Introduction: Radiolucency in the DeLee and Charnley zone 1 of the acetabulum in the early post operative period is a strong predictor of long-term failure of the cemented acetabulum. There is a wide variety in the acetabular anatomy of patients presenting for total hip replacement. Zone 1 radiolucency is an indicator of the failure of penetration of cement into the relatively hard cortical bone encountered in zone 1. Cement penetration is achieved by adequate preparation, achieving containment and effective pressurisation. Aim: To use pre operative radiological measurements to predict the risk of radiolucency around the cemented acetabular component post operation. Hypotheses:. Dysplastic acetabuli are associated with a higher incidence of zone 1 radiolucency. Retroverted acetabuli are associated with a higher risk of zone 1 radiolucency. Radiolucencies progress in the early post operative period. Materials and Methods: A cohort of 300 patients undergoing cemented THR in our institution was identified. Radiographs performed on the patients pre operatively, post operatively, at first follow up (6 weeks to 3months) and follow up at 1 year were analysed. The following measurements of the native acetabulum were performed: Tonnis grade of osteoarthritis, Crowe grade of dysplasia, acetabular index of depth to width, ACM angle, peak to edge distance, acetabular index of weight bearing zone, centre-edge angle of Widberg, acetabular angle of Sharp, cross over sign and posterior wall sign to assess retroversion, acetabular inclination and anteversion angle. Post operative films were then assessed for the presence of zone 1 keyholes, incidence and degree of radiolucency, cup inclination and anteversion. Results: Patients with an acetabulum outside the normal range were more likely to have a post operative radiolucency. Radiolucency tended to progress with time. Zone 1 keyholes appeared to terminate this progression. Retroverted and steeply inclined acetabuli demonstrated a higher incidence of radiolucency. A large change in version from the native to prosthetic acetabulum was associated with an increased risk of radiolucency. Conclusion: Thorough pre operative radiological assessment of the acetabular anatomy allows us to predict patients at high risk of post operative radiolucency. Patients with unsuitable anatomy may be more appropriate for an alternative method of fixation or require different techniques of acetabular preparation or augmentation in order to reduce their risk of loosening of the acetabular component in the long term

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: Radiolucency (RL) under the tibial component is a common finding following the Oxford UKA. Many theories have been proposed to explain the cause of RL, such as poor cementing, osteonecrosis, micromotion, and thermal necrosis. However, the true aetiology and clinical significance remain unclear. We attempted to address this. We found no significant relationship between physiological RL, pre-operative demographics, intra-operative variables and clinical outcome scores in this study. Tibial RL remains a common finding following the Oxford UKA yet we do not know why it occurs but in the medium term, clinical outcome is not influenced by RL. In particular, it is not a sign of loosening. Physiological RL can therefore be ignored even if associated with adverse symptoms following the Oxford UKA

Introduction: Radiolucent lines (RLL) underneath the tibial component are common findings following the Oxford Uni-compartmental Knee Arthroplasty (OUKA)[1]. Many theories have been proposed to explain the cause of RLL, such as poor cementing, osteonecrosis, micromotion, and thermal necrosis, however, the true aetiology and clinical significance remain unclear. We undertook a retrospective study analysing the association between RLL and pre-operative, intra-operative factors, as well as clinical outcome scores.

Method: One hundred and sixty-one knees which had undergone primary Phase 3 medial Oxford OUKA were included in the study. Fluoroscopic radiography films were assessed at five years post-operatively for areas of tibial RLL. The presence of RLL was compared to

patients’ pre-operative demographics for age, weight, height, BMI,

Results: Of the 161 knees in the study, 126 (78%) were found to have tibial RLL. No statistical difference was found between knees with RLL and those without in terms of preoperative demographics, intra-operative factors, or clinical assessment criteria.

Discussion: No clear relationship between RLL, preoperative demographics, and intra-operative factors has been identified in this study. We conclude that tibial RLL following OUKA is a common finding but do not seem to affect medium term clinical outcome.

Introduction

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.

Purpose of Study

To assess the incidence of radiolucency in cemented and cementless Oxford unicompartmental knee replacement at two years.

Purpose

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.

Aims

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.

Background: The principal cause of late failure of the cemented acetabular component is aseptic loosening. The acetabulum is a horse shoe of cortico-cancellous bone surrounding a cortical fovea. The cancellous bone becomes denser and less porous peripherally, limiting cement penetration. A radiolucent line in the DeLee and Charnley zone 1 of the acetabulum increases the risk of loosening of the acetabular component by 38.8 times. We propose that the use of 0.5cm keyholes in zone 1 decreases the incidence of zone 1 radiolucency.

Materials and Methods: Two contemporous cohorts of 100 patients were analysed for the incidence of zone 1 radiolucency on the first post operative film. In one cohort, zone 1 keyholes were used and in the other they were not. The films were analysed independently by two blinded investigators. The incidence, length and thickness of any radiolucency were recorded.

Results: The cohort of patients in which zone 1 keyholes were used demonstrated a 9% incidence of any zone 1 radiolucency, 8% were of 1mm width or greater and 2% involved 50% or more of the zone. In the cohort of patients in which zone 1 keyholes were not used the incidence of zone 1 radiolucency was 40% with 29% demonstrating a width of 1mm or greater and 12% affecting 50% or more of the zone.

Conclusions: The use of peripheral keyholes aids penetration of cement into the denser peripheral acetabular bone as demonstrated by decreased rates of post operative zone 1 radiolucency. This decrease in the incidence of early radiolucency should result in lower rates of subsequent loosening of the acetabular component.

Aims

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.

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.

Introduction: Radiolucencies are frequently observed around joint replacements. Their signiþcance & etiology remain unclear. Aim: 1. To study radiolucency under tibial tray of Oxford UKA and correlate it to the clinical outcome. 2. To study implant migration using RSA and study the correlation between migration and radiolucency. Materials and Methods: Fifty consecutive patients cemented Oxford UKA with a minimum follow up of two years were studied. At 2 years precisely aligned radiographs were obtained and evaluated for presence and extent of radiolucency under the tibial tray. The patients were divided into two groups Ð those with (Group I) and those without presence of radiolucency under the tibial tray (Group II). All the patients were assessed using KSS. Patients had RSA marker balls inserted around the prosthesis at the time of index procedure. Using RSA, the degree and direction of implant movement was measured at 1 & 2 yrs post surgery. Results: A) There were 26 patients in group I and 24 in group II. Both the groups were well matched for age and sex distribution. There was no signiþcant difference between the two groups when various clinical scores were compared. Maximum width of radiolucency was 1.1 mm and the average width was 0.57 mm. B) RSA study: By 12 months, the tibial component had migrated signiþcantly distally (mean: 0.42 mm, S.D.: 0.15 mm) and anteriorly (mean: 0.47 mm, S.D. 0.27mm). No signiþcant migration occurred after 12 mths. There was no correlation between presence or extent of radiolucency and migration of the tibial component. Conclusion: There is no relationship at 2 years between radiolucency and clinical results. There is also no relationship between radiolucency and migration. Therefore radiolucencies of 1mm or less can be ignored

Introduction: Most unicompartmental knee replacements (UKRs) employ cement for fixation of the prosthetic components to the bone. The information in the literature about the relative merits of cemented and cementless UKR is contradictory, with some favouring cementless fixation while others favouring cemented fixation. There is concern about the radiolucency which frequently develops around the tibial component with cemented fixations. The exact cause of the occurrence of radiolucency is unknown but according to some, it may suggest suboptimal fixation.

Method: Following ethical approval, 62 patients with medial OA were randomised to receive either cemented (n=31) or cementless components (n=31). All patients underwent identical surgical procedure with either a cemented or cementless Oxford UKR. Patients were assessed clinically and radiologically. The x-rays were taken with an image intensifier (I.I.). The position of the I.I. was adjusted until it was perfectly aligned with the tibial bone-implant interface thereby allowing accurate assessment of presence and extent of the radiolucency.

Results: The patients in the two groups were well matched. There was no significant difference in the clinical scores between the two groups. The mean OKS for the cemented group was 40 (± 8.3) and 42 (± 4.6) for cementless group. Narrow radiolucent lines were seen at the bone-implant interfaces of 75% of the cemented tibial components; partial in 43% and complete in 32%. In the cementless implants, partial radiolucencies were seen in 7% and complete radiolucencies in none. The differences are statistically highly significant (p< 0.0001) and imply satisfactory bone ingrowth into the cementless implants.

Conclusions: The method of fixation influences the incidence of radiolucency. With identical designs, no patient with cementless components developed any complete radiolucency. The observation raises the question as to whether cementless rather than cemented components should be routinely used for UKR.

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.

Aims

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.

Aims

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.

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: Bone Joint J 2013;95-B:881–6.

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: Bone Joint J 2013;95-B:181–7.

This study aims to implement and assess the inter and intra-reliability of a modernised radiolucency assessment system; the Radiolucency In cemented Stemmed Knee (RISK) arthroplasty classification. Furthermore, we assessed the distribution of regions affected by radiolucency in patients undergoing stemmed cemented knee arthroplasty. Stemmed knee arthroplasty cases over 7-year period at a single institution were retrospectively identified and reviewed. The RISK classification system identifies five zones in the femur and five zones in the tibia in both the anteroposterior (AP) and lateral planes. Post-operative and follow-up radiographs were scored for radiolucency by four blinded reviewers at two distinct time points four weeks apart. Reliability was assessed using the kappa statistic. A heat map was generated to demonstrate the reported regions of radiolucency. 29 cases (63 radiographs) of stemmed knee arthroplasty were examined radiographically using the RISK system. Intra-reliability (0.83) and Inter-reliability (0.80) scores were both consistent with a strong level of agreement using the kappa scoring system. Radiolucency was more commonly associated with the tibial component (76.6%) compared to the femoral component (23.3%), and the tibial anterior-posterior (AP) region 1 (medial plateau) was the most affected (14.9%). The RISK classification system is a reliable assessment tool for evaluating radiolucency around stemmed knee arthroplasty using defined zones on both AP and lateral radiographs. Zones of radiolucency identified in this study may be relevant to implant survival and corresponded well with zones of fixation, which may help inform future research

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. Radiolucency may be a herald of component loosening, therefore, close surveillance of this implant is recommended

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. Radiolucency surrounding the implant and the presence of a soft periosteal reaction were significantly associated with the presence of infection, though sensitivity of the signs remained very low

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. Radiolucency, osteolysis (around cup, caudal hook, screws), migration (medial, cranial) and dumping was noted and the results divided into 3 groups: stable (no migration) at risk (cranial or medial migr.), loosened (cranial and medial migr.). Results:18 Patients with implants in situ could be examined at an average follow up time of 18,3 months (3–30). (1died, 1 could not be reached, 2 did not want to come to fu, 2 explantations after infection). Average stay in hospital: 26 days, non weight bearing for av.: 9,8 weeks. Complications: 1 transient common peroneal nerve palsy, 1 luxation after 4 months (treated conservatively). HHS improved from 36,4 to 69,3 points (max. 100). Pain: 15,5 to 36,8 pts (max. 44). Activity of daily living:14,3 to 36,8pts (max. 47). Walking distance 3,6–5,8 pts (max.11). Radiological results (n=19, patient who died included in rad. FU): Radiolucency and osteolysis: Cup 5, hook 12, screws 10. Migration: medial:7 (all of those had medial bone defects), cranial:4, angulation > 4°:4 Outcome: stable: 11, at risk: 3, loosened 5 (1 died, 1 explanted, 3 control every 3 months). Conclusion: In our series the SPH Bicomponente does not provide sufficient postoperative stability to facilitate good ingrowth of bone graft. Loosening occurs especially in cases with medial bone defects where the cup has too little contact to pelvic bone. In these cases cemented cups or structural grafts might give better stability. ‘At risk’ patients show better clinical performance than one would expect from the radiological findings. A second follow up is starting recently with an average FU time of about 36 months

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). Radiolucency was observed in 20 knees but all except four were non-progressive lesions smaller than 2 mm. None of the implants were revised for subsidence or aseptic loosening of tibial component. The technique of PCL retaining total knee arthroplasty with tibial end plate resection in arthritic knees with flexible varus or valgus deformity yields good functional outcome in medium term follow up with relatively low incidence of subsidence of the tibial implant. This technique appears promising for total knee arthroplasty in osteoporotic bones where retaining the strong subchondral bone increases the longevity of the implant

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. Radiolucency around the glenoid base plate was found in one patient (0.8%) and around the humeral stem in five (4.0%). In all, three RTSA (2.4%) underwent revision surgery for aseptic mechanical failure of the glenoid within 11 months of surgery due to malseating of the glenosphere. Conclusion. The clinical results of this large independent single unit series are comparable to those from previous series of RTSA reported in the literature. A trabecular metal base plate is safe and effective in the medium-term. Cite this article: Bone Joint J 2016;98-B:969–75

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. Radiolucency beneath the tibial component occurred in 22 of 81 prostheses (27.2%) without evidence of loosening. Conclusion. This study supports the use of UKA in medial compartment osteoarthritis with excellent long-term functional and radiological outcomes with an excellent 15-year survival rate. Cite this article: Bone Joint J 2016;98-B(10 Suppl B):41–7

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. Radiolucency is significantly increasing with the follow-up time (p=0.009). Migration in the frontal plane is significantly associated with conversion to arthrodesis (p=0.005) and migration in the sagittal plane to revision of a component or conversion to arthrodesis (p=0.04). Finally, pain is significantly associated with re-operations (p=0.023) and complications (p=0.026). Remarkable is that the clinical outcome is independent of the direct post-op alignment of the TAR. The complication-, re-operation and revision or conversion to arthrodesis rates makes the clinical outcome of TAR still questionable favourable. Especially the complication and re-operation incidences are greater than found in the systematic review. However, it is remarkable that the minor complications and re-operations not related to the TAR are not often mentioned in the literature. Radiographic characteristics could be of value in predicting this clinical outcome and thereby influence the post-operative handling. In conclusion, our results show relatively high incidences of complications (37.0%) and re-operations (31.0%) when minor complications and re-operations are included. TAR clinical outcome can be predicted by radiographic migration characteristics and pain

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 Radiolucency along CBI by the total Length of CBI. Statistical analysis was performed by SPSS v17.0. Inter-observer and Intra-observer variability was determined by Intraclass Correlation Coefficient for a two way mixed model. New cementation index showed excellent agreement for both inter and intra-observer reliability with intraclass correlation coefficient of 0.79 and 0.82 respectively. On contrary, results of inter-observer reliability for Barrack's grading were poor with value of 0.20. intra-observer reliability was found to be fair with 0.55. As evident from this study, it is a more reliable way of assessing the quality of cementation, with excellent agreement in both inter and intra-observer categories

Aims

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.

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. Radiolucency was found in one DeLee-Charnley zone in four acetabular components. None of the implants required revision for aseptic loosening. Two patients were treated for infection, one requiring a two-stage revision of the implant. One femoral stem was revised for osteolysis due to the production of metal wear debris, but the acetabular shell did not require revision. This study demonstrates that a non-porous titanium acetabular component with adjunct surface fixation offers an alternative to standard porous-coated implants

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. Radiolucency at the prosthesis-bone interface was observed in 3 cases, 2 patients had proximal migration < of 20 mm. Only one patient was treated for aseptic loosening because of incorrect initial position of the implant. The iliac osteotomy was consolidated in all cases, while a delayed union was frequently observed in the pubic osteotomy, however without compromise the stability of implant. Functional result were evaluated according to the MSTS system and this showed 65% of excellent or good clinical results. The procedure requires appropriate patient selection, accurate preoperative planning, meticulous selection and preparation of allograft. Usually artificial ligaments are applied to reduce hip instability, however, this type of reconstruction do not require complex fixation, thus reducing surgical time and early complications

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]. Radiolucency rates were insignificant and at LFU no joints showed evidence of osteolysis, implant subsidence or polyethylene wear. One unresurfaced patella spontaneously fractured 10m postoperatively and one patella showed persistent subluxation. There were no other significant complications. The present short term study attests to the efficacy of semi-constrained implants in the revision of unstable primary arthroplasties. However, in the longer term, implant longevity remains undetermined

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. Radiolucency of 1 mm or less about the tibial prosthesis was observed at follow-up in four of the 24 knees. Our results have shown that one-stage TKA and skeletal traction after operation can achieve correction of severe flexion deformity of the knee with marked improvement in the function and quality of life

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. Radiolucency around stem < 2 mm. 19 cases, radiolucency around the cup in 11 cases; bone grafts resorption 10 out of 57 cases. Mean preoperative Harris Hip Score was 60; mean postoperative HHS 85. Conclusions: The good mid-term results reported conþrm that stemmed cup is a valid solution in revision surgery with mid and severe bone loss but also in CDH when conventional cup are not indicated

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. Radiolucency below the tibial component was seen in 2 cases. Conclusions: This independent study has conþrmed preliminary þndings that using a minimally invasive approach good radiological and clinical results can be obtained. Presence of PFA had no inßuence on good clinical outcome

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. Radiolucency was determined by radiolucent lines that were at least 1–2 mm wide and were seen in sequential radiographs, not apparent on the initial postoperative radiograph. Linear and rotational migration was defined as > 3 mm or > 5°change in the cup position, respectively, as measured on serial radiographs. Any changes in cup position or presence of circumferential radiolucencies were considered as loosening. Results. The average duration of follow-up was 6.2 ± 1.1 years (5 – 10 years). The mean HSS score was 34.8 ± 5.0 (19 – 40). There was an overall revision rate of 3.6% (8 cases) with Kaplan-Meier survivorship for all causes of 96.4% (95% CI: 0.92 – 0.98). There was one periprosthetic femur fracture. One stem was revised for fracture at the truniun/neck junction. There were 2 dislocation (0.9%); in one hip the cup was revised and the other was treated with a constrained liner. In 3 THAs (1.3%), stems were revised for loosening/failure of osseointegration (2 non-cemented stems, 0.9%) and osteolysis (one cemented stem, 0.4%). One THA (0.45%) underwent two stage revision for treatment of periprosthetic infection. There were no revisions for cup loosening or osteolysis or ceramic head fractures. The Kaplan-Meier survivorship for cup revision for any failure was 99% (95% CI: 0.96 – 0.99) and for mechanical failure was 100% (95% CI: 0.97 – 1). In radiographic analysis, the average functional cup abduction angle and anteversion were 41.7° ± 5.2 (range, 30 – 52) and 16.8° ± 6.1 (range, 4 – 30). 96% of the cups were within the safezone of Lewinnek. There were no migration or change in cup position in any cases. Presence of SIRCaB and radial trabeculae in all 3 zones were seen in 47% and 93% of cups, respectively; both were most prevalent in Zone 1. The absence of radiolucent line was observed in 96% of cases. In 161 THAs (72%), no screws were used due to excellent initial stability. Detail radiographic osseointegration assessment in the non-screw fixation group (as compared to the THAs with screw fixation) showed significantly higher incidence of SIRCaB (49% versus 39.7%, p=0.05) and radial trabeculae (97.5% versus 94.7%, p=0.001). There was also significantly less radiolucent lines in the non-screw fixation group (p=0.001). Discussion. No evidence of radiographic failure to osseointegrate was found in this study as evidenced by absence of radiolucency, evidence of radial trabeculae, and a reactive condensation of new bone to the well-fixed acetabular shell. Interestingly, we found that the solid designs had significantly better osseointegration when compared to multi-hole designs. In this single surgeon series with mid-term follow-up reiterates that the HA-coated hemispherical rim-fit acetabular component has excellent radiographic osseointegration, clinical outcomes and high survivorship for mechanical failures

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. Radiolucency was observed in all forty radiographs in region 7. Discussion: After implantation with a cemented or cementless PKR the bone strains and SED in region 7 are reduced. This reduction may provide the signal for adaptive bone remodelling and bone will be resorbed from this region, decreasing the volume and increasing the SED. Bone resorption will continue until the equilibrium state is reached. If a ‘lazy’ zone between 35% and 50% of the remodelling signal is considered, bone resorption will still occur due to the large decrease in SED for this region. For region 7 to return its SED to the equilibrium state, its volume will need to be reduced by 80%. This is likely to be the reason why a radiolucency is observed clinically in this region in almost every case, whether a cemented or cementless implant is used

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. Radiolucency appeared around both the humeral and ulnar components in five elbows, around humeral component in two and around ulnar component also in two. Five elbow replacements were revised. Four of them due to aseptic loosening and one due to instability problem (dislocation). No deep infection was noticed in any elbow. In our hands, Kudo Elbow Replacements seemed to have aseptic loosening rates comparable to other series and low dislocation rates

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. Radiolucency at the tray wall was observed in all forty radiographs examined. Discussion. This work has presented a static snapshot of the load being carried through the proximal tibia following implantation with an Oxford UKR. It has been shown that by introducing a mechanical tie between the tibial tray wall and the adjacent bone, the SED in the region observed to have radiolucency is increased; this has the potential of reducing the likelihood of a radiolucency occurring in that region. Moreover, the strain observed in the proximal tibia was reduced when a mechanical tie was introduced, which may reduce the incidence of pain following implantation with a UKR. It is recommended that integration between the bone and the tray wall is important for UKR

Aims

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.

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. Radiolucency was noted in only one case, and no migrations of more than 2 mm were seen. No further stem revisions were required in this series, though we believe a future revision will be necessary in at least one case. Discussion and Conclusions: The use of femoral stems with diaphyseal fixation is an acceptable alternative in revision surgery of the hip, even in cases of major bone deficit. Modular stems have the added advantage of versatility to adapt to a great variety of prosthetic salvage procedures

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). Radiolucency of all 3 acetabular zones was identified in one of the CP hips. There was no evidence of osteolysis or loosening identified in the remaining hips. The mean time of wear measurement for the CC group was 8.3 years (SD 1.3, Range 4.8–10.1 years) and for the CP group was 8.1 years (SD 0.9, Range 6.1–9.2 years)(p=0.471). Wear was identified in all but one of the CP replacements but only 12 of 23 CC articulations. The mean wear for the CC group was 0.14 mm (SD 0.16, Range 0–0.48 mm) and for the CP group was 0.89 mm (SD 0.6, Range 0–2.43 mm)(p< 0.001). Extrapolating the annual wear rate from these figures, the respective wear is 0.02mm for the CC group compared to 0.11mm per year for the CP group. To our knowledge this is the first long term randomized trial comparing in vivo ceramic-on-ceramic with ceramic-on-conventional polyethylene hip articulations. Other than significantly greater wear in the polyethylene group there was no significant difference in long-term outcome scores between the two groups with up to 10 years of follow-up. The use of a ceramic-on-ceramic bearing is a safe and durable option in the young patient avoiding the concerns of active metal ions and osteolytic polyethylene debris. These patients remain under review

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. Radiolucency around the femoral stem according to Gruen (zone 1-7) and the acetabulum as described by Charnly and De Lee (zone 1–3) is documented. A fully coated femoral component along with the press –fit HA coated CSF cup with a 28mm ceramic insert was used. All cups were routinely augmented with screws. Results: The mean Harris Hip score was 90 (46–96). 4 patients had a score less than 80. 84.2% were completely pain free. Acetabular radioleucencies were noted in 32 hips (72 %).28 cups had radiolucent lines (RLL) in zone 2, 2 cups in zone 1 and 1 cup in zone 3. In 10 patients (23%) the lucent area measured > 2mm at the cup bone interface. No hips had RLL in more than two zones. 4 stems had RLL > 2 mm involving the Gruen zone 7. 90 % showed a distinct osteoblastic reaction at the tip of the femoral component. There was no calcar resorption, endosteal cavitation or ectopic ossification. There were no instances of ceramic fractures and no hips were revised. Discussion: The JRI Furlong hip gives good functional results in young patients in the medium term. Although of concern, there was no co-relation between the presence of acetabular RLL and functional outcome. The RLLs were not thought to be progressive. The RLLs can be explained by backside wear or by fretting of the screws by the ceramic liner. Long term follow up of the CSF cup will be required to determine if these radio-lucent lines are an early sign of failure at the interface or whether they simply represent stable in- growth of fibrous tissue in this highly stressed region

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 Radiolucency Scoring Scheme. Patients with less than 4 points (n=87, mean KS 71.2) had better outcomes than patients with 4 or more points (n=8, mean KS 56.4). 87% of patients were aligned within 4° of mechanical axis. Conclusion:. Outcomes of revision TKA are inferior to primary TKA. Early failures were mainly caused by infection, instability, malalignment. Grouping revision TKA’s to etiology of failure did not lead to significant differences in outcomes. Significant better outcomes were reported for late revisions, patients with older age at revision surgery and partial knee replacement. Survivorship analysis was significally better for late than for early revisions

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. Radiolucency between the cement-bone interface was present in two hips, one in Zone 1 and the other in Zone 7. Average subsidence of the triple-tapered stems was 0.77 mm (range 0 to 2.5), which compared to 0.82 mm (range 0 to 2.5) in the double-tapered group. No stems were considered at risk of aseptic loosening. There was no significant difference in the extent of proximal femoral resorption and heterotopic ossification. Conclusions In our study, the triple and double-tapered components performed equally well clinically and are comparable on radiological analysis. The triple-tapered stem is safe and is not associated with increased rates of loosening, subsidence or radiolucency, compared to the double-tapered stem. There is potential to translate the promising early results of the triple-tapered design into the future and expect similar long-term success

Aims

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.

Aims

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.

Aims

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.

Aims

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.

Aims

The primary aim of this study was to compare the wear properties of vitamin E-diffused, highly crosslinked polyethylene (VEPE) and one formulation of moderately crosslinked and mechanically annealed ultra-high molecular weight polyethylene (ModXLPE) in patients five years after primary total hip arthroplasty (THA). The secondary aim was to assess the clinical results of patients treated with VEPE by evaluating patient-reported outcome measures (PROMs), radiological evidence of fixation, and the incidence of mechanical failure.