Introduction:
Purpose: To identify associative factors for radiolucency (RL) under the tibial component following the Oxford unicompartmental arthroplasty (UKA), and to evaluate its effect on clinical outcome scores. Method: One hundred and sixty-one knees which had undergone primary Phase 3 medial Oxford UKA were included. Fluoroscopic radiography films were assessed at five years post-operatively for areas of tibial RL. The two groups of patients, with and without RL, were compared to. patients’ pre-operative demographics for age, weight, height, BMI,. intra-operative variables such as the operating surgeon (n=2), insert and component sizes,. post-operative varus/valgus deformity, and. clinical outcome, assessed by the change in Oxford knee (OKS) and Tegner (TS) scores, from before surgery to five-year post-operatively. Results: 101 (62%) knees were found to have tibial RL. All RL were categorised as physiological or they were <
1mm thick, with sclerotic margins and non-progressive. No statistical difference was found between knees with RL and those without, in terms of pre-operative demographics, intra- or post-operative factors, and clinical outcome scores (p>
0.1 in all variables). Discussion:
patients’ pre-operative demographics for age, weight, height, BMI, intraoperative variables such as the operating surgeon (n=2), insert and component sizes, and clinical assessment criteria including pre-operative and five-year post-operative Oxford knee (OKS) and Tegner (TS) scores.
Radiolucencies beneath the tibial component are well recognized in knee arthroplasty; the aetiology and significance are poorly understood. Non-progressive narrow radiolucencies with a sclerotic margin are thought not to be indicative of loosening. Factors which decrease the incidence of radiolucencies include cementless fixation and the use of pulse lavage. Leg/component alignment or BMI do not influence radiolucency. We are not aware of any studies that have looked at the effect of load type on radiolucency. The Oxford domed lateral tibial component was introduced to decrease the bearing dislocation rate that was unacceptably high with the flat tibial tray. However, the introduction of the domed tibial component alters the forces transmitted through the implant-cement-bone interface. As the Oxford UKR uses a fully congruent mobile bearing, the forces transmitted through the interface with a flat tray are compressive, except for the effect of friction. However, with the domed tibial component shear forces are introduced. The aim of this study was to assess the prevalence of radiolucency beneath the previous flat design and the new domed tibial tray. A consecutive series of 248 cemented lateral UKRs (1999–2009) at a single institution were assessed. The first 55 were with a flat tibia and the subsequent 193 with a domed component. One year post-op radiographs were assessed, by two observers, for the presence (full or partial) and distribution of radiolucency. The distribution and thickness of each radiolucency. Cases were excluded for missing or poorly aligned radiographs.Introduction
Patients and methods
To assess the incidence of radiolucency in cemented and cementless Oxford unicompartmental knee replacement at two years. Most unicompartmental knee replacements (UKRs) employ cement for fixation of the prosthetic components. The information in the literature about the relative merits of cemented and cementless UKR is contradictory, with some favouring cementless fixation and others favouring cemented fixation. In addition, there is concern about the radiolucency that frequently develops beneath the tibial component with cemented fixation. The exact cause of the occurrence of radiolucency is unknown but it has been hypothesised that it may suggest suboptimal fixation.Purpose of Study
Introduction
Although the use of stems in revision total knee arthroplasty (RTKA) enhances survival by improving the stability of implant, questions as to the optimal fixation method as well as the vertical extent of the cement, remain unanswered. This study aimed 1) to determine the correlation between the vertical extent of cement and implant loosening; and 2) to determine the minimum cementing extent for a stable implant in revision TKA with a hybrid technique. We retrospectively analyzed 109 stemmed RTKAs with average follow-up of 63 months. In each case, a single varus-valgus constrained implant was used and fixed with a hybrid technique. During surgery, stem was partially covered with cement beyond stem-implant junction. Stability of implant was evaluated according to the modified Knee Society Radiographic Scoring System. Cementing extent was defined as length from implant base to the end of the radiopaque line around the stem. The correlation between the vertical cementing extent and implant stability was analyzed, and the minimal vertical cementing extent for a stable implant was evaluated with a scatter plot.Purpose
Materials and Methods
Loosening of components after total knee arthroplasty (TKA) can be associated with the development of radiolucent lines (RLLs). The aim of this study was to assess the rate of formation of RLLs in the cemented original design of the ATTUNE TKA and their relationship to loosening. A systematic search was undertaken using the Cochrane methodology in three online databases: MEDLINE, Embase, and CINAHL. Studies were screened against predetermined criteria, and data were extracted. Available National Joint Registries in the Network of Orthopaedic Registries of Europe were also screened. A random effects model meta-analysis was undertaken.Aims
Methods
This study reports updates the previously published two-year clinical, functional, and radiological results of a group of patients who underwent transfibular total ankle arthroplasty (TAA), with follow-up extended to a minimum of five years. We prospectively evaluated 89 patients who underwent transfibular TAA for end-stage osteoarthritis. Patients’ clinical and radiological examinations were collected pre- and postoperatively at six months and then annually for up to five years of follow-up. Three patients were lost at the final follow-up with a total of 86 patients at the final follow-up.Aims
Methods
Studies have reported stem subsidence without loosening in cemented polished tapered stems. And also, the initial radiolucency seen immediately after surgery at the bone-cement interface has decreased in some cases with polished tapered stem as time passed. The etiologies of these phenomena are not still elucidated. We made a comparative study on the relation between stem subsidence and the initial radiolucency in polished and rough surface stems. Subjects were 42 hips of 38 cases and 36 hips of 31 cases received primary THA using a Collarless Polished Tapered (CPT) stem and a polymethylmethacrylate pre-coated (VerSys Cemented Plus) stem respectively. Three x-ray films taken within 2 months, at 6 months and a year after surgery were reviewed. Stem subsidence was seen in 34 hips of 31 cases (81.0%) in the CPT group and averaged 0.72mm (range, 0–2.52mm) at a year after surgery. Decrease in the initial radiolucency was seen in 15 hips (35.7%) in the CPTgroup. Stem subsidence averaged 1.12mm (range, 0.46–2.52mm) and 0.48 mm(range, 0.00–1.91mm) in the cases with decrease in the initial radiolucency and in those without any change respectively. Stem subsidence was significantly greater in the cases with decrease in the initial radiolucency(P<
0.005). In the VerSys group, no stem subsidence was seen except in 1 case of mechanical failure with 0.65mm of subsidence. No decrease in the initial radiolucency was seen, either. It has been reported that the decrease in the radiolucency as we showed was thought a dense appearance of cancellous bone by load transfer in other polished tapered stem. In this study, stem subsidence may have caused decrease in the initial radiolucency. It has a possibility that not only a dense appearance of cancellous bone but also cement creep caused decrease in the initial radiolucency.
Press-fit cups have given excellent clinico-radiographical results. This is a retrospective clinico-radiographical study about the long term performance of pure Titanium cementless modular press-fit cups (FitekTM) having, on the outer surface, an oriented multilayer titanium mesh (SulmeshTM) with 65% porosity (average pore size=400–640 micron). The cup was implanted after underreaming the acetabulum by 2 mm. In the cup’s equatorial area there are two “fins” originary designed to improve rotational stability but actually representing two excellent primary mechanical stabilizers. We have evaluated the first 100 consecutive cups implanted in 92 patients with an average FU of 9,7 years (range 9–11 years). All operations have ben performed by the two Senior Authors (PGM and RB). Regarding etiology, we had 43 Primary Arthritis, 37 Dysplastic Arthritis, 12 Osteonecrosis and 8 Post-traumatic Arthritis. results were evaluated with the Harris score. Radiographic evaluation was performed using AP and lateral x-rays pre-op. post-op and at the last follow-up. We had 86 Excellent, 10 Good, 2 Fair and 2 Poor. The 2 Poor results were 2 aseptic loosenings of the stem The Mann-Whitney nonparametric U test and the Kruskal-Wallis test showed that the survival rate of the 100 analyzed cups, after a mean follow-up of 9.7 years, was 100% (end point: revision for any cause) Etiology was not statistically correlated with post-op score. Nevertheless, dysplastic patients showed inferior results compared to arthritic patients in different parameters, as pain, limp, Range Of Motion (p <
0.05), putting socks and shoes (p <
0.05). Our cups were intentionally implanted and radiographically appear in a fairly horizontal position (36.5° on average). In 6 cases we could calculate an eccentricity of the metal heads proving bidimensional linear wear of the liner (average 0.265 mm / year). At the last follow-up we had 3 femoral osteolysis, while in the acetabular side radiolucent lines were present in 14 % of the cases, never progressive. In no case we found a change of position of the cup. FitekTM cementless cups gave excellent results at 10 years with complete stability and osteo-integration. Excellent primary mechanical stability was given by the rough surface (SulmeshTM) and by the two “fins” in the equatorial area.
Although the short stem concept in hip arthroplasty procedure shows acceptable clinical performance, we sometimes get unexplainable radiological findings. The aim of this retrospective study was to evaluate changes of radiological findings up to three years postoperatively, and to assess any potential contributing factors on such radiological change in a Japanese population. This is a retrospective radiological study conducted in Japan. Radiological assessment was done in accordance with predetermined radiological review protocol. A total of 241 hips were included in the study and 118 hips (49.0%) revealed radiological change from immediately after surgery to one year postoperatively; these 118 hips were eligible for further analyses. Each investigator screened whether either radiolucent lines (RLLs), cortical hypertrophy (CH), or atrophy (AT) appeared or not on the one-year radiograph. Further, three-year radiographs of eligible cases were reviewed to determine changes such as, disappeared (D), improved (I), stable (S), and progression (P). Additionally, bone condensation (BC) was assessed on the three-year radiograph.Aims
Methods
This study aimed to determine the diagnostic performance of radiographic
criteria to detect aseptic acetabular loosening after revision total
hip arthroplasty (THA). Secondary aims were to determine the predictive
values of different thresholds of migration and to determine the
predictive values of radiolucency criteria. Acetabular component migration to re-revision was measured retrospectively
using Ein-Bild-Rontgen-Analyse (EBRA-Cup) and manual measurements
(Sutherland method) in two groups: Group A, 52 components (48 patients) found
not loose at re-revision and Group B, 42 components (36 patients)
found loose at re-revision between 1980 and 2015. The presence and
extent of radiolucent lines was also assessed.Aims
Patients and Methods
A total of 397 hips were randomised to receive
Metasul metal-on-metal (MoM), metal-on-conventional polyethylene (MoP)
or ceramic-on-polyethylene (CoP) bearings using a cemented triple-tapered
polished femoral component (MS-30). There were 129 MoM hips in 123
patients (39 male and 84 female, mean age 63.3 years (40.7 to 72.9)),
137 MoP hips in 127 patients (39 male and 88 female, mean age 62.8
years (24.5 to 72.7)) and 131 CoP hips in 124 patients (51 male
and 73 female, mean age 63.9 years (30.6 to 73.8)). All acetabular
components were cemented Weber polyethylene components with the
appropriate inlay for the MoM articulation. Clinical evaluation
was undertaken using the Harris hip score (HHS) and radiological
assessments were made at two, five and seven years. The HHS and radiological
analysis were available for 341 hips after seven years. The MoM
group had the lowest mean HHS (p = 0.124), a higher rate of revision
(p <
0.001) and a higher incidence of radiolucent lines in unrevised
hips (p <
0.001). In all, 12 revisions had been performed in
12 patients: eight in the MoM group (four for infection, four for
aseptic loosening, three in the MoP group (one each of infection,
dislocation and pain) and one in the CoP group (infection). Our findings reveal no advantage to the MoM bearing and identified
a higher revision rate and a greater incidence of radiolucent lines
than with the other articulations. We recommend that patients with
a 28 mm Metasul MoM bearing be followed carefully. Cite this article:
The Cementless Oxford Unicompartmental Knee Replacement
(OUKR) was developed to address problems related to cementation,
and has been demonstrated in a randomised study to have similar
clinical outcomes with fewer radiolucencies than observed with the
cemented device. However, before its widespread use it is necessary
to clarify contraindications and assess the complications. This
requires a larger study than any previously published. We present a prospective multicentre series of 1000 cementless
OUKRs in 881 patients at a minimum follow-up of one year. All patients
had radiological assessment aligned to the bone–implant interfaces
and clinical scores. Analysis was performed at a mean of 38.2 months
(19 to 88) following surgery. A total of 17 patients died (comprising
19 knees (1.9%)), none as a result of surgery; there were no tibial
or femoral loosenings. A total of 19 knees (1.9%) had significant
implant-related complications or required revision. Implant survival
at six years was 97.2%, and there was a partial radiolucency at
the bone–implant interface in 72 knees (8.9%), with no complete radiolucencies.
There was no significant increase in complication rate compared
with cemented fixation (p = 0.87), and no specific contraindications
to cementless fixation were identified. Cementless OUKR appears to be safe and reproducible in patients
with end-stage anteromedial osteoarthritis of the knee, with radiological
evidence of improved fixation compared with previous reports using
cemented fixation. Cite this article:
This study aims to implement and assess the inter and intra-reliability of a modernised radiolucency assessment system; the
Abstract. Introduction. Higher than expected rates of tibial loosening with the ATTUNE® total knee arthroplasty (TKA) implant has been reported. Component loosening can be associated with the development of radiolucency lines (RLL) and our study aim was to systematically assess the reported rates of these. Methodology. A systematic search was undertaken using the Cochrane methodology in four online databases. Identified studies were assessed and screened against predetermined inclusion criteria. Meta-analysis was conducted using a random-effects model. Results. Nine studies (n=2,727 TKAs) from 6,590 titles met the inclusion criteria: 1 Randomised Controlled Trial (n=74), 1 prospective cohort (n=200), 4 retrospective cohort (n=1,639), and 3 case-series (n=814). All used the 2013 ATTUNE® design. In meta-analysis: 8 studies (n=1,440 ATTUNE TKAs) reported an overall prevalence of 11% (95%CI: 6.4-18.3%) for medial tibia RLL; 7 studies (n=940) a 12.3% (95%CI: 4.0-32%) rate of any tibia RLL.; 5 studies (n=736) femoral RLL in 11% (95%CI: 7.2-106.5%) and 7 studies (n=896) any RLL in 20.7% (95%CI: 13.4-30.6%). Meta-analysis of 4 studies (n=1,036) comparing the ATTUNE® with another implant (PFC Sigma®, LCS®, or PERSONA®) showed a higher risk of medial tibia RLL (OR: 2.538; 95%CI: 1.397-4.611, P=0.002) and any RLL (OR: 2.725; 95%CI: 1.302-5.703, P=0.008) in the ATTUNE® group. Conclusions. The 2013 ATTUNE® TKA system is associated with high rates of radiolucency around the tibial and femoral components. Comparative studies suggesting these rates are more than double those of other systems.
Aim. Radiologic signs such as radiolucent lines around the implant, hardware fracture or displacement and periosteal reaction have been considered suggestive of implant-associated infection. The goal of this study is to assess the correlation of these signs with confirmed internal fixation-associated infection evaluated in a prospective cohort. Method. We evaluated the radiologic appearance of preoperative standard x-ray images in 421 surgeries performed in 380 patients with internal fixation device in place (56.8% male, mean age 53 ± 17 years). This prospective study was performed in a large single center for musculoskeletal surgery from 2013–2017. Infection was suspected preoperatively in only 23.8% of the surgeries. The most common indications for surgeries in which infection was not suspected were nonunion (84 cases) and symptomatic hardware (57 cases). All removed implants were sent to sonication for biofilm removal and detection. In addition, several peri-implant tissue samples were collected. Radiographs were analyzed in a blinded fashion for signs of radiolucent lines around the implant before removal, hardware fracture or displacement, and soft periosteal reactions suggestive of infection. Diagnosis was established according to the IDSA criteria for PJI. Contingency tables were constructed to determine sensitivity and specificity, and to perform Chi-square tests to compare the presence of infection with radiological signs of infection. Results. Radiologic signs suggestive for infection were uncommon, including radiolucent lines in 48 cases (11.4%); hardware breakage in 542cases (12.4%); hardware displacement in 45 cases (10.7%); periosteal reaction in 30 cases (7.1%). Infection was confirmed in 27.6% of the surgeries, and radiological signs of infection were only marginally more common in this group. Only the presence of radiolucent lines (p = 0.47; OR = 1.86 [95% CI 1.00 – 3.38]) and periosteal reaction (p = 0.15; OR = 2.48 [1.17 – 5.26]) were significantly associated with confirmed infection. Sensitivity of radiolucent lines and periosteal reaction were low (16,4% and 12,1%, respectively), while specificity remained acceptable (90.5%and 94.8%, respectively). Conclusions. Radiologic signs of infection are uncommon, even in the context of a confirmed infection.
Introduction: Loosening of the acetabular Implant after Total Hip Replacement (THR) is often associated with massive bone loss. Many different solutions to this problem have been reported. The implant we used in our series is a cementless cup that consists of two different modular components: the outer shell, with a caudal hook and 3 iliac wings, and the inner module that can be placed in 20° angulation, where the liner is inserted. Non-structural bone graft was used. Materials and Methods: From April 2002 to October 2004 24 patients were treated with this implant (age 70,7 years, 48–88). They had had zero to six prior surgeries. Indications were: Aseptic loosening (20), septic loosening (2), repetitive luxations(1), intraoperative acetabular fracture (1). Acetabular bone loss was intraoperatively graded using the DGOT classification. Paprosky Classification was used for preoperative radiological grading. Harris Hip Score (HHS) was used for clinical evaluation (preoperative scores were retrospectively ascertained from patients’ charts). For radiological follow up plain X-rays of the pelvis a.p. and targeted views of the cup were used.
It is a well-known fact that total knee arthroplasty is a soft tissue operation. Soft tissue balancing is the key to success in total knee arthroplasty. It is paramount importance to preserve the maximal amount of bone on both the femur and tibial side. In Indian scenario, majority of the patients present relatively late with varus or valgus deformity. Adding to this problem is poor bone quality due to osteoporosis. Our technique of Posterior cruciate ligament (PCL) retaining TKA with tibial end plate resection facilitates soft tissue balancing, preserves PCL and maximizes bone preservation on both tibial and femoral side achieving good results in minimum seven year follow up. We retrospectively analyzed seven year outcomes of 120 knees (110 patients), mean age was 65 years (range 55 to 75 years), who received contemporary cruciate-retaining prostheses with tibial end plate resection technique. The diagnosis was osteoarthritis in 96%, Rheumatoid arthritis in 2% and posttraumatic arthritis in 2% cases. There were more number of flexible varus knees as compared to flexible valgus knees. All the patients were followed up for minimum of 84 months with average follow up of 96 months. They were followed up at 3mths, 6mths, 1,3,5,7,9 and 10 years. The functional assessment was done using knee society knee and function scores. Radiographic analysis was done to rule out subsidence and aseptic loosening. The statistical significance was assessed using chi square test. Survival analysis was done using the Kaplan Meier analysis with revision taken as the endpoint. The average ROM was 100 degrees preoperatively and 120 degrees at last follow-up. The average knee society knee score improved from 45 points preoperatively to 90 points at last follow-up. The average knee society functional score improved from 48 points preoperatively to 84 points at last follow-up (p<0.05).
Aim. We present the medium-term clinical results of a reverse total
shoulder arthroplasty with a trabecular metal glenoid base plate. Patients and Methods. We reviewed 125 consecutive primary reverse total shoulder arthroplasties
(RTSA) implanted in 124 patients for rotator cuff arthropathy. There
were 100 women and 24 men in the study group with a mean age of
76 years (58 to 89). The mean follow-up was 32 months (24 to 60).
No patient was lost to follow-up. Results. There were statistically significant improvements in the mean
range of movement and Oxford Shoulder Score (p <
0.001). Kaplan-Meier
survivorship at five years was 96.7% (95% confidence interval 91.5
to 98.7) with aseptic glenoid failure as the end point. . Radiologically, 63 shoulders (50.4%) showed no evidence of notching,
51 (40.8%) had grade 1 notching, ten (8.0%) had grade 2 notching
and one (0.8%) had grade 4 notching.
Aims. The interest in unicompartmental knee arthroplasty (UKA) for
medial osteoarthritis has increased rapidly but the long-term follow-up
of the Oxford UKAs has yet to be analysed in non-designer centres.
We have examined our ten- to 15-year clinical and radiological follow-up
data for the Oxford Phase III UKAs. Patients and Methods. Between January 1999 and January 2005 a total of 138 consecutive
Oxford Phase III arthroplasties were performed by a single surgeon
in 129 patients for medial compartment osteoarthritis (71 right
and 67 left knees, mean age 72.0 years (47 to 91), mean body mass
index 28.2 (20.7 to 52.2)). Both clinical data and radiographs were
prospectively recorded and obtained at intervals. Of the 129 patients,
32 patients (32 knees) died, ten patients (12 knees) were not able
to take part in the final clinical and radiological assessment due
to physical and mental conditions, but via telephone interview it
was confirmed that none of these ten patients (12 knees) had a revision
of the knee arthroplasty. One patient (two knees) was lost to follow-up. Results. The mean follow-up was 11.7 years (10 to 15). A total of 11 knees
(8%) were revised. The survival at 15 years with revision for any
reason as the endpoint was 90.6% (95% confidence interval (CI) 85.2
to 96.0) and revision related to the prosthesis was 99.3% (95% CI
97.9 to 100). The mean total Knee Society Score was 47 (0 to 80)
pre-operatively and 81 (30 to 100) at latest follow-up. The mean
Oxford Knee Score was 19 (12 to 40) pre-operatively and 42 (28 to 55)
at final follow-up.
Total ankle replacement (TAR) is increasingly used in the treatment of end-stage ankle arthropathy, but much debate exists about the clinical result. The goals of present study are: 1) to provide an overview of the clinical outcome of 58 TAR's in a single centre and 2) to assess the association between radiological characteristics and clinical outcome. We reviewed a prospective included cohort of 58 TAR's in 54 patients with a mean age of 66.9 (range 54–82) and a mean follow-up of 21.6 months (range 1.45–66.0). The TAR's where performed by a single surgeon in a single centre (MUMC) between 2010 and 2015, using the CCI ankle replacement. A standard surgical protocol and standardized post-op rehabilitation was used. Patients were followed-up pre-op and at 1 day, 6 weeks, 3–6–12 months and yearly thereafter post-op. The AOFAS and range of motion (ROM) were assessed and all complications, re-operations and the presence of pain were recorded. Radiographic assessment consisted of the estimation of prosthesis alignment, migration, translation and radiolucent lines using the Rippstein protocol (1). The clinical outcome was compared with a systematic review of TAR outcome. Ten intra-operative complications occurred and 9 were malleolar fractures. Post-operative complications occurred in 20 out of the 54 patients (37.0%). Impingement (5/54 patients), deep infection (4/54 patients), delayed wound healing (3/54 patients) and minor nerve injuries (3/54 patients) were the most frequently recorded. 18 patients (31.0%) underwent one or more re-operations and 12 of these 18 patients underwent a component revision (mostly the PE insert) or a conversion to arthrodesis. Despite the complications and revisions, the functional outcome improved. Radiologically 15.8% of the TAR's were positioned in varus and 1.8% in valgus. Migration in the frontal and sagittal plane is seen in 3 and 2 TAR's respectively.
Quality of cementation in the early postoperative period has been proven to be an indicator of long-term survival of the total hip arthroplasty. Cementation grading described by Barrack et al is widely used but has certain limitations. It is based upon second-generation cementation technique and has unacceptably high inter- and intra-observer variability due to its subjective evaluation method. We are introducing a new grading system of quality of femoral cementation. It is based upon the ratio of the length of radiological lucency to the total length of cement-bone interface on both antero-posterior and lateral views. Because of its objective nature, it is likely to show reproducible results. We recruited five observers of various grades of surgical experience (trainees to consultant). Each observer graded the quality of femoral cementation on immediate postop xrays twice (gap of atleast two weeks) of 30 primary hip arthroplasties, using Barrack's grading and a new cementation index measured by dividing the ength of
The purpose of this study was to assess mid-term survivorship following primary total knee arthroplasty (TKA) with Optetrak Logic components and identify the most common revision indications at a single institution. We identified a retrospective cohort of 7,941 Optetrak primary TKAs performed from January 2010 to December 2018. We reviewed the intraoperative findings of 369 TKAs that required revision TKA from January 2010 to December 2021 and the details of the revision implants used. Kaplan-Meier analysis was used to determine survivorship. Cox regression analysis was used to examine the impact of patient variables and year of implantation on survival time.Aims
Methods
Cementless acetabular fixation has demonstrated superior long-term durability in total hip replacement, but most series have studied implants with porous metal surfaces. We retrospectively evaluated the results of 100 consecutive patients undergoing total hip replacement where a non-porous Allofit component was used for primary press-fit fixation. This implant is titanium alloy, grit-blasted, with a macrostructure of forged teeth and has a biradial shape. A total of 81 patients (82 hips) were evaluated at final follow-up at a mean of 10.1 years (8.9 to 11.9). The Harris Hip Score improved from a mean 53 points (23 to 73) pre-operatively to a mean of 96 points (78 to 100) at final review. The osseointegration of all acetabular components was radiologically evaluated with no evidence of loosening. The survival rate with revision of the component as the endpoint was 97.5% (95% confidence interval 94 to 100) after 11.9 years.
Reconstruction following internal hemipelvectomy for bone tumors remains a major surgical challenge. Most of the cases are considered not suitable for reconstruction because of high complication occurrence. Allografts coupled with standard prosthesis is a reliable method of reconstruction. 26 patients received a McMinn stemmed cup (Link, Germany) after periacetabular tumor resection from February 1999 to 2006. In 18 patients the reconstruction followed resection of the acetabular area while in other 8 an extrarticular resection of the proximal femur was performed. In 21 cases a stemmed acetabular cup were associated with massive bone allograft. There were 13 female and 13 male with a mean age of 41 years (13 to 70). Average follow-up was 45 months (7 to 105). Six patients were affected by local recurrence of the tumour and five underwent hindquarter amputation. In 4 of them the index surgery followed a previous recurrence of the tumour. Finally 6 patients died for related causes within 2 years. All the other 20 have been followed clinically and radiographically for a minimum of 24 months. Deep infection occurred in one case, there were no cases of dislocation.
The aim of the present study was to assess the outcome of revision surgery, using semiconstrained implants, in the management of tibiofemoral instability complicating primary total knee arthroplasty. Between Feb 1987 and Oct 2000, 177 primary, unconstrained, surface replacement total knee arthroplasties were revised at our institution. Instability was the commonest reason for revision surgery and accounted for 22.6 % of overall revisions. Excluding tertiary referrals, instability necessitated revision surgery in 0.31% of 1918 primary total knee arthroplasties performed ‘in-house’ during the same period. The results of 17 revision total knee arthroplasties using semiconstrained prostheses are presented. Six operations were performed for sagittal plane instability, 5 for coronal and 6 for multiplanar instability. 10 revisions were performed using the PFC ‘stabilised plus’ prostheses, and a further 7 with TC3 prostheses. 17 patients (13 F: 4 M), aged 48–83 years (average 67.8 years) underwent revisions, between 9–132 m from the date of the index arthroplasty. At an average follow-up of 36m, the Knee Society score had risen from 31.2 points preoperatively to 60.9 at last follow-up (LFU) [Joint score from 47.5 preop to 81.5 at LFU/Function score: from 14.4 to 39.7 at LFU].
Between June 1993 and December 1994, we performed total knee arthroplasty (TKA) on 27 knees in 24 patients with spontaneous bony ankylosis in severe flexion. The mean age at operation was 43.5 years (30 to 60). No patient had preoperative pain. Three were unable to walk and 21 could manage less than five blocks. The mean duration of the ankylosis was 18.7 years (13 to 25) and its mean position was 105° flexion (75 to 135). The preoperative Hospital for Special Surgery Knee Score of 60 points was improved to 87 at the final follow-up three to five years later. All knees were free from pain. The mean range of active flexion in 24 knees was 97° (78 to 115) and the mean arc of movement 91° (78 to 98). The mean fixed flexion deformity was 6° (0 to 25) and the extension lag 8° (0 to 25). Angular deformity was corrected to between 0° and 10° of valgus. Four patients were able to walk one block and 20 five to seven blocks. Thirteen knees (48%) showed some necrosis at the skin edge; one knee required arthrodesis and another resection arthroplasty. One had a recurrence of tuberculous infection requiring arthrodesis. One patient had a rupture of the quadriceps tendon. To date no prosthesis has required revision for loosening.
Aims: Stemmed cup is the evolution of Ring cup. The iliac stem is positioned in direction of sacro-iliac sin-condrosis, in axis with weight-bearing lines. It allows an optimal stability in the iliac bone avoiding the dameged acetabular region. The stemmed cup is indicated:. Ð in CDH primary implant. Ð in revision surgery (grade 2–4 according to Paproskyñs classiþcation). In severe bone loss cases (grade 3–4) we preferred to use auto or homologous bone grafts impacted to þll the bone defect. Methods:We report about 168 stemmed cup implants in 159 patients (9 bilateral cases). 37 CDH was treated as a primary implant (6 bilateral patients). The average age is 69 years (range 38–87). The mean follow up is 36 months (range 6 months Ð 6 years). 21 cases were lost at follow up. We evaluated all patients by X-rays at 1,3,6 months and every year and CT in some cases to check the iliac stem position. Results: 13 patients died because of non-related surgery. Superþcial infections 5 cases; deep infections 6 cases (two-stages revision); proximal migration <
1 cm. In 9 cases without loosening; malpositioning of the stem 7 cases; sciatic nerve palsy 5 cases (1 permanent case); DVT 3 cases.
Introduction: The introduction of Oxford UKA byminimally invasive techniques has signiþcantly changed the treatment of anteromedial osteoarthritis of the knee joint. It is therefore necessary to evaluate this treatment option both clinically and radiologically. Aims: To study the radiographic and clinical results of the Oxford medial UKA in patients with a minimum follow up of 2 years in a single centre. Methods: A prospective independent study in which 67 consecutive UKAs were implanted by a single surgeon, using a minimally invasive technique. All patients with a minimum follow up of 2 years were pre- and postoperatively clinically evaluated by the AKSS and radiologically according to the Oxford Centre criteria, including ßuoroscopy. Results: Clinical: 28 patients with 30 prostheses (mean FU: 2.54 yr; mean age: 71.4 yrs) were included. The Knee Score improved signiþcantly from 58.7 (pre-op) to 95.0 (FU). The Function Score improved from 54.5 to 88.8. Mean ROM was 125û preoperatively and 121û at FU.Radiological: preop: varus deformity (n=18; mean 3.4û; range 2–10û), and valgus (n=12; 5.4, 2–12û). Postop: valgus alignment in all (n=30; 6.3û, 4–12û). Fifteen cases (50%) showed signs of patellofemoral arthritis (PFA); 11 cases with grade 2–3 PFA had a maximum pain score of 50. Full congruency of the tibial and femoral components was obtained in 18 cases, 10 cases were within and 2 out of margin according to the Oxford Centre criteria.
Introduction. Acetabular fixation is one of the major factors affecting long-term longevity and durability of total hip arthroplasty (THA). Limited data exist regarding mid-term performance of modern non-cemented rim-fit cups with HA coating. The aim of this study was to assess the minimum 5 year clinical and radiographic performance of PSL cups. Therefore we retrospectively analyzed results of this component in patients that had adequate followup from a prospective institutional database. Materials and Methods. A retrospective analysis of a prospective database was performed to identify patients that underwent non-cemented THA between 2003 and 2007. 223 primary THA (210 patients) were performed by single surgeon via posterolaeral approach using a grit-blasted, HA coated rim-fit design and highly cross-linked polyethylene and were followed with minimum 5 years. The mean age was 62.5 years ± 10.8. The majority of the stems were non-cemented (87%) and the majority of the femoral heads were metal (75%), 22- or 28-mm diameter. 72% of the cups were solid and 28% were multi-hole. Clinical assessment included the Hospital for Special Surgery (HSS) hip score [18] at final follow-up, and Kaplan-Meier survivorship. All patients received pre- and post-operative anteroposterior (AP) weight bearing pelvis radiograph as well as a false profile view of the hip. Cup positioning was analyzed using the EBRA software (Einzel-Bild-Roentgen-Analysis; University of Innsbruck, Innsbruck, Austria) for functional abduction angle, anteversion, and cup migration. Osseointegration was assessed on the DeLee and Charnley's zones on both AP and false profile views. Osseointegration was defined based on the following characteristics:. presence of Stress Induced Reactive Cancellous Bone (SIRCaB), where new bone condensation (not apparent on preoperative radiographs) was present at the load bearing area of the cup (Figure 1). presence of radial trabeculae that project in continuum from the shell into the pelvis, suggesting integration of the trabecular bone onto the metal surface at the load bearing area, (Figure 2). absence of radiolucency.
Introduction: Partial Knee Replacement (PKR) is an appealing alternative to Total Knee Replacement (TKR) when the patient has isolated compartment osteoarthritis (OA). In nearly all cases there is a radiolucency observed between the tibial tray wall and the boney interface. The reasons why radiolucencies appear are unknown, but the bone will adapt to its altered mechanical environment by bone remodelling in accordance with ‘Wollf’s Law’. The aim of this study was to investigate the mechanical environment of the tibia bone adjacent to the tray wall, following cemented and cementless PKR, in order to determine whether this region of bone resorbs. Methods: A validated finite element (FE) model of a cadaver tibia implanted with an Oxford PKR was used in this study. Kinematic data from fluoroscopy measurements during a step-up activity were used to determine the relative tibio-femoral positioning for the Oxford PKR model. Load data were adapted from the in-vivo measured loads using an instrumented implant during a step-up activity. The standard operating protocol was simulated for the Oxford PKR FE models, with the tibial tray implanted in a neutral position. The tibia was sectioned around the tray. Zone 7 was defined as parallel to the vertical tray wall, corresponding to the region on screened x-rays where radiolucencies are observed. It was assumed that the bone in the implanted tibia will attempt to normalise its stress-strain patterns locally to its equilibrium state, the intact tibia, for the same loading conditions. Forty patients (20 cemented, 20 cementless) who had undergone PKR were randomly selected from a database, and their screened x-rays assessed for radiolucency in region 7. Results: The SED in region 7 was 80% lower in the cemented and cementless tibia, compared to the intact tibia (Figure 2). The maximum tensile stress was 63% lower in the cemented and cementless tibia, compared to the intact tibia. The corresponding maximum compressive stress was 52% lower.
The purpose of this study was to evaluate the outcomes of treatment of rheumatoid elbows with Kudo Total Elbow Replacements. Between 1993–1997 we performed 39 Kudo Total Elbow Replacements in 35 patients with Rheumatoid Arthritis, aged 39–81 years old (mean age: 60,7 yrs). Eleven patients (13 elbows) were male and 24 (26 elbows) were female. Twenty-eight (28) replacements were performed on the right side and eleven (11) on the left. All the patients were evaluated clinically (pre-op and post-op, using Mayo score system) and radiographically. In seven elbows another procedure (radial head excision (three), radial head excision &
synovectomy (three), arthroscopy &
interposition arthroplasty(one)) had been performed previously for the rheumatoid arthritis. Eight elbows seemed to have ulnar nerve problems pre-op. We followed-up 31 patients (35 elbows). Mean follow-up was 5years (range: 4–8 years). The pre-operative pain had been reduced significantly in almost all patients. In the majority, the movement had also been improved post-operatively. Two elbows were unstable (one subluxated, one dislocated). Both presented early postoperatively. Only one patient developed a postoperative ulnar nerve problem and that resolved. One elbow had a delay in wound healing.
Introduction. Unicompartmental Knee Replacement (UKR) is an appealing alternative to Total Knee Replacement (TKR) when the patient has isolated compartment osteoarthritis (OA). A common observation post-operatively is radiolucency between the tibial tray wall and the bone. In addition, some patients complain of persistent pain following implantation with a UKR; this may be related to elevated bone strains in the tibia. The aim of this study was to investigate the mechanical environment of the tibia bone adjacent to the tray wall, following UKR, to determine whether this region of bone resorbs, and how altering the mechanical environment affects tibia strains. Materials and methods. A finite element (FE) model of a cadaver tibia implanted with an Oxford UKR was used in this study, based on a validated model. A single static load, measured in-vivo during a step-up activity was used. There was a 1 mm layer of cement surrounding the keel in the cemented UKR, and the cement filled the cement pocket. In accordance with the operating procedure, no cement was used between the tray wall and bone. For the cementless UKR a layer of titanium filled the cement pocket. An intact tibia was used to compare to the cemented and cementless UKR implanted tibiae. The tibia was sectioned by the tray wall, defining the radiolucency zone (parallel to the vertical tray wall, 2 mm wide with a volume of 782.5 mm. 3. ), corresponding to the region on screened x-rays where radiolucencies are observed. Contact mechanics algorithms were used between all contacting surfaces; bonded contact was also introduced between the tray wall and adjacent bone, simulating a mechanical tie between them. Strain energy density (SED), was compared between the intact and implanted tibia for the radiolucency zone. Equivalent strains were compared on the proximal tibia between the intact and implanted tibia models. Forty patients (20 cemented, 20 cementless) who had undergone UKR were randomly selected from a database, and assessed for radiolucency. Results. The SED in the radiolucency zone was 80% lower in the cemented and cementless tibia, compared to the intact tibia, without a mechanical tie between the tibial tray wall and adjacent bone. When a mechanical tie was introduced the SED in the radiolucency zone was 35% higher in the cemented and cementless tibia, compared to the intact tibia. The strain on the proximal tibia was reduced by 20% when a mechanical tie was used between the tray wall and adjacent bone.
The use and variety of stemless humeral components in anatomical total shoulder arthroplasty (TSA) have proliferated since their advent in 2004. Early outcomes are reassuring but independent mid-term results are scarce. This independent study reports a consecutive series of 143 Eclipse stemless shoulder prostheses with a minimum five-year (5 to 10) follow-up. Outcomes of 143 procedures undertaken for all indications in 131 patients were reviewed, with subset analysis of those for osteoarthritis (OA) (n = 99). The primary outcome was the Oxford Shoulder Score (OSS) at a minimum of five years. Secondary outcomes were ranges of motion and radiological analysis of humeral radiolucency, rotator cuff failure, and glenoid loosening.Aims
Methods
Introduction and Objectives: The purpose of this study is to analyse the clinical and radiographic results of revision total hip prosthesis using femoral stems with diaph-yseal fixation. Materials and Methods: We assessed failure of the primary prosthesis based on Paprosky’s classification to identify the femoral defect and determine the optimal component for revision, keeping in mind the difficulty of classifying bone defects based on radiographic parameters. The most commonly-used replacement models were KAR revision stems (wide, straight, long necks and hydroxyapatite-coated along the entire length) and Restoration-T3 stems (diaphyseal fixation, modular, fits different necks, Wagner model progression, particularly indicated to facilitate extraction of cement using a buried diaphyseal osteotomy). Clinical evaluation was done using the Merle D’Aubigné and Postel scales modified by Charnley. Radiographic evaluation of prosthetic stability and osseointegration was done using Engh’s criteria, checking for presence or absence of radiolucency, migration, pedestal, and increase or decrease of endosteal and periprosthetic density (calcar, diaphysis, and greater trochanter). Results: We examined 47 KAR stems and 16 Restoration-T3 stems, with an average follow-up period of 4.1 years (range: 1–9 years) and an average patient age of 69.4 years (range: 40–79 years). Of these, 6 were Paprosky type 1, 36 were type II, 14 were type IIIA, 5 were type IIIB, and 2 were type IV. Average preoperative clinical score was 9.76 points. Aetiology in all cases was aseptic loosening of a primary prosthesis, with the exception of one case of a delayed Corynebacterium infection. There were 2 partial Monk prosthesis revisions and 3 periprosthetic fractures. Average postoperative clinical score was 15.83 points. There were no deep infections or dislocations.
Total hip replacement in the young active patient remains one of the major challenges in orthopaedics today. The use of ultra high molecular weight (UHMW) polyethylene acetabular liners is known to cause polyethylene wear related osteolysis, the major limiting factor in its use in the younger active patient. Modern alumina ceramic articulations have been developed in order to reduce wear and avoid polyethylene debris. This prospective randomized long-term study aims to compare the outcome between an alumina ceramic-on-ceramic (CC) articulation with a ceramic on UHMW polyethylene articulation (CP). In the younger active patient, is one option superior to the other with regard to patient satisfaction, osteolysis and implant longevity?. 56 hips in 55 patients with mean age 42.2 (range 19–56) each received uncemented components (Wright Medical) and a 28mm alumina head with acetabular liner selected via sealed envelope randomization following anesthetic induction. Subsequent regular clinical and radiologic follow up measured patient outcome scores and noted any radiological changes. 26 CP hips and 30 CC hips were evaluated. One failure required revision in each group. Mean St Michael’s outcome score for each group with up to 10 years follow-up (median 8 years, range 1–10) was 22.8 and 22.9 respectively (p=0.057). Radiographs with a minimum 5 years post-operative follow-up were analyzed in 42 hips (23 CC and 19 CP).
Background: Total Hip Replacements in younger active patients continues to pose a major challenge. Surface replacement techniques, designed to preserve bone stock do not yet have proven long term results. Early cemented designs in this population had high failure rates. Concept of fixation of total hip prosthesis by bony in-growth rather than by cement is an attempt to decrease the incidence of loosening. Ceramic joint surfaces produce minimal wear debris. Objectives: A medium term follow-up of clinical and radiological results of the JRI Furlong hydroxyapatite coated prosthesis with ceramic bearing surfaces in young active patients. Methods: A retrospective analysis of 43 JRI Furlong Hip Replacements (mean age 32 Yrs) in 33 patients is presented. The minimum follow-up was 60 months. Functional assessment was done using the Harris Hip Score.
Methodology: A retrospective review based on a prospective database was performed on 146 consecutive revision TKA’s. An independent observer measured clinical outcomes using the Knee Society Knee (KS) and Function Score (FS). X-ray evaluation, including rating of radiolucent lines, tibiofemoral and patellofemoral alignment, was carried out by an independent radiologist. ANOVA was used for statistical analysis, with significance set at p≤0.05 (SPSS version 15.0). Post-hoc Bonferroni testing was carried out for single variables including primary cause of failure, age at revision surgery, time span between index operation and revision, type of index operation, partial or total revision and the performance of a tuberosity osteotomy. Results: 146 files were available in 135 patients. 16 patients deceased (17 knees) during the follow-up period and 2 patients (2 knees) were lost to follow-up. 117 patients (127 knees) were available for evaluation. Age at revision surgery averaged 67.7 years (range 32.3–88.1). Mean follow-up time was 4.5 years (range 1–14). Patients had revision TKA between 51 days and 16.1 years (average 4.7 years) after the index TKA. 54% of the early revisions were due to infection and instability, 55% of late revisions were caused by polyethylene-wear and loosening. The mean postoperative KS was 70.8 with a mean improvement of 43.2 points as compared to pre-operative. The mean postoperative FS was 52.9 with a mean improvement of 25.4 points. Grouping outcomes according to cause of failure of the index TKA gave the following ranking from better to worse, without being significant: wear (n=15; KS 80.8; range 43–99, SD 17.5), loosening (n=44; KS 75.8; range 15–100, SD=21.2), malalignment (n=19; KS 70.0; range 9–95, SD 25.9), instability (n=33; KS 68.2; range 5–100, SD 24.1), others (n=16; KS 66.7; range 10–100, SD 25.9), and infection (n=21; KS 64.2; range 3–100, SD 31.7). Survivorship at 5 years was 90.0% (CI 86.4% –93.6%), at 10 years 84,6% (CI 77.0% –92.3%) and at 14 years 84,6% (CI 37.7% –131.6%). Significant better outcomes were seen with late revisions, index operation being partial knee replacement and older age at revision. More failures (p=0.002) were seen with early revisions. In 32.6% of the patients radiolucent lines of ≥1 mm were observed. Points were granted with the use of a
Introduction The double-tapered femoral stem is recognised for its excellent long-term results. The design allows greater cement engagement by capitalising on the phenomenon of cement creep. An additional third taper is thought to provide greater stability, fixation and improved femoral neck loading. This study compares prospectively the early clinical and radiological results between triple and double-tapered stems in cemented THA. Methods Between March 1998 and October 2002, 391 patients (405 hips) underwent primary THA and received either a triple, 192 patients (200 hips) or double 189 patients (205 hips) tapered stem. The post-operative protocol was identical and patients were followed-up clinically and radiologically at approximately three, six and 12 months and yearly thereafter. Clinical outcomes were assessed with respect to mortality, complications, Harris Hip Score (HHS) and Merle d’Aubigne and Postel score (MDA). Radiological analysis was performed looking for evidence of radiolucent lines, aseptic loosening, subsidence, endosteolysis, heterotrophic ossification, cortical hypertrophy and cement fractures. Age, sex, weight, height, indications for surgery and the distribution of right and left hips were comparable between the two groups. The average follow-up in the triple and double tapered groups was 21 and 23 months respectively. Results Clinically, in the triple-taper group, there was a mean improvement in HHS of 44 points and MDA of 5.8. Similar improvements were seen in the double-tapered group, with increases of 45 and 5.6 points in the HHS and MDA respectively. No significant difference was noted in terms of complications. In the triple-tapered group, evidence of radiolucency between the cement-stem interface was seen in only one patient in Zone 1, and this was associated with a small cement fracture in Zone 3. Cement-bone radiolucency occurred in one hip at Zone 1. In the double-tapered group, five hips showed cement-stem radiolucency, all in Zone 1.
We aimed to investigate if the use of the largest possible cobalt-chromium head articulating with polyethylene acetabular inserts would increase the in vivo wear rate in total hip arthroplasty. In a single-blinded randomized controlled trial, 96 patients (43 females), at a median age of 63 years (interquartile range (IQR) 57 to 69), were allocated to receive either the largest possible modular femoral head (36 mm to 44 mm) in the thinnest possible insert or a standard 32 mm head. All patients received a vitamin E-doped cross-linked polyethylene insert and a cobalt-chromium head. The primary outcome was proximal head penetration measured with radiostereometric analysis (RSA) at two years. Secondary outcomes were volumetric wear, periacetabular radiolucencies, and patient-reported outcomes.Aims
Methods
The Mathys Affinis Short is the most frequently used stemless total shoulder prosthesis in the UK. The purpose of this prospective cohort study is to report the survivorship, clinical, and radiological outcomes of the first independent series of the Affinis Short prosthesis. From January 2011 to January 2019, a total of 141 Affinis Short prostheses were implanted in 127 patients by a single surgeon. Mean age at time of surgery was 68 (44 to 89). Minimum one year and maximum eight year follow-up (mean 3.7 years) was analyzed using the Oxford Shoulder Score (OSS) at latest follow-up. Kaplan-Meier survivorship analysis was performed with implant revision as the endpoint. Most recently performed radiographs were reviewed for component radiolucent lines (RLLs) and proximal humeral migration.Aims
Methods
Vitamin E-infused highly crosslinked polyethylene (VEPE) has been introduced into total hip arthroplasty (THA) with the aim of further improving the wear characteristics of moderately and highly crosslinked polyethylenes (ModXLPE and HXLPE). There are few studies analyzing the outcomes of vitamin E-infused components in cemented arthroplasty, though early acetabular component migration has been reported. The aim of this study was to measure five-year polyethylene wear and acetabular component stability of a cemented VEPE acetabular component compared with a ModXLPE cemented acetabular component. In a prospective randomized controlled trial (RCT), we assessed polyethylene wear and acetabular component stability (primary outcome) with radiostereometric analysis (RSA) in 68 patients with reverse hybrid THA at five years follow-up. Patients were randomized to either a VEPE or a ModXLPE cemented acetabular component.Aims
Methods
Total knee arthroplasty is an established treatment for knee osteoarthritis with excellent long-term results, but there remains controversy about the role of uncemented prostheses. We present the long-term results of a randomized trial comparing an uncemented tantalum metal tibial component with a conventional cemented component of the same implant design. Patients under the age of 70 years with symptomatic osteoarthritis of the knee were randomized to receive either an uncemented tantalum metal tibial monoblock component or a standard cemented modular component. The mean age at time of recruitment to the study was 63 years (50 to 70), 46 (51.1%) knees were in male patients, and the mean body mass index was 30.4 kg/m2 (21 to 36). The same cruciate retaining total knee system was used in both groups. All patients received an uncemented femoral component and no patients had their patella resurfaced. Patient outcomes were assessed preoperatively and postoperatively using the modified Oxford Knee Score, Knee Society Score, and 12-Item Short-Form Health Survey questionnaire (SF-12) score. Radiographs were analyzed using the American Knee Society Radiograph Evaluation score. Operative complications, reoperations, or revision surgery were recorded. A total of 90 knees were randomized and at last review 77 knees were assessed. In all, 11 patients had died and two were lost to follow-up.Aims
Methods
Aims
Patients and Methods
The reasons for failure of a hemirthroplasty (HA) when used to
treat a proximal humeral fracture include displaced or necrotic
tuberosities, insufficient metaphyseal bone-stock, and rotator cuff
tears. Reverse total shoulder arthroplasty (rTSA) is often the only
remaining form of treatment in these patients. The aim of this study
was to evaluate the clinical outcome after conversions from a failed
HA to rTSA. A total of 35 patients, in whom a HA, as treatment for a fracture
of the proximal humerus, had failed, underwent conversion to a rTSA.
A total of 28 were available for follow-up at a mean of 61 months
(37 to 91), having been initially reviewed at a mean of 20 months
(12 to 36) postoperatively. Having a convertible design, the humeral
stem could be preserved in nine patients. The stem was removed in
the other 19 patients and a conventional rTSA was implanted. At
final follow-up, patients were assessed using the American Shoulder
and Elbow Surgeons (ASES) score, the Constant Score, and plain radiographs.Aims
Material and Methods
Vitamin E-diffused, highly crosslinked polyethylene (VEPE) and porous titanium-coated (PTC) shells were introduced in total hip arthroplasty (THA) to reduce the risk of aseptic loosening. The purpose of this study was: 1) to compare the wear properties of VEPE to moderately crosslinked polyethylene; 2) to assess the stability of PTC shells; and 3) to report their clinical outcomes at seven years. A total of 89 patients were enrolled into a prospective study. All patients received a PTC shell and were randomized to receive a VEPE liner (n = 44) or a moderately crosslinked polyethylene (ModXLPE) liner (n = 45). Radiostereometric analysis (RSA) was used to measure polyethylene wear and component migration. Differences in wear were assessed while adjusting for body mass index, activity level, acetabular inclination, anteversion, and head size. Plain radiographs were assessed for radiolucency and patient-reported outcome measures (PROMs) were administered at each follow-up.Aims
Patients and Methods
The crucial role of the radial head in the stability of the elbow in terrible triad injury is acknowledged. This retrospective study aims to compare the results of resection of a severely comminuted radial head with or without prosthetic arthroplasty as part of the reconstruction for this injury. The outcome of radial head resection was compared with prosthetic arthroplasty in 29 and 15 patients with terrible triad injuries, respectively. There were ten female patients (34.5%) in the resection group and six female patients (40%) in the prosthesis group. The mean age was 40.7 years (Aims
Patients and Methods
Advances in polyethylene (PE) in total hip arthroplasty
have led to interest and increased use of highly crosslinked PE
(HXLPE) in total knee arthroplasty (TKA). Biomechanical data suggest
improved wear characteristics for HXLPE inserts over conventional
PE in TKA. Short-term results from registry data and few clinical
trials are promising. Our aim is to present a review of the history
of HXLPEs, the use of HXLPE inserts in TKA, concerns regarding potential mechanical
complications, and a thorough review of the available biomechanical
and clinical data. Cite this article:
Unlinked, linked and convertible total elbow
arthroplasties (TEAs) are currently available. This study is the
first to report the clinical results of the convertible Latitude
TEA. This was a retrospective study of a consecutive cohort of 63
patients (69 primary TEAs) with a mean age of 60 years (23 to 87).
Between 2006 and 2008 a total of 19 men and 50 women underwent surgery.
The mean follow-up was 43 months (8 to 84). The range of movement,
function and pain all improved six months post-operatively and either
continued to improve slightly or reached a plateau thereafter. The
complication rate is similar to that reported for other TEA systems.
No loosening was seen. Remarkable is the disengagement of the radial
head component in 13 TEAs (31%) with a radial head component implanted. Implantation of both the linked and the unlinked versions of
the Latitude TEA results in improvement of function and decreased
pain, and shows high patient satisfaction at mid-term follow-up. Cite this article:
The relationship between post-operative bone
density and subsequent failure of total knee replacement (TKR) is
not known. This retrospective study aimed to determine the relationship
between bone density and failure, both overall and according to
failure mechanism. All 54 aseptic failures occurring in 50 patients
from 7760 consecutive primary cemented TKRs between 1983 and 2004
were matched with non-failing TKRs, and 47 failures in 44 patients
involved tibial failures with the matching characteristics of age
(65.1 for failed and 69.8 for non-failed), gender (70.2% female), diagnosis
(93.6% OA), date of operation, bilaterality, pre-operative alignment
(0.4 and 0.3 respectively), and body mass index (30.2 and 30.0 respectively).
In each case, the density of bone beneath the tibial component was assessed
at each follow-up interval using standardised, calibrated radiographs.
Failing knees were compared with controls both overall and, as a
subgroup analysis, by failure mechanism. Knees were compared with
controls using univariable linear regression. Significant and continuous elevation in tibial density was found
in knees that eventually failed by medial collapse (p <
0.001)
and progressive radiolucency (p <
0.001) compared with controls,
particularly in the medial region of the tibia. Knees failing due
to ligamentous instability demonstrated an initial decline in density
(p = 0.0152) followed by a non-decreasing density over time (p =
0.034 for equivalence). Non-failing knees reported a decline in
density similar to that reported previously using dual-energy x-ray
absorptiometry (DEXA). Differences between failing and non-failing
knees were observable as early as two months following surgery.
This tool may be used to identify patients at risk of failure following
TKR, but more validation work is needed. Cite this article:
Revision total elbow arthroplasty (TEA) is often challenging.
The aim of this study was to report on the clinical and radiological
results of revision arthroplasty of the elbow with the Latitude
TEA. Between 2006 and 2010 we used the Latitude TEA for revision in
18 consecutive elbows (17 patients); mean age 53 years (28 to 80);
14 women. A Kudo TEA was revised in 15 elbows and a Souter-Strathclyde
TEA in three. Stability, range of movement (ROM), visual analogue score (VAS)
for pain and functional scores, Elbow Functional Assessment Scale
(EFAS), the Functional Rating Index of Broberg and Morrey (FRIBM)
and the Modified Andrews’ Elbow Scoring System (MAESS) were assessed
pre-operatively and at each post-operative follow-up visit (six,
12 months and biennially thereafter). Radiographs were analysed
for loosening, fractures and dislocation. The mean follow-up was
59 months (26 to 89).Aims
Patients and Methods
Until now, there has been no consensus as to whether stemmed
acetabular components are appropriate for use in patients undergoing
revision total hip arthroplasty (THA) who have major acetabular
defects or pelvic discontinuity. We wished to address this deficiency
in the literature. We carried out a retrospective study of 35 patients (six men
and 29 women) with a mean age of 68 years (37 to 87), with major
acetabular defects who underwent revision THA between 2000 and 2012.Aim
Patients and Methods
We evaluated clinical and radiographic outcomes of total shoulder
arthroplasty (TSA) using the second-generation Trabecular Metal
(TM) Glenoid component. The first generation component was withdrawn
in 2005 after a series of failures were reported. Between 2009 and
2012, 40 consecutive patients with unilateral TSA using the second-generation
component were enrolled in this clinical study. The mean age of
the patients was 63.8 years (40 to 75) and the mean follow-up was
38 months (24 to 42). Patients were evaluated using the Constant score (CS), the American
Shoulder and Elbow Surgeons (ASES) score and routine radiographs.Aims
Methods
This prospective study reports the 15-year survival and ten-year
functional outcome of a consecutive series of 1000 minimally invasive
Phase 3 Oxford medial UKAs (818 patients, 393 men, 48%, 425 women,
52%, mean age 66 years; 32 to 88). These were implanted by two surgeons
involved with the design of the prosthesis to treat anteromedial
osteoarthritis and spontaneous osteonecrosis of the knee, which
are recommended indications. Patients were prospectively identified
and followed up independently for a mean of 10.3 years (5.3 to 16.6). At ten years, the mean Oxford Knee Score was 40 (standard deviation
( This is the only large series of minimally invasive UKAs with
15-year survival data. The results support the continued use of
minimally invasive UKA for the recommended indications. Cite this article:
We analysed the long-term clinical and radiological results of 63 uncemented Low Contact Stress total knee replacements in 47 patients with rheumatoid arthritis. At a mean follow-up of 12.9 years (10 to 16), 36 patients (49 knees) were still alive; three patients (five knees) were lost to follow-up. Revision was necessary in three knees (4.8%) and the rate of infection was 3.2%. The mean clinical and functional Knee Society scores were 90 (30 to 98) and 59 (25 to 90), respectively, at final follow-up and the mean active range of movement was 104° (55° to 120°). The survival rate was 94% at 16 years but 85.5% of patients lost to follow-up were considered as failures. Radiological evidence of impending failure was noted in one knee.
The presacral retroperitoneal approach for axial lumbar interbody fusion (presacral ALIF) is not widely reported, particularly with regard to the mid-term outcome. This prospective study describes the clinical outcomes, complications and rates of fusion at a follow-up of two years for 26 patients who underwent this minimally invasive technique along with further stabilisation using pedicle screws. The fusion was single-level at the L5-S1 spinal segment in 17 patients and two-level at L4–5 and L5-S1 in the other nine. The visual analogue scale for pain and Oswestry Disability Index scores were recorded pre-operatively and during the 24-month study period. The evaluation of fusion was by thin-cut CT scans at six and 12 months, and flexion-extension plain radiographs at six, 12 and 24 months. Significant reductions in pain and disability occurred as early as three weeks postoperatively and were maintained. Fusion was achieved in 22 of 24 patients (92%) at 12 months and in 23 patients (96%) at 24 months. One patient (4%) with a pseudarthrosis underwent successful revision by augmentation of the posterolateral fusion mass through a standard open midline approach. There were no severe adverse events associated with presacral ALIF, which in this series demonstrated clinical outcomes and fusion rates comparable with those of reports of other methods of interbody fusion.
We report the clinical and radiological outcome of 86 revisions of cemented hip arthroplasties using JRI-Furlong hydroxyapatite-ceramic-coated acetabular and femoral components. The acetabular component was revised in 62 hips and the femoral component in all hips. The mean follow-up was 12.6 years and no patient was lost to follow-up. The mean age of the patients was 71.2 years. The mean Harris hip and Oxford scores were 82 (59 to 96) and 23.4 (14 to 40), respectively. The mean Charnley modification of the Merle d’Aubigné and Postel score was 5 (3 to 6) for pain, 4.9 (3 to 6) for movement and 4.4 (3 to 6) for mobility. Migration of the acetabular component was seen in two hips and the mean acetabular inclination was 42.6°. The mean linear polyethylene wear was 0.05 mm/year. The mean subsidence of the femoral component was 1.9 mm and stress shielding was seen in 23 (28%) with bony ingrowth in 76 (94%). Heterotopic ossification was seen in 12 hips (15%). There were three re-revisions, two for deep sepsis and one for recurrent dislocation and there were no re-revisions for aseptic loosening. The mean EuroQol EQ-5D description scores and health thermometer scores were 0.69 (0.51 to 0.89) and 79 (54 to 95), respectively. With an end-point of definite or probable loosening, the probability of survival at 12 years was 93.9% and 95.6% for the acetabular and femoral components, respectively. Overall survival at 12 years, with removal or further revision of either component for any reason as the end-point, was 92.3%. Our study supports the continued use of this arthroplasty and documents the durability of hydroxyapatite-ceramic-coated components.
We randomised 62 knees to receive either cemented or cementless versions of the Oxford unicompartmental knee replacement. The implants used in both arms of the study were similar, except that the cementless components were coated with porous titanium and hydroxyapatite. The tibial interfaces were studied with fluoroscopically-aligned radiographs. At one year there was no difference in clinical outcome between the two groups. Narrow radiolucent lines were seen at the bone-implant interfaces in 75% of cemented tibial components. These were partial in 43%, and complete in 32%. In the cementless implants, partial radiolucencies were seen in 7% and complete radiolucencies in none. These differences are statistically significant (p <
0.0001) and imply satisfactory bone ingrowth into the cementless implants.
We compared the clinical and radiographic results
of total ankle replacement (TAR) performed in non-diabetic and diabetic
patients. We identified 173 patients who underwent unilateral TAR
between 2004 and 2011 with a minimum of two years’ follow-up. There
were 88 male (50.9%) and 85 female (49.1%) patients with a mean
age of 66 years ( The mean AOS and AOFAS scores were significantly better in the
non-diabetic group (p = 0.018 and p = 0.038, respectively). In all,
nine TARs (21%) in the diabetic group had clinical failure at a
mean follow-up of five years (24 to 109), which was significantly
higher than the rate of failure of 15 (11.6%) in the non-diabetic
group (p = 0.004). The uncontrolled diabetic subgroup had a significantly
poorer outcome than the non-diabetic group (p = 0.02), and a higher
rate of delayed wound healing. The incidence of early-onset osteolysis was higher in the diabetic
group than in the non-diabetic group (p = 0.02). These results suggest
that diabetes mellitus, especially with poor glycaemic control,
negatively affects the short- to mid-term outcome after TAR. Cite this article:
Between 2002 and 2008, 130 consecutive ankles were replaced with an hydroxyapatite (HA) and titanium-HA-coated Ankle Evolutive System total ankle prosthesis. Plain radiographs were analysed by two independent observers. Osteolytic lesions were classified by their size and location, with cavities >
10 mm in diameter considered to be ‘marked’. CT scanning was undertaken in all patients with marked osteolysis seen on the plain radiographs. Osteolytic lesions were seen on the plain films in 48 (37%) and marked lesions in 27 (21%) ankles. The risk for osteolysis was found to be 3.1 (95% confidence interval 1.6 to 5.9) times higher with implants with Ti-HA porous coating. Care should be taken with ankle arthroplasty until more is known about the reasons for these severe osteolyses.
We carried out a prospective study to assess the clinical outcome, complications and survival of the NexGen Legacy posterior-stabilised-Flex total knee replacement (TKR) in a consecutive series of 278 knees between May 2003 and February 2005. Mean follow-up for 259 TKRs (98.2%) was 3.8 years (3.0 to 4.8). Annual follow-up showed improvement in the Knee Society scores (paired This relatively large study indicates that the legacy posterior stabilised-Flex design provides excellent short-term outcome but warrants ongoing evaluation to confirm the long-term durability and functioning of the implant.
The strain on clinic and surgeon resources resulting
from a rise in demand for total knee replacement (TKR) requires reconsideration
of when and how often patients need to be seen for follow-up. Surgeons
will otherwise require increased paramedical staff or need to limit
the number of TKRs they undertake. We reviewed the outcome data
of 16 414 primary TKRs undertaken at our centre to determine the
time to re-operation for any reason and for specific failure mechanisms.
Peak risk years for failure were determined by comparing the conditional
probability of failure, the number of failures divided by the total
number of TKRs cases, for each year. The median times to failure
for the most common failure mechanisms were 4.9 years (interquartile
range (IQR) 1.7 to 10.7) for femoral and tibial loosening, 1.9 years
(IQR 0.8 to 3.9) for infection, 3.1 years (IQR 1.6 to 5.5) for tibial
collapse and 5.6 years (IQR 3.4 to 9.3) for instability. The median
time to failure for all revisions was 3.3 years (IQR 1.2 to 8.5),
with an overall revision rate of 1.7% (n = 282). Results from our
patient population suggest that patients be seen for follow-up at
six months, one year, three years, eight years, 12 years, and every
five years thereafter. Patients with higher pain in the early post-operative
period or high body mass index (≥ 41 kg/m2) should be
monitored more closely. Cite this article:
The technique of femoral cement-in-cement revision
is well established, but there are no previous series reporting its
use on the acetabular side at the time of revision total hip replacement.
We describe the technique and report the outcome of 60 consecutive
acetabular cement-in-cement revisions in 59 patients at a mean follow-up
of 8.5 years (5 to 12). All had a radiologically and clinically
well-fixed acetabular cement mantle at the time of revision. During
the follow-up 29 patients died, but no hips were lost to follow-up.
The two most common indications for acetabular revision were recurrent
dislocation (46, 77%) and to complement femoral revision (12, 20%). Of the 60 hips, there were two cases of aseptic loosening of
the acetabular component (3.3%) requiring re-revision. No other
hip was clinically or radiologically loose (96.7%) at the latest
follow-up. One hip was re-revised for infection, four for recurrent
dislocation and one for disarticulation of a constrained component.
At five years the Kaplan-Meier survival rate was 100% for aseptic
loosening and 92.2% (95% CI 84.8 to 99.6), with revision for any cause
as the endpoint. These results support the use of cement-in-cement revision on
the acetabular side in appropriate cases. Theoretical advantages
include preservation of bone stock, reduced operating time, reduced
risk of complications and durable fixation.
In a retrospective study we compared 32 HINTEGRA
total ankle replacements (TARs) and 35 Mobility TARs performed between
July 2005 and May 2010, with a minimum follow-up of two years. The
mean follow-up for the HINTEGRA group was 53 months (24 to 76) and
for the Mobility group was 34 months (24 to 45). All procedures
were performed by a single surgeon. There was no significant difference between the two groups with
regard to the mean AOFAS score, visual analogue score for pain or
range of movement of the ankle at the latest follow-up. Most radiological
measurements did not differ significantly between the two groups.
However, the most common grade of heterotopic ossification (HO)
was grade 3 in the HINTEGRA group (10 of 13 TARs, 76.9%) and grade
2 in the Mobility group (four of seven TARs, 57.1%) (p = 0.025).
Although HO was more frequent in the HINTEGRA group (40.6%) than
in the Mobility group (20.0%), this was not statistically significant
(p = 0.065).The difference in peri-operative complications between
the two groups was not significant, but intra-operative medial malleolar
fractures occurred in four (11.4%) in the Mobility group; four (12.5%)
in the HINTEGRA group and one TAR (2.9%) in the Mobility group failed
(p = 0.185). Cite this article:
We examined the effects of previous resection of the radial head and synovectomy on the outcome of subsequent total elbow arthroplasty in patients with rheumatoid arthritis. Fifteen elbows with a history of resection and synovectomy were compared with a control group of patients who had elbow arthroplasty with an implant of the same design. The mean age in both groups was 63 years. In the study group, resection of the radial head and synovectomy had been undertaken at a mean of 8.9 years before arthroplasty. The mean radiological follow-up for the 13 available patients in the study group was 5.89 years (0.3 to 11.0) and in the control group was 6.6 years (2.2 to 12.6). There were no revisions in either group. The mean Mayo elbow performance score improved from 29 to 96 in the study group, with similar improvement in the control group (28 to 87). The study group had excellent results in 13 elbows and good results in two. The control group had excellent results in seven and good results in six. Our experience indicates that previous resection of the radial head and synovectomy are not associated with an increased rate of revision following subsequent arthroplasty of the elbow. However, there was a higher rate of complication in the study group compared with the control group.
In this prospective study a total of 80 consecutive
Chinese patients with Crowe type I or II developmental dysplasia of
the hip were randomly assigned for hip resurfacing arthroplasty
(HRA) or total hip replacement (THR). Three patients assigned to HRA were converted to THR, and three
HRA patients and two THR patients were lost to follow-up. This left
a total of 34 patients (37 hips) who underwent HRA and 38 (39 hips)
who underwent THR. The mean follow-up was 59.4 months (52 to 70)
in the HRA group and 60.6 months (50 to 72) in the THR group. There was
no failure of the prosthesis in either group. Flexion of the hip
was significantly better after HRA, but there was no difference
in the mean post-operative Harris hip scores between the groups.
The mean size of the acetabular component in the HRA group was significantly
larger than in the THR group (49.5 mm vs 46.1 mm, p = 0.001). There was
no difference in the mean abduction angle of the acetabular component
between the two groups. Although the patients in this series had risk factors for failure
after HRA, such as low body weight, small femoral heads and dysplasia,
the clinical results of resurfacing in those with Crowe type I or
II hip dysplasia were satisfactory. Patients in the HRA group had
a better range of movement, although neck-cup impingement was observed.
However, more acetabular bone was sacrificed in HRA patients, and
it is unclear whether this will have an adverse effect in the long
term.
The purpose of this study was to examine the effect of posterior
cruciate ligament (PCL) retention, PCL recession, and PCL excision
during cruciate-retaining total knee replacement. A total of 3018 anatomic graduated component total knee replacements
were examined; 1846 of these retained the PCL, 455 PCLs were partially
recessed, and in 717 the PCL was completely excised from the back
of the tibia.Objectives
Methods
Radiological changes and differences between cemented and uncemented components of Grammont reverse shoulder arthroplasties (DePuy) were analysed at a mean follow-up of 9.6 years (8 to 12). Of 122 reverse shoulder arthroplasties implanted in five shoulder centres between 1993 and 2000, a total of 68 (65 patients) were available for study. The indications for reversed shoulder arthroplasty were cuff tear arthropathy in 48 shoulders, revision of shoulder prostheses of various types in 11 and massive cuff tear in nine. The development of scapular notching, bony scapular spur formation, heterotopic ossification, glenoid and humeral radiolucencies, stem subsidence, radiological signs of stress shielding and resorption of the tuberosities were assessed on standardised true anteroposterior and axillary radiographs. A scapular notch was observed in 60 shoulders (88%) and was associated with the superolateral approach (p = 0.009). Glenoid radiolucency was present in 11 (16%), bony scapular spur and/or ossifications in 51 (75%), and subsidence of the stem and humeral radiolucency in more than three zones were present in three (8.8%) and in four (11.8%) of 34 cemented components, respectively, and in one (2.9%) and two (5.9%) of 34 uncemented components, respectively. Radiological signs of stress shielding were significantly more frequent with uncemented components (p <
0.001), as was resorption of the greater (p <
0.001) and lesser tuberosities (p = 0.009).
We describe the longer term clinical and radiological findings in a prospectively followed series of 49 rheumatoid patients (58 shoulders) who had undergone Neer II total shoulder replacement. The early and intermediate results have been published previously. At a mean follow-up of 19.8 years (16.5 to 23.8) 14 shoulders survived. Proximal migration of the humeral component was associated with progressive loosening of the glenoid and humeral components, but was independent of the state of the rotator cuff at the time of operation. Despite these changes the range of movement was preserved. Most patients had little or no pain in the shoulder, could sleep undisturbed and could attend to personal hygiene and grooming.
We have investigated the mid-term outcome of total shoulder replacement using a keeled cemented glenoid component and a modern cementing technique with regard to the causes of failure and loosening of the components. Between 1997 and 2003 we performed 96 total shoulder replacements on 88 patients, 24 men and 64 women with a mean age of 69.7 years (31 to 82). The minimum follow-up was five years and at the time of review 87 shoulders (77 patients) were examined at a mean follow-up of 89.1 months (60 to 127). Cumulative survival curves were generated with re-operations (accomplished and planned), survivorship of the proshesis, loosening of the glenoid (defined as tilt >
5° or subsidence >
5 mm), the presence of radiolucent lines and a Constant score of <
30 as the endpoints. There were two re-operations not involving revision of the implants and the survival rate of the prosthesis was 100.0% for the follow-up period, with an absolute Constant score of >
30 as the endpoint the survival rate was 98%. Radiological glenoid loosening was 9% after five years, and 33% after nine years. There was an incidence of 8% of radiolucent lines in more than three of six zones in the immediate post-operative period, of 37.0% after the first year which increased to 87.0% after nine years. There was no correlation between the score of Boileau and the total Constant score at the latest follow-up, but there was correlation between glenoid loosening and pain (p = 0.001). We found that total shoulder replacement had an excellent mid-term survivorship and clinical outcome. The surgical and cementing techniques were related to the decrease in radiolucent lines around the glenoid compared with earlier studies. One concern, however, was the fact that radiolucent lines increased over time and there was a rate of glenoid loosening of 9% after five years and 33% after nine years. This suggests that the design of the glenoid component, and the implantation and cementing techniques may need further improvement.
We systematically reviewed the peer-reviewed literature to relate the survival of hybrid metal-on-metal hip resurfacing arthroplasty devices to a National Institute of Clinical Excellence (NICE) benchmark for choosing a primary total hip replacement, which is a survival rate of 90% at a follow-up of ten years. A total of 29 articles (10 621 resurfaced hips) met the inclusion criteria. The mean follow-up ranged from 0.6 to 10.5 years and the survival of the implant ranged from 84% to 100%. Of the 10 621 hips, 370 were revised (3.5%), with aseptic loosening as the most frequent mode of failure. None of the hip resurfacing arthroplasty implants used to date met the full ten-year NICE benchmark of survival. A total of 13 studies showed satisfactory survival compared with the three-year NICE benchmark.
We analysed the outcome of the Coonrad-Morrey total elbow replacement used for fracture of the distal humerus in elderly patients with no evidence of inflammatory arthritis and compared the results for early One patient in the early group developed chronic regional pain syndrome and another type 4 aseptic loosening. Two elbows in the early group also showed type 1 radiological loosening. Two patients in the delayed group had an infection, two an ulnar nerve palsy, one developed heterotopic ossification and one type 4 aseptic loosening. Two elbows in this group also showed type 1 radiological loosening. The Kaplan-Meier survivorship analysis for the early and delayed treatment groups was 93% at 88 months and 76% at 84 months, respectively. No significant difference was found between the two groups.
We evaluated the use of a stemmed acetabular component in the treatment of severe acetabular deficiency during revision and complex primary total hip arthroplasty. There were 31 hips of which 24 were revisions (20 for aseptic loosening, four for infection) and the remainder were complex primary arthroplasties. At a mean follow-up of 10.7 years (6 to 12.8), no component had been revised for aseptic loosening; one patient had undergone a revision of the polyethylene liner for wear. There was one failure because of infection. At the latest follow-up, the cumulative survival rate for aseptic loosening, with revision being the end-point, was 100%; for radiographic loosening it was 92% and for infection and radiographic loosening it was 88%. These results justify the continued use of this stemmed component for the reconstruction of severe acetabular deficiency.