follow-up. Reinfection and revision surgery after THA for any reason was documented. Results. There was significant improvement in HHS, Modified Merle d’Aubigne Postel hip score, and QOL index SF 12-PCS and MCS (p < 0.001) and there was no case of reinfection reported during the follow-up. The minimum follow-up for the study was three years with a mean of 6.5 (SD 2.3; 3 to 12). LLD decreased from a mean of 3.3 cm (SD 1) to 0.9 cm (SD 0.8) during follow-up. One patient required revision surgery for femoral component loosening. Kaplan-Meier survival analysis estimated revision-free survivorship of 100% at the end of five years and 96.9% (95% confidence interval 79.8 to 99.6) at the end of ten years. Conclusion. We found that cementless THA results in good to excellent functional outcomes in patients with a prior history of childhood infection. There is an exceedingly low rate of risk of reinfection in these patients, even though complications are not uncommon. Cite this article: Bone Jt Open 2022;3(4):314–320

Aims

The aim of this study was to evaluate the performance of first-generation annealed highly cross-linked polyethylene (HXLPE) in cementless total hip arthroplasty (THA).

Aims. Total hip arthroplasty (THA) is a very successful and cost-effective operation, yet debate continues about the optimum fixation philosophy in different age groups. The concept of the 'cementless paradox' and the UK 'Getting it Right First Time' initiative encourage increased use of cemented fixation due to purported lower revision rates, especially in elderly patients, and decreased cost. Methods. In a high-volume, tertiary referral centre, we identified 10,112 THAs from a prospectively collected database, including 1,699 cemented THAs, 5,782 hybrid THAs, and 2,631 cementless THAs. The endpoint was revision for any reason. Secondary analysis included examination of implant survivorship in patients aged over 70 years, over 75 years, and over 80 years at primary THA. Results. Cemented fixation had the lowest implant survival in all age groups, with a total ten-year survivorship of 97.0% (95% confidence interval (CI) 95.8 to 97.8) in the cemented group, 97.6% (95% CI 96.9 to 98.1) in the hybrid group, and 97.9% (95% CI 96.9 to 98.6) in the cementless group. This was not statistically significant (p = 0.092). There was no age group where cemented fixation outperformed hybrid or cementless fixation. Conclusion. While all fixation techniques performed well at long-term follow-up, cemented fixation was associated with the lowest implant survival in all age groups, including in more elderly patients. We recommend that surgeons should carefully monitor their own outcomes and use fixation techniques that they are familiar with, and deliver the best outcomes in their own hands. Cite this article: Bone Joint J 2022;104-B(2):206–211

The clinical success of THA is accepted, however wide variation in implant usage and outcomes is reported across the world. The Getting It Right First Time initiative in the UK has recommended increased use of cemented constructs in patients over 70. A clear clinical directive has been proposed aiming to reduce revision rates, improve outcomes and increase cost effectiveness. This study compares the outcomes of cemented, hybrid and cementless THA from a high-volume single center at long-term follow-up. A prospective database identified 1,699 cemented, 5,782 hybrid and 2,631 cementless THAs. Mean follow-up was 8.1 years, 5.3 years and 6.3 years respectively. Primary endpoint was revision for any reason. 47 (1.79%) cemented, 93 (1.60%) hybrid and 39 (1.48%) cementless THAs underwent revision. The difference in overall revision rate was statistically significant (P=0.002). Mean time to revision was 4.5 years in the cemented group, 2.1 years in the hybrid group and 2.6 years in the cementless group. 1 year survivorship was 99.2% in the cemented group, 99.0% in the hybrid group and 98.9% in the cementless group. 3 year survivorship was 98.6% in the cemented group, 98.8% in the hybrid group and 98.9% in the cementless group. At 10 years it was 97.0%, 97.6% and 97.9% respectively. (Difference not statistically significant (p=0.09). Of relevance cemented fixation showed the lowest 10-year survivorship in patients over 70, over 75 and over 80. (not statistically significant P=0.5, 0.6 and 0.47 respectively). In a high-volume center, excellent outcomes were achieved at 10 years with all three constructs. Cemented THA had the lowest survivorship compared to hybrid, then cementless fixation. Cemented fixation did not outperform cementless fixation in any age group. Surgeons should monitor their outcomes. Use of a philosophy that works best in their own hands should be supported

Aims

“Get It Right First Time” (GIRFT) and NHS England’s Best Practice Tariff (BPT) have published directives advising that patients over the ages of 65 (GIRFT) and 69 years (BPT) receiving total hip arthroplasty (THA) should receive cemented implants and have brought in financial penalties if this policy is not observed. Despite this, worldwide, uncemented component use has increased, a situation described as a ‘paradox’. GIRFT and BPT do, however, acknowledge more data are required to support this edict with current policies based on the National Joint Registry survivorship and implant costs.

Aims

We present the clinical and radiological results at a minimum follow-up of 20 years using a second-generation uncemented total hip arthroplasty (THA). These results are compared to our previously published results using a first-generation hip arthroplasty followed for 20 years.

Aims

Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF.

Ceramic bearings have several desirable properties, such as resistance to wear, hardness, and biocompatibility, that favour it as an articulating surface in hip arthroplasty. However, ceramic fracture remains a concern. We have reviewed the contemporary literature, addressing the factors that can influence the incidence of ceramic bearing surface fracture.

Cite this article: Bone Joint J 2019;101-B:897–901.

Aims

The aim of this study was to describe temporal trends and survivorship of total hip arthroplasty (THA) in very young patients, aged ≤ 20 years.

Aims

For this retrospective cohort study, patients aged ≤ 30 years (very young) who underwent total hip arthroplasty (THA) were compared with patients aged ≥ 60 years (elderly) to evaluate the rate of revision arthroplasty, implant survival, the indications for revision, the complications, and the patient-reported outcomes.

Ceramic-on-ceramic bearings provide a solution to the osteolysis seen with traditional metal-on-polyethylene bearings. Sporadic reports of ceramic breakage and squeaking concern some surgeons and this bearing combination can show in vivo signs of edge loading wear which was not predicted from in vitro studies. Taper damage or debris in the taper between the ceramic and metal may lead to breakage of either a ceramic head or insert. Fastidious surgical technique may help to minimise the risk of ceramic breakage. Squeaking is usually a benign complication, most frequently occurring when the hip is fully flexed. Rarely, it can occur with each step of walking when it can be sufficiently troublesome to require revision surgery. The etiology of squeaking is multifactorial in origin. Taller, heavier and younger patients with higher activity levels are more prone to hips that squeak. Cup version and inclination are also relevant factors. Osteolysis following metal-on-UHMW polyethylene Total Hip Arthroplasty (THA) is well reported. Earlier generation ceramic-on-ceramic bearings did produce some osteolysis, but in flawed implants. As third and now fourth generation ceramic THAs come into mid- and long-term service, the orthopaedic community has begun to see reports of high survival rates and very low incidence of osteolysis in these bearings. The technique used by radiologists for identifying the nature of lesions on Computed Tomography (CT) scan is the Hounsfield score which will identify the density of the tissue within the lucent area. Commonly the radiologist will have no access to previous imaging, especially pre-operative imaging if a long time has elapsed. With such a low incidence of osteolysis in this patient group, what, then, should a surgeon do on receiving a CT report on a ceramic-on-ceramic THA, which states there is osteolysis? This retrospective review aims to determine the accuracy of CT in identifying true osteolysis in a cohort of long-term third generation ceramic-on-ceramic uncemented hip arthroplasties in our department. Pelvic CT scans were performed on the first 27 patients from a cohort of 301 patients undergoing 15-year review with third generation alumina-alumina cementless THAs. The average follow-up was 15 years (15–17). The CT scans were reviewed against pre-operative and post-operative radiographs and reviewed by a second musculoskeletal specialist radiologist. Eleven of the CT scans were reported to show acetabular osteolysis, two reported osteolysis or a possible pre-existing cyst and one reported a definitive pre-existing cyst. After review of previous imaging including pre-operative radiographs, eleven of the thirteen patients initially reported to have osteolysis were found to have pre-existing cysts or geodes in the same size and position as the reported osteolysis, and a further patient had spot-welds with stress-shielding. One patient with evidence of true osteolysis awaits aspiration or biopsy to determine if he has evidence of ceramic wear or metallosis. Reports of osteolysis on CT should be interpreted with care in modern ceramic-on-ceramic THA to prevent unnecessary revision. Further imaging and investigations may be necessary to exclude other conditions such as geodes, or stress shielding which are frequently confused with osteolysis on CT scans

Intra-operative fractures of the femur are on the rise mainly due to the increased use of cementless implants and the desire to get a tight press fit. The prevalence has been reported to be between 1–5% in cementless THAs. The key to preventing these fractures is to identify patients at high risk and careful surgical technique. Surgical risk factors include the use of cementless devices, revision hip surgery, the use of flat tapered wedges and MIS surgery. Patient factors that increased risk include increasing age, female gender, osteopenia and rheumatoid arthritis. These risk factors tend to be additive and certainly when more than one is present extra caution needs to be taken. Surgical technique is critical to avoid these intra-operative fractures. Fractures can occur during exposure and dislocation, during implant removal (in revision THA), during canal preparation and most commonly during stem insertion. In both primary, and especially in revision, THA be wary of the stiff hip in association with osteopenia or osteolysis. These patients require a very gentle dislocation. If this cannot be achieved, then alteration of the standard approach and dislocation may be needed. Examples of these include protrusion with an osteopenic femur and revision THA with a very stiff hip with lysis in the femur. Lastly, in cases with retained hardware, dislocate prior to removing plates and screws. After dislocation, the next challenge is gentle preparation of the femoral canal. A reasonable exposure is required to access the femoral canal safely. MIS procedures do not offer good access to femoral canal and this probably results in increased risk of fracture during broaching or implant insertion. When broaching, stop when broach will not advance further. When inserting a tapered wedge stem, be worried if stem goes further in than broach. In revision surgery, when taking the stem out from above, make sure the area of the greater trochanter does not overhang the canal. A high speed burr can clear the shoulder for easier access for removal. In revision THA with an ETO, place a cerclage wire prior to reaming and retighten prior to stem insertion. Even with careful surgical technique intra-operative femoral fractures will still occur. When inserting the stem, a sudden change in resistance is highly suggestive of fracture. Wide exposure of the entire proximal femur is necessary to confirm the diagnosis. The distal extent of the fracture must be seen. Only on occasion is an intra-operative radiograph needed. Management is directed to ensuring component stability and good fracture fixation. In primary total hip arthroplasty, calcar fractures are by far the most common. If using proximal fixation and you are certain the stem is stable, then all that is needed is cerclage wiring. As already mentioned, you must follow the fracture line distally so you are aware of how far down it goes. Often what appears to be a calcar split actually propagates distal to the lesser trochanter. In these cases, one would probably go for distal fixation plus wiring. In conclusion, intra-operative femoral fractures are on the rise. Prevention is the key

The fourth generation Delta ceramic, in which zirconia is incorporated into the alumina matrix, was developed to provide improved fracture toughness and wear characteristics. The purpose of this study was to evaluate the minimum 5-year outcomes and bearing-specific complications in a single surgeon series of Delta ceramic-on-ceramic total hip arthroplasties (THAs). We retrospectively analysed 667 patients (749 hips) who underwent cementless THAs using Delta ceramic-on-ceramic bearings by a single surgeon. There were 315 men and 352 women with mean age of 55 years (range, 16 to 88 years) at the time of index surgery. Acetabular and femoral components were cementless in all hips. A 36 mm head was used in 472 hips and a 32 mm head was used in 227 hips. The mean duration of follow-up was 6.3 years (range, 5 to 8 years). The mean Harris hip score improved from 47.6 points preoperatively to 91.1 points at the time of final follow-up. All but one acetabular components were well-fixed, and all but one femoral components were well-fixed. No radiographic evidence of osteolysis was identified at the time of final follow-up. There were 2 (0.27%) ceramic liner fractures and no ceramic head fracture. A total of 48 hips (6.4%) exhibited an audible noise (29 clickings and 19 squeakings), but no patient required revision. Kaplan-Meier survivorship with an end point of revision for any reason was 98.7% at 6.3 years. Delta ceramic-on-ceramic THAs provide excellent clinical outcomes without osteolysis at the minimum 5-year follow-up. However, we also found 0.27% ceramic liner fractures and 6.4% audible noises associated with the use of Delta ceramic-on-ceramic bearings

Non-traumatic osteonecrosis of the femoral head is a potentially devastating condition, the prevalence of which is increasing. Many joint-preserving forms of treatment, both medical and surgical, have been developed in an attempt to slow or reverse its progression, as it usually affects young patients.

However, it is important to evaluate the best evidence that is available for the many forms of treatment considering the variation in the demographics of the patients, the methodology and the outcomes in the studies that have been published, so that it can be used effectively.

The purpose of this review, therefore, was to provide an up-to-date, evidence-based guide to the management, both non-operative and operative, of non-traumatic osteonecrosis of the femoral head.

Cite this article: Bone Joint J 2017;99-B:1267–79.

Ceramic-on-ceramic bearings provide a solution to the osteolysis seen with traditional metal-on-polyethylene bearings. Sporadic reports of ceramic breakage and squeaking concern some surgeons and this bearing combination can show in vivo signs of edge loading wear which was not predicted from in vitro studies. Taper damage or debris in the taper between the ceramic and metal may lead to breakage of either a ceramic head or insert. Fastidious surgical technique may help to minimise the risk of ceramic breakage. Squeaking is usually a benign complication, most frequently occurring when the hip is fully flexed. Rarely, it can occur with each step of walking when it can be sufficiently troublesome to require revision surgery. The etiology of squeaking is multifactorial origin. Taller, heavier and younger patients with higher activity levels are more prone to hips that squeak. Cup version and inclination are also relevant factors. Fifty-five ceramic bearings revised at our center were collected over 12 years. Median time to revision was 2.7 years. Forty-six (84%) cases had edge loading wear. The median femoral head wear volume overall was 0.2mm. 3. /yr, for anterosuperior edge loading was 2.0mm. 3. /yr, and the median volumetric wear rate for posterior edge loading was 0.15mm. 3. /yr (p=0.005). Osteolysis following metal-on-polyethylene total hip arthroplasty (THA) is well reported. Earlier generation ceramic-on-ceramic bearings did produce some osteolysis, but in flawed implants. As 3rd and now 4th generation ceramic THAs come into mid- and long-term service, the orthopaedic community has begun to see reports of high survival rates and very low incidence of osteolysis in these bearings. The technique used by radiologists for identifying the nature of lesions on Computed Tomography (CT) scan is the Hounsfield score which will identify the density of the tissue within the lucent area. Commonly the radiologist will have no access to previous imaging, especially pre-operative imaging if a long time has elapsed. With such a low incidence of osteolysis in this patient group, what, then, should a surgeon do on receiving a CT report on a ceramic-on-ceramic THA, which states there is osteolysis? This retrospective review aims to determine the accuracy of CT in identifying true osteolysis in a cohort of long-term 3rd generation ceramic-on-ceramic uncemented hip arthroplasties in our department. Methods. Pelvic CT scans were performed on the first 27 patients from a cohort of 301 patients undergoing 15-year review with 3rd generation alumina-alumina cementless THAs. The average follow-up was 15 years (15–17). The CT scans were reviewed against pre-operative and post-operative radiographs and reviewed by a second musculoskeletal specialist radiologist. Results. Eleven of the CT scans were reported to show acetabular osteolysis, two reported osteolysis or possible pre-existing cyst and one reported a definitive pre-existing cyst. After review of previous imaging including pre-operative radiographs, eleven of the thirteen patients initially reported to have osteolysis were found to have pre-existing cysts or geodes in the same size and position as the reported osteolysis, and a further patient had spot-welds with stress-shielding. One patient with evidence of true osteolysis awaits aspiration or biopsy to determine if he has evidence of ceramic wear or metallosis. Conclusions. Reports of osteolysis on CT should be interpreted with care in modern ceramic-on-ceramic THA to prevent unnecessary revision. Further imaging and investigations may be necessary to exclude other conditions such as geodes, or stress shielding which are frequently confused with osteolysis on CT scans

Aims

To determine the effect of a change in design of a cementless ceramic acetabular component in fixation and clinical outcome after total hip arthroplasty