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

Aims

Custom-made partial pelvis replacements (PPRs) are increasingly used in the reconstruction of large acetabular defects and have mainly been designed using a triflange approach, requiring extensive soft-tissue dissection. The monoflange design, where primary intramedullary fixation within the ilium combined with a monoflange for rotational stability, was anticipated to overcome this obstacle. The aim of this study was to evaluate the design with regard to functional outcome, complications, and acetabular reconstruction.

Aims. This study compares the re-revision rate and mortality following septic and aseptic revision hip arthroplasty (rTHA) in registry data, and compares the outcomes to previously reported data. Methods. This is an observational cohort study using data from the German Arthroplasty Registry (EPRD). A total of 17,842 rTHAs were included, and the rates and cumulative incidence of hip re-revision and mortality following septic and aseptic rTHA were analyzed with seven-year follow-up. The Kaplan-Meier estimates were used to determine the re-revision rate and cumulative probability of mortality following rTHA. Results. The re-revision rate within one year after septic rTHA was 30%, and after seven years was 34%. The cumulative mortality within the first year after septic rTHA was 14%, and within seven years was 40%. After multiple previous hip revisions, the re-revision rate rose to over 40% in septic rTHA. The first six months were identified as the most critical period for the re-revision for septic rTHA. Conclusion. The risk re-revision and reinfection after septic rTHA was almost four times higher, as recorded in the ERPD, when compared to previous meta-analysis. We conclude that it is currently not possible to assume the data from single studies and meta-analysis reflects the outcomes in the ‘real world’. Data presented in meta-analyses and from specialist single-centre studies do not reflect the generality of outcomes as recorded in the ERPD. The highest re-revision rates and mortality are seen in the first six months postoperatively. The optimization of perioperative care through the development of a network of high-volume specialist hospitals is likely to lead to improved outcomes for patients undergoing rTHA, especially if associated with infection. Cite this article: Bone Joint J 2024;106-B(6):565–572

Aims. Revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) are complex procedures with higher rates of re-revision, complications, and mortality compared to primary TKA and THA. We report the effects of the establishment of a revision arthroplasty network (the East Midlands Specialist Orthopaedic Network; EMSON) on outcomes of rTKA and rTHA. Methods. The revision arthroplasty network was established in January 2015 and covered five hospitals in the Nottinghamshire and Lincolnshire areas of the East Midlands of England. This comprises a collaborative weekly multidisciplinary meeting where upcoming rTKA and rTHA procedures are discussed, and a plan agreed. Using the Hospital Episode Statistics database, revision procedures carried out between April 2011 and March 2018 (allowing two-year follow-up) from the five network hospitals were compared to all other hospitals in England. Age, sex, and mean Hospital Frailty Risk scores were used as covariates. The primary outcome was re-revision surgery within one year of the index revision. Secondary outcomes were re-revision surgery within two years, any complication within one and two years, and median length of hospital stay. Results. A total of 57,621 rTHA and 33,828 rTKA procedures were performed across England, of which 1,485 (2.6%) and 1,028 (3.0%), respectively, were conducted within the network. Re-revision rates within one year for rTHA were 7.3% and 6.0%, and for rTKA were 11.6% and 7.4% pre- and postintervention, respectively, within the network. This compares to a pre-to-post change from 7.4% to 6.8% for rTHA and from 11.7% to 9.7% for rTKA for the rest of England. In comparative interrupted time-series analysis for rTKA there was a significant immediate improvement in one-year re-revision rates for the revision network compared to the rest of England (p = 0.024), but no significant change for rTHA (p = 0.504). For the secondary outcomes studied, there was a significant improvement in trend for one- and two-year complication rates for rTHA for the revision network compared to the rest of England. Conclusion. Re-revision rates for rTKA and complication rates for rTHA improved significantly at one and two years with the introduction of a revision arthroplasty network, when compared to the rest of England. Most of the outcomes studied improved to a greater extent in the network hospitals compared to the rest of England when comparing the pre- and postintervention periods. Cite this article: Bone Joint J 2023;105-B(6):641–648

Aims. Custom triflange acetabular components (CTACs) play an important role in reconstructive orthopaedic surgery, particularly in revision total hip arthroplasty (rTHA) and pelvic tumour resection procedures. Accurate CTAC positioning is essential to successful surgical outcomes. While prior studies have explored CTAC positioning in rTHA, research focusing on tumour cases and implant flange positioning precision remains limited. Additionally, the impact of intraoperative navigation on positioning accuracy warrants further investigation. This study assesses CTAC positioning accuracy in tumour resection and rTHA cases, focusing on the differences between preoperative planning and postoperative implant positions. Methods. A multicentre observational cohort study in Australia between February 2017 and March 2021 included consecutive patients undergoing acetabular reconstruction with CTACs in rTHA (Paprosky 3A/3B defects) or tumour resection (including Enneking P2 peri-acetabular area). Of 103 eligible patients (104 hips), 34 patients (35 hips) were analyzed. Results. CTAC positioning was generally accurate, with minor deviations in cup inclination (mean 2.7°; SD 2.84°), anteversion (mean 3.6°; SD 5.04°), and rotation (mean 2.1°; SD 2.47°). Deviation of the hip centre of rotation (COR) showed a mean vector length of 5.9 mm (SD 7.24). Flange positions showed small deviations, with the ischial flange exhibiting the largest deviation (mean vector length of 7.0 mm; SD 8.65). Overall, 83% of the implants were accurately positioned, with 17% exceeding malpositioning thresholds. CTACs used in tumour resections exhibited higher positioning accuracy than rTHA cases, with significant differences in inclination (1.5° for tumour vs 3.4° for rTHA) and rotation (1.3° for tumour vs 2.4° for rTHA). The use of intraoperative navigation appeared to enhance positioning accuracy, but this did not reach statistical significance. Conclusion. This study demonstrates favourable CTAC positioning accuracy, with potential for improved accuracy through intraoperative navigation. Further research is needed to understand the implications of positioning accuracy on implant performance and long-term survival. Cite this article: Bone Jt Open 2024;5(4):260–268

Aims. The aims of this systematic review were to assess the learning curve of semi-active robotic arm-assisted total hip arthroplasty (rTHA), and to compare the accuracy, patient-reported functional outcomes, complications, and survivorship between rTHA and manual total hip arthroplasty (mTHA). Methods. Searches of PubMed, Medline, and Google Scholar were performed in April 2020 in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Search terms included “robotic”, “hip”, and “arthroplasty”. The criteria for inclusion were published clinical research articles reporting the learning curve for rTHA (robotic arm-assisted only) and those comparing the implantation accuracy, functional outcomes, survivorship, or complications with mTHA. Results. There were 501 articles initially identified from databases and references. Following full text screening, 17 articles that satisfied the inclusion criteria were included. Four studies reported the learning curve of rTHA, 13 studies reported on implant positioning, five on functional outcomes, ten on complications, and four on survivorship. The meta-analysis showed a significantly greater number of cases of acetabular component placement in the safe zone compared with the mTHA group (95% confidence interval (CI) 4.10 to 7.94; p < 0.001) and that rTHA resulted in a significantly better Harris Hip Score compared to mTHA in the short- to mid-term follow-up (95% CI 0.46 to 5.64; p = 0.020). However, there was no difference in infection rates, dislocation rates, overall complication rates, and survival rates at short-term follow-up. Conclusion. The learning curve of rTHA was between 12 and 35 cases, which was dependent on the assessment goal, such as operating time, accuracy, and team working. Robotic arm-assisted total hip arthroplasty was associated with improved accuracy of component positioning and functional outcome, however no difference in complication rates or survival were observed at short- to mid-term follow-up. Overall, there remains an absence of high-quality level I evidence and cost analysis comparing rTHA and mTHA. Cite this article: Bone Joint J 2021;103-B(6):1009–1020

Aims. The primary aim of this study was to compare the hip-specific functional outcome of robotic assisted total hip arthroplasty (rTHA) with manual total hip arthroplasty (mTHA) in patients with osteoarthritis (OA). Secondary aims were to compare general health improvement, patient satisfaction, and radiological component position and restoration of leg length between rTHA and mTHA. Methods. A total of 40 patients undergoing rTHA were propensity score matched to 80 patients undergoing mTHA for OA. Patients were matched for age, sex, and preoperative function. The Oxford Hip Score (OHS), Forgotten Joint Score (FJS), and EuroQol five-dimension questionnaire (EQ-5D) were collected pre- and postoperatively (mean 10 months (SD 2.2) in rTHA group and 12 months (SD 0.3) in mTHA group). In addition, patient satisfaction was collected postoperatively. Component accuracy was assessed using Lewinnek and Callanan safe zones, and restoration of leg length were assessed radiologically. Results. There were no significant differences in the preoperative demographics (p ≥ 0.781) or function (p ≥ 0.383) between the groups. The postoperative OHS (difference 2.5, 95% confidence interval (CI) 0.1 to 4.8; p = 0.038) and FJS (difference 21.1, 95% CI 10.7 to 31.5; p < 0.001) were significantly greater in the rTHA group when compared with the mTHA group. However, only the FJS was clinically significantly greater. There was no difference in the postoperative EQ-5D (difference 0.017, 95% CI -0.042 to 0.077; p = 0.562) between the two groups. No patients were dissatisfied in the rTHA group whereas six were dissatisfied in the mTHA group, but this was not significant (p = 0.176). rTHA was associated with an overall greater rate of component positioning in a safe zone (p ≤ 0.003) and restoration of leg length (p < 0.001). Conclusion. Patients undergoing rTHA had a greater hip-specific functional outcome when compared to mTHA, which may be related to improved component positioning and restoration of leg length. However, there was no difference in their postoperative generic health or rate of satisfaction. Cite this article: Bone Joint Res 2021;10(1):22–30

Aims. The burden of revision total hip arthroplasty (rTHA) continues to grow. The surgery is complex and associated with significant costs. Regional rTHA networks have been proposed to improve outcomes and to reduce re-revisions, and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for a rTHA service, and to assess the financial impact of case complexity at a tertiary referral centre within the NHS. Methods. A retrospective analysis of all revision hip procedures was performed at this centre over two consecutive financial years (2018 to 2020). Cases were classified according to the Revision Hip Complexity Classification (RHCC) and whether they were infected or non-infected. Patients with an American Society of Anesthesiologists (ASA) grade ≥ III or BMI ≥ 40 kg/m. 2. are considered “high risk” by the RHCC. Costs were calculated using the Patient Level Information and Costing System (PLICS), and remuneration based on Healthcare Resource Groups (HRG) data. The primary outcome was the financial difference between tariff and cost per patient episode. Results. In all, 199 revision episodes were identified in 168 patients: 25 (13%) least complex revisions (H1); 110 (55%) complex revisions (H2); and 64 (32%) most complex revisions (H3). Of the 199, 76 cases (38%) were due to infection, and 78 patients (39%) were “high risk”. Median length of stay increased significantly with case complexity from four days to six to eight days (p = 0.006) and for revisions performed for infection (9 days vs 5 days; p < 0.001). Cost per episode increased significantly between complexity groups (p < 0.001) and for infected revisions (p < 0.001). All groups demonstrated a mean deficit but this significantly increased with revision complexity (£97, £1,050, and £2,887 per case; p = 0.006) and for infected failure (£2,629 vs £635; p = 0.032). The total deficit to the NHS Trust over two years was £512,202. Conclusion. Current NHS reimbursement for rTHA is inadequate and should be more closely aligned to complexity. An increase in the most complex rTHAs at major revision centres will likely place a greater financial burden on these units. Cite this article: Bone Jt Open 2023;4(8):559–566

Aims. The aim of this study was to explore the relationship between reason for revision total hip arthroplasty (rTHA) and outcomes in terms of patient-reported outcome measures (PROMs). Methods. We reviewed a prospective cohort of 647 patients undergoing full or partial rTHA at a single high-volume centre with a minimum of two years’ follow-up. The reasons for revision were classified as: infection; aseptic loosening; dislocation; structural failure; and painful THA for other reasons. PROMs (modified Oxford Hip Score (mOHS), EuroQol five-dimension three-level health questionnaire (EQ-5D-3L) score, and visual analogue scales for pain during rest and activity), complication rates, and failure rates were compared among the groups. Results. The indication for revision influenced PROMs improvement over time. This finding mainly reflected preoperative differences between the groups, but diminished between the first and second postoperative years. Preoperatively, patients revised due to infection and aseptic loosening had a lower mOHS than patients with other indications for revision. Pain scores at baseline were highest in patients being revised for dislocation. Infection and aseptic loosening groups showed marked changes over time in both mOHS and EQ-5D-3L. Overall complications and re-revision rates were 35.4% and 9.7% respectively, with no differences between the groups (p = 0.351 and p = 0.470, respectively). Conclusion. Good outcomes were generally obtained regardless of the reason for revision, with patients having the poorest preoperative scores exhibiting the greatest improvement in PROMs. Furthermore, overall complication and reoperation rates were in line with previous reports and did not differ between different indications for rTHA. Cite this article: Bone Joint J 2022;104-B(7):859–866

The aim of this study was to measure the effect of hospital case volume on the survival of revision total hip arthroplasty (RTHA). This is a retrospective analysis of Scottish Arthroplasty Project data, a nationwide audit which prospectively collects data on all arthroplasty procedures performed in Scotland. The primary outcome was RTHA survival at ten years. The primary explanatory variable was the effect of hospital case volume per year on RTHA survival. Kaplan-Meier survival curves were plotted with 95% confidence intervals (CIs) to determine the lifespan of RTHA. Multivariate Cox proportional hazards were used to estimate relative revision risks over time. Hazard ratios (HRs) were reported with 95% CI, and p-value < 0.05 was considered statistically significant. From 1999 to 2019, 13,020 patients underwent RTHA surgery in Scotland (median age at RTHA 70 years (interquartile range (IQR) 62 to 77)). In all, 5,721 (43.9%) were female, and 1065 (8.2%) were treated for infection. 714 (5.5%) underwent a second revision procedure. Co-morbidity, younger age at index revision, and positive infection status were associated with need for re-revision (p<0.001). The ten-year survival estimate for RTHA was 93.3% (95% CI 92.8 to 93.8). Adjusting for sex, age, surgeon volume, and indication for revision, high hospital case volume was not significantly associated with lower risk of re-revision (HR1, 95% CI 1.00 to 1.00, p 0.073)). The majority of RTHA in Scotland survive up to ten years. Increasing yearly hospital case volume cases is not independently associated with a significant risk reduction of re-revision

Aims. The aim of this study was to examine the implant accuracy of custom-made partial pelvis replacements (PPRs) in revision total hip arthroplasty (rTHA). Custom-made implants offer an option to achieve a reconstruction in cases with severe acetabular bone loss. By analyzing implant deviation in CT and radiograph imaging and correlating early clinical complications, we aimed to optimize the usage of custom-made implants. Methods. A consecutive series of 45 (2014 to 2019) PPRs for Paprosky III defects at rTHA were analyzed comparing the preoperative planning CT scans used to manufacture the implants with postoperative CT scans and radiographs. The anteversion (AV), inclination (IC), deviation from the preoperatively planned implant position, and deviation of the centre of rotation (COR) were explored. Early postoperative complications were recorded, and factors for malpositioning were sought. The mean follow-up was 30 months (SD 19; 6 to 74), with four patients lost to follow-up. Results. Mean CT defined discrepancy (Δ) between planned and achieved AV and IC was 4.5° (SD 3°; 0° to 12°) and 4° (SD 3.5°; 1° to 12°), respectively. Malpositioning (Δ > 10°) occurred in five hips (10.6%). Native COR reconstruction was planned in 42 cases (93%), and the mean 3D deviation vector was 15.5 mm (SD 8.5; 4 to 35). There was no significant influence in malpositioning found for femoral stem retention, surgical approach, or fixation method. Conclusion. At short-term follow-up, we found that PPR offers a viable solution for rTHA in cases with massive acetabular bone loss, as highly accurate positioning can be accomplished with meticulous planning, achieving anatomical reconstruction. Accuracy of achieved placement contributed to reduced complications with no injury to vital structures by screw fixation. Cite this article: Bone Joint J 2022;104-B(10):1110–1117

Instability and aseptic loosening are the two main complications after revision total hip arthroplasty (rTHA). Dual-mobility (DM) cups were shown to counteract implant instability during rTHA. To our knowledge, no study evaluated the 10-year outcomes of rTHA using DM cups, cemented into a metal reinforcement ring, in cases of severe acetabular bone loss. We hypothesized that using a DM cup cemented into a metal ring is a reliable technique for rTHA at 10 years, with few revisions for acetabular loosening and/or instability. This is a retrospective study of 77 rTHA cases with severe acetabular bone loss (Paprosky ≥ 2C) treated exclusively with a DM cup (NOVAE STICK; SERF, DÉCINES-CHARPIEU, FRANCE) cemented into a cage (Kerboull cross, Burch-Schneider, or ARM rings). Clinical scores and radiological assessments were performed preoperatively and at the last follow-up. The main endpoints were revision surgery for aseptic loosening or recurring dislocation. With a mean follow-up of 10.7 years [2.1-16.2], 3 patients were reoperated because of aseptic acetabular loosening (3.9%) at 9.6 years [7-12]. Seven patients (9.45%) dislocated their hip implant, only 1 suffered from chronic instability (1.3%). Cup survivorship was 96.1% at 10 years. No sign of progressive radiolucent lines were found and bone graft integration was satisfactory for 91% of the patients. The use of a DM cup cemented into a metal ring during rTHA with complex acetabular bone loss was associated with low revision rates for either acetabular loosening or chronic instability at 10 years. That's why we also recommend DM cup for all high risk of dislocation situations

Studies and meta-analyses worldwide show an increased use of one-stage revisions for treating periprosthetic hip infections, often yielding comparable or better outcomes than two-stage revisions. However, it remains unclear if these successful results can be consistently achieved nationwide besides large centers. This observational cohort study used data from the German Arthroplasty Registry (EPRD) to compare the mortality and re-revision rates between one-stage (n=8183) and two-stage (n=657) first-time revision total hip arthroplasty (RTHA). Kaplan-Meier estimates were applied to evaluate the re-revision rate and cumulative mortality for RTHA. There was a significant difference in mortality between one-stage and two-stage RTHA (p=0.02). One-year post-surgery, the mortality rate was 9.4% for one-stage revisions and 5.5% for two-stage revisions. At the five-year follow-up, the mortality rate for one-stage revisions was 25.5%, compared to 20.0% for two-stage revisions. No significant differences (p=0.30) were found in re-revision rates between one-stage and two-stage revisions after one year (one-stage 16.5% vs. two-stage 13.5%) or five years (one-stage 21.6% vs. two-stage 20.8%). For multiple revisions, the mortality differences were even larger (p<0.001), with a one-year mortality rate of 12.8% for one-stage RTHA and 5.7% for two-stage RTHA. Despite the excellent results of one-stage RTHA in the literature from individual large centers, it shows a significantly higher mortality rate with equal re-revision rate compared to two-stage revision in the nationwide care besides large centers. Significant differences can already be seen within the first year, indicating an increased perioperative mortality for one-stage revision, which might be explained by longer surgery duration, blood-loss and patient selection or maybe a lack of experience concerning proper surgical debridement for one-stage revision. This illustrates the need to establish centers for joint-revision surgery that provide interdisciplinary care and high case numbers to improve perioperative outcomes

Reported incidence of blood transfusion following primary and revision total hip arthroplasty (pTHA, rTHA) has decreased considerably compared to historical rates. However, it is not known if further adoption of techniques to limit transfusions has resulted in further reduction on a large scale. The purpose of this study was to assess recent trends in blood transfusions and contemporary risk factors for transfusions using a large, national database. The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing pTHA and rTHA between 2011 to 2019. pTHA for fracture, infection, tumor, and bilateral procedures were excluded. Only aseptic rTHA were included. Annual incidence of transfusions and proportion of patients with optimized preoperative hematocrit (HCT) (defined as ≥33%) were assessed. Risk factors for transfusion were evaluated with 2018 and 2019 data using multivariate analyses. 234,352 pTHA and 16,322 rTHA were included. Transfusion following pTHA decreased from 21.4% in 2011 to 2.5% in 2019 and from 33.5% in 2011 to 12.0% in 2019 for rTHA (p<0.0001). Patients with optimized HCT increased for pTHA (96.7% in 2011 vs 98.1% in 2019, p<0.0001) and did not change for rTHA (91.5% in 2011 vs 91.6% in 2019, p=0.27). Decreased HCT was most strongly associated with transfusions, with each three-point change corresponding to odds ratio of 1.90 and 1.78 for pTHA and rTHA, respectively. Increased age, female sex, history of bleeding disorders or preoperative transfusion, ASA score ≥3, non-spinal anesthesia, and longer operative times were also associated with increased odds for transfusion. Incidence of blood transfusion has continued to decrease following pTHA and rTHA. Despite care improvements, transfusions still occur in certain high-risk patients. While transfusion in pTHA may have reached the lower asymptote, further reduction in rTHA may be possible through further improvements in preoperative optimization and surgical technique

Aims. The aim of this study was to assess the incidence the microbiological spectrum and clinical outcome of hip and knee revision arthroplasties with unexpected-positive-intraoperative-cultures (UPIC) at a single center with minimum follow up of 2 years. Methods. We retrospectively analyzed our prospectively maintained institutional arthroplasty registry. Between 2011 and 2020 we performed presumably aseptic rTHA (n=939) and rTKA (n= 1,058). Clinical outcome, re-revision rates and causes as well as the microbiological spectrum were evaluated. Results. In total, 219/939 (23.3%) rTHA and 114/ 1,058 (10.8%) rTKA had a UPIC (p<0.001). Single positive intraoperative cultures were found in 173/219 (78.9%) in rTHA and 99/114 (86.8%) in rTKA, whereas 46/219 (21.0%) rTHA and 15/114 (13.2%) rTKA had positive results in ≥2 intraoperative cultures. A total of 390 microorganisms were found among the 333 cases. Staphylococcus epidermidis 30.9%, CoNS (21.9%), Cutibacterium acnes 21.1%, and Bacillus spp. 7.3% were the most common microorganisms. Overall, detected microorganisms showed high sensitivity to daptomycin (96.6%), vancomycin (97.3%) and linezolid (98.0%). After a minimum follow up of 2 years (rTHA 1,470 (735; 3,738) days; rTKA 1,474 (749; 4,055) days). During the 2-year follow-up, 8 patients died and 5 were lost to follow-up. There were 54/219 (24.7%) re-revision in rTHa and 20/114 (17.5%) in rTKA. Overall, there were 23 (10.5%) septic re-rTHA and 9 (7.9%) septic re-rTKA as well as 31 (14.2%) aseptic re-rTHA and 11 (9.6%) aseptic re-rTKA. Patients with previous septic revisions bevor UPIC procedure showed a significant higher risk for septic re-revision (p<0.05). Moreover, there were less septic re-revisions after single culture positive UPIC (rTHA: 16/173 (9.2%); rTKA 6/99 (6.1%)) compared to ≥2 positive intraoperative cultures UPIC (rTHA: 7/46 (15.2%); rTKA 3/15 (20.0%)). The most common reason for re-revision in the rTHA-group was aseptic loosening of the cup (34.2%) or of the stem (23.3%), dislocation (18.3%) and periprosthetic-fractures (7.8%). In the rTKA-group it was aseptic loosening (40.4%), instability (24.6%) and secondary patella resurfacing (7.9%). There was a higher septic re-revision rate in consecutive revisions than in planned revisions 17.3% vs. 8.5% in the rTHA-group and 14.3% vs. 7.5% in the rTKA-group, p<0.001. Conclusion. UPICs are common in rTJA. The rate was higher in hips which may partly explained by the easier pre op joint aspiration in the knee. UPIC may lead to an increase in subsequent re-revisions

Revision total hip arthroplasty (rTHA) can be complex and associated with significant cost, with an increasing burden within the UK and globally. Regional rTHA networks have been proposed aiming to improve outcomes, reduce re-revisions and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for the rTHA service and to assess the financial impact of case complexity at a tertiary referral centre within the NHS. A retrospective analysis of all revision hip procedures was performed over two consecutive financial years (2018–2020). Cases were classified according to the Revision Hip Complexity Classification (RHCC) and by mode of failure; infected or non-infected. Patients of ASA grade of 3 or greater or BMI over 40 are considered “high-risk” by the RHCC. Costs were calculated using PLICS and remuneration based on the HRG data. The primary outcome was the financial difference between tariff and cost per episode per patient. Comparisons between groups were analysed using analysis of variance and two-tailed unpaired t-test. 199 revision episodes were identified in 168 patients: 25 (13%) least complex revisions (H1), 110 (55%) complex revisions (H2) and 64 (32%) most complex revisions (H3). 76 (38%) cases were due to infection. 78 (39%) of patients were in the “high-risk” group. Median length of stay increased with case complexity from 4, to 6 to 8 days (p=0.17) and significantly for revisions performed for infection (9 vs 5 days; p=0.01). Cost per episode increased significantly between complexity groups (p=0.0002) and for infected revisions (p=0.003). All groups demonstrated a mean deficit, but this significantly increased with revision complexity (£301, £1,820 and £4,757 per case; p=0.02) and for infected failure (£4,023 vs £1,679; p=0.02). The total deficit to the trust for the two-years was £512,202. Current NHS reimbursement for rTHA is inadequate and should be more closely aligned to complexity. An increase in the most complex rTHA at major revision centres (MRC) will likely place a greater financial burden on these units

Aim of this study was to identify reoperation rates in patients with short oblique and transverse fractures around a well fixed cemented polished taper slip stem and to determine any associations with treatment failure. Retrospective cohort study of 31 patients with AO transverse or short oblique Vancouver B1 PFFs around THA (total hip arthroplasty) cemented taper slip stems: 12 male (39%); mean age 74±11.9 (range 44–91); mean BMI 28.5±1.4 (range 16–48); and median ASA 3. Patient journeys were assessed, re-interventions reviewed. The primary outcome measure was reoperation. Time from primary THA to fracture was 11.3±7.8yrs (0.5–26yrs). Primary surgical management was fixation in 27/31 and rTHA (revision total hip arthroplasty) in 4/31. 10 of 31 (32%) patients required reoperation, 9 within 2 years of fracture: 1 following rTHA and 8 following ORIF. The commonest mode of failure was non-union (n=6). No significant associations with reoperation requirement were identified. Kaplan-Meier free from reoperation was 67.4% (49.8–85.0 95% CI) at 2 years and this was unaffected by initial management with ORIF or rTHA (Log rank 0.898). Of those reoperated, 6/10 required multiple reoperations to obtain either bony union or a stable revision construct and 13% ultimately required proximal femoral endoprostheses. The relative risk of 1 year mortality was 1.6 (0.25 to 10.1 95%CI) among patients who required reoperation compared to those who did not. These are difficult fractures to manage, should not be underestimated and patients should be counselled that there is a 30% risk of reoperation and 20% of requiring multiple reoperations

Aims. Advances in surgical technique and implant design may influence the incidence and mechanism of failure resulting in revision total hip arthroplasty (rTHA). The purpose of the current study was to characterize aetiologies requiring rTHA, and to determine whether temporal changes existed in these aetiologies over a ten-year period. Methods. All rTHAs performed at a single institution from 2009 to 2019 were identified. Demographic information and mode of implant failure was obtained for all patients. Data for rTHA were stratified into two time periods to assess for temporal changes: 2009 to 2013, and 2014 to 2019. Operative reports, radiological imaging, and current procedural terminology (CPT) codes were cross-checked to ensure the accurate classification of revision aetiology for each patient. Results. In all, 2,924 patients with a mean age of 64.6 years (17 to 96) were identified. There were 1,563 (53.5%) female patients, and the majority of patients were Caucasian (n = 2,362, 80.8%). The three most frequent rTHA aetiologies were infection (27.2%), aseptic loosening (25.2%), and wear (15.2%). The frequency of rTHA for adverse local tissue reaction (ALTR) was significantly greater from 2014 to 2019 (4.7% vs 10.0%; p < 0.001), while the frequency of aseptic loosening was significantly greater from 2009 to 2013 (28.6% vs 21.9%; p < 0.001). Conclusion. Periprosthetic joint infection was the most common cause for rTHA in the current cohort of patients. Complications associated with ALTR necessitating rTHA was more frequent between 2014 to 2019, while aseptic loosening necessitating rTHA was significantly more frequent between 2009 to 2013. Optimizing protocols for prevention and management of infection and ALTR after THA may help to avoid additional financial burden to institutions and healthcare systems. Cite this article: Bone Joint Open 2020;2(1):16–21

Revision total hip arthroplasty (rTHA) in the presence of femoral defects can be technically challenging. Reconstruction with long stems is widely accepted as the standard. However long stems can be difficult to insert and can compromise distal bone stock for future revisions. The aims of this study were to identify whether there was a difference in survival and outcomes following rTHA using a long versus standard or short femoral stem. A comprehensive systematic review was performed according to PRISMA guidelines using the MEDLINE, EMBASE, Chochrane Library and Web of Science databases. Inclusion criteria were (i) adult patients >18 years; (ii) randomised controlled trials, joint registry, or cohort studies; (iii) single or staged rTHA for Paprosky 1–3B femoral defects. Exclusion criteria were (i) mixed reporting without subgroup analysis for revision stem length; (ii) ex-vivo studies. Screening for eligibility and assessment of studies was performed by the authors. Out of 341 records, 9 studies met criteria for analysis (including 1 study utilising joint registry data and 1 randomised controlled trial). Across studies there were 3102 rTHAs performed in 2982 patients with a mean age of 67.4 years and a male: female ratio of 0.93. Revision prostheses were long-stemmed in 1727 cases and short or standard in 1375 cases with a mean follow up of 5 years (range, 0-15 years). On subgroup analysis the use of a long cemented stem compared to a long cementless prosthesis was associated with fewer complications and periprosthetic fracture in older patients. Survivorship was 95% with short stems compared to 84% with long stems at 5 years. Moderate quality evidence suggests that in rTHA with Paprosky type 1-3B femoral defects, the use of a short or standard stem can achieve comparable outcomes to long stems with fewer significant complications and revisions. Using a shorter stem may yield a more straightforward surgical technique and can preserve distal bone stock for future revision

Sound management decisions are critical to outcomes in revision arthroplasty. Aiming to improve outcomes, revision networks facilitate speciality trained, high volume surgeons, share experience and best practice, contributing to decision making within and away from their base hospital. We have reported the early clinical experience of East Midlands Specialist Orthopaedic Network (EMSON). In this paper we report beneficial clinical effects, both demonstrable and unquantifiable supporting the process. Using the UK HES database of revisions, performed before and after EMSON was established, (April 2011 – March 2018), data from EMSON hospitals were compared to all other hospitals in the same time-period. Primary outcome was re-revision surgery within 1 year. Secondary outcomes were re-revision, complications within first two years and median LOS. 57,621 RTHA and 33,828 RTKA procedures were involved with around 1,485 (2.6%) and 1,028 (3.0%) respectively performed within EMSON. Re-revision THA rates, within 1 year, in EMSON were 7.3% and 6.0% with re-revision knee rates 11.6% and 7.4%, pre- and post-intervention. Re-revision rates in the rest England in the same periods were 7.4% to 6.8% for hips and 11.7% to 9.7% for knees. This constituted a significant improvement in 1-year re-revision rates for EMSON knees. (β = −0.072 (−0.133 to −0.01), p = 0.024). The reduction in hip re-revision did not reach statistical significance. Secondary outcomes showed a significant improvement for 1 and 2-year RTHA complication rates. Re-revision rates for RTKA and complication rates for RTHA improved significantly after the introduction of EMSON. Other outcomes studied also improved to a greater extent in the network hospitals. While anecdotal experience with networks is positive, the challenge in collating data to prove clinic benefit should not be underestimated. Beyond the formal process, additional communication, interaction, and support has immeasurable benefit in both elective and emergency scenarios