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Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_6 | Pages 20 - 20
2 May 2024
Khaled A Eyre-Brook A Petrie M Gordon A Harrison T Salih S
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The benefits of cell salvage autotransfusion are well reported. There is a common non-evidenced belief amongst revision arthroplasty surgeons that auto-transfusion is potentially contraindicated in infected revisions.

The aim is to study the immediate and delayed outcomes of using cell saver on patients undergoing PJI surgery.

Prospective cohort service evaluation registered with the local audit department. 20 PJI cases in 18 patients where cell saver was used over a period of 4 years. Intraoperative fluid and tissue samples were taken for culture. Blood culture from salvaged blood pre and post leucodepletion filter were sent for microbiological analysis. Data on type of surgery, blood loss, further allogenic transfusion and SIRS response was collected. Success of infection clearance was assessed using 2019 MSIS ORT. Five patients receiving autologous blood in non-infection cases were used as controls.

Mean age for the PJI group was 67.7 years, 67% female. 11 patients (67%) had 1st stage surgery and 5 (25%) underwent 2nd stage whereas 4 patients had single stage surgery. The mean calculated blood loss was 1398 mls (range 400–3000mls). 6 Patients required further allogenic transfusion. 16 patients received blood via a leuco-depletion filter. The same organism grown from tissues was identified in post-filter blood in 8/17 patients (47%).

2/20 have grown a different organism in post-filtered blood, _P.Acne._

2 patients developed SIRS upon auto-transfusion, however one was thought to be secondary to cementing. The control group had 443 mls mean amount of blood loss and 1 patient developed a SIRS response.

14/20 (70%) patients had successful clearance of infection (tier 1) 2 patients died prior to undergoing 2nd stage.

Using cell saver did not impact main outcome of infection clearance in PJI surgery. We would advocate its routine usage whilst avoiding direct collection of heavily contaminated blood.


Bone & Joint Open
Vol. 4, Issue 8 | Pages 559 - 566
1 Aug 2023
Hillier DI Petrie MJ Harrison TP Salih S Gordon A Buckley SC Kerry RM Hamer A

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/m2 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.


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_4 | Pages 4 - 4
1 Apr 2022
Hillier D Petrie M Harrison T Hamer A Kerry R Buckley S Gordon A Salih S Wilkinson M
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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.


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_2 | Pages 90 - 90
1 Mar 2021
Mahatma M Jayasuriya R Gossiel F Gallagher O Hughes D Buckley S Gordon A Hamer A Tomouk M Wilkinson JM
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Abstract

Objective

In this phase 2 clinical trial (EudraCT 2011-000541-20) we examined the effect of denosumab versus placebo on osteolytic lesion activity in patients undergoing revision surgery after THA.

Methods

Men and women ≥ 30 years old scheduled for revision surgery for symptomatic, radiologically-confirmed osteolysis were randomised (1:1) to receive either denosumab 60mg or placebo subcutaneously eight weeks prior to operation. At surgery, biopsies from the osteolytic membrane-bone interface were taken for histomorphometric analysis of osteoclast number, the primary outcome measure. Secondary outcome measures included other static histomorphometric indices and systemic bone turnover markers. Adverse events and patient-reported clinical outcome scores were recorded as safety endpoints.


Introduction

Early surgery for hip fractures is beneficial but is often delayed by anticoagulation. Direct acting anticoagulants (DOAC), Rivaroxaban and Apixiban, are increasingly used in primary and secondary care but there is no specific reversal agent. Current guidance is to delay surgery 48 hours. Anti-factorXa levels < 80 ug/l are considered safe for major surgery and for spinal anaesthesia. We investigated if delay in this cohort of patients can be predicted or reduced.

Patients/Materials & Methods

41 consecutive patients presenting with a hip fracture on therapeutic dose DOAC were identified. Anti- factorXa levels were collected at 24hours and repeated at 48hours if elevated. We investigated if renal function or clotting screen could help predict safe time to surgery.


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_4 | Pages 115 - 115
1 Apr 2019
Verstraete M Conditt M Chow J Gordon A Geller J Wade B Ronning C
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Introduction

Close to 30% of the surgical causes of readmission within 90 days post-total knee arthroplasty (TKA) and nearly half of those occurring in the first 2 years are caused by instability, arthrofibrosis, and malalignment, all of which may be addressed by improving knee balance. Furthermore, the recently launched Comprehensive Care for Joint Replacement (CJR) initiative mandates that any increase in post-acute care costs through 90-days post-discharge will come directly from the bundle payment paid to providers. Post-discharge costs, including the cost of readmissions for complications are one of the largest drivers of the 90-day cost of care. It is hypothesized that balanced knees post-TKA will lower the true provider costs within the 90-day bundle.

Methods

Cost, outcomes and resource utilization data were collected from three independent surgeons pre- and post- adoption of intraoperative technology developed to provide real-time, quantitative load data within the knee. In addition, data were collected from Medicare claims, hospital records, electronic medical records (EMR), clinical, and specialty databases. The cohorts consisted of 932 patients in the pre-adoption group and 709 patients in the post-adoption group. These 2 groups were compared to the CMS national average data from 291,201 cases. The groups were controlled for age, sex, state, and BMI with no major differences between cohorts. The cost factors considered were the length of hospital stay, physician visits and physical therapy visits in addition to post-operative complications (e.g., manipulation under anesthesia (MUA) and aseptic revision).


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_4 | Pages 116 - 116
1 Apr 2019
Gordon A Golladay G Bradbury TL Fernandez-Madrid I Krebs VE Patel P Higuera C Barsoum W Suarez J
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Introduction & Aims

Studies have shown that as many as 1 in 5 patients is dissatisfied following total knee replacement (TKA). There has also been a large reported disparity between surgeon and patient perception of clinical “success”. It has long been shown that surgeon opinion of procedural outcomes is inflated when compared with patient-reported outcomes. Additionally, TKA recipients have consistently reported higher pain levels, greater inhibition of function, and lower satisfaction than total hip replacement (THA) recipients. It is imperative that alternative methods be explored to improve TKA patient satisfaction. Therefore, the purpose of this study was to determine whether or not patients with a balanced TKA, as measured using intraoperative sensors, exhibit better clinical outcomes.

Methods

310 patients scheduled for TKA surgery were enrolled in a 6 center, randomized controlled trial, resulting in two patient groups: a sensor-guided TKA group and a surgeon-guided TKA group. Intraoperative load sensors were utilized in all cases, however in one group the surgeon used the feedback to assist in balancing the knee and in the other group the surgeon balanced without load data and the sensor was used to blindly record the joint balance. For this evaluation, the two groups were pooled and categorized as either balanced or unbalanced, as defined by a mediolateral load differential less than 15 lbf (previously described in literature). Clinical outcomes data were collected at 6 weeks, 6 months and 1 year post- operatively, including Knee Society Satisfaction and the Forgotten Joint Score. Using linear mixed models, these outcome measures were compared between the balanced and unbalanced patient groups.


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_9 | Pages 43 - 43
1 May 2018
Wood D Salih S Sharma S Gordon A Bruce A
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Introduction

Training the next generation of surgeon's forms part of routine Consultant practice. Stress causes activation of the Autonomic Nervous System and this can be directly measured using heart rate (HR). Training time is limited with pressures from EWTD and management and efficiency targets. The aim of this study was to assess whether being an orthopaedic trainer is more stressful than performing the surgery.

Methodology

This was a prospective multicentre study. Consultant orthopaedic surgeon HR was monitored intra-operatively using a ‘Wahoo Fitness’ chest strap and the data recorded by the proprietary Android app. Data was collected prior to surgery to obtain a resting heart rate, and at set points during total hip arthroplasty (THA) and total knee arthroplasty (TKA).

The peak and mean HR for each stage of the operation were recorded and compared to cases where the consultant surgeon was performing the case or assisting a trainee. Data was compared with a 2-way ANOVA with repeated measures.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_11 | Pages 35 - 35
1 Jun 2016
Petrie M Harrison T Buckley S Gordon A Kerry R Stockley I Tomouk M Wilkinson J Hamer A
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Background

An extended trochanteric osteotomy (ETO) is a widely used approach for revision hip arthroplasty. Following an ETO it is common practice to use a long stemmed femoral prosthesis at the second stage to bypass the osteotomy. We propose that at the second stage, if the osteotomy has united, it is appropriate to use a standard length prosthesis, which preserves bone stock for any future revisions.

Methods

We performed a retrospective review of our institution's prospective arthroplasty database, identifying all patients who had undergone an ETO at the first stage revision. A radiograph review was then performed and any subsequent complications recorded. A selection of patients radiographs were individually reviewed by three reviewers and intra-class correlation (ICC) was performed to assess intra-observer reliability.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_11 | Pages 122 - 122
1 Jul 2014
Moretti V Gordon A
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Summary Statement

Navigated total knee arthroplasty (TKA) is becoming increasingly popular in the United States. Compared to traditional unnavigated TKA, the use of navigation is associated with decreased blood transfusions and shorter hospital stays.

Introduction

Navigated total knee arthroplasty (TKA) is a recent modification to standard TKA with many purported benefits in regards to component positioning. Controversy currently exists though regarding its clinical benefits. The purpose of this study was to assess recent national trends in navigated and unnavigated total knee arthroplasty and to evaluate perioperative outcomes for each group.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_28 | Pages 121 - 121
1 Aug 2013
Merz M Bohnenkamp F Sadr K Goldstein W Gordon A
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Introduction

Risks and benefits of bilateral total knee arthroplasty (TKA), whether simultaneous, sequential single-staged, or staged is a topic of debate. Similarly, computer-assisted navigation for TKA is controversial regarding complications, cost-effectiveness, and benefits over conventional TKA. To our knowledge, no studies have compared computer-assisted and conventional techniques for sequential bilateral TKA. We hypothesise that the computer-assisted technique has fewer complications.

Methods

We retrospectively reviewed 40 computer-assisted and 36 conventional bilateral sequential TKAs from 2007–2011 with 1 year follow-up for complications. Groups were matched by age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI), and American Society of Anesthesiologists Classification (ASA). Pearson's Chi-square, Fisher's exact test, and independent samples t-test were used to compare groups.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_III | Pages 396 - 396
1 Jul 2010
Gordon A Hamer A Stockley I Eastell R Wilkinson J
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Introduction: Polymorphisms within genes encoding bone regulatory cytokines influence individuals’ susceptibility to osteolysis after THA. We aimed to determine whether single nucleotide polymorphisms (SNPs) within these genes influence the severity of these osteolytic lesions in 272 patients with established aseptic loosening.

Methods: Assessment of osteolytic lesions was made from pre-revision radiographs in conjunction with direct visualisation in those subjects undergoing surgery. Osteolytic lesions were defined as linear (AAOS pelvic and femoral osteolysis classification grade 0) or expansile, in the presence of segmental or cavitary defects (AAOS grade 1 or greater). We analysed 11 SNPs in the pro-inflammatory cytokines IL-1A, IL-1B, IL-1RA, IL-6 and TNF; 2 SNPs within the FRZB gene, which modulates osteoblast function; and 6 SNPS in the RANK/RANKL/OPG pathway, that modulates osteoclast function.

Results: Femoral Osteolysis: Carriage of the IL-6 −174C allele was 60% in the expansile osteolysis group versus 80% in the linear osteolysis group (χ2 test p=0.007). Carriage of the OPG −163G allele was 34% in the expansile osteolysis group versus 18% in the linear group (χ2 test p=0.03). The odds ratios for expansile osteolysis associated with carriage of IL-6-174G and OPG −163G were 2.7 (1.3 to 5.7, p=0.008) and 2.3 (1.1 to 5.0, p=0.03) respectively.

Acetabular Osteolysis: No differences in SNP genotype were found between osteolysis groups.

Discussion: The IL-6-174G allele and the OPG-163G allele are over-represented in subjects with expansile femoral versus linear osteolysis, but do not relate to severity of pelvic osteolysis. These differences in association may reflect differences in the mechanism of osteolysis between the bone sites, however, replication of the results are required to confirm this differential association.


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The use of tapered titanium femoral stems has gained in popularity for primary total hip arthroplasty. One of the basic stem designs is a fully grit blast square tapered stem with distal fixation (Zweymuller-type). Another stem design (Muller-type), a proximally porous coated flat wedge stem with proximal fixation is associated with a low but significant perioperative femoral fracture risk. Both of these implant types are inserted with a broach-only technique. We theorize that the Zweymuller-type implant can be inserted safely with pneumatic broaching with a very low fracture risk even when broached by rotating residents with no prior experience.

We prospectively reviewed 300 consecutive hip arthroplasty cases using Zweymuller-type stems from eight different manufacturers implanted using the Woodpecker TM pneumatic broaching system. The series included both THA and hemiarthroplasty cases with a wide range of cortical/canal indexes. Patient age ranged from 14 to 98 (avg. 68). Half of the hip stems were inserted through a posterolateral modified Kocher-Gibson approach, and half through an anterolateral Hardinge approach. Approximately 25 rotating residents who were initially unfamiliar with this broaching technique and stem implant type performed the majority of the procedures. We routinely obtained an intra-operative AP pelvis x-ray to confirm trial implant size, alignment, and adjust the leg lengths.

The overall technique/implant-related perioperative complication rate was 2% (6/300). These included intra-operative femoral fractures(2), post-operative femoral fractures (1), dislocations(3), and deep infections(2). There were no cases of nerve palsy or leg length inequality > 1cm. Rates of post-op blood transfusions and venous thromboembolism were not reviewed for the purposes of this study. Only one of the complications (one deep infection) required exchange of the original femoral component. There was no significant difference in complication rates between type of surgical approach, brand of square tapered stem manufacturer, or experience of the operating surgeon.

We conclude that hip arthroplasty using pneumatically broached, square tapered, cementless distal fixation (Zweymuller-type) hip stems has a low learning curve and can be implanted safely even in very osteoporotic bone. This technique/implant gives the surgeon control of stem anteversion for stability and leg length inequality correction. The incidence of certain perioperative complications can be reduced by using Zweymuller-type stems using pneumatic broaching regardless of approach, implant manufacturer, or surgeon experience. These patients will continue to be followed clinically for implant survivorship.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 55 - 56
1 Mar 2010
Gordon* A Kiss-Toth E Greenfield E Eastell R Wilkinson J
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Total hip arthroplasty (THA) wear debris induced macrophage expression of pro-inflammatory cytokines has been associated with osteolysis both in vitro and in animal and human subjects. Interleukin-1 receptor antagonist (IL-1RA) is an anti-inflammatory cytokine which may limit bone destruction. Polymorphisms (SNPs) within the IL-1RN gene are associated with differences in susceptibility to infectious and inflammatory conditions and disorders of bone remodelling. This study investigated the association between the IL-1RA+2018T/C SNP (rs419598) and osteolysis after THA, and with mRNA and protein expression in an in-vitro wear debris-macrophage stimulation assay.

611 North European Caucasians who had received a cemented THA for primary osteoarthritis were genotyped for the IL-1RN+2018 SNP using Taqman methods. 62 subjects with a Charnley THA were selected from the genotyping population. Control subjects had no radiographic osteolysis and the osteolysis group had previously undergone revision surgery for aseptic loosening. Peripheral blood mononuclear cells were extracted and stimulated with endotoxin-stripped titanium particles (TiCL, endotoxin level 0 Eu/ml) and endotoxin-stripped particles with adherent LPS added back (TiAB, endotoxin level 140 Eu/ml); non-stimulated and LPS-stimulated cells were used as negative and positive controls. Cell lysate IL-1RA mRNA levels were assessed by rqRT-PCT following a 3-hour stimulation. Cell supernatant IL-1RA protein levels were assayed after 24 hours stimulation using a multiplex method.

The IL-1RN+2018C allele was underrepresented in patients with osteolysis after THA versus control THA subjects (chi-squared test 5.96, P=0.015). After correction for other risk factors for osteolysis, the adjusted odds ratio for osteolysis associated with carriage of the IL-1RN+2018C SNP was 0.69 (0.48 to 0.99, p=0.048). IL-1RA mRNA expression increased linearly with IL-1RN+2018C allele copy number in gene-dose dependent manner (ANOVA p=0.013). The IL-1RA+2018C allele did not significantly affect IL-1RA protein expression (ANOVA p> 0.05), however a similar trend towards increased levels with increased C allele copy number was observed.

Carriage of the IL-1RA+2018C allele is associated with both a decreased risk of osteolysis after THA and increased IL-1RA mRNA expression in-vitro. The mechanism for this functional effect remains unclear, however these findings support the importance of the IL-1RA in osteolysis and aseptic loosening.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 403 - 403
1 Sep 2009
Gordon A Kiss-Toth E Greenfield E Eastell R Wilkinson J
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Introduction: Immune responses in patients susceptible to aseptic loosening may differ to those without this susceptibility. We compared stimulated cytokine mRNA and protein expression in peripheral blood mononuclear cells (PBMC) in 34 subjects (M:F 16:18; mean age 75 years) with previous revision surgery for aseptic loosening versus 28 subjects (14:14; 75 years) with well-fixed implants after Charnley THA for osteoarthritis.

Methods: Extracted PBMCs were stimulated with endotoxin (LPS 200ng/mL), endotoxin-free titanium particles (Ti, endotoxin level =0 Eu/mL), or particles with adherent LPS (TiLPS, 140 Eu/mL). Cell lysate IL-1α, IL-1β, IL-1RA, IL-6, IL-10, IL-18, and TNF mRNA were assayed after 3 hours stimulation using standard rqRT-PCR techniques. Cell supernatant IL-1β, IL-1RA, IL-6 and TNF protein were assayed after 24 hours stimulation using a multiplex method.

Results: mRNA and protein levels in non-stimulated cells were lower in revision versus control subjects for all cytokines (p< 0.05 all analyses). mRNA expression relative to baseline was greater in revision subjects versus controls for all cytokines and all modes of stimulation (LPS, Ti, and TiLPS, p< 0.05 all analyses). LPS induced the greatest inflammatory cytokine response at both the mRNA and protein level in both groups, TiLPS particles induced a more attenuated response, and responses to Ti particles were weakest. In the control group endotoxin free particles showed a negative cytokine mRNA response for IL-1α, IL-1β, and IL-6 (p< 0.05), and reduced protein levels for IL-1β, IL-1RA, IL-6, and TNF versus non-stimulated cells (p< 0.05).

Discussion: Patients with a susceptibility to aseptic loosening have lower baseline but greater stimulated immune responses versus patients without loosening that may contribute to the pathogenesis of aseptic loosening.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 533 - 533
1 Aug 2008
Gordon A Hamer AJ Stockley I Wilkinson JM
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Introduction: The concept that aseptic loosening is a function of polyethylene wear has led to the introduction of cross-linked polyethylene in THA. We studied the relationship between polyethylene wear rate and aseptic loosening to model the potential effects of wear-reducing strategies on the failure rate for each prosthetic component.

Methods: 350 subjects who had previously undergone Charnley THA were divided into 3 groups: Controls (n=273); isolated femoral stem looseners (n=43); and isolated cup looseners (n=34). Polyethylene wear was measured using a validated method (EBRA). The relationship between wear rate and loosening was examined using logistic regression analysis, and estimates of the effect of wear rate modulation made using odds-ratios (OR ).

Results: The median annual wear rate in the controls (0.07mm) was lower than both stem looseners (0.09mm, p=0.002) and cup looseners (0.18mm, p< 0.001). The OR of cup loosening increased 4.7 times per standard deviation (SD) increase in wear rate above the reference (control) population (p< 0.001). The OR of stem loosening increased 1.7 times per SD, but was not independent of other risk factors (p> 0.05). The potential reduction in risk of loosening was calculated using the following formula: (OR ^SD2)/(OR ^SD1), where 1 and 2 are the predicted mean z-score wear rates of modified versus conventional polyethylene. Thus, for a 25% or 50% reduction in wear rate, the incidence of cup loosening may reduce by 71% and 293%, respectively. The rate of stem loosening may reduce by 7% and 17%, respectively.

Discussion: The use of cross-linked-polyethylene has the potential for a major impact on the incidence of cemented cup loosening. However their effect on femoral stem loosening may be limited.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 533 - 533
1 Aug 2008
Gordon A Southam L Loughlin J White G Wilson AG Stockley I Hamer A Eastell R Wilkinson JM
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Introduction: Bone phenotype, such as osteoarthritis (OA) pattern and development of osteolysis or heterotopic ossification (HO) after THA, may be governed by genetic and environmental factors. We investigated whether single nucleotide polymorphisms within the gene encoding secreted-Frizzled Related Protein-3, FRZB Arg200Trp and FRZB Arg324Gly influence bone phenotype.

Methods: Genomic DNA was extracted from 609 subjects at a mean of 11 years following cemented THA for idiopathic osteoarthritis. Pre-operative OA was defined using The American College of Rheumatology criteria and post operative HO after primary THA was assessed using Brooker’s classification

Results: For FRZB Arg200Trp, minor allele carriage (MAC) was greater in subjects with pre-operative pelvic osteophytes (n=267) versus those without osteophytes (n=34) (MAC 27.9% versus 6.3%, Fisher’s exact test p=0.037). There were no associations with other radiographic criteria of OA. MAC was also higher in HO+ve subjects (n=291) versus HO-ve subjects (n=341), (MAC 21.7% versus 12.0%, χ2 test p=0.063). Finally MAC was 14.2% in osteolysis +ve subjects (n=268) and 21.7% in osteolysis –ve subjects (n=341) (χ2 test p=0.041).

The adjusted odds ratios for pelvic osteophytes and HO with carriage of the rare FRZB 200 variant were 4.34 (1.01–18.7 p=0.048) and 1.64 (1.05 to 2.54, p=0.028) respectively. The adjusted odds ratio for osteolysis was 0.62 (0.38 to 0.99 p=0.049).

There were no bone phenotype associations with the FRZB Arg324Gly variants.

Discussion: Carriage of the FRZB 200Trp allele is positively associated with osteophyte and HO formation and negatively associated with osteolysis, suggesting this locus may be a marker for pro-osteoblastic activity.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 549 - 549
1 Aug 2008
White G Gordon A Stockley I Hamer A Wilkinson JM
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Introduction: Aseptic loosening due to periprosthetic osteolysis is the main cause of implant failure after total hip arthroplasty (THA). Some previous studies have suggested a link between pattern of pre-operative osteoarthritis (OA) and subsequent aseptic loosening. Specifically, atrophic OA may predict implant loosening1,2 however this remains controversial.3

Methods: We retrospectively assessed the survival of 301 cemented THAs inserted for idiopathic osteoarthritis to determine whether pre-operative patterns of osteoarthritis predict subsequent risk of osteolysis. There were 204 control subjects and 97 subjects with osteolysis. The mean age of patients at insertion of primary implant was 63.4 years and lysis free survival or follow up was 10.6 years. The osteoblastic response in OA was assessed using Bombelli’s classification. The American College of Rheumatology criteria for radiographic evidence of OA was used to assess the pattern of OA prior to primary THA

Results: Atrophic OA was not a risk factor for osteolysis. Atrophic OA in osteolysis group was 16% versus 14% in the control group (χ2 test p> 0.05). There was no association between osteolysis and joint space narrowing, femoral or pelvic osteophytes, femoral or pelvic sclerosis, femoral or pelvic cysts and femoral head collapse (χ2 test p> 0.05 all comparisons).

Conclusion: The morphological pattern of OA does not predict osteolysis after THA


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 312 - 312
1 Jul 2008
Gordon A Hamer A Stockley I Eastell R Wilkinson J
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Introduction: Activated peri-prosthetic macrophages release pro-inflammatory cytokines, including interleukin-6 (IL-6), that stimulate osteoclast activation and aseptic loosening. Natural sequence variations (polymorphisms) within the IL-6 gene promoter region are associated with diseases characterised by increased osteoclast activity, including osteoporosis, and affect IL-6 production in-vitro. We tested whether polymorphisms in the IL-6 gene promoter influence the risk of aseptic loosening after total hip arthroplasty (THA).

Methods: 614 Caucasians, 292 men and 322 women, mean age 75.8 years who had undergone primary cemented THA for idiopathic osteoarthritis a mean of 13.4 years previously were recruited. Peripheral blood was taken and DNA extracted using standard techniques. Subjects were genotyped for the IL-6 -174, -572, and -597 promoter single nucleotide polymorphisms using the Taqman 5′ nuclease method.

Results: The allele frequencies and carriage rates for both alleles at promoter positions −174, −572, and −597 were similar between controls and aseptic loosening subjects (Table, χ2 P> 0.05 all comparisons).

Discussion: Although Il-6 has been implicated in the pathogenesis of aseptic loosening and the −174, −572, and −597 polymorphisms are associated with bone loosing pathologies, they do not appear to play a major role in aseptic loosening after THA.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_II | Pages 249 - 249
1 May 2006
Gordon A Southam L Loughlin J Stockley I Hamer A Macdonald D Eastell R Wilkinson M
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In-vitro evidence suggests that wear debris can alter osteoblast function resulting in decreased bone matrix production and negative remodelling balance. FRZB encodes for Secreted Frizzled-Related Protein 3 which may play a role in bone formation and osteoarthritis. This study was undertaken to investigate whether the recently described single nucleotide polymorphisms (SNPs) at positions [+6] and [+109] of the FRZB gene are associated with osteolysis after THA.

Genomic DNA was extracted from 481 North European Caucasians at a mean of 12 years following cemented THA for idiopathic osteoarthritis. The control group consisted of 267 subjects and the osteolysis group 214 subjects. The [+6] and [+109] FRZB SNPs were genotyped using standard techniques.

For the FRZB [+6] SNP, the rare T allele was significantly over-represented in control versus the osteolysis group (χ2 test for trend, p=0.02,). The odds ratio for osteolysis associated with carriage of the [+6] T-allele versus the [+6] C-allele was 0.58 (95%CI 0.36 to 0.94), p=0.03. The odds ratio for osteolysis associated with carriage of the [+109] G-allele versus the [+109] C-allele was 0.66 (0.38 to 1.12), p=0.15. A number of covariates have previously been described in this cohort and after adjustment for the effects of these covariates, the odds ratio for osteolysis with carriage of the [+6] T-allele was 0.69 (0.42–1.16).

We found that the FRZB [+6] T-allele is less common in subjects with osteolysis after THA versus controls, suggesting that allelic variants of genes associated with bone formation pathways may have a role in modulating the risk of osteolysis. However its loss of significance after correction for other factors suggests an interaction between this allele and other risk factors in osteolysis.