Aims. The aim of this study was to perform a systematic review of the evidence for the use of intraoperative cell salvage in patients undergoing revision hip arthroplasty, and specifically to analyze the available data in order to quantify any associated reduction in the use of allogenic blood transfusion, and the volume which is used. Methods. An electronic search of MEDLINE (PubMed), Embase, Scopus, and the Cochrane Library was completed from the date of their inception to 24 February 2022, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were patients aged > 18 years who underwent revision hip arthroplasty when cell salvage was used. Studies in which pre-donated red blood cells were used were excluded. A meta-analysis was also performed using a random effects model with significance set at p = 0.05. Results. Of the 283 studies which were identified, 11 were included in the systematic review, and nine in the meta-analysis. There was a significant difference (p < 0.001) in the proportion of patients requiring allogenic transfusion between groups, with an odds ratio of 0.331 (95% confidence interval (CI) 0.165 to 0.663) associated with the use of cell salvage. For a total of 561 patients undergoing revision hip arthroplasty who were treated with cell salvage, 247 (44.0%) required allogenic transfusion compared with 418 of 643 patients (65.0%) who were treated without cell salvage. For those treated with cell salvage, the mean volume of allogenic blood which was required was 1.95 units (390 ml) per patient (0.7 to 4.5 units), compared with 3.25 units (650 ml) per patient (1.2 to 7.0 units) in those treated without cell salvage. The mean difference of -1.91 units (95% CI -4.0 to 0.2) in the meta-analysis was also significant (p = 0.003). Conclusion. We found a a significant reduction in the need for allogenic blood transfusion when cell salvage was used in patients undergoing revision hip arthroplasty, supporting its routine use in these patients. Further research is required to determine whether this effect is associated with types of revision arthroplasty of differing complexity. Cite this article: Bone Joint J 2023;105-B(10):1038–1044

Aims. With increasing burden of revision hip arthroplasty (THA), one of the major challenges is the management of proximal femoral bone loss associated with previous multiple surgeries. Proximal femoral arthroplasty (PFA) has already been popularized for tumour surgeries. Our aim was to describe the outcome of using PFA in these demanding non-neoplastic cases. Methods. A retrospective review of 25 patients who underwent PFA for non-neoplastic indications between January 2009 and December 2015 was undertaken. Their clinical and radiological outcome, complication rates, and survival were recorded. All patients had the Stanmore Implant – Modular Endo-prosthetic Tumour System (METS). Results. At mean follow-up of 5.9 years, there were no periprosthetic fractures. Clearance of infection was achieved in 63.6% of cases. One hip was re-revised to pseudo arthroplasty for deep infection. Instability was noted in eight of the hips (32%), of which seven needed further surgery. Out of these eight hips with instability, five had preoperative infection. Deep infection was noted in five of the hips (20%), of which four were primarily revised for infection. One patient had aseptic loosening of the femoral component and awaits revision surgery. The Kaplan-Meier survivorship free of revision of any component for any reason was 72% (95% confidence interval (CI) 51.3% to 92.7%), and for revisions of only femoral component for any reason was 96% (95% CI 86.3% to 105.7%) at five years. Conclusion. Dislocation and infection remain the major cause for failure, particularly in patients with pre-existing infection. The use of dual mobility cups, silver-coated implants, and less aggressive postoperative rehabilitation regimens would possibly aid in the reduction of complications. PFA performed in patients with periprosthetic fracture seem to fair better. This study supports the judicious use of PFA in non-oncological revision hip arthroplasties, and that they be performed by experienced revision arthroplasty surgeons. Cite this article: Bone Jt Open 2022;3(3):229–235

The aim of this study was to systemically review the evidence for the use of intra-operative cell salvage (ICS) among patients undergoing revision hip arthroplasty, and synthesis the available data to quantify any associated reduction in allogeneic blood transfusion. An electronic database search of MEDLINE (PubMed), EMBASE, Scopus and the Cochrane Library was completed from the date of inception to 9. th. February 2021, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were (i) adult patients >18 years, (ii) ICS utilised in one study group, (iii) revision hip arthroplasty performed. Exclusion criteria were (i) pre-donation of red blood cells, (ii) mixed reporting without dedicated subgroup analysis for revision hip arthroplasty. Screening for eligibility, and quality assessment of included studies, was performed independently by two authors (TW and DH), and any disputes settled by third author (AK). Of the 187 records identified, 11 studies were included in the qualitative analysis, and 5 studies suitable for quantitative meta-analysis. Across the included studies there were 1856 participants, with a mean age of 63.86 years and a male: female ratio of 0.90. Quality assessment demonstrated low or medium risk of bias only. For revision hip arthroplasty patients receiving ICS, 37.07% required ABT with a mean transfusion of 1.92 units or 385ml per patient. For patients treated without ICS, 64.58% required ABT with a mean transfusion of 4.02 units or 803ml per patient. This difference achieved statistical significance (p < 0.05). This study has demonstrated a significant reduction in the need for allogenic blood transfusion associated with intra-operative cell salvage use among patients undergoing revision hip arthroplasty. This study therefore supports the routine use of ICS in this patient group. However, a major limitation is the lack of clinical outcomes reported by the available studies. Further research is required to determine whether this effect is associated with sub-groups of revision arthroplasty procedure, and whether ICS impacts clinical outcomes such as length of stay, rehabilitation progress and mortality

The rising prevalence of osteoarthritis, associated with an ageing population, is expected to deliver increasing demand across Scotland for arthroplasty services in the future. Understanding the scale of potential change to operative workflow is essential to ensure adequate provision of services and prevent prolonged waiting times that can cause patient harm. This future service demand for primary and revision hip arthroplasty across Scotland, and the rest of the U.K., is hitherto unknown. We set out to provide projections of future primary & revision hip arthroplasty out to 2038 utilising historical trend data (2008–2018) from the Scottish Arthroplasty Project. All analyses were performed using the Holt's exponential smoothing projection method with the forecast package in R statistics. Results were adjusted for projected future population estimates provided by National Records of Scotland. Independent age & sex group predictions were also performed. All results are presented per 100,000 population at-risk per year (/100k/year). The predicted rise of primary hip arthroplasty for all ages is from 120/100k/year in 2018 to 152/100k/year in 2038, a 27% increase. Based on a static 3 day length of stay average this would see 4280 additional patient bed days required for primary hip arthroplasty patients per annum. The number of revision hip arthroplasty procedures for all ages is projected to fall from 14/100k/year to 4/100k/year based on historical trend data. This does not however take into account the suspect increase in primary arthroplasty numbers that is likely to influence future revision rates. Anticipated future demand for primary hip arthroplasty will require significant additional resource and funding to prevent deterioration in quality of care and an increase in patient wait times. Demand for revision arthroplasty is set to decrease, likely on account of improved implant materials, technique, and understanding of best practice to minimise complication risk. This doesn't however take into account the impact of the complex interaction between an increasing primary arthroplasty rate and revision risk. Understanding presented projections of changes to arthroplasty demand is key to future service delivery

Aims. The purpose of this study was to evaluate unexpected positive cultures in total hip arthroplasty (THA) revisions for presumed aseptic loosening, to assess the prevalence of low-grade infection using two definition criteria, and to analyze its impact on implant survival after revision. Methods. A total of 274 THA revisions performed for presumed aseptic loosening from 2012 to 2016 were reviewed. In addition to obtaining intraoperative tissue cultures from all patients, synovial and sonication fluid samples of the removed implant were obtained in 215 cases (79%) and 101 cases (37%), respectively. Histopathological analysis was performed in 250 cases (91%). Patients were classified as having low-grade infections according to institutional criteria and Musculoskeletal Infection Society (MSIS) International Consensus Meeting (ICM) 2013 criteria. Low-grade infections according to institutional criteria were treated with targeted antibiotics for six weeks postoperatively. Implant failure was defined as the need for re-revision resulting from periprosthetic joint infection (PJI) and aseptic reasons. The mean follow-up was 68 months (26 to 95). Results. Unexpected positive intraoperative samples were found in 77 revisions (28%). Low-grade infection was diagnosed in 36 cases (13%) using institutional criteria and in nine cases (3%) using MSIS ICM 2013 criteria. In all, 41 patients (15%) had single specimen growth of a low-virulent pathogen and were deemed contaminated. Coagulase-negative Staphylococcus and anaerobes were the most commonly isolated bacteria. Implant failure for PJI was higher in revisions with presumed contaminants (5/41, 12%) compared to those with low-grade infections (2/36, 6%) and those with negative samples (5/197, 3%) (p = 0.021). The rate of all-cause re-revision was similar in patients diagnosed with low-grade infections (5/36, 14%) and those with presumed contaminants (6/41, 15%) and negative samples (21/197, 11%) (p = 0.699). Conclusion. Our findings suggest that the presumption of culture contamination in aseptic revision hip arthroplasty may increase the detection of PJI. In this cohort, the presence of low-grade infection did not increase the risk of re-revision. Further studies are needed to assess the relevance of single specimen growth and the benefits of specific postoperative antibiotic regimens. Cite this article: Bone Joint J 2021;103-B(6):1070–1077

Aims. We investigated the long-term performance of the Tripolar Trident acetabular component used for recurrent dislocation in revision total hip arthroplasty. We assessed: 1) rate of re-dislocation; 2) incidence of complications requiring re-operation; and 3) Western Ontario and McMaster Universities osteoarthritis index (WOMAC) pain and functional scores. Patients and Methods. We retrospectively identified 111 patients who had 113 revision tripolar constrained liners between 1994 and 2008. All patients had undergone revision hip arthroplasty before the constrained liner was used: 13 after the first revision, 17 after the second, 38 after the third, and 45 after more than three revisions. A total of 75 hips (73 patients) were treated with Tripolar liners due to recurrent instability with abductor deficiency, In addition, six patients had associated cerebral palsy, four had poliomyelitis, two had multiple sclerosis, two had spina bifida, two had spondyloepiphyseal dysplasia, one had previous reversal of an arthrodesis, and 21 had proximal femoral replacements. The mean age of patients at time of Tripolar insertions was 72 years (53 to 89); there were 69 female patients (two bilateral) and 42 male patients. All patients were followed up for a mean of 15 years (10 to 24). Overall, 55 patients (57 hips) died between April 2011 and February 2018, at a mean of 167 months (122 to 217) following their tripolar liner implantation. We extracted demographics, implant data, rate of dislocations, and incidence of other complications. Results. At ten years, the Kaplan–Meier survivorship for dislocation was 95.6% (95% confidence interval (CI) 90 to 98), with 101 patients at risk. At 20 years, the survivorship for dislocation was 90.6% (95% CI 81.0 to 95.5), with one patient at risk. Eight patients (7.2%) had a dislocation of their constrained liners. At ten years, the survival to any event was 89.4% (95% CI 82 to 93.8), with 96 patients at risk. At 20 years, the survival to any event was 82.5% (95% CI 71.9 to 89.3), with one patient at risk. Five hips (4.4%) had deep infection. Two patients (1.8%) developed dissociated constraining rings with pain but without dislocation, which required re-operation. Two patients (1.8%) had periprosthetic femoral fractures, without dislocation, that were treated by revision stems along with exchange of the well-functioning constrained liners. Conclusion. Constrained tripolar liners used at revision hip arthroplasty provided favourable results in the long term for treatment of recurrent dislocation and for patients at high risk of dislocation. Cite this article: Bone Joint J 2019;101-B(6 Supple B):123–126

Aims. This study describes the variation in the annual volumes of revision hip arthroplasty (RHA) undertaken by consultant surgeons nationally, and the rate of accrual of RHA and corresponding primary hip arthroplasty (PHA) volume for new consultants entering practice. Methods. National Joint Registry (NJR) data for England, Wales, Northern Ireland, and the Isle of Man were received for 84,816 RHAs and 818,979 PHAs recorded between April 2011 and December 2019. RHA data comprised all revision procedures, including first-time revisions of PHA and any subsequent re-revisions recorded in public and private healthcare organizations. Annual procedure volumes undertaken by the responsible consultant surgeon in the 12 months prior to every index procedure were determined. We identified a cohort of ‘new’ HA consultants who commenced practice from 2012 and describe their rate of accrual of PHA and RHA experience. Results. The median annual consultant RHA volume, averaged across all cases, was 21 (interquartile range (IQR) 11 to 34; range 0 to 181). Of 1,695 consultants submitting RHA cases within the study period, the top 20% of surgeons by annual volume performed 74.2% of total RHA case volume. More than half of all consultants who had ever undertaken a RHA maintained an annual volume of just one or fewer RHA, however, collectively contributed less than 3% of the total RHA case volume. Consultant PHA and RHA volumes were positively correlated. Lower-volume surgeons were more likely to undertake RHA for urgent indications (such as infection) as a proportion of their practice, and to do so on weekends and public holidays. Conclusion. The majority of RHAs were undertaken by higher-volume surgeons. There was considerable variation in RHA volumes by indication, day of the week, and between consultants nationally. The rate of accrual of RHA experience by new consultants is low, and has important implications for establishing an experienced RHA consultant workforce. Cite this article: Bone Joint J 2023;105-B(10):1060–1069

Introduction. Patients with osteonecrosis of the femoral head are typically younger, more active, and often require high rates of revision following primary total hip arthroplasty. However, outcomes of revision hip arthroplasty in this patient population have been rarely reported in the literature. The purpose of this study was to report the intermediate-term clinical and radiographic outcomes of revision hip arthroplasty in patients with osteonecrosis of the femoral head. Materials & Methods. Between November 1994 and December 2009, 187 revision hip arthoplasty were performed in 137 patients who had a diagnosis of osteonecrosis of the femoral head. Exclusion criteria included infection, recurrent instability, isolated polyethylene liner exchange, and inadequate follow-up (less than 3 years). The final study cohort of this retrospective review consisted of 72 patients (75 hips) with a mean age of 53.3 years (range, 34 to 76). Components used for the acetabular revision included a cementless porous-coated cup in 58 hips and an acetabular cage in 2 hips. Components used for the femoral revision included a fully grit-blasted tapered stem in 30 hips and a proximally porous-coated modular stem in 9 hips. The mean duration of follow-up was 7 years (range, 3 to 17). Results. Mean Harris hip score improved 49 points preoperatively to 90 points. At the time of final follow-up, 11 hips (14.7%) patients required additional reoperation procedure. Of these, six for aseptic loosening of acetabular cup and/or femoral stem, two for deep infection, one for recurrent dislocation, one for periprosthetic femoral fracture, and one for ceramic head fracture. Kaplan-Meier survivorship with an end point for cup revision for aseptic loosening was 98.4% at 5 years, 93.4% at 10 years, and with an end point for stem revision for aseptic loosening was 100% at 5 years, 97.4% at 10 years (Fig. 1). Conclusions. Unlike the previous report, our study showed lower failure rate of femoral stem after revision hip arthroplasty using modern cementless femoral components in patients with osteonecrosis of the femoral head. Aseptic cup loosening or osteolysis is the most common mechanism of failure at the medium-term follow-up following revision hip arthroplasty in these patients group

The in-cement technique for revision hip arthroplasty involves retaining the original cement-bone interface. This has been proven to be a biomechanically stronger method than recementing after complete removal of the original cement mantle. This study reviewed a series of 54 consecutive revision hip arthroplasty procedures, using the in-cement technique, between November 1999 and November 2003. Clinical and radiological follow-up included functional assessment. There were 54 procedures performed in 51 patients, whose mean age at surgery was 70.3 years (45 to 85). A total of 42 were available at a mean follow-up of 29.2 months (6 to 51). There was no radiological evidence of loosening. Functional assessments were available for 40 patients who had a mean Harris hip score of 85.2 (51.9 to 98.5), a mean Oxford hip score of 19.6 (12 to 41), a mean UCLA activity profile score of 5.9 (3 to 8) and a mean SF-36 score of 78.0 (31.6 to 100). The in-cement technique provides consistent, high functional outcomes and should be considered in appropriately selected cases

Introduction There are no reports on the epidemiology of revision hip arthroplasty in Australia. The aim of this study was to characterise the epidemiology of revision hip arthroplasty in relation to primary hip replacements in Australia. Methods This study covered the seven year period 1993/1994 to 1999/2000. Data on all primary hip replacements and revisions done were obtained from the Australian Institute of Health and Welfare using the ICD-9 (81.53) and ICD-10 (Block No. 1492) cartegorisation. The data was stratified by age (five year age groups), sex, year and state or territory. Log linear modelling was used to examine the rate of revision procedures out of the total number of procedures (primary and revision). The effects of gender, age and year were examined in a series of hierarchical log-rate models (Poisson Loglinear Regression). Results For the period of the study there were 18,027 revision cases and 122,595 cases of primary hip replacement, representing a revision rate of 14%. The rate of increase of primary hip replacements was significantly higher than the rate of increase of revisions (t= −12.1, p< 0.0005). The number of primary hip replacements performed nationally increased by 810 (95% confidence intervals 658,964) a year. The number of revisions increased by only 62 (95% confidence intervals 21,104) a year. The proportion of revisions decreased by 0.3% per year as determined by regression analysis. The hierarchical log-rate models indicate significant interactions between age and gender and beween age and year. Conclusions The number of primary and revision hip replacements has been increasing with time. The rate of increase of revision hip replacements has been lower. The proportion of hip replacements that are revisions has been gradually dropping, probably due to a greater increase in the number of primary hip replacements

Revision of the femoral component during revision hip arthroplasty may pose significant technical challenges, most notably femoral fracture and bone perforation. The in-cementing technique allows use of the original bone-cement interface which has been proven to be biomechanically stronger than recementing after complete removal of the original cement mantle. This study reviews a series of 54 consecutive revision hip arthroplasty procedures carried out by the senior author using the in-cementing technique from November 1999 to March 2003. Patients were followed up clinically and radiologically with serial outpatient reviews and their functional outcome was assessed using the Harris hip scoring system, the Oxford hip scoring system and the University of California at Los Angeles (UCLA) activity profile. Their physical and mental well-being was also assessed using the SF-36 self-questionnaire. Fifty-four procedures were performed on 51 patients. There were 31 males and 20 females. The average age was 70.3+/-8.1 years (range: 45-83 years). The average time to revision from the original procedure was 132.8+/-59.0 months (range: 26-286 months). The average length of follow-up was 29.2+/-13.4 months (range: 6-51 months) post revision arthroplasty. Two patients suffered dislocations, one of which was recurrent and was revised with a Girdlestone's procedure. No patient displayed any evidence of radiographical loosening. The average Harris hip score of the study group was 85.2+/-11.6 (range: 51.9-98.5). The average Oxford hip score recorded was 19.6+/-7.7 (range: 12-41) and the average UCLA activity profile score was 5.9+/-1.6 (range: 3-8). The SF-36 questionnaire had an average value of 78.0+/-18.3 (range: 31.6-100). In conclusion, the results of this study show excellent clinical and radiological results of the in-cementing technique with high patient satisfaction in terms of functional outcome. This technique merits consideration where possible in revision hip arthroplasty

This study was performed to assess the relationship between patients’ pre-operative symptoms and their expectations at the time of revision hip arthroplasty. The WOMAC (Western Ontario and McMaster Osteoarthritis Index) scale for osteoarthritis of the hip and the Short Form 36 (SF-36) general health status scale have both been validated for the assessment of the outcome of hip arthroplasty. We prospectively assessed 60 patients using these scales as well as the “expectation WOMAC” that asked the patients to estimate how they expected to feel 6 months after revision hip replacement. All the questions were completed prior to informed consent, and were scored form 1 to 5 with increasing severity with a Likert scale. The maximum possible scores for pain, stiffness and difficulty with physical activity were therefore 25, 10 and 85 respectively. The mean preoperative WOMAC score for pain was 13.4 (CI 12.2.-14.6), for stiffness 5.9 (CI 5.6-6.2) and for physical activity 50.9 (CI 47.2-54.6) The mean expectation WOMAC scores for these modalities were 7.4 (CI 6.2-8.6), 3.5 (CI 3.0-4.0) and 28.1 (CI 24.0-32.2.) respectively. Although there was a wide spread of expectations, we were unable to find any significant correlation between the patients’ preoperative pain and The abstracts were prepared by Mr Simon Donell. Correspondence should be addressed to him at the Department of Orthopaedics, Norfolk & Norwich Hospital, Level 4, Centre Block, Colney Lane, Norwich NR4 7UY, United Kingdom. stiffness levels and their expectations for pain and stiffness after revision hip arthroplasty. There was however a statistical association between their preoperative difficulty with physical activity and their expectations for physical activity (r=0.38; p=0.02) There was no significant correlation between the SF-36 scores and the patients’ expectations. The expectations of patients awaiting revision hip replacements are high, and do not appear to be closely related to their level of pre-operative disability. Even patients with severe symptoms have high expectations that in some cases may be unrealistic. The use of the “expectation WOMAC” may help us to identify such patients, and to improve patient education and satisfaction

Introduction. Previous reports have investigated the correlation between time to revision hip arthroplasty (rTHA) and reason for revision, but little is known regarding the impact of timing on outcomes following rTHA. The purpose of this study is to evaluate the effect of time to rTHA on both indication and outcomes of rTHA. Methods. This retrospective observational study reviewed patients who underwent unilateral, aseptic rTHA at an academic orthopedic specialty hospital between January 2016 and April 2019 with at least 1-year of follow-up. Patients were early revisions if they were revised within 2 years of primary THA (pTHA) or late revisions if revised after greater than 2 years. Patient demographics, surgical factors, and post-operative outcomes were compared between the groups. Post-hoc power analysis was performed (1-β=0.991). Results. 188 cases were identified, with 61 hips undergoing early revision and 127 undergoing late revision. There were no differences in demographics and comorbidities between the groups. Type of revision differed between the groups, with early revisions having a greater proportion of femoral revisions (54.1% vs.20.5%) and late revisions having a greater proportion of both component (10.2% vs.6.6%), acetabular (30.7% vs.26.2%), or head/liner (38.6% vs. 13.1%;p< 0.001) revisions. Indication for index revision differed between the groups, with early revisions having a greater proportion for dislocation/instability (21.3% vs. 10.2%) and peri-prosthetic fracture (42.6% vs.9.4%), and late revisions having a greater proportion for loosening/osteolysis (40.9% vs.24.6%), metal-on-metal complications (11.0% vs.0.0%), and liner wear (18.9% vs.0.0%;p< 0.001). Early revisions experienced longer length of stay (LOS; 5.18±4.43 vs.3.43±2.76 days;p=0.005) and more often underwent reoperation (8.2% vs 1.6%;p=0.037). Conclusions. Early aseptic revisions had worse outcomes with longer LOS and higher rates of reoperation. These differences may be attributable to the type and indication for revision. Arthroplasty surgeons should be aware of these differences when counseling patients after THA

This study evaluates the association between consultant and hospital volume and the risk of re-revision and 90-day mortality following first-time revision of primary hip replacement for aseptic loosening. We conducted a cohort study of first-time, single-stage revision hip replacements (RHR) performed for aseptic loosening and recorded in the National Joint Registry (NJR) data for England, Wales, Northern Ireland, and the Isle of Man between 2003 and 2019. Patient identifiers were used to link records to national mortality data, and to NJR data to identify subsequent re-revision procedures. Multivariable Cox proportional hazard models with restricted cubic splines were used to define associations between volume and outcome. Among 12,676 RHR there were 513 re-revisions within two years, and 95 deaths within 90 days of surgery. The risk of re-revision was highest for a consultant's first RHR (Hazard Ratio (HR) 1·58 (95%CI 1·16 to 2·15)) and remained significantly elevated for their first 26 cases (HR 1·26 (95%CI 1·00 to 1·58)). Annual consultant volumes of five/year were associated with an almost 30% greater risk of re-revision (HR 1·28 (95%CI 1·00 to 1·64)) and 80% greater risk of 90-day mortality (HR 1·81 (95%CI 1·02 to 3·21)) compared to volumes of 20/year. RHR performed at hospitals which had cumulatively undertaken fewer than 168 RHR were at up to 70% greater risk of re-revision (HR 1·70 (95% CI 1·12 to 2·60)), and those having undertaken fewer than 309 RHR were at up to three times greater risk of 90-day mortality (HR 3·06 (95% CI 1·19 to 7·86)). This study found a significantly higher risk of re-revision and early postoperative mortality following first-time single-stage RHR for aseptic loosening when performed by lower-volume consultants and at lower-volume institutions, supporting the move towards the centralisation of such cases towards higher-volume units and surgeons

Introduction: The purpose of this study was to assess the efficacy and complications associated with revision hip arthroplasty undertaken in patients under the age group of 55 years. Methods: A review of our institutions revision hip database showed that 430 revision hip arthroplasties undertaken over the past 9 years had a minimum follow up of 2 years. Of this 84 (56 female, 38 male) patients were under 55 years of age (range 2 to 8 years). The index procedures were preformed at an average age of 46 years (range 15 years to 54 years). The single major etiology of failure was aseptic loosening (74%), followed by infection (8%) and recurrent dislocation (7%). In majority of cases uncemented implants were used at revision surgery (91% femoral stem, 100% acetabular cups). Bone grafts were necessary in 39% of cases. Results: There was 1% incidence of DVT requiring treatment and 1% incidence of deep infection requiring a further revision hip surgery. There were no cases of dislocation in this series. At final follow up satisfactory progress was noted in all cases with a significant improvement in Harris hip score (p < 0.05). Discussion: In conclusion, revision of hip arthroplasty in patients below 55 years is associated with improvement in function and patient satisfaction. They perform better than older cohorts but not as good as primary THRs. The complication profile is comparable in the two groups

Aim: To evaluate the medium term results of revision hip replacements using the ‘Furlong’(© JRI, London) HAC covered total hip replacement system. Methods: The first one hundred revision hip replacements were identified from the arthroplasty register of the senior author. The notes and x-rays at presentation were retrospectively analysed to ascertain the clinical and radiological state pre-operatively. The surgical findings were also noted. The final clinical and radiological states were obtained from the latest outpatient appointment. Modified Harris Hip Score was used to discern the clinical state. SPSS © vol 11.0 was used for statistical analysis. Results: There were one hundred revision hip replacements performed in 97 patients between 1991 and 2000 by the senior author. There were 72 cemented and 18 uncemented prosthesis revised. 9 of the revisions were for infection. 79 were revised for aseptic loosening of one or both of the components. There were 4 recurrent dislocators and one revision was carried out for a peri-prosthetic fracture. The median to follow up was 3 years (mean 3.8, range 1–8).The changes in the clinical state of the patient at the last follow up are shown in the table: At the time of the latest follow-up 74 of the cups and 69 of the stems showed definite radiological signs of osseointegration. Discussion: Our results show that clinical results of revision surgery using this system give good results in the short to medium term. Radiological results are less easy to interpret as osseointegration can take a long time to become visible on x-rays. The need for longer term follow-up is highlighted by the results

Aim: We audited medical complications after revision hip arthroplasty, in elderly and young patients and correlated its occurrence to the preoperative medical status. Methods: 104 revision hip replacements in 100 patients (mean age 71.5 years) were followed up for a mean of 33.9 months. (9–67). 49 were above 75 years of age. The American Society of Anaesthetists grading system was used to assess preoperative medical fitness. 50% patients were in ASA grade III. Medical complications in the first 3 postoperative months were classified into major, moderate and minor (Phillips). There were pre-existing cardiac problems in 57, COPD in 13, vascular disease in 7, cerebro vascular disease in 7, previous DVT in 6 and renal/endocrine problems in 16. Results: Overall medical complication rate was 35% (7% major, 14% moderate and 14% minor). The rate in elderly patients was 21%. There was 1 postoperative death due to cardiac reasons at 2 months. There were cardiac complications in 23%, anaemia in 17%, respiratory problems in 10%, hematemesis in 7%, renal in 7%, circulatory in 7%, deep vein thrombosis in 5%, pulmonary thromboembolism in 5%. Mean hospital stay was 17.8 days. 83 patients had no pain, 88 were independent, and 7 had poor mobility. 85% were satisfied with the operation. The major medical complications were not significantly higher in elderly than in younger patients. Conclusion ASA grade correlated positively with frequency and severity of medical complications (Fisher exact test p < 0.001). The occurrence was independent of the age of the patient (p=0.106). Revision hip arthroplasty was well-tolerated in elderly patients and age alone is not a contra-indication. This compared favourably with other reported series. Good anaesthetic and medical support is vital

Introduction. The aim of this study is to report the results of Revision hip arthroplasty using large diameter, metal on metal bearing implants- minimum 2 year follow up. Methods. A single centre retrospective study was performed of 22 consecutive patients who underwent acetabular revision surgery using metal on metal bearing implants between 2004 and 2007. Birmingham hip resurfacing (BHR) cup was used in all patients - monoblock, uncemented, without additional screws in 16 cases and cemented within reinforcement or reconstruction ring in 6 cases. Femoral revisions were carried out as necessary. Results. There were 16 men and 6 women with a mean age of 71 years (51-83). Revision surgery was performed for aseptic loosening in 10, infected primary hip arthroplasty in 8, infected Hemiarthroplasty in 1 and Peri-prosthetic fracture with loosening in 3 patients. A 2-stage revision was performed for all infected hips. One patient died and the remaining 21 patients had clinical and radiological assessment at a mean 35 months (24-60). The mean Harris hip score was 75 (23-98) with 50% good to excellent results. Only 1 patient had further revision to a proximal femoral replacement and constrained cup in 2 stages for recurrent infection at 24 months. There were 2 recurrent infections (both revised for septic loosening) and 1 non-union of trochanteric osteotomy. There were no dislocations in the group. No radiological loosening of implants or metal ion complications have been seen at last follow up. Conclusions. We believe this is the first reported series on the use of large diameter metal on metal bearing surfaces for revision hip arthroplasty. Our series shows satisfactory short to medium term results in this complex group of patients with no component loosenings, despite monoblock cups and no dislocations

Introduction & Aims: Revision hip arthroplasty surgery is technically demanding and good exposure is a pre-requisite to successful re-implantation. The traditional pertro-chanteric approach gives circumferential exposure of the acetabulum and excellent exposure of the proximal femur. The Trochanteric Slide approach theoretically reduces the incidence of trochanteric pull off and non-union. The aim of this study was to establish the efficacy of the Trochanteric Slide approach to revision hip arthroplasty. Materials & Methods: Fifty revision hip replacements were performed using the Trochanteric Slide surgical approach. Fixation of the osteotomy was performed with the Dall Miles cable grip system. All patients were prospectively followed for a minimum of 18 months (Mean 3.4 years). 36 of the revisions were for aseptic loosening, 6 for septic loosening, 3 for peri-prosthetic fracture and 5 for recurrent dislocation. In 19 cases, previous revision surgery had been performed. Results: 8 of the 50 trochanteric re-attachments showed suggestion of movement from the immediate postoperative x-ray. 8 showed less than 5mm migration, 3 showed 5–10mm migration, 1 showed 10–15mm migration and 1 showed 15–20mm migration. Radiological union was definite in 38 cases. Probable union was observed in 5 cases and non-union in 7 cases. 36 hips had a positive Trendelenberg test prior to surgery compared to 11 cases at 12-month review. Trochanteric bursitis was present in 15 cases. Cable end fraying occurred in 8 cases. There were 2 instances of cable breakage and one instance of cable migration onto the prosthesis. Conclusion: The authors feel that the trochanteric slide approach gives excellent exposure whilst retaining the distal tether of vastus lateralis. This distal tether when combined with cable grip fixation appears to give a good outcome with regards trochanteric migration but is prone to causing trochanteric bursitis

Aim We have prospectively investigated the effect of tranexamic acid in reducing blood loss and transfusion requirements in primary and revision total hip arthroplasty in a comparative study. Patients and Methods In the study group, tranexamic acid was given half an hour before the skin incision. (10 mg/kg as an intravenous bolus, followed by 10 mg/kg as intravenous infusion over 6 hours). We recorded the haemoglobin level preoperatively and prior to discharge, and number of units of blood transfused. The total peri-operative blood loss and the fall in haemoglobin after surgery was calculated in consultation with our haematologist. There were 9 primary and 17 revision hip replacements in the study group. We compared the results with a control group of 10 primary and 20 revisions performed during a similar period, without tranexamic acid, recording identical parameters. Thrombo-embolic and wound complications were recorded. Results Patients receiving tranexamic acid had a mean fall in haemoglobin level of 3.1 g/dl and mean blood loss of 4.1 litres. The control group operated without tranexamic acid had a mean fall in the level of haemoglobin of 3.7 g/dl, and the mean blood loss 5.4 litres. The average number of units of blood transfusion required was 0.77 per patient in the study group compared to 2.03 per patient in the control group. The differences were significant (p value of 0.05). There was no increase in the incidence of complications such as deep vein thrombosis, pulmonary embolism, or wound problems in the study group. Conclusion Tranexamic acid given prior to surgery reduces blood loss and need for blood transfusion, not only in primary but also in revision hip arthroplasty, without any increase in the rate of thrombo-embolic complications