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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Revision of the femoral component during revision hip arthroplasty may pose significant technical challenges, most notably femoral fracture and bone perforation. The in-cementing technique allows use of the original bone-cement interface that has been proven to be biomechanically stronger than recementing after complete removal of the original cement mantle. This historical prospective study reviews a series of 54 consecutive revision hip arthroplasty procedures carried out by the senior author using the in-cementing technique from November 1999 to March 2003. Patients were followed up clinically and radiologically with serial outpatient reviews and their functional outcome was assessed using the Harris hip scoring system, the Oxford hip scoring system and the University of California at Los Angeles (UCLA) activity profile. Their physical and mental well being was also assessed using the SF-36 self-questionnaire. Fifty-four procedures were performed on 51 patients. There were 31 males and 20 females. The average age was 70.3+/−8.1 years (range: 45 – 83 years). The average time to revision from the original procedure was 132.8+/−59.0 months (range: 26 – 286 months). The average length of follow up was 29.2+/−13.4 months (range: 6 – 51 months) post revision arthroplasty. Two patients suffered dislocations, one of which was recurrent and was revised with a Girdlestone’s procedure. No patient displayed any evidence of radiographical loosening. The average Harris hip score of the study group was 85.2+/−11.6 (range: 51.9 – 98.5). The average Oxford hip score recorded was 19.6+/−7.7 (range: 12 – 41) and the average UCLA activity profile score was 5.9+/−1.6 (range: 3 – 8). The SF-36 questionnaire had an average value of 78.0+/−18.3 (range: 31.6 – 100) with an average physical score of 73.3+/−22.2 (range: 20.5 – 100). In conclusion, we feel the results of this study show excellent clinical and radiological results of the in-cementing technique with high patient satisfaction in terms of functional outcome. This technique merits consideration where possible in revision hip arthroplasty

Introduction: Freezing and storage of fresh frozen femoral heads destined for use in revision hip arthroplasty is thought to result in graft cell death. Washing of the graft following the morsellisation process also removes a large proportion of the marrow content of the allograft. However, the immunological load of the impaction allografting process remains unknown. The aim of this study was to investigate the immune response by observing any changes in peripheral blood lymphocyte subsets in response to allografted bone used in revision hip replacement. Methods: 87 patients were entered into this prospective study and grouped according to whether impaction allograft was used or not. Venous blood samples were collected pre-operatively and at set time intervals up to one year post-operatively. Using flow cytometry, analysis of venous blood allowed counts of the following cells: Helper T-lymphocytes, cytotoxic T-lymphocytes, memory T-lymphocytes, naïve T-lymphocytes, Natural Killer cells and B-lymphocytes. Results: All patients had a successful outcome at one year. 50 patients with radiologically defined host-graft union were compared with 37 patients who did not receive allograft. Pre-operatively, a significant difference (p=0.03) was found between the groups of patients with respect to Natural Killer cells but other subsets showed no significant difference. Post-operatively the significant difference between Natural Killer cells resolved. T-helper lymphocytes, cytotoxic lymphocytes, memory T-lymphocytes and naïve T-lymphocytes in both groups showed decreases in values immediately post surgery, recovering to normal values within 6 weeks post-surgery. The allograft group showed significant increases from baseline in cytotoxic T-lymphocytes at 6 months (p< 0.01) and memory T-lymphocytes one year postoperatively (p=0.04). B-lymphocyte numbers did not alter significantly from baseline. Conclusion: Cytotoxic T-lymphocytes recognise HLA-class I molecules which are present on all nucleated cells and have been implicated in having a role in osteoclast regulation. Memory T-lymphocytes are produced after a naïve T-lymphocyte is exposed to an antigen. The observed increases of these subsets were not observed in the non-grafting group suggesting the allografted bone had elicited an immunological response. At 12 months all grafts appeared radiologically stable and the immunological response may have been beneficial to the outcome

We have followed a consecutive series of revision hip arthroplasties, performed for severe femoral bone loss using anatomic specific proximal femoral allografts. Forty-nine revision hip arthroplasties, using anatomic specific proximal femoral allografts longer than five centimetres were followed for a mean of 10.4 years. The mean preoperative HHS improved from 42.9 points to 76.9 points postoperatively. Six hips (12.2%) were further revised, four for non-union and aseptic failure of the implant (8.2%), one for infection (2%), and one for host step-cut fracture (2%). Junctional union was observed in 44 hips (90%). Three hips underwent re-attachment of the greater trochanter for trochanteric escape (6.1%). Asymptomatic non-union of the greater trochanter was noticed in three hips (6.1%). Moderate allograft resorption was observed in five hips (10.2%). Two fractures of the host step-cut occurred (4.1%). There were four dislocations (8.2%), two of them developed in conjunction with trochanteric escape. By definition of success as increase of HHS by 20 points or more, and no need for any subsequent re-operation related to the allograft and/or the implant, a 75.5% rate of success was found. Kaplan-Meier survivorship analysis predicted 73% rate of survival at 12 years, with the need for further revision of the allograft and/or implant as the end point. We conclude that the good medium-term results with the use of large anatomic- specific femoral allografts justify their continued use in cases of revision hip arthroplasty with severe bone stock loss

Proximal femoral replacements are commonly used in oncologic limb salvage procedures. Recently, these megaprostheses have been utilized in complex revision arthroplasties where proximal femoral bone is compromised. The purpose of this study is to evaluate the clinical and radiographic survivorship of proximal femoral replacements as a salvage treatment for bone loss after hip arthroplasty. We retrospectively reviewed the clinical and radiographic outcomes of 31 proximal femoral replacements of a single design between 2004 and 2013 at a single institution. The mean age at time of index surgery was 62 years, 58% were female, and mean BMI was 28.1 Kg/m. 2. The indications and complications associated with megaprosthesis implantation were collected. Average follow-up was 60 months (range 24–120 months). Kaplan-Meier survivorship assessed clinical and radiographic survivorship. Indication for revision, use of a constrained liner and construct length were assessed as risk factors for construct failure. The indications for proximal femoral replacement were periprosthetic infection (n=12, 38.7%), aseptic loosening (n=10, 32.3%), periprosthetic fracture (n=6, 19.3%), and non-union (n=3, 9.7%). A constrained liner was used in 22 hips (71%). The average length of bone resection was 148 cm (range 81–240 cm). There were nine revisions (29.2%): 3 for infection (9.7%) 2 for dislocation (6.5%), 2 for aseptic loosening (6.5%), and 2 for periprosthetic fracture (6.5%). Two of the 3 infections were in patients treated for infection. Overall survivorship was at 70.8%. There was no relation between the length of the bone resection, indication for revision and failure rate. Proximal femoral replacement in non-oncologic revision hip arthroplasty demonstrated a high failure rate at 2–10 year follow-up. Despite the high failure rate, the benefits of this salvage construct are that they allow full weight-bearing and allow rapid mobilization with minimal morbidity

Aim: To review the early complications associated with staged revision hip Arthroplasty utilising the Biomet antibiotic loaded cement spacer. Method: We report on 80 consecutive staged revision hip replacements using the Biomet antibiotic loaded cement system in our institution over 3 years (1999–2002), performed by three consultant surgeons, with a minimum 1 year follow up. Results: Our patients had an average age of 68 (range 48–90) years, with an equal sex distribution. The median time between the first and second stage was 147 (range 50–619) days. Fractures of the Biomet antibiotic loaded acrylic spacer occurred in 11% revisions when associated with an increase in time between stages and there was a 7% dislocation rate. Patients did not receive a revision prosthesis in 19% cases and had early recurrent sepsis following their two stage procedure in 6%. Three patients had a single episode of dislocation of their revision hip prosthesis within a month postoperatively. Two patients had a proximal DVT and one patient had a pulmonary embolus. The mortality within eight weeks was 7%, rising to 10% within a year. This may be related to patient sepsis and comorbidities or the energy expenditure required to mobilise following a first stage procedure that we have analysed. Conclusions: The risks of staged revision hip surgery for infection are substantial when considering the time involved, the energy expenditure required to mobilise following a first stage, the possibility of not achieving a revision hip prosthesis and the mortality rate. The Biomet antibiotic loaded cement system articulates and maintains soft tissue length in the majority of patients for the duration required between stages

Reconstruction of severe acetabular defects during revision hip arthroplasty presents a significant surgical challenge. Such defects are associated with significant loss of host bone stock, which must be addressed in order to achieve stable implant fixation. A number of imaging techniques including CT scanning with 3D image reconstruction are available to assist the surgeon in the pre-operative planning of such procedures. We describe the use of a novel technique to assist the pre-operative planning of severe acetabular defects during revision hip arthroplasty. Patient and Methods – We present the use of this technique in the case of a 78 year old patient who presented 20 years from index procedure with severe hip pain and inability to weight bear due aseptic loosening of a previously revised total hip arthroplasty. A Paprosky 3B defect was noted with intra-pelvic migration of the acetabular component. Pre-operative investigations included: inflammatory markers, pelvic CT scan with 3D reconstruction, pelvic angiography and hip aspiration. Using DICOM images obtained from the CT scan, we used free open source software to carry out a 3D surface render of the bony pelvis. This was processed and converted to a suitable format for 3D printing. Using selective laser sintering, a physical 3D model of the pelvis, acetabular component and proximal femur were produced. Using this model the surgeon was able to gain an accurate representation of both the position of the intra-pelvic cup and more accurately assess the loss of bone stock. This novel technique is particularly useful in the pre-operative planning of such complex acetabular defects in order to determine if/which reconstruction technique is most likely to be successful. 3D printing is a relatively recent technology, which has numerous potential clinical applications. This is the first reported case of this technology being used to assess acetabular defects during revision hip arthroplasty. The use of this technology gives the surgeon a 3D model of the pelvis, quickly (7 days from CT) and at a tenth of the cost (£280) of producing such a model through the traditional commercial routes. The model allowed the surgeon to size potential implant, quantify the amount of bone graft required (if applicable) and to more accurately classify the loss of acetabular bone stock

In revision hip surgery, a solidly cemented femoral component may obstruct access to the acetabulum, may be poorly orientated, or may have inadequate offset and head diameter. These problems can be addressed by revising the femoral component. The object of this study was to determine the outcome of cementing a polished, tapered, modular implant into the retained cement mantle. Benefits of cement within cement revision of a femoral stem include simplicity, reduced theatre time, and potentially reduced complication rates. A consecutive series of 36 patients (11 men, 25 women) age range 35 to 90 years (mean age 70) underwent c stem cement in cement revision hip arthroplasty between June 2000 and April 2006. Indications for revision arthroplasty included 20 patients with aseptic acetabular loosening and 13 patients with recurrent instability. Follow up (12–84 months, mean 48 months) was annual and the outcome for every implant was known. Outcome measures included the shortened WOMAC score, Orthowave patient satisfaction survey, radiographic analysis, and assessment of the records for perioperative complications. No patients were lost to follow up, 2 patients died with their hip in situ. The mean post operative WOMAC score at latest follow up was 10.89 (median 11, range 0 to 29). There has been no clinical or radiological signs of prosthesis loosening or failure on follow up. Complications included: one sacral plexus palsy which had a partial recovery, and one intra-operative periprosthetic fracture identified and treated at the time of the revision procedure. One patient underwent a further cup revision for recurrent dislocation. Cement within cement revision hip arthroplasty using a highly polished tapered stem in the short to medium term provides satisfactory functional outcomes and is associated with low complication rates and good survivorship. Longer term results are awaited

Background. Highly porous acetabular components are widely used in revision hip surgery. The purpose of this study is to compare the mid-term survivorship, clinical and radiological outcomes of a hemispherical cup (Stryker Tritanium Revision component) and a peripherally expanded cup (Zimmer TM modular component) in revision hip surgery. Methods. Between 2010 and 2017, 30 patients underwent revision hip replacement using a hemispherical cup and 54 patients using a peripherally expanded cup. The surgery was carried out by two arthroplasty surgeons, both fellowship-trained in revision hip surgery. Kaplan-Meier analysis was used to determine the survivorship of the components. Clinical outcomes were measured using the Oxford Hip Score. Radiographs were analysed for the presence of radiolucent lines in the DeLee and Charnley zones. Results. Follow up of both components ranged from 2 – 8 years. All the hemispherical cups were reinforced with screws whilst 86% of the peripherally expanded cups required screws. Four (13%) of the hemispherical cups required re-revision surgery for aseptic loosening. One (2%) of the peripherally expanded cups was revised for dislocation, but none for aseptic loosening. None of the peripherally expanded cups exhibited significant radiolucency as compared to 8 (27%) hemispherical cups. The mean Oxford Hip Score of the hemispherical and peripherally expanded cups was 38 and 40 respectively. Using revision for any cause as the end, survivorship of the hemispherical cups at 7.6 years was 80.66% while the peripherally expanded cups at 8.2 years was 98.15%. Conclusions. In our case-series, a peripherally expanded cup has shown a better mid-term radiological and clinical result, with a lower rate of re-revision surgery, when compared to a hemispherical cup

Revision hip arthroplasty for severe acetabular deficiency is a technically challenging operation. Many different methods have been described for the management of acetabular deficiency. These include augmentation with bone cement, structural allografts, impaction grafting, support rings with graft and reconstruction with a high centre of rotation. The long term results of many of these methods were variable. We reviewed the outcome of a stemmed acetabular cup (McMinn cup, Link UK) used with morsellised bone graft for revision hip arthroplasty with severe acetabular deficiency. The implant was used only in the most severe cases of acetabular deficiency where it was impossible to achieve stable fixation using simpler methods. This device was used in only 13 out of 265 revision arthroplasties performed by the senior author. Between 1995 and 2002 13 acetabulae were reconstructed using a stemmed acetabular cup and non-structural morsellised bone graft. All were revision procedures with the number of previous operations on the same hip ranging between 1 and 4. 2 patients died from causes not related to surgery. 1 hip was revised for persistent discharge although no organisms were identified on repeated cultures. The mean follow-up of the remaining 10 hips was 72 months (range 46 – 108 months). All patients were satisfied with the results and their function improved significantly post-operatively. 8 of the 10 people report no pain from the hip and 2 reported slight or occasional pain which did not interfere with their activities at last follow-up. The mean Harris Hip Score was 84.6 (range 70 to 99.8). Radiological assessment showed regeneration of acetabular bone stock. Some X-Rays showed proximal migration of the cup but with no evidence of loosening at last follow-up. Acetabular reconstruction using the McMinn stemmed acetabular cup is a useful technique in revision hip arthroplasty with severe acetabular deficiency

Background. Over 96% of primary total hip replacements (THR) recorded in the National Joint Registry (NJR) are performed through a posterior or lateral surgical approach. There is no high quality evidence available to support the use of one approach over the other in primary THR and even less evidence when the outcome of revision THR is considered. Methods. Questionnaires were sent to 267 patients who had revision hip replacements between January 2006 and March 2010 for aseptic loosening. They rated their pain from 0–10, and used the Self-Administered Patient Satisfaction Scale (SAPS), Oxford Hip Score (OHS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and Short form-12 (SF-12). Results. We performed 275 revision total hip replacements for aseptic loosening on patients in whom the primary operation details were available. Their mean age was 69 years (SD12) with 43% male and 57% right-sided procedures. 205 patients responded to our questionnaires (209/275 hips, 76%). Unfortunately 19 patients had died, 4 had dementia and 13 declined to participate. We were unable to contact a further 33.Grouping by approach, 20% (43/209) had primary and revision lateral approaches, 20% (43/209) had primary lateral and revision posterior and 60% (123/209) had both primary and revision via posterior approaches. The WOMAC and OHS were significantly better in patients who had a posterior approach for both primary and revision surgery, compared to those that did not (OHS p=0.028, WOMAC p=0.026). We found no significant differences in pain, satisfaction or health-related quality of life between the groups. Conclusions. Registry data may help further explore the relationship between surgical approach and outcome in revision hip surgery. A randomised controlled trial of the posterior versus lateral approach for revision surgery would provide a definitive answer. Level of Evidence. 2b - retrospective cohort study. Disclosures. No financial disclosures or conflicts of interests from any authors

Purpose. To evaluate the radiographic long-term result of femoral revision hip arthroplasty using impacted cancellous allograft combined with cemented, collarless, polished and tapered stem. Materials and methods. Among 28 patients with impacted cancellous allograft with a cemented stem, 28 hips from 26 consecutive patients were analyzed retrospectively. The average patient age was 59 years. The follow-up period ranged 9 years 6 months to 14 years 5 months (mean, 12, 5 years). Radiographic parameters analyzed in this study included subsidence of the stem in the cement, subsidence of the cement mantle in the femur, bone remodeling of the femur, radiolucent line, and osteolysis. Results. Radiographic analysis showed very stable stem initially. 27 stems showed minimal subsidence (less than 5 mm) and 1 stem showed moderate subsidence (about 10 mm) in the cement. But there was no mechanical failure and subsidence at the composit-femur interface. Evidence of cortical and trabecular remodeling were observed in all cases. No radiolucent line or osteolysis were found in the follow-up period. There were 4 proximal femoral cracks and 1 distal femoral splitting during operation. Conclusion. The result of cemented stem revision with the use of impacted cancellous allograft was good long-terand femoral bone stock deficiency may be reconstructed successfully

Patients report similar or better pain and function before revision hip arthroplasty than before primary arthroplasty but poorer outcomes after revision surgery. The trajectory of post-operative recovery during the first 12 months and any differences by type of surgery have received little attention. We explored the trajectories of change in pain and function after revision hip arthroplasty to 12-months post-operatively and compared them with those observed after primary hip arthroplasty. We conducted a single-centre UK cohort study of patients undergoing primary (n = 80) or revision (n = 43) hip arthroplasty. WOMAC pain and function scores and 20-metres walking time were collected pre-operatively, at 3 and 12-months post-operatively. Multilevel regression models were used to chart and compare the trajectories of post-operative change (0–3 months and 3–12 months) between the types of surgery. Patients undergoing primary arthroplasty had a total hip replacement (n=74) or hip resurfacing (n=6). Osteoarthritis was the indication for surgery in 92% of primary cases. Patients undergoing revision arthroplasty had revision of a total hip arthroplasty (n=37), hemiarthroplasty (n=2) or hip resurfacing (n=4). The most common indication for revision arthroplasty was aseptic loosening (n=29); the remaining indications were pain (n=4), aseptic lymphocyte-dominated vasculitis-associated lesion (n=4) or other reasons (n=6). Primary (87%) and revision arthroplasties (98%) were mostly commonly performed via a posterior surgical approach. The improvements in pain and function following revision arthroplasty occurred within the first 3-months following operation (WOMAC-pain, p<0.0001; WOMAC-function, p<0.0001; timed 20-metres walk, p<0.0001) with no evidence of further change beyond this initial period (p>0.05). While the pattern of recovery after revision arthroplasty was similar to that observed after primary arthroplasty, improvements in the first 3-months were smaller after revision compared to primary arthroplasty (p<0.0001). Patients listed for revision surgery reported lower pre-operative pain levels (p=0.03) but similar post-operative levels (p=0.268) compared to those undergoing primary surgery. At 12-months post-operation patients who underwent a revision arthroplasty had not reached the same level of function achieved by those who underwent primary arthroplasty (WOMAC-function p=0.015; Time walk p=0.004). Patients undergoing revision hip arthroplasty should be informed that the majority of their improvement will occur in the first 3-months following surgery and that the expected improvement will be less marked than that experienced following primary surgery. More research is now required to 1.) identify whether specific in-patient and post-discharge rehabilitation tailored towards patients undergoing revision arthroplasty would improve or achieve equivalent outcomes to primary surgery and 2.) whether patients who are achieving limited improvements at 3-months post-operative would benefit from more intensive rehabilitation. This will become all the more important with the increasing volume of revision surgery and the high expectations of patients who aspire to a disease-free and active life

We reviewed 19 revision hip arthroplasties in which the new femoral component had been recemented into the old, intact cement mantle. The mean time from the first operation to revision was 64 months and the average follow-up was 59 months. There were 7 excellent, 11 good, and one fair result. No femoral component had been revised for loosening and all the stems appeared radiographically stable. Complications included intraoperative perforation of the femur on two occasions and one dislocation. The use of the cement-within-cement technique requires that the old cement surface be dry and roughened to increase the surface area and that the cement be injected in the liquid phase to prevent lamination. The indications for this technique include a broken stem with an intact distal cement mantle, the removal of a femoral component for revision of a loose cup to improve exposure and/or increase offset, recurrent dislocation secondary to component malposition, and debonding of the femoral component within an intact cement mantle

We have used the Oxford hip score to monitor the progress of 1908 primary and 279 revision hip replacements undertaken since the start of 1995. Our review programme began in early 1999 and has generated 3900 assessments. The mean pre-operative scores for primary and revision cases were 40.95 and 40.11, respectively. The mean annual score for primary replacement at between 12 and 84 months ranged between 20.60 and 22.57. A comparison of cross-sectional and longitudinal data showed no significant differences. All post-operative reviews showed a significant improvement (p ≤ 0.0001). The 50- to 60-year-old group scored significantly better than the patients over 80 years of age up to 48 months (p < 0.01). A subgroup of 826 National Health Service (NHS) and 397 private patients, treated by the senior author (2292 Oxford assessments), had a higher (i.e. worse) mean pre-operative score for the NHS patients (p ≤ 0.001). The private patients scored better than the NHS group up to 84 months (p < 0.05). Patients treated by a surgeon performing more than 100 replacements each year had a significantly better outcome up to five years than those operated on by surgeons performing fewer than 20 replacements each year. The age of the patients at the time of operation, and their pre-operative level of disability, have both been identified as affecting the long-term outcome. Awareness of the influence of these factors should assist surgeons to provide balanced advice

We present a new method of trochanter stabilisation designed for use in difficult revision hip arthroplasties. A fixator is secured to the metaphysis of the femur, and its two malleable prongs encompass the trochanter fragment and stabilise it using the tension band principle. The fixator is versatile, simple to apply and has better mechanical properties than any technique using wires. We reviewed 49 revisions after a mean follow-up of 40 months. Patients had been mobilised early, but there were no detachments or displacements from the initial postoperative position. Although 31% of patients were osteoporotic and 16% had poor trochanter fragments, there was bony union in 46 of the 49 hips, the remaining three developing stable fibrous union

Introduction: Revision hip arthroplasty for aseptic loosening of femoral component is successfully treated with impaction bone grafting technique. Owing to easier technique and shorter operative time, distally fixed non-cemented long stems have gained popularity in the present era. However, use of long stems could make subsequent re-revision difficult due to further bone loss. The standard length stem has been often critiqued due to apprehension of peri-prosthetic fracture. This study aims to determine the long-term outcomes of the impaction bone grafting of the femur for aseptic loosening in revision hip arthroplasty using standard length C-stems. 168 total hip revisions of 162 patients with impaction bone grafting and cemented standard C-stem (done with standardized technique) between 1995 and 2008 at a tertiary referral centre were included. Revisions for infection and segmental bone defects were excluded. Mean follow-up of the 168 revision hips was 10.5 years (range 5 – 19.1 years). 14 patients (8.3%) were re-revised, reasons being, persistent deep infection (1.8%), repeated dislocations (1.2%), cup loosening (4.8%) and stem loosening (1.2%). Only 1 patient (0.6%) was re-revised due to stem loosening alone. No peri-prosthetic fractures (intra-operative or post-operative) or stem breakage were identified. Use of standard stem length in hip revisions with impaction bone grafting does not increase the risk of peri-prosthetic fractures, instead, reconstitutes the bone stock. This questions the conventional principle of bypassing the distal cavitation of femur by 2 cortical diameters with the use of long stem. In our experience, a good proximal femur support is key to performance of standard length cemented stems in revision for aseptic loosening irrespective of grade of distal cavitation for cavitatory defects of femur when treated with impaction bone grafting

We have followed a consecutive series of forty-nine revision hip arthroplasties (45 patients), performed for severe femoral bone loss using anatomic specific proximal femoral allografts longer than five centimetres. The patients were followed for a mean of 10.4 years, with a five year minimum follow-up. The mean preoperative Harris Hip Score improved from 42.9 points to 76.9 points postoperatively, an average improvement of 33.8 points. Six hips were further revised, for a failure rate of 12.2%, four for non-union and aseptic failure of the implant (8.2%), one for infection (2%), and one for host step-cut fracture (2%). Junctional union was observed in 44 hips (89.8%). Three hips underwent re-attachment of the greater trochanter for trochanteric escape (6.1%). Asymptomatic non-union of the greater trochanter were noticed in three hips (6.1%). Moderate allograft resorption was observed in five hips (10.2%), non were full-thickness graft resorption. Two fractures of the host step-cut occurred (4.1%). There were four dislocations (8.2%), two of them developed in conjunction with trochanteric escape. By definition of success as increase of HHS by 20 points or more, and no need for any subsequent re-operation related to the allograft and/or the implant, a 75.5% rate of success was found. Kaplan-Meier survivorship analysis predicted 73% rate of survival at 12 years, with the need for further revision of the allograft and/or implant as the end point. We conclude that the good medium-term results with the use of large anatomic-specific femoral allografts justify their continued use in cases of revision hip arthroplasty with severe bone stock loss

Aims: The aims of our study were:. to measure the total metal content in cell saver blood recovered during revision hip arthroplasty,. to evaluate the efficacy of centrifuging and washing the recovered blood in reducing the metal content,. to investigate whether transfusion of the salvaged blood resulted in a significant increase in the metal ion levels in the patients’ blood in the immediate post-operative period. Materials and methods: We analysed the levels of metallic debris and metal ions in cell saver blood in nine patients undergoing revision hip replacement. Using inductively coupled plasma mass spectrometry (ICP-MS), the levels were measured for titanium, aluminium, vanadium, chromium, cobalt, nickel and molybdenum. The metal ion levels were analysed using a dilution technique and the total metal content levels (particulate debris and ions) were analysed with a digestion technique. Results: Significantly higher levels of metal ions and metal debris were found in the pre-processed blood compared with the processed blood (after centrifuging and washing). The ion levels in the processed blood were not high enough to cause a significant increase in the patients’ immediate post-operative blood ion levels when compared with pre-operative levels. Discussion: There are markedly elevated levels of metal ions and particulate metal debris in the blood salvaged during revision total hip arthroplasty. The processing of the recovered blood in a commercial “cell saver” significantly reduces the total metal load that is re-infused. Re-infusion of salvaged blood does not result in elevated metal ion levels in the immediate post-operative period

The best type of stem fixation for revision hip arthroplasty is still controversial with regard to medium and long tem results. We wanted to ascertain the medium term results of revision hip arthroplasty using cemented collarless polished tapered femoral stem. Methods: 44 hips in 39 patients (23 female, 16 male) who had revision THR for aseptic loosening with a minimum follow-up of 10 years were reviewed clinically, radiographically and by using the oxford hip score. Flanged cemented polyethylene cup and polished tapered cemented stem were used. Clinical and radiological evidence of failure and revision rates were determined. Details of grafting and reinforcement required at surgery and any complications in the operative and postoperative period were noted. Results: The mean age of patients was 70 years (range 35–87 years). Femoral component alone was revised in 2 hips and both cup and stem were revised in 42 hips. Impaction grafting for acetabulum was required in 16 hips and for femur in 5 hips. Failure rate, with revision or excision arthroplasty as the end point, was 13.6% (Total 6 hips – cup and stem in 2 hips, cup only in 3 hips and excision arthroplasty with spacer for infection in 1 hip). The survival rate for femoral stem was 93% and for acetabular cup was 86%. Heterotopic ossification was seen in 9 hips, trochanteric bursitis in 5, short term thigh pain in 3. Mean last Oxford hip score was 30.5/60. Conclusion: Revision hip arthroplasty using cemented tapered polished stem provides good results at 10 – 13 year follow-up

Aim

The duration of systemic antibiotic therapy following first-stage surgery is contentious. Our Institution's philosophy is to perform an aggressive debridement, use high concentration targeted antibiotics through cement beads and systemic prophylactic antibiotics alone. In the presence of significant soft tissue infection or microbiological diagnostic uncertainty; systemic antibiotics may be prescribed for 5 days whilst awaiting tissue culture results. The aim of this study was to assess the success of our philosophy in the management of PJI of the hip using our two-stage protocol.

Aims

The duration of systemic antibiotic treatment following first-stage revision surgery for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is contentious. Our philosophy is to perform an aggressive debridement, and to use a high local concentration of targeted antibiotics in cement beads and systemic prophylactic antibiotics alone. The aim of this study was to assess the success of this philosophy in the management of PJI of the hip using our two-stage protocol.

Femoral impaction grafting with cancellous bone and cement is an important technique in reconstituting deficient bone stock in revision hip arthroplasty. We report the medium to long term results of 75 consecutive patients using a collarless, polished, tapered femoral stem with an average age of 68 (±11.4) years and a mean follow up of 10.5 (±2.4) years (range 6.3 to 14.1 years). The median Endoklinik pre-operative bone defect score was 3 (IQR: 2–3) with a median subsidence at 1 year of 2mm (IQR: 1–3mm). At the most recent follow-up (mean 10.5±2.4 years), the median Harris Hip Score (HHS) was 80.6 (IQR: 67.6–88.9) and median subsidence 2mm (IQR: 1–4mm). Ten-year survivorship with any further femoral operation as an endpoint was 92%. Four prostheses required further revision. Subsidence of the Exeter stem continued, albeit at a slower rate after the first year and was related to the Endoklinik pre-operative bone loss (p=0.037). The degree of subsidence at 1 year was a strong predictor of long term subsidence (p<0.001). Neither subsidence nor bone stock were related to long term outcome (HHS). There was a correlation between previous revision surgery and a poor Harris Hip Score (p=0.028) and those who had undergone previous revision surgery for infection had a higher risk of complications (p=0.048). The good long term results of this technique commend its use in revision hip arthroplasty for patients with poor femoral bone stock

This study reports the results of hybrid stem fixation in difficult revision hip arthroplasties where proximal femoral bone stock loss was severe. Twenty-six revision arthroplasties (21 women and 5 men, aged from 58 to 86 years), were performed between 1998 and 2008. The indication for surgery was aseptic loosening. In all cases, stabilization of the stem presented problems because of severe proximal femoral bone stock loss (due to extensive periprosthetic osteolytic defects), or because of iatrogenic defects or surgical procedures (attempts to remove the stem and cement with fenestration or extended osteotomy). The average follow-up was 48 months (range 16 to 120). Primary stability is necessary for the successful definite fixation of a cementless implant by bone. When this was not possible (because of proximal cortical insufficiency), we used a modular distally cemented long stem, bypassing the area of bone defect for at least 6–7 cm. Proximally bone defects were grafted and osteotomy was closed with cerclage wires. Four stems (15%) had an asymptomatic subsidence (3 stems subsided less than 3–4 mm and 1 stem about 15mm). No stem was revised to date. Major complications did not occur. The mean Harris hip score improved from 32 points preoperatively to 82.3 points (at the most recent evaluation). Hybrid fixation offers the advantage of initial and secure stability of the cemented stem on the short term, until stabilization of the entire implant by bone occurs. Thus early subsidence and loosening is avoided and on the long term benefits of the cementless fixation are attained. Our results support the method of hybrid fixation in patients with severe femoral bone loss (and consequently problematic stabilization), when primary stability is needed

Aims

To determine mortality risk after first revision total hip arthroplasty (THA) for periprosthetic femoral fracture (PFF), and to compare this to mortality risk after primary and first revision THA for other common indications.

Purpose: The aims of our study were: (i) to measure the total metal content in cell saver blood recovered during revision hip arthroplasty, (ii) to evaluate the efficacy of centrifuging and washing the recovered blood in reducing the metal content, (iii) to investigate whether transfusion of the salvaged blood resulted in a significant increase in the metal ion levels in the patients’ blood in the immediate post-operative period. Materials and methods: We analysed the levels of metallic debris and metal ions in cell saver blood in nine patients undergoing revision hip replacement. Using inductively coupled plasma mass spectrometry (ICP-MS), the levels were measured for titanium, aluminium, vanadium, chromium, cobalt, nickel and molybdenum. The metal ion levels were analysed using a dilution technique and the total metal content levels (particulate debris and ions) were analysed with a digestion technique. Results: Significantly higher levels of metal ions and metal debris were found in the pre-processed blood compared with the processed blood (after centrifuging and washing). The ion levels in the processed blood were not high enough to cause a significant increase in the patients’ immediate post-operative blood ion levels when compared with pre-operative levels. Conclusion: There are markedly elevated levels of metal ions and particulate metal debris in the blood salvaged during revision total hip arthroplasty. The processing of the recovered blood in a commercial ‘cell saver’ sig-nificantly reduces the total metal load that is re-infused. Re-infusion of salvaged blood does not result in elevated metal ion levels in the immediate post-operative period

Revision hip arthroplasty requires a comprehensive appreciation of abnormal bony anatomy. Advances in radiology and manufacturing technology have made three-dimensional representation of actual osseous anatomy obtainable. These models provide a visual and tactile reproduction of the bony abnormality in question. Life size three dimensional models were manufactured from CT scans of two patients. The first had multiple previous hip arthroplasties and bilateral hip infections. There was a pelvic discontinuity on the right and a severe postero-superior deficiency on the left. The second patient had a first stage revision for infection and recurrent dislocations. Specific metal reduction protocols were used to reduce artefact. The dicom images were imported into Mimics, medical imaging processing software. The models were manufactured using the rapid prototyping process, Selective Laser Sintering (SLS). The models allowed accurate templating using the actual prosthesis templates prior to surgery. Acetabular cup size, augment and buttress sizes, as well as cage dimensions were selected, adjusted and re-sterilised in advance. This reduced operative time, blood loss and improved surgical decision making. Screw trajectory simulation was also carried out on the models, thus reducing the chance of neurovascular injury. With 3D printing technology, complex pelvic deformities can be better evaluated and can be treated with improved precision. The life size models allow accurate surgical simulation, thus improving anatomical appreciation and pre-operative planning. The accuracy and cost-effectiveness of the technique were impressive and its use should prove invaluable as a tool to aid clinical practice

Background

Data regarding the diagnostic value of ultrasound (US)-determined fluid film and joint aspiration prior to revision total hip arthroplasty (THA) for suspected periprosthetic joint infections (PJIs) is limited. This study aimed to analyse (1) the value of US-determined fluid film, (2) characterisation of the pre- and intraoperative microbiological spectrum and resistance patterns and (3) the concordance between preoperative synovial fluid and intraoperative culture results.

The duration of systemic antibiotics following first-stage surgery is contentious. Our Institution's philosophy is to perform an aggressive debridement, high concentration of targeted antibiotics through cement beads and systemic prophylactic antibiotics alone. In the presence of significant soft tissue infection or microbiological diagnostic uncertainty; systemic antibiotics may be prescribed for 5 days whilst awaiting tissue culture results. The aim of this study was to assess the success of our philosophy for two-stage hip revision.

A retrospective review of our Institution's prospective database was performed to identify all intended two-stage hip revision procedures for PJI. All patients had a confirmed PJI as per MSIS 2013 criteria, minimum 5-years follow up and outcomes according to the MSIS working group outcome-reporting tool; then grouped into “successful” or “unsuccessful” (suppressive antibiotics, further revision for infection, death within 1 year).

383 intended two-stage hip revisions were identified; of which 299 met our inclusion criteria, in 289 patients (6 repeat ipsilateral two-stage, 4 bilateral two-stage). Median follow up was 10.7 years (IQR 6.3 – 15.0). 258 (86%) patients proceeded to 2^nd stage surgery. 91% success rate was observed for those patients who underwent reimplantation, although dropping to 86% when including the patients who did not proceed to second stage. The median duration of post-operative systemic antibiotics was 5 days (IQR 5–9). No significant difference was observed in patients who received either; < / = 48 hours (86%; n=70) compared to > 48 hours antibiotics (86%; n=229; p=0.96) or </= 5 days of antibiotics (88%; n=202) compared to > 5 days antibiotics (82%; p=0.38). A significant majority had gram-positive (88%) infection with 30% being polymicrobial. Greater success rates were observed with two-stage exchange or gram-positive PJI (86%); than for gram-negative PJI (81%) and polymicrobial infection (74%) (p=0.36). Fungal PJI was observed to have a significantly reduced rate of success (n=3; 33%; p=0.03).

Aggressive surgical debridement with high concentration, targeted local antibiotic delivery at time of first stage to manage PJI of the hip provides a high rate of success, responsible antibiotic stewardship and reduced hospital costs.

Revision hip arthroplasty presents a challenge in the setting of femoral bone loss. Tapered stems are susceptible to subsidence which leads to leg length inequality, hip instability and may necessitate repeat femoral revision surgery. The purpose of this study was to compare radiographic outcomes in two modular tapered revision systems with different distal stem geometries. We sought to establish the minimum postoperative stem bi-cortical contact length that predicts subsidence for tapered stems. This study examined revision total hip arthroplasties between 2009 and 2016 in a European university affiliated major trauma center. Modular stem A has a taper of 3 degrees whereas modular stem B has a taper of 2 degrees. Radiologic assessment compared x-rays at two time points: immediately post-surgery and most recent x-ray available at a minimum follow up of two years. Leg length discrepancy, subsidence and postoperative bi cortical contact was assessed. Descriptive summary statistics calculated clinical factors (i.e. age, gender, Paprosky classification). 122 arthroplasties were completed. Complete data was available for 112. Revisions were carried out for Paprovski grade 3a/ 3b femoral deficits. Post-operative bi-cortical contact of the proximal stem < 20mm was associated with higher subsidence rates (P = 0.047). Subsidence rates for implant A and B system were 4.27mm (0.12–25.62mm) and 3.43 mm (0.3–11.1 mm) respectively. Significant subsidence was noted in 9.8% (n=8) in implant A and 5.2%(n=2) in implant B. We conclude that immediate postoperative bi-cortical stem contact of <20mm was associated with significantly higher subsidence rates in this study

Introduction. There are conflicting reports in the literature regarding the migration of femoral stems in revision hip arthroplasty following the use of impaction allografting with or without cement. In some cemented series distal migration of the prosthesis within the cement mantle has been recorded, as well as migration of the whole cement/prosthesis construct into the graft. Method and Results. The results of 26 cases of revision hip replacement using femoral impaction allografting in the absence of bone cement are reported. The mean follow up was 8.5 years (range 4 to 17 years). The technique employed a Freeman stem coated proximally with hydroxyapatite. Three cases required further revision at 2, 4 and 5 years for high subsidence and unacceptable thigh pain. The remaining 23 cases stabilised following a period of initial settlement and overall results have been comparable to other series that have utilised cement. The initial sinkage in this series occurred mainly in the first six postoperative months. These results, from a single surgeon series, demonstrate that the method is highly technique dependent and relies on adequate graft impaction. Discussion. With sufficient graft and an appropriate prosthetic design, cement is not essential to the overall success of this method. However, the extent of the initial migration did not accurately predict a successful outcome for the procedure. The absence of cement removes any confusion as to the location of any migration. All prostheses settled into the graft bed. These results should be extrapolated to other prosthetic designs with caution