Aims. Instability is a common indication for revision total hip arthroplasty (THA). However, even after the initial revision, some patients continue to have recurrent dislocation. The aim of this study was to assess the risk for recurrent dislocation after revision THA for instability. Methods. Between 2009 and 2019, 163 patients underwent revision THA for instability at Stanford University Medical Center. Of these, 33 (20.2%) required re-revision due to recurrent dislocation. Cox proportional hazard models, with death and re-revision surgery for periprosthetic infection as competing events, were used to analyze the risk factors, including the size and alignment of the components. Paired t-tests or Wilcoxon signed-rank tests were used to assess the outcome using the Veterans RAND 12 (VR-12) physical and VR-12 mental scores, the Harris Hip Score (HHS) pain and function, and the Hip disability and Osteoarthritis Outcome score for Joint Replacement (HOOS, JR). Results. The median follow-up was 3.1 years (interquartile range 2.0 to 5.1). The one-year cumulative incidence of recurrent dislocation after revision was 8.7%, which increased to 18.8% at five years and 31.9% at ten years postoperatively. In multivariable analysis, a high American Society of Anesthesiologists (ASA) grade (hazard ratio (HR) 2.72 (95% confidence interval (CI) 1.13 to 6.60)), BMI between 25 and 30 kg/m. 2. (HR 4.31 (95% CI 1.52 to 12.27)), the use of specialized liners (HR 5.39 (95% CI 1.97 to 14.79) to 10.55 (95% CI 2.27 to 49.15)), lumbopelvic stiffness (HR 6.03 (95% CI 1.80 to 20.23)), and postoperative abductor weakness (HR 7.48 (95% CI 2.34 to 23.91)) were significant risk factors for recurrent dislocation. Increasing the size of the acetabular component by > 1 mm significantly decreased the risk of dislocation (HR 0.89 (95% CI 0.82 to 0.96)). The VR-12 physical and HHS (pain and function) scores improved significantly at mid term. Conclusion. Patients requiring revision THA for instability are at risk of recurrent dislocation. Higher ASA grades, being overweight, a previous lumbopelvic fusion, the use of specialized liners, and postoperative abductor weakness are significant risk factors. Cite this article: Bone Joint J 2024;106-B(5 Supple B):105–111

Aims. Our objective was describing an algorithm to identify and prevent vascular injury in patients with intrapelvic components. Methods. Patients were defined as at risk to vascular injuries when components or cement migrated 5 mm or more beyond the ilioischial line in any of the pelvic incidences (anteroposterior and Judet view). In those patients, a serial investigation was initiated by a CT angiography, followed by a vascular surgeon evaluation. The investigation proceeded if necessary. The main goal was to assure a safe tissue plane between the hardware and the vessels. Results. In ten at-risk patients undergoing revision hip arthroplasty and submitted to our algorithm, six were recognized as being high risk to vascular injury during surgery. In those six high-risk patients, a preventive preoperative stent was implanted before the orthopaedic procedure. Four patients needed a second reinforcing stent to protect and to maintain the vessel anatomy deformed by the intrapelvic implants. Conclusion. The evaluation algorithm was useful to avoid blood vessels injury during revision total hip arthroplasty in high-risk patients. Cite this article: Bone Jt Open 2022;3(11):859–866

Aims. Large acetabular bone defects encountered in revision total hip arthroplasty (THA) are challenging to restore. Metal constructs for structural support are combined with bone graft materials for restoration. Autograft is restricted due to limited volume, and allogenic grafts have downsides including cost, availability, and operative processing. Bone graft substitutes (BGS) are an attractive alternative if they can demonstrate positive remodelling. One potential product is a biphasic injectable mixture (Cerament) that combines a fast-resorbing material (calcium sulphate) with the highly osteoconductive material hydroxyapatite. This study reviews the application of this biomaterial in large acetabular defects. Methods. We performed a retrospective review at a single institution of patients undergoing revision THA by a single surgeon. We identified 49 consecutive patients with large acetabular defects where the biphasic BGS was applied, with no other products added to the BGS. After placement of metallic acetabular implants, the BGS was injected into the remaining bone defects surrounding the new implants. Patients were followed and monitored for functional outcome scores, implant fixation, radiological graft site remodelling, and revision failures. Results. Mean follow-up was 39.5 months (36 to 71), with a significant improvement in post-revision function compared to preoperative function. Graft site remodelling was rated radiologically as moderate in 31 hips (63%) and strong in 12 hips (24%). There were no cases of complete graft site dissolution. No acetabular loosening was identified. None of the patients developed clinically significant heterotopic ossification. There were twelve reoperations: six patients developed post-revision infections, three experienced dislocations, two sustained periprosthetic femur fractures, and one subject had femoral component aseptic loosening. Conclusion. Our series reports bone defect restoration with the sole use of a biphasic injectable BGS in the periacetabular region. We did not observe significant graft dissolution. We emphasize that successful graft site remodelling requires meticulous recipient site preparation. Cite this article: Bone Jt Open 2022;3(12):991–997

Instability is a common indication for revision total hip arthroplasty (THA). However, even after the initial revision, some patients continue to have recurrent dislocations. This study investigates those at risk for recurrent dislocation after revision THA for instability at a single institution. Between 2009 and 2019, 163 patients underwent revision THA for instability at a single institution. Thirty-three of these patients required re-revision THA due to recurrent dislocation. Cox proportional hazard models with death as a competing event were used to analyze risk factors, including prosthesis sizing and alignment. Paired t-tests or Wilcoxon signed rank tests were used to assess patient outcomes (Veterans RAND 12 (VR-12) physical score, VR-12 mental score, Harris Hip Score, and hip disability and osteoarthritis outcome score for joint replacement). Duration of follow-up until either re-revision or final follow-up was a mean of 45.3 ± 38.2 months. The 1-year cumulative incidence for recurrent dislocation after revision was 8.7%, which increased to 19.6% at 5 years and 32.9% at 10 years postoperatively. In the multivariable analysis, high ASA score [HR 2.71], being underweight (BMI<18 kg/m. 2. ) [HR 36.26] or overweight/obese (BMI>25 kg/m. 2. ) [HR 4.31], use of specialized liners [HR 5.51–10.71], lumbopelvic stiffness [HR 6.29], and postoperative abductor weakness [HR 7.20] were significant risk factors for recurrent dislocation. Increasing the cup size decreased the dislocation risk [HR 0.89]. The dual mobility construct did not affect the risk for recurrent dislocation in univariate or multivariable analyses. VR-12 physical and HHS (pain and function) scores improved postoperatively at midterm. Patients requiring revision THA for instability are at risk for recurrent dislocation. Higher ASA scores, abnormal BMI, use of special liners, lumbopelvic stiffness, and postoperative abductor weakness are significant risk factors for re-dislocation

The advent of modular porous metal augments has ushered in a new form of treatment for acetabular bone loss. The function of an augment can be seen as reducing the size of a defect or reconstituting the anterosuperior/posteroinferior columns and/or allowing supplementary fixation. Depending on the function of the augment, the surgeon can decide on the sequence of introduction of the hemispherical shell, before or after the augment. Augments should always, however, be used with cement to form a unit with the acetabular component. Given their versatility, augments also allow the use of a hemispherical shell in a position that restores the centre of rotation and biomechanics of the hip. Progressive shedding or the appearance of metal debris is a particular finding with augments and, with other radiological signs of failure, should be recognized on serial radiographs. Mid- to long-term outcomes in studies reporting the use of augments with hemispherical shells in revision total hip arthroplasty have shown rates of survival of > 90%. However, a higher risk of failure has been reported when augments have been used for patients with chronic pelvic discontinuity. Cite this article: Bone Joint J 2024;106-B(4):312–318

Aims. There is little information in the literature about the use of dual-mobility (DM) bearings in preventing re-dislocation in revision total hip arthroplasty (THA). The aim of this study was to compare the use of DM bearings, standard bearings, and constrained liners in revision THA for recurrent dislocation, and to identify risk factors for re-dislocation. Methods. We reviewed 86 consecutive revision THAs performed for dislocation between August 2012 and July 2019. A total of 38 revisions (44.2%) involved a DM bearing, while 39 (45.3%) and nine (10.5%) involved a standard bearing and a constrained liner, respectively. Rates of re-dislocation, re-revision for dislocation, and overall re-revision were compared. Radiographs were assessed for the positioning of the acetabular component, the restoration of the centre of rotation, leg length, and offset. Risk factors for re-dislocation were determined by Cox regression analysis. The modified Harris Hip Scores (mHHSs) were recorded. The mean age of the patients at the time of revision was 70 years (43 to 88); 54 were female (62.8%). The mean follow-up was 5.0 years (2.0 to 8.75). Results. DM bearings were used significantly more frequently in elderly patients (p = 0.003) and in hips with abductor deficiency (p < 0.001). The re-dislocation rate was 13.2% for DM bearings compared with 17.9% for standard bearings, and 22.2% for constrained liners (p = 0.432). Re-revision-free survival for DM bearings was 84% (95% confidence interval (CI) 0.77 to 0.91) compared with 74% (95% CI 0.67 to 0.81) for standard articulations, and 67% (95% CI 0.51 to 0.82) for constrained liners (p = 0.361). Younger age (hazard ratio (HR) 0.92 (95% CI 0.85 to 0.99); p = 0.031), lower comorbidity (HR 0.44 (95% CI 0.20 to 0.95); p = 0.037), smaller heads (HR 0.80 (95% CI 0.64 to 0.99); p = 0.046), and retention of the acetabular component (HR 8.26 (95% CI 1.37 to 49.96); p = 0.022) were significantly associated with re-dislocation. All DM bearings which re-dislocated were in patients with abductor muscle deficiency (HR 48.34 (95% CI 0.03 to 7,737.98); p = 0.303). The radiological analysis did not reveal a significant relationship between restoration of the geometry of the hip and re-dislocation. The mean mHHSs significantly improved from 43 points (0 to 88) to 67 points (20 to 91; p < 0.001) at the final follow-up, with no differences between the types of bearing. Conclusion. We found that the use of DM bearings reduced the rates of re-dislocation and re-revision in revision THA for recurrent dislocation, but did not guarantee stability. Abductor deficiency is an important predictor of persistent instability. Cite this article: Bone Joint J 2024;106-B(5 Supple B):89–97

The number of revision total hip arthroplasties (THA) is increasing. This procedure is associated with a higher complication rate than primary THA, and so it is important for patients to have realistic expectations. The aim of this systematic review was to gather and summarise the available evidence on patients’ expectations following revision THA. A literature search was conducted in PubMed, PsycINFO, Cochrane, Google Scholar and Web of Science from inception to December 2021. Methodological quality was assessed by two independent reviewers using the National Heart, Lung and Blood Institute (NIH) study quality assessment tool for observational cohort and cross-sectional studies. The search strategy generated 3132 references of which 4 articles met the inclusion criteria. Methodological quality scores ranged from 7–10. Patients have high expectations concerning future walking ability, pain and implant longevity. Implant longevity expectations vary according to the longevity of the primary implant. A significant positive correlation was found between fulfilled expectations of pain and walking ability and patient satisfaction (r = .46 – .47). Only one study assessed fulfilment of patient expectations. Great variability was seen in operationalisation and assessment of expectations. Patients undergoing revision THA appear to have high expectations with regards to future outcomes. Whilst results are promising, there is a paucity of high-quality data in this area. Further research is needed, which places emphasis on developing a sound theoretical framework for expectations, allowing for the consistent implementation of valid measurement tools

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

Aims. Modular dual mobility (MDM) acetabular components are often used with the aim of reducing the risk of dislocation in revision total hip arthroplasty (THA). There is, however, little information in the literature about its use in this context. The aim of this study, therefore, was to evaluate the outcomes in a cohort of patients in whom MDM components were used at revision THA, with a mean follow-up of more than five years. Methods. Using the database of a single academic centre, 126 revision THAs in 117 patients using a single design of an MDM acetabular component were retrospectively reviewed. A total of 94 revision THAs in 88 patients with a mean follow-up of 5.5 years were included in the study. Survivorship was analyzed with the endpoints of dislocation, reoperation for dislocation, acetabular revision for aseptic loosening, and acetabular revision for any reason. The secondary endpoints were surgical complications and the radiological outcome. Results. The overall rate of dislocation was 11%, with a six-year survival of 91%. Reoperation for dislocation was performed in seven patients (7%), with a six-year survival of 94%. The dislocations were early (at a mean of 33 days) in six patients, and late (at a mean of 4.3 years) in four patients. There were three intraprosthetic dissociations. An outer head diameter of ≥ 48 mm was associated with a lower risk of dislocation (p = 0.013). Lumbrosacral fusion was associated with increased dislocation (p = 0.004). Four revision THAs (4%) were further revised for aseptic acetabular loosening, and severe bone loss (Paprosky III) at the time of the initial revision was significantly associated with further revision for aseptic acetabular loosening (p = 0.008). Fourteen acetabular components (15%) were re-revised for infection, and a pre-revision diagnosis of reimplantation after periprosthetic joint infection (PJI) was associated with subsequent PJI (p < 0.001). Two THAs had visible metallic changes on the backside of the cobalt chromium liner. Conclusion. When using this MDM component in revision THA, at a mean follow-up of 5.5 years, there was a higher rate of dislocation (11%) than previously reported. The size of the outer bearing was related to the risk of dislocation. There was a low rate of aseptic acetabular loosening. Longer follow-up of this MDM component and evaluation of other designs are warranted. Cite this article: Bone Joint J 2021;103-B(7 Supple B):66–72

Aims. There are limited long-term studies reporting on outcomes of the Zimmer Modular Revision (ZMR) stem, and concerns remain regarding failure. Our primary aim was to determine long-term survival free from all-cause revision and stem-related failure for this modular revision stem in revision total hip arthroplasty (THA). Secondary aims included evaluating radiological and functional outcomes. Methods. We retrospectively identified all patients in our institutional database who underwent revision THA using the ZMR system from January 2000 to December 2007. We included 106 patients (108 hips) with a mean follow-up of 14.5 years (2.3 to 22.3). Mean patient age was 69.2 years (37.0 to 89.4), and 51.9% were female (n = 55). Indications for index revision included aseptic loosening (73.1%), infection (16.7%), fracture (9.3%), and stem fracture (0.9%). Kaplan-Meier analysis was used to determine the all-cause and stem-related failure revision-free survival. At most recent follow-up, Oxford Hip Scores (OHS) were collected, and radiological stem stability was determined using the Engh classification. Results. A total of 17 hips (15.7%) underwent re-revision of any component. Indications for re-revision were stem failure (35.3%; n = 6), infection (29.4%; n = 5), instability (29.4%; n = 5), and acetabular aseptic loosening (5.9%; n = 1). The five- and 15-year all-cause survival was 89.7% (95% confidence interval (CI) 86.7 to 92.7) and 83.3% (95% CI 79.6 to 87.0), respectively. There were six re-revisions (5.6%) for stem failure; five for stem fracture and one for aseptic loosening. The five- and 15-year survival free from stem-related failure was 97.2% (95% CI 95.6 to 98.8) and 94.0% (95% CI 91.6 to 96.4), respectively. At final follow-up, the mean OHS was 36.9 (8.0 to 48.0) and 95.7% (n = 66) of surviving modular revision stems were well-fixed in available radiographs. Conclusion. Femoral revision with the ZMR offers satisfactory long-term all-cause revision-free survival, good survival free of stem-related failure, and favourable clinical outcomes. Stem fracture was the most common reason for stem-related failure and occurred both early and late. This highlights the importance of both early and long-term surveillance for stem-related failure. Cite this article: Bone Joint J 2024;106-B(5 Supple B):112–117

Introduction. Total joint arthroplasty rates have increased dramatically in recent decades. However, a comprehensive analysis of trends in revision total hip arthroplasty has not been performed recently to address the changing volume, costs, and location of these complex cases. We sought to identify trends in volume of these procedures, geographic distribution changes, and cost trends using a national sample. Materials and methods. The National Inpatient Sample, a representative sample of all hospital discharges within the United States, was used to determine the volume of revision total hip arthroplasty (THA) from 1993 to 2014. Procedures were identified by ICD-9 codes corresponding to revision THA. Annual incidence of revision THA was compared to annual incidence of primary THA to determine whether relative growth of revisions differed proportionally from the primary procedure. State-specific data was analyzed where available to develop geographic trend maps in the incidence of revision THA procedures using the estimated state population for years under review. Trends were also reviewed for hospital location (urban versus rural; teaching versus non-teaching) and total hospital charges. Analysis of trends was performed using linear regression models. Results. Volume of revision THA increased slower than primary THA from 1993 to 2014. Revision THA volume increased from 28,429 in 1993 to 48,295 in 2014. However, the relative proportion of revision compared to primary THA during this time period decreased from 21.3% in 1993 to 13.0% in 2014. While revision THA grew significantly at 925 additional procedures per year (p <0.001), the revision/primary proportion declined at a rate of −0.4 percentage points annually (p <0.001). Nationally, only one state demonstrated statewide incidence rate of revision THA >100 / 100,000 residents in 2001, while 31 of 36 states reporting in 2014 demonstrated statewide incidence rate of revision THA >100 / 100,000 residents. Revision THA shifted dramatically away from rural and urban non-teaching hospitals to urban teaching hospitals. In the year 2000, 52.3% of revision THA was performed in urban teaching hospitals, which had increased to 71.2% by 2014. Only 5.2% of revision THA was performed in rural hospitals in 2014. Similarly, hospital charges for revision THA increased significantly from a mean of $32,007 in 2000 to $83,927 in 2014. Discussion. Dramatic changes in the geographic distribution, hospital type, and cost of revision THA have occurred over the past two decades. The importance of this cannot be overstated, especially within the context of shifting payment models including mandated and voluntary bundles that have been applied to total joint arthroplasty procedures. With the burden of these costly, complex surgical cases falling predominantly on urban teaching hospitals, there must be a mechanism for adequately valuing these procedures to allow surgeons to be able to properly care for these patients. For any tables or figures, please contact the authors directly

Aims. Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors. Methods. We retrospectively included 125 patients with chronic hip PJI who underwent a staged THA revision performed between January 2013 and December 2019. All spacer complications were systematically collected, and risk factors were analyzed. Statistical evaluations were performed using the Student's t-test, Mann-Whitney U test, and Fisher's exact test. Results. Our staged exchange practice shows poor results, which means a 42% mechanical spacer failure rate, and a 20% recurrent infection rate over the two years average follow-up period. Moreover, we found a high rate of spacer dislocation (23%) and a low rate of spacer fracture (8%) compared to the previous literature. Our findings stress that the majority of spacer complications and failures is reflecting a population with high comorbid burden, highlighted by the American Society of Anesthesiology grade, Charlson Comorbidity Index, and Lee score associations, as well as the cardiac, pulmonary, kidney, or hepatic chronic conditions. Conclusion. Our experience of a two-stage hip exchange revision noted important complication rates associated with high failure rates of polymethylmethacrylate spacers. These findings must be interpreted in the light of the patient’s comorbidity profiles, as the elective population for staged exchange has an increasing comorbid burden leading to poor results. In order to provide better results for this specific population, our conclusion suggests that comparative strategy studies are required to improve our therapeutic indication. Cite this article: Bone Jt Open 2022;3(6):485–494

Aims. Studying the indications for revision total hip arthroplasty (THA) may enable surgeons to change their practice during the initial procedure, thereby reducing the need for revision surgery. The aim of this study was to identify and describe the potentially avoidable indications for revision THA within five years of the initial procedure. Patients and Methods. A retrospective review of 117 patients (73 women, 44 men; mean age 61.5 years (27 to 88)) who met the inclusion criteria was conducted. Three adult reconstruction surgeons independently reviewed the radiographs and medical records, and they classified the revision THAs into two categories: potentially avoidable and unavoidable. Baseline demographics, perioperative details, and quality outcomes up to the last follow-up were recorded. Results. A total of 60 revision THAs (51.3%) were deemed potentially avoidable and 57 (48.7%) were deemed unavoidable. The following were identified as avoidable factors: suboptimal positioning of the acetabular component (29; 48%), intraoperative fracture or a fracture missed on an intraoperative radiograph (20; 33%), early (less than two weeks) aseptic loosening (seven; 11.7%), and symptomatic leg length discrepancy of > 1 cm (four; 6.7%). Conclusion. A surprisingly large proportion of acute revision THAs are potentially avoidable. Surgeons must carefully evaluate the indications for revision THAs in their practice and identify new methods to address these issues. Cite this article: Bone Joint J 2019;101-B(6 Supple B):97–103

Introduction. Re-revision due to instability and dislocation can occur in up to 1 in 4 cases following revision total hip arthroplasty (THA). Optimal placement of components during revision surgery is thus critical in avoiding re-revision. Computer-assisted navigation has been shown to improve the accuracy and precision of component placement in primary THA; however, its role in revision surgery is less well documented. The purpose of our study was to evaluate the effect of computer-assisted navigation on component placement in revision total hip arthroplasty, as compared with conventional surgery. Methods. To examine the effect of navigation on acetabular component placement in revision THA, we retrospectively reviewed data from a multi-centre cohort of 128 patients having undergone revision THA between March 2017 and January 2019. An imageless computer navigation device (Intellijoint HIP®, Intellijoint Surgical, Kitchener, ON, Canada) was utilized in 69 surgeries and conventional methods were used in 59 surgeries. Acetabular component placement (anteversion, inclination) and the proportion of acetabular components placed in a functional safe zone (40° inclination/20° anteversion) were compared between navigation assisted and conventional THA groups. Results. Mean inclination decreased post-operatively versus baseline in both the navigation (44.9°±12.1° vs. 43.0°±6.8°, p=0.65) and control (45.8°±19.4° vs. 42.8°±7.1°, p=0.08) groups. Mean anteversion increased in both study groups, with a significant increase noted in the navigation group (18.6°±8.5° vs. 21.6°±7.8°, p=0.04) but not in the control group (19.4°±9.6° vs. 21.2°±9.8°, p=0.33). Post-operatively, a greater proportion of acetabular components were within ±10° of a functional target (40° inclination, 20° anteversion) in the navigation group (inclination: 59/67 (88%), anteversion: 56/67 (84%)) than in the control group (49/59 (83%) and 41/59, (69%), respectively). Acetabular component precision in both study groups improved post-operatively versus baseline. Variance in inclination improved significantly in both control (50.6° vs. 112.4°, p=0.002) and navigation (46.2° vs. 141.1°, p<0.001) groups. Anteversion variance worsened in the control group (96.3° vs. 87.6°, p=0.36) but the navigation group showed improvement (61.2° vs. 72.7°, p=0.25). Post-operative variance amongst cup orientations in the navigation group (IN: 46.2°; AV: 61.2°) indicated significantly better precision than that observed in the control group (IN: 50.6°, p=0.36; AV: 96.3°, p=0.04). Discussion. Re-revision is required in up to 25% of revision THA cases, of which 36% are caused by instability. This places a significant burden on the health care system and highlights the importance of accurate component placement. Our data indicate that the use of imageless navigation in revision THA – by minimizing the likelihood of outliers – may contribute to lower rates of re-revision by improving component orientation in revision THA. Conclusion. Utilizing imageless navigation in revision THAs results in more consistent placement of the acetabular component as compared to non-navigated revision surgeries

Background. Standard preoperative protocols in total joint arthroplasty utilize the International Normalized Ratio (INR) to determine patient coagulation profiles. However, the relevance of preoperative INR values in joint arthroplasty remains controversial. Acceptable INR cutoff values for joint replacement are inconsistent, and are often based on studies of primary arthroplasty, or even non-orthopedic procedures. This analysis examined the relationship between preoperative INR values and post-operative outcomes in revision total hip arthroplasty (rTHA). Optimal cutoff INR values correlated with specific outcomes were subsequently determined. Methods. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was retrospectively queried for revision total hip arthroplasty procedures performed between 2006 and 2017. Patients with a preoperative INR collected no later than 1 day prior to surgery were further stratified for analysis. INR values which correlated with specific outcomes were determined using receiver operating characteristics (ROC) curves for each outcome of interest. The optimal cutoff INR value for each outcome was then obtained using univariate and multivariate models which determined INR values that maximized both sensitivity and specificity. Results. There were a total of 11,393 patients who underwent a revision total hip arthroplasty from 2006–2017 recorded in NSQIP. Of the 2,012 patients who met inclusion and exclusion criteria, 858 had an INR < 1.0, 931 had an INR > 1.0 to 1.25, 175 had an INR > 1.25 to 1.5, and 48 patients had an INR > 1.5. Patients with progressively higher INR values had a significantly different risk of mortality within 30 days (p=0.005), bleeding requiring transfusion (p< 0.001), sepsis (p=0.002), stroke (p<0.001), failure to wean from ventilator within 48 hours (p=0.001), readmission (p=0.01), and hospital length of stay (p< 0.001). Similar results were obtained when utilizing optimal INR cutoff values. When correcting for other factors, the following poor outcomes were significantly associated with the respective INR cutoff values (Estimate, 95% CI, p value): LOS (1.67, 1.34–2.08, p <0.001), bleeding requiring transfusion (1.65, 1.30–2.09, p<0.001), sepsis (2.15, 1.11–4.17, p 0.02), and any infection (1.82, 1.01–3.29, p 0.04). Conclusions. INR values >1.65, >1.67, >1.82, and >2.15 were correlated with increased transfusion requirements, LOS, any infection, and sepsis respectively. Therefore, even subtherapeutic elevations in INR may predict poor outcomes following revision total joint replacement. Surgeons and perioperative medical specialists should consider more stringent INR goals when optimizing patients prior to revision arthroplasty. Level of Evidence. Prognostic Level IV. For any figures or tables, please contact authors directly

Safe and meticulous removal of the femoral cement mantle and cement restrictor can be a challenging process in revision total hip arthroplasty (rTHA). Many proximal femoral osteotomies have been described to access this region however they can be associated with fracture, non-union and revision stem instability. The aim of this study is to report outcomes of our previously unreported vascularised anterior window to the proximal femur. We report on a cohort of patients who underwent cemented single and staged rTHA at our single institution by the same surgeon between 2012 and 2017 using a novel vascularised anterior window of the femur to extract the cement mantle and restrictor safely under direct vision. We describe our technique, which maintains the periosteal and muscular attachments to the osteotomised fragment, which is then repaired with a polymer cerclage cable. In all revisions a polished, taper slip, long stem Exeter was cemented. Primary outcome measures included the time taken for union and the patient reported WOMAC score. Thirty-two rTHAs were performed in 29 consecutive patients (13 female, 16 male) with a mean age of 63.4 years (range, 47–88). The indications for revision included infection, aseptic loosening and implant malpositioning. Mean follow up was 5.3 (range, 3.2–8 years). All femoral windows achieved radiographic union by a mean of 7.2 weeks. At the latest point in follow-up the mean WOMAC score was 21.6 and femoral component survivorship was 100%. There were no intraoperative complications or additional revision surgery. Our proposed vascularised anterior windowing technique of the femur is a safe and reproducible method to remove the distal femoral cement and restrictor under direct vision without the need for perilous instruments. This method also preserves the proximal bone stock and provides the surgeon with the option of cemented stems over uncemented revision implants that predominantly rely on distal fixation

Dual-mobility (DM) bearings are effective to mitigate dislocation in revision total hip arthroplasty (THA). However, data on its use for treating dislocation is scarce. Aim of this study was to compare DM bearings, standard bearings and constrained liner (CL) in revision THA for recurrent dislocation and to identify risk factors for re-dislocation. We reviewed 100 consecutive revision THAs performed for dislocation from 2012 and 2019. 45 hips (45%) received a DM construct, while 44 hips (44%) and 11 hips (11%) had a standard bearing and CL, respectively. Rates of re-dislocation, re-revision for dislocation and overall re-revision were compared. Radiographs were assessed for cup positioning, restoration of centre of rotation, leg length and offset. Risk factors for re-dislocation were determined by cox regression analysis. Modified Harris hip scores (mHHS) were calculated. Mean follow-up was 53 months (1 to 103). DM constructs were used more frequently in elderly patients (p=0.011) and hips with abductor deficiency (p< 0.001). The re-dislocation rate was 11.1% for DM bearings compared with 15.9% for standard bearings and 18.2% for CL (p=0.732). Revision-free survival for DM constructs was 83% (95% CI 0.77 – 0.90) compared to 75% (95% CI 0.68 – 0.82) for standard articulations and 71% (95% CI 0.56 – 0.85) for CL (p=0.455). Younger age (HR 0.91; p=0.020), lower comorbidity (HR 0.42; p=0.031), smaller heads (HR 0.80; p=0.041) and cup retention (HR 8.23; p=0.022) were associated with re-dislocation. Radiological analysis did not reveal a relationship between restoration of hip geometry and re-dislocation. mHHS significantly improved from 43.8 points to 65.7 points (p<0.001) with no differences among bearing types. Our findings suggest that DM bearings do not sufficiently prevent dislocation in revision THA for recurrent dislocation. Reconstruction of the abductor complex may play a key role to reduce the burden in these high-risk patients

Previous reports on the outcomes of isolated head and liner exchange in revision total hip arthroplasty have found high rates of instability following these surgeries. Most reports have studied constructs using ≤28mm femoral heads. The purpose of this study was to determine if modern techniques with the use of larger head sizes can improve the rate of instability after head and liner exchange. We identified 138 hips in 132 patients who underwent isolated head and liner exchange for polyethylene wear/osteolysis (57%), acute infection (27%), metallosis (13%), or other (2%). All patients underwent revision with either 32mm (23%), 36mm (62%), or 40mm (15%) diameter heads. Crosslinked polyethylene was used in all revisions. Lipped and/or offset liners were used in 104 (75%) hips. Average follow up was 3.5 (1.0–9.1) years. Statistical analyses were performed with significance set at p<0.05. Revision-free survivorship for any cause was 94.6% and for aseptic causes was 98.2% at 5 years. 11 (8%) hips experienced a complication with 7 (5%) hips requiring additional revision surgery. Following revision, 4 (3%) hips experienced dislocation, 5 (4%) hips experienced infection, and 1 (1%) hip was revised for trunnionosis. No demographic or surgical factors significantly affected outcomes. Our study shows that isolated head and liner exchange using large femoral heads and modern liners provides for better stability than previous reports. The most common complication was infection. We did not identify specific patient, surgical or implant factors that reduced the risk of instability or other complication

Principles of bone preservation and restoration of biomechanical alignment should be followed during revision total hip arthroplasty (THA). Where possible, conservative femoral revision techniques and even reconstructive de-escalation involving using primary stems should be considered. This study aims to investigate the outcome of patients who have undergone conservative femoral revision THA in our Institution. We retrospectively identified patients from our Institution's revision arthroplasty database who had cemented, or un-cemented primary stems implanted during revision THA of a previous stemmed femoral implant. Our primary outcome measure was all-cause re-revision THA with a secondary outcome measure of improvement in Oxford hip score (OHS). Radiographic evidence of stem loosening and post-op complications were recorded. Between 02/12/2014 to 12/12/2019, there were 226 patients identified with a mean follow up of 2 years (1–5 years). The majority of cases were represented by Paprosky type 1 (63%) and type 2 (25%) femoral defects. There were 45 patients (20%) who underwent impaction bone grafting (IBG) and 43 patients (19%) who had a cement in cement (CinC) femoral revision and cemented primary stem in 137 (60%), 1 uncemented stem with no IBG or CinC revision. Kaplan Meier survival for all-cause re-revision THA was 93.7% (95% CI: 88.3 – 100) at 3 years. The reasons for re-revision included 4 periprosthetic fractures, 4 dislocations, 1 deep infection, 1 loosening of femoral component and 1 loosening of acetabular component. Pre- and post-operative OHS scores were available in 137 hips (60%) with a mean improvement of 13. Radiographic review revealed 7% of cases with evidence of loosening in 1 or more Gruen zones. Our early results support the use of conservative femoral revision THA techniques where appropriate, with low complication and re-revision rates. Revisions using primary femoral components, where appropriate, should be considered in surgical planning to avoid unnecessary reconstructive escalation

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

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

Two-stage exchange revision total hip arthroplasty performed in case of infection has been considered during many years the gold standard for treatment of chronic infection. Nevertheless, during the last decade, concerns have risen regarding its safety and its efficiency. The purpose of our study was to, first investigate the spacer complications, then to analyze their risks factors. We retrospectively included 125 patients with chronic hip periprosthetic joint infection who underwent a two stage exchange revision arthroplasty performed between January 2013 and December 2019. All spacer complications were systematically collected and risk factors were analyzed. Statistical evaluation were performed using the Student and Mann-Whitney tests. Our study confirms the hypothesis of a high-risk strategy with 42% of patients who had a mechanical spacer failure and a 20% recurrence of infection during the average two years period of follow-up. We found a high rate of spacer migration (23%) and a low rate of spacer fracture (8%) compared to literature. The most important finding was that the majority of spacer complications and failures were found in a population with high medical comorbidities as highlighted by the ASA, Charlson and Lee score associations, as well as with the cardiac, pulmonary, kidney or hepatic chronic conditions. This study showed that a two-stage hip exchange revision is a high-risk procedure regarding complications and mechanical failures of PMMA spacers. In patients with high medical comorbidities, other strategies may be considered and interdisciplinary cooperation with other facilities are needed to identify and control each risk factor

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

Aims. The aim of this study was to identify modifiable risk factors associated with mortality in patients requiring revision total hip arthroplasty (THA) for periprosthetic hip fracture. Methods. The electronic records of consecutive patients undergoing revision THA for periprosthetic hip fracture between December 2011 and October 2018 were reviewed. The data which were collected included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, the preoperative serum level of haemoglobin, time to surgery, operating time, blood transfusion, length of hospital stay, and postoperative surgical and medical complications. Univariate and multivariate logistic regression analyses were used to determine independent modifiable factors associated with mortality at 90 days and one year postoperatively. Results. A total of 203 patients were identified. Their mean age was 78 years (44 to 100), and 108 (53%) were female. The median time to surgery was three days (interquartile range (IQR) 2 to 5). The mortality rate at one year was 13.8% (n = 28). The commonest surgical complication was dislocation (n = 22, 10.8%) and the commonest medical complication within 90 days of surgery was hospital-acquired pneumonia (n = 25, 12%). Multivariate analysis showed that the rate of mortality one year postoperatively was five-fold higher in patients who sustained a dislocation (odds ratio (OR) 5.03 (95% confidence interval (CI) 1.60 to 15.83); p = 0.006). The rate of mortality was also four-fold higher in patients who developed hospital-acquired pneumonia within 90 days postoperatively (OR 4.43 (95% CI 1.55 to 12.67); p = 0.005). There was no evidence that the time to surgery was a risk factor for death at one year. Conclusion. Dislocation and hospital-acquired pneumonia following revision THA for a periprosthetic fracture are potentially modifiable risk factors for mortality. This study suggests that surgeons should consider increasing constraint to reduce the risk of dislocation, and the early involvement of a multidisciplinary team to reduce the risk of hospital-acquired pneumonia. We found no evidence that the time to surgery affected mortality, which may allow time for medical optimization, surgical planning, and resource allocation. Cite this article: Bone Joint J 2020;102-B(5):580–585

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

Introduction. Wound complications following revision total hip arthroplasty (THA) are associated with an increased risk of superficial and deep infections. Closed incision negative-pressure therapy (ciNPT) has been reported to decrease this risk. This study's purpose was to assess if ciNPT decreases the rate of wound complications following revision THA versus a conventional, silver-impregnated dressing. Methods. This was a single center, randomized controlled trial of patients undergoing both septic and aseptic revision THA. Patients received either ciNPT or a silver-impregnated dressing (control) for 7 days. Wound complications within 90 days of the procedure were recorded, including: surgical site infection (SSI), periprosthetic joint infection (PJI), prolonged drainage greater than 5 days, erythema requiring antibiotics, and hematoma formation. An a priori power analysis determined 201 patients per cohort were necessary to demonstrate a 10% decrease in wound complication rate. Results. Between 2017 and 2020, 113 patients have been enrolled: 57 (50.4%) to ciNPT and 56 (49.6%) to the control dressing. Two revisions (1.8%) were performed via a direct lateral approach; all others via a posterior approach. There were no differences in age, BMI, ASA score, revision performed, wound closure method (staples, superficial nylons, subcuticular), or postoperative anti-coagulation (p=0.2–0.8). Seven (12.3%) patients in the ciNPT cohort sustained a wound complication versus 4 (7.1%) in the control cohort (p=0.2). There was no difference in type of wound complication sustained (p=0.4). Four (7.0%) patients in the ciNPT cohort underwent re-operation for wound-related complications (2 PJI, 1 SSI, 1 prolonged drainage) versus zero in the control cohort (p=0.04). Conclusion. Prior studies have shown ciNPT to be effective in decreasing the rate of wound complications in total joint arthroplasty. Preliminary results of this randomized trial of revision THA patients do not corroborate these prior reports. Continued enrollment is required to confirm these initial findings

Femoral impaction bone grafting (IBG) may be used to restore bone stock in revision total hip arthroplasty (THA) and allow use of a shorter, than otherwise, length prosthesis. This is most beneficial in young patients who are more likely to require further revision surgery. This study aimed to assess the results of femoral IBG for staged revision THA for infection. A prospective cohort of 29 patients who underwent staged revision THA for infection with femoral IBG and a cemented polished double-tapered (CPDT) stem at the final reconstruction was investigated. The minimum follow-up was two years (2 – 10 years, median 6 years). Stem subsidence was measured with radiostereometric analysis. Clinical outcomes were assessed with the Harris Hip, Harris Pain, and and Société Internationale de Chirurgie Orthopédique et de Traumatologie Activity (SICOT) Scores. The original infection was eradicated in 28 patients. One patient required a repeat staged revision due to re-infection with the same organism. At two-year follow-up, the median subsidence at the stem-bone interface was −1.70 mm (−0.31 to −4.98mm). The median Harris Hip Score improved from 51 pre-operatively to 80 at two years (p=0.000), the Harris Pain Score from 20 to 44 (p=0.000) and the SICOT Score from 2.5 to 3 (p=0.003). As successful eradication of infection was achieved in the majority of patients and the stem migration was similar to that of a primary CPDT stem, this study supports the use of femoral IBG during the final reconstruction of the femur after staged revision THA for infection

Aims

This study compares the re-revision rate and mortality following septic and aseptic revision hip arthroplasty (rTHA) in registry data, and compares the outcomes to previously reported data.

The aim of this study is to examine the differences in long-term mortality rates between infected and aseptic revision total hip arthroplasty (rTHA) in a single specialist centre over an 18-year period. Retrospective consecutive study of all patients who underwent rTHA at our tertiary centre between 2003 and 2020 was carried out. Revisions were classified as infected or aseptic. We identified patients’ age, gender, American Society of Anaesthesiologists grade (ASA) and body mass index (BMI). The primary outcome measure was all-cause mortality at 5 years, 10 years and over the whole study period at 18 years. Death was identified through both local hospital electronic databases and linked data for the National Joint Registry. Kaplan-Meier survival curves were used to estimate time to death. Where two-stage revision techniques were used of the management of infected cases, these were grouped as a single revision episode for the purpose of analysis. In total, 1138 consecutive hip revisions were performed on 1063 patients (56 bilateral revisions – aseptic, 10 Excision arthroplasties – infection, 9 – Debridement, Antibiotics, Implant retention (DAIR) with 893 aseptic revisions in 837 patients (78.7%) and 245 infected revisions in 226 patients (21.3%). Average age of the entire study cohort was 71.0 (24–101) with 527 female (49.6%). Average age of the infection and aseptic cohorts was 68.8 and 71.5 respectively. Revisions for infection had higher mortality rates throughout the three time points of analysis. Patients’ survivorship for infected vs aseptic revisions was; 77.8% vs 87.7% at 5 years, 62.8% vs 76.5% at 10 years and 62.4% vs 72.0% at 18 years. The unadjusted 10-year risk ratio of death after infected revision was 1.58 (95% confidence interval 1.28–1.95) compared to aseptic revisions. rTHA performed for infection is associated with significantly higher long-term mortality at all time points compared to aseptic revision surgery

Introduction and Aims: To compare the outcomes between primary and revision total hip arthroplasty in patients at one institution with regard to demographics, complication rates and functional outcome. Further study of the problems associated with revision total hip replacement, focused on complication rates, would appear to be warranted. Method: All patients were entered prospectively in a database and were assessed by means of physical examination, radiographs, SF-36 and WOMAC questionnaires. Patients were followed for a minimum of two years with a range of two to five years. Patients were seen on an annual basis. Results: Five hundred and forty-seven patients underwent primary total hip replacement and 213 patients underwent revision total hip replacement. 53.4% of patients undergoing primary and 52% of patients undergoing revision arthroplasty were female. Mean age at primary hip replacement 61.8 years, revision hip replacement 67.1 years. Post-operative complication rate was 7.6% in primary patients and 14.7% in revision patients (p< .05); there was no statistically significant difference between the two groups with regard to intra-operative fracture, implant loosening or post-operative infection; there was a statistically significant difference in terms of dislocation with 0.8% of primary arthroplasties and 5.6% of revision patients sustaining at least one dislocation following their surgery (p< .01). Both groups of patients had a statistically significant improvement between their pre- and post-operative WOMAC and SF-36 physical scores (p< .0001); however, there was also a statistically significant difference in outcome when the two groups were compared with primary patients having significantly improved WOMAC scores (p< .0001) and significantly improved SF-36 physical socres (p< .0001). Conclusions: Revision hip arthroplasty does not bring to the patient the same degree of benefit as the primary operation. The reason for this is multi-factorial and includes a higher complication rate and lower functional outcome

Aims. Accurate diagnosis of chronic periprosthetic joint infection (PJI) presents a significant challenge for hip surgeons. Preoperative diagnosis is not always easy to establish, making the intraoperative decision-making process crucial in deciding between one- and two-stage revision total hip arthroplasty (THA). Calprotectin is a promising point-of-care novel biomarker that has displayed high accuracy in detecting PJI. We aimed to evaluate the utility of intraoperative calprotectin lateral flow immunoassay (LFI) in THA patients with suspected chronic PJI. Methods. The study included 48 THAs in 48 patients with a clinical suspicion of PJI, but who did not meet European Bone and Joint Infection Society (EBJIS) PJI criteria preoperatively, out of 105 patients undergoing revision THA at our institution for possible PJI between November 2020 and December 2022. Intraoperatively, synovial fluid calprotectin was measured with LFI. Cases with calprotectin levels ≥ 50 mg/l were considered infected and treated with two-stage revision THA; in negative cases, one-stage revision was performed. At least five tissue cultures were obtained; the implants removed were sent for sonication. Results. Calprotectin was positive (≥ 50 mg/l) in 27 cases; out of these, 25 had positive tissue cultures and/or sonication. Calprotectin was negative in 21 cases. There was one false negative case, which had positive tissue cultures. Calprotectin showed an area under the curve of 0.917, sensitivity of 96.2%, specificity of 90.9%, positive predictive value of 92.6%, negative predictive value of 95.2%, positive likelihood ratio of 10.6, and negative likelihood ratio of 0.04. Overall, 45/48 patients were correctly diagnosed and treated by our algorithm, which included intraoperative calprotectin measurement. This yielded a 93.8% concordance with postoperatively assessed EBJIS criteria. Conclusion. Calprotectin can be a valuable tool in facilitating the intraoperative decision-making process for cases in which chronic PJI is suspected and diagnosis cannot be established preoperatively. Cite this article: Bone Joint J 2024;106-B(5 Supple B):118–124

Aims. Revision total hip arthroplasty in patients with Vancouver type B3 fractures with Paprosky type IIIA, IIIB, and IV femoral defects are difficult to treat. One option for Paprovsky type IIIB and IV defects involves modular cementless, tapered, revision femoral components in conjunction with distal interlocking screws. The aim of this study was to analyze the rate of reoperations and complications and union of the fracture, subsidence of the stem, mortality, and the clinical outcomes in these patients. Methods. A total of 46 femoral components in patients with Vancouver B3 fractures (23 with Paprosky type IIIA, 19 with type IIIB, and four with type IV defects) in 46 patients were revised with a transfemoral approach using a modular, tapered, cementless revision Revitan curved femoral component with distal cone-in-cone fixation and prospectively followed for a mean of 48.8 months (SD 23.9; 24 to 112). The mean age of the patients was 80.4 years (66 to 100). Additional distal interlocking was also used in 23 fractures in which distal cone-in-cone fixation in the isthmus was < 3 cm. Results. One patient (2.2%) died during the first postoperative year. After six months, 43 patients (93.5%) had osseous, and three had fibrous consolidation of the fracture and the bony flap, 42 (91.3%) had bony ingrowth and four had stable fibrous fixation of the stem. No patient had radiolucency around the interlocking screws and no screw broke. One patient had non-progressive subsidence and two had a dislocation. The mean Harris Hip Score increased from of 57.8 points (SD 7.9) three months postoperatively to 76.1 points (SD 10.7) 24 months postoperatively. Conclusion. The 2° tapered, fluted revision femoral component with distal cone-in-cone-fixation, combined with additional distal interlocking in patients with bony deficiency at the isthmus, led to reproducibly good results in patients with a Vancouver B3 fracture and Paprosky type IIIA, IIIB, and IV defects with regard to union of the fracture, subsidence or loosening of the stem, and clinical outcomes. Cite this article: Bone Joint J 2024;106-B(4):344–351

Revision hip arthroplasty does not bring to the patient the same degree of benefit as the primary operation. We compared two hundred and thirteen patients undergoing revision arthroplasty with five hundred and forty-seven patients undergoing primary total hip replacement. The complication rate in the revision arthroplasty group was approximately twice as high in the primary group (p< .05) primarily as a result of postoperative dislocation. Both groups of patients had a statistically significant improvement between their pre- and postoperative WOMAC and SF-36 physical scores; however, there was also a statistically significant difference in outcome when the two groups were compared, with primary patients having significantly improved WOMAC and SF-36 physical scores. To compare the outcomes between primary and revision total hip arthroplasty patients at one institution with regard to demographics, complication rates and functional outcome. Revision hip arthroplasty does not bring to the patient the same degree of benefit as does the primary operation. The reason for this is multi-factorial and includes a higher complication rate and lower functional outcome. Further study of the problems associated with revision total hip replacement especially focused on complication rates would appear to be warranted. All patients were entered prospectively in a database and were assessed by means of physical examination, radiographs, SF-36 and WOMAC questionnaires. Patients were followed for a minimum of two years with a range of two to five years. Patients were seen on an annual basis. Five hundred and forty-seven patients underwent primary total hip replacement and two hundred and thirteen patients underwent revision total hip replacement. 53.4% of patients undergoing primary and 52% of patients undergoing revision arthroplasty were female. Mean age at primary hip replacement 61.8 years, revision hip replacement 67.1 years. Post-operative complication rate was 7.6% in primary patients and 14.7% in revision patients (p< .05); there was no statistically significant difference between the two groups with regard to intra-operative fracture, implant loosening or postoperative infection; there was a statistically significant difference in terms of dislocation with 0.8% of primary arthroplasties and 5.6% of revision patients sustaining at least one dislocation following their surgery (p< .01). Both groups of patients had a statistically significant improvement between their pre- and post-operative WOMAC and SF-36 physical scores (p< .0001); however, there was also a statistically significant difference in outcome when the two groups were compared with primary patients having significantly improved WOMAC scores (p< .0001) and significantly improved SF-36 physical scores (p< .0001)

We prospectively evaluated the long-term outcome of 158 consecutive patients who underwent revision total hip replacement using uncemented computer-assisted design-computer-assisted manufacture femoral components. There were 97 men and 61 women. Their mean age was 63.1 years (34.6 to 85.9). The mean follow-up was 10.8 years (10 to 12). The mean Oxford, Harris and Western Ontario and McMaster hip scores improved from 41.1, 44.2 and 52.4 pre-operatively to 18.2, 89.3 and 12.3, respectively (p < 0.0001, for each). Six patients required further surgery. The overall survival of the femoral component was 97% (95% confidence interval 94.5 to 99.7). These results are comparable to those of previously published reports for revision total hip replacement using either cemented or uncemented components

Background. Modular dual mobility (MDM) acetabular components are often used to prevent dislocation in revision total hip arthroplasty (THA). As there is insufficient data on these components, the outcomes were evaluated in a cohort with a mean follow-up time of greater than five years. Methods. Using the database of a single academic center, 126 revision THAs (117 patients) with one MDM were retrospectively reviewed. There were 94 hips in 88 patients with a mean follow-up time of 5.5 years. Survivorship analysis was performed with the endpoints of dislocation, reoperation for dislocation, cup revision for aseptic loosening, and cup revision for any reason. The secondary endpoints were perioperative complications and radiographic review. Results. The overall rate of dislocation was 11%, with a 6-year survival of 91%. Reoperation for dislocation was performed in 7 patients (7%), with a 6-year survival of 94%. The dislocations were early (mean 33 days) in 6 patients, and late (mean 4.3 years) in 4 patients. There were three intraprosthetic dissociations. An outer head diameter of 48 mm or greater was associated with a lower risk of dislocation (p=0.013). Four hips (4%) were revised for aseptic cup loosening, and 14 (15%) cups were revised for infection. Two hips had visible metallic changes of the backside of the cobalt chromium liner. Conclusion. Using this MDM component in revision THA, at mean follow-up time of 5.5 years, there was a higher rate of dislocation (11%) than previously reported. Outer bearing size was related to the risk of dislocation. There was a low rate of aseptic cup loosening. Longer follow-up of this MDM component and evaluation of other designs is warranted

Failed ingrowth and subsequent separation of revision acetabular components from the inferior hemi-pelvis constitutes a primary mode of failure in revision total hip arthroplasty (THA). Few studies have highlighted other techniques than multiple screws and an ischial flange or hook of cages to reinforce the inferior fixation of the acetabular components, nor did any authors report the use of porous metal augments in the ischium and/or pubis to reinforce inferior fixation of the acetabular cup. The aims of this study were to introduce the concept of inferior extended fixation into the ischium and/or pubis during revision total hip arthroplasty, and to answer the following questions: (1) what are early clinical outcomes using inferior extended fixation and (2) what are the radiographic outcomes of hips revised with inferior extended fixation?. Patients who underwent revision THA utilizing the surgical technique of inferior extended fixation with porous metal augments secured in the ischium and/or pubis in a single institution from 2014 to 2016 were reviewed. Twenty-four patients were initially identified, and 16 patients were included based on the criteria of minimum 18 months clinical and radiographic follow-up. The median HHS, as well as the SF-12 physical and mental components improved significantly at the latest follow-up (p<0.001). The WOMAC global score decreased significantly at the latest follow-up (p<0.001). All constructs were considered to have obtained bone ingrowth fixation. Early follow-up of patients reconstructed with porous metal augments using the inferior extended fixation surgical technique demonstrated satisfactory clinical outcomes, restoration of the center of rotation and adequate biological fixation

Background. Failed ingrowth and subsequent separation of revision acetabular components from the inferior hemi-pelvis constitutes a primary mode of failure in revision total hip arthroplasty (THA). Few studies have highlighted other techniques than multiple screws and an ischial flange or hook of cages to reinforce the ischiopubic fixation of the acetabular components, nor did any authors report the use of porous metal augments in the ischium and/or pubis to reinforce ischiopubic fixation of the acetabular cup. The aims of this study were to introduce the concept of extended ischiopubic fixation into the ischium and/or pubis during revision total hip arthroplasty [Fig. 2], and to determine the early clinical outcomes and the radiographic outcomes of hips revised with inferior extended fixation. Methods. Patients who underwent revision THA utilizing the surgical technique of extended ischiopubic fixation with porous metal augments secured in the ischium and/or pubis in a single institution from 2014 to 2016 were reviewed. 16 patients were included based on the criteria of minimum 24 months clinical and radiographic follow-up. No patients were lost to follow-up. The median duration of follow-up for the overall population was 37.43 months. The patients' clinical results were assessed using the Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and Short form (SF)-12 score and satisfaction level based on a scale with five levels at each office visit. All inpatient and outpatient records were examined for complications, including infection, intraoperative fracture, dislocation, postoperative nerve palsy, hematoma, wound complication and/or any subsequent reoperation(s). The vertical and horizontal distances of the center of rotation to the anatomic femoral head and the inclination and anteversion angle of the cup were measured on the preoperative and postoperative radiographs. All the postoperative plain radiographs were reviewed to assess the stability of the components. Results. At the most recent follow-up, 11 (68.8%) patients rated their satisfaction level as “very satisfied” and 4 (25.0%) were “satisfied.” The median HHS improved significantly and the WOMAC global score decreased significantly at the latest follow-up (? 0.001). No intraoperative or postoperative complications were identified. All constructs were considered to have obtained bone ingrowth fixation. The median vertical distance between the latest postoperative center of rotation to the anatomic center of the femoral head improved from 14.7±10.05 mm preoperatively to 6.77±9.14 mm at final follow-up (p=0.002). The median horizontal distance between the latest postoperative center of rotation to the anatomic center of femoral head improved from 6.3±12.07 mm laterally preoperatively to 2.18±6.98 mm medially at the most recent follow-up (p=0.013) postoperatively. The median acetabular cup abduction angle improved from 55.04°±10.11° preoperatively to 44.43°± 5.73° at the most recent follow-up postoperatively (p=0.001). However, there was no difference in the median cup anteversion angles preoperatively (9.15°±5.36°) to postoperatively (9.66°±3.97°) (P=0.535). Conclusions. Early follow-up of patients reconstructed with the technique of extended ischiopubic fixation with porous metal augments demonstrated satisfactory clinical outcomes, restoration of the center of rotation and adequate biological fixation. For any figures or tables, please contact the authors directly

Aim. The aim of this study is to evaluate if obesity negatively affects: (1) complication rate, (2) reoperation and revision rate and (3) functional outcome (based on patient reported outcome measures, PROMs) in revision total hip arthroplasty (rTHA). To our knowledge this is the only recent study to prospectively review these three aspects in what might be considered challenging rTHA. Methods. 444 rTHAs (cup, stem, both, n= 265, 57, 122 respectively), performed in a specialized high-volume orthopaedic center from 2013 to 2015, were prospectively followed. Complications and Oxford Hip Score (OHS) were evaluated at 4 months, 1 year and 2 years. Thirtyfour patients had a BMI >35 kg/m2 (obese), of which thirteen patients with a BMI >40 kg/m2 (morbidly obese). Results. Infection following rTHA was more common in obese patients (8/34: 24%) and in morbidly obese patients (5/13: 38%) than in non-obese patients (15/410: 4%; p's < 0.001). No differences between obese and non-obese groups for other complications were observed (aseptic loosening, dislocation, periprosthetic fractures, thromboembolic events). Reoperation and revision rates were similar overall (p = 0.067 / 0.303 respectively) and due to infection (p = 0.469 / 0.879 respectively) for obese and non-obese groups. Scores on the OHS improved from 42 ±13 at baseline to 27±12 at 1 and 2 year follow-up (p < 0.001). Obese patients had overall poorer OHS scores than non-obese patients (p < 0.001), but improvement of OHS did not differ between obese and non-obese patients (p = 0.198). Conclusion. Obesity is associated with an increased risk of infection following revision THA. Patients with high BMI should be counselled appropriately before surgery

Background: There area some controversies about the need for revision of well fixed femoral stem during the revision total hip arthroplasty. The purpose of this study is to evaluate the state of unretrieved femoral stem, in revision total hip arthroplasty where only acetabular component was revised. Methods: From January 1998 to December 2004, thirty-one patients underwent revision total hip arthroplasty whose well fixed femoral stem was retained and acetabular components revised. Twenty-six patients(29hips) with a minimum follow-up of three years were included in this study. Out of those twenty-six patients, sixteen patients(18hips) were male and ten patients(11hips) were female with an average age of 54.3 years for the study group. The average time from the primary operation until the revision surgery was 9.2 years and the average follow-up period after the revision was 5 years. The femoral head component was exchanged in all cases and same size femoral head component was used in eleven hips. The clinical results wee analyzed using Harris Hip Score, and the radiographs were reviewed for stability of acetabular components, femoral stem, and degree of osteolysis and radiolucent lines. Results: The average Harris Hip score improved from 56.3 points preoperatively to 89.8 points postoperatively. Femoral stems were found to be stable in all hips. Sixteen hips(55.2%) showed evidence of osteolysis and seven hips(24.1%) showed non-progressive radiolucent lines. The osteolysis was detected at Gruen Zone I and VII in most of the affected hips except for two hips which showed distal osteolysis. The average life of femoral stem from primary operation until the final follow up varied from 10.8 years to 18.2 years, with the average being 14.2 years. Conclusions: We recommended that well fixed, stable femoral components can be retained at the time of revision total hip arthroplasty. Level of evidence: Therapeutic Level IV

Aims. The use of trabecular metal (TM) shells supported by augments has provided good mid-term results after revision total hip arthroplasty (THA) in patients with a bony defect of the acetabulum. The aim of this study was to assess the long-term implant survivorship and radiological and clinical outcomes after acetabular revision using this technique. Patients and Methods. Between 2006 and 2010, 60 patients (62 hips) underwent acetabular revision using a combination of a TM shell and augment. A total of 51 patients (53 hips) had complete follow-up at a minimum of seven years and were included in the study. Of these patients, 15 were men (29.4%) and 36 were women (70.6%). Their mean age at the time of revision THA was 64.6 years (28 to 85). Three patients (5.2%) had a Paprosky IIA defect, 13 (24.5%) had a type IIB defect, six (11.3%) had a type IIC defect, 22 (41.5%) had a type IIIA defect, and nine (17%) had a type IIIB defect. Five patients (9.4%) also had pelvic discontinuity. Results. The overall survival of the acetabular component at a mean of ten years postoperatively was 92.5%. Three hips (5.6%) required further revision due to aseptic loosening, and one (1.9%) required revision for infection. Three hips with aseptic loosening failed, due to insufficient screw fixation of the shell in two and pelvic discontinuity in one. The mean Harris Hip Score improved significantly from 55 (35 to 68) preoperatively to 81 points (68 to 99) at the latest follow-up (p < 0.001). Conclusion. The reconstruction of acetabular defects with TM shells and augments showed excellent long-term results. Supplementary screw fixation of the shell should be performed in every patient. Alternative techniques should be considered to address pelvic disconinuity. Cite this article: Bone Joint J 2019;101-B:311–316

Background. Ultraporous metals have now been used in acetabular reconstruction for two decades with excellent survival. The purpose of this study is to evaluate a newer porous metal made from Ti6Al4V titanium alloy in complex primary and revision hip arthroplasty. Methods. A retrospective review as performed on all total hip arthroplasty (THA) procedures in which a G7 Osseo-Ti (Zimmer Biomet, Warsaw, IN) acetabular component was used between 2015 and 2017. Patients with 2-year minimum follow-up or failure were included, yielding a cohort of 123 patients (126 hips). There were 50 male patients (41%; 51 hips) and 73 females (59%; 75 hips). Mean age was 65 years (range, 43–88) and mean BMI was 30.7 kg/m. 2. (range, 18–56). Indications for ultraporous metal components were in hips with compromised bone stock or severe acetabular deformity. Procedures were 35 complex primary THA and 91 revision THA that included 12 conversions and 24 reimplantations as part of 2-staged exchange for treatment of infection. Results. With an average 3.3-year follow-up (range, 2–5 years), 1 hip in the primary series (2.9%) and 4 hips in the revision series (4.4%) were revised for aseptic loosening of the acetabular component. Three of these re-revisions required custom triflange devices. Five patients (4%) failed for periprosthetic infection, which included 1 primary THA done for rheumatoid arthritis and post-radiation necrosis, and 4 second-stage reimplantation revision THAs for prior infection. Two revision patients, one done for active instability and one multiply revised, subsequently dislocated and required liner revision to constrained constructs. Kaplan-Meier analysis to endpoint of acetabular revision for aseptic loosening was 96.6% (±3.4%) in the primary series and 95.3% (±2.3%) in the revision series. Conclusion. This three-dimensionally printed ultraporous titanium acetabular component demonstrated promising early results in complex primary and revision total hip arthroplasty

Objectives. Previous studies have evidenced cement-in-cement techniques as reliable in revision arthroplasty. Commonly, the original cement mantle is reshaped, aiding accurate placement of the new stem. Ultrasonic devices selectively remove cement, preserve host bone, and have lower cortical perforation rates than other techniques. As far as the authors are aware, the impact of ultrasonic devices on final cement-in-cement bonds has not been investigated. This study assessed the impact of cement removal using the Orthosonics System for Cemented Arthroplasty Revision (OSCAR; Orthosonics) on final cement-in-cement bonds. Methods. A total of 24 specimens were manufactured by pouring cement (Simplex P Bone Cement; Stryker) into stainless steel moulds, with a central rod polished to Stryker Exeter V40 specifications. After cement curing, the rods were removed and eight specimens were allocated to each of three internal surface preparation groups: 1) burr; 2) OSCAR; and 3) no treatment. Internal holes were recemented, and each specimen was cut into 5 mm discs. Shear testing of discs was completed by a technician blinded to the original grouping, recording ultimate shear strengths. Scanning electron microscopy (SEM) was completed, inspecting surfaces of shear-tested specimens. Results. The mean shear strength for OSCAR-prepared specimens (33.6 MPa) was significantly lower than for the control (46.3 MPa) and burr (45.8 MPa) groups (p < 0.001; one-way analysis of variance (ANOVA) with Tukey’s post hoc analysis). There was no significant difference in shear strengths between control and burr groups (p = 0.57). Scanning electron microscopy of OSCAR specimens revealed evidence of porosity undiscovered in previous studies. Conclusion. Results show that the cement removal technique impacts on final cement-in-cement bonds. This in vitro study demonstrates significantly weaker bonds when using OSCAR prior to recementation into an old cement mantle compared with cement prepared with a burr or no treatment. This infers that care must be taken in surgical decision-making regarding cement removal techniques used during cement-in-cement revision arthroplasty, suggesting that the risks and benefits of ultrasonic cement removal need consideration. Cite this article: A. Liddle, M. Webb, N. Clement, S. Green, J. Liddle, M. German, J. Holland. Ultrasonic cement removal in cement-in-cement revision total hip arthroplasty: What is the effect on the final cement-in-cement bond? Bone Joint Res 2019;8:246–252. DOI: 10.1302/2046-3758.86.BJR-2018-0313.R1

We report on a cadaveric study and early experience using patient specific drill guides to prevent cortex perforations and reduce the need for a trochanteric osteotomy in revision THA. Mimic software (Materialise) was used for 3D analysis of the cement mantle and cement plug. Based on the CT findings a Cannulated drill guide with the shape of the femoral stem was printed in medical graded nylon intraoperative findings and complications were recorded on videotape using a standard 5mm laparoscope for medullary inspection. Surgical Technique was to attain a pre-operative CT scan with MARS protocol of the proximal femur to evaluate the femoral stem positioning, the 3D anatomy of the cement mantle, the length of the cement plug and the quality of the surrounding bone. Subsequent a 3D printing of patient specific cannulated drill guide with the shape of the removed femoral component but an eccentric cannulation was made. Endoscopic inspection was performed of the inside of the cement mantle, then insertion of the autoclaved cannulated drill guide in the existing cement mantle. After perforation of the distal plug through the PSI drill guide using either a long drill or an ultrasound plug perforation tool (Zimmer Biomet, Warsaw) the excessive cement was removed with standard available flexible femoral shaft reamers (Zimmer Biomet). Further laproscopic examination of the femoral canal performed to verify completeness of the cement removal. Results. CT scans with 3D reconstruction of the existing cement mantle is possible using Modern CT with MARS protocols. After the training on sawbones and cadaveric bones a predictable plug perforation was obtained in all clinical cases. There were no intraoperative cortex perforations and no intraoperative femoral fractures. Conclusion. CT scan analysis of femoral cement mantles together with patient specific drill guides are promising tools to reduce the risk of femoral perforation in revision total hip arthroplasty

We hypothesised that the use of tantalum (Ta) acetabular components in revision total hip arthroplasty (THA) was protective against subsequent failure due to infection. We identified 966 patients (421 men, 545 women and 990 hips) who had undergone revision THA between 2000 and 2013. The mean follow up was 40.2 months (3 months to 13.1 years). The mean age of the men and women was 62.3 years (31 to 90) and 65.1 years (25 to 92), respectively. . Titanium (Ti) acetabular components were used in 536 hips while Ta components were used in 454 hips. In total, 73 (7.3%) hips experienced subsequent acetabular failure. The incidence of failure was lower in the Ta group at 4.4% (20/454) compared with 9.9% (53/536) in the Ti group (p < 0.001, odds ratio 2.38; 95% CI 1.37 to 4.27). Among the 144 hips (64 Ta, 80 Ti) for which revision had been performed because of infection, failure due to a subsequent infection was lower in the Ta group at 3.1% (2/64) compared with 17.5% (14/80) for the Ti group (p = 0.006). . Thus, the use of Ta acetabular components during revision THA was associated with a lower incidence of failure from all causes and Ta components were associated with a lower incidence of subsequent infection when used in patients with periprosthetic joint infection. . Cite this article: Bone Joint J 2015;97-B:45–9

Introduction. Highly cross-linked polyethylene has been introduced to decrease osteolysis secondary to polyethylene wear debris generation, but there are few long-term data on revision total hip arthroplasty using highly cross-linked polyethylene liners. The purpose of this study was to report the long-term radiographic and clinical outcomes of a highly cross-linked polyethylene liner in revision total hip arthroplasty. Materials & Methods. We analyzed 63 revision total hip arthoplasties that were performed in 63 patients using a highly cross-linked polyethylene liner between April 2000 and February 2005. Of these, nine died and four were lost to follow-up before the end of the 10-year evaluation. Thus, the final study cohort consisted of 50 patients (50 hips). There were 26 males and 24 females with a mean age at time of revision total hip arthoplasty of 53 years (range, 27–75 years). Mean duration of follow-up was 11 years (range, 10–14 years). Results. Mean Harris hip score improved from 44 points preoperatively to 85 points at final follow-up. No radiographic evidence of osteolysis was found in any hip. One hip required re-revision surgery for acetabular cup loosening at 6.5 years postoperatively. One required re-revision with a constrained liner because of recurrent dislocation. Three sustained deep infections requiring additional surgical procedures. Kaplan-Meier survivorship with an end point of re-revision for any reason was 91.0% and for aseptic cup loosening was 97.9% at 11 years (Figs. 1 and 2). Conclusions. At a minimum of 10 years, the highly cross-linked polyethylene liners showed excellent clinical performance and implant survivorship, and were not associated with osteolysis in our group of patients with revision total hip arthoplasties

Acetabular reconstruction of extensive bone defect is troublesome in revision total hip arthroplasty (rTHA). Kerboull or Kerboull type reinforcement acetabular device with allobone grafting has been applied since 1996. Clinical results of the procedure were evaluated. Patients. One hundred and ninety-two consecutive revision total hip arthroplasties were performed with allograft bone supported by the Kerboull or Kerboull type reinforcement acetabular device from 1996 to 2009. There were 23 men and 169 women. Kerboull plates were applied to 18 patients, and Kerboull type plates to 174. The mean follow up of the whole series was 8 years (4–18years). Surgical Technique. The superior bone defect was reconstructed principally by a large bulky allo block with plate system. Medial bone defect was reconstructed by adequate bone chips and/or sliced bone plates. After temporally fixation of bulky bone block with two 2.0mm K-wires, it was remodeled by reaming to fit the gap between host bone and plate, followed by fixation to the iliac bone by screws. Finally, residual space of the defect between host bone and the fixed plated was filled up with morselized cancellous bones, bone chips, and/or wedged bony fragments with impaction. This method was sufficiently applicable to AAOS Typeâ�, II, and III bone defects. In case of AAOS Typeâ�£, the procedure was also available after repairing discontinuation between distal and proximal bones by reconstrusion plate or allografting with tibial bone plates or sliced femoral head. Results. Nine patients (4.7%) required revision surgery (infection 5, breakage 3, and malalignment 1). The plate breakage was observed in 8 joints (4.2%). Three patients had no symptoms after the breakage. Three required revision, but the other cases were carefully observed without additional surgical intervention. Ten-year survival rate by Kaplan-Meier method was 96.6% when the endpoint was set revision by asceptic loosning. Conclusions. This study indicated that acetabular allograft reconstructions reinforced by Kerboull or Kerboull type acetabular device were able to recover bone stock with anatomic reconstruction of femoral head center, thus providing satisfactory clinical results in middle term period

Introduction: Bone stock in revision total hip arthroplasty is one of the most important issues for the orthopaedic surgeon. Different options have been described to manage acetabular bone defects. We reviewed the clinical and radiological results of two different uncemented oblong cups. Material and methods: 18 LOR (Sulzer) and 21 BOFOR (EndoPlus) uncemented cups were evaluated. Morsellized cancellous bone graft was used in all cases but 3. Mean follow-up was 31.6 months. Mean patient age was 72.3 years (32 to 91). Bone defects were classified according to Paprosky’s criteria. Clinical and radiological results were recorded. Results: There have been no infections and no re-revisions in this series, although one patient is awaiting evaluation for re-revision. Clinical results improved according to the Harris Hip Score from 44 to 75 points. 34 cups were considered stable and 5 showed migration. All unstable cups were implanted in patients with type IIIA or IIIB bone defects. We observed the appearance of non-progressive radiolucent lines of less than 2 mm in 7 hips, sclerosis lines in 1 and acetabular osteolysis in 2. Conclusions: Uncemented oblong cups are a valid option in revision total hip arthroplasty. The results were worse in patients with major acetabular bone defects. A longer follow-up is needed to evaluate these cups and confirm our findings

Aims

United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures.

Introduction. Modular tapered implants have been suggested as the optimal treatment in patients with severe femoral bone loss undergoing revision total hip arthroplasty (THA). The purpose of this study is to describe minimum 2 year follow up of patients treated with modular tapered prostheses for Paprosky type IIIB and IV femoral bone loss in revision THA. Methods. 44 Consecutive patients with Paprosky type IIIB (23) or IV (21) femurs undergoing revision total hip arthroplasty to cementless modular tapered prostheses were studied. Harris Hip Scores were obtained prior to revision on all patients except those presenting with acute implant failure or periprosthetic fracture. 10 Patients were deceased within 2 years of surgery; the remaining 18 were followed for an average of 42 months (range 25-69 months). Clinical outcomes were measured using the Harris Hip Score, and radiographs were assessed for signs of stem loosening or subsidence >4mm. Results. No further revisions were required in patients who were deceased within 2 years. In those with >2 year follow up, there were 4 additional revisions: 1 for infection, 2 for instability, and 1 for periprosthetic fracture. In patients with surviving implants, the mean Harris Hip Score improved from 33 (range 11-49) pre-operatively to 77 (range 55-100), and there was no radiographic evidence of loosening or subsidence at time of final follow up. Conclusions. These outcomes support the use of modular tapered implants as a safe and effective option for revision arthroplasty of type IIIB and IV femurs

Tapered, fluted, modular, titanium stems have a long history in Europe and are increasing in popularity in North America. We have reviewed the results at our institution looking at stem survival and clinical outcomes. Radiological outcomes and quality of life assessments have been performed and compared to cylindrical non-modular cobalt chromium stems. Survival at five years was 94%. This fell to 85% at ten years due to stem breakage with older designs. Review of radiology showed maintenance or improvement of bone stock in 87% of cases. Outcome scores were superior in tapered stems despite worse pre-operative femoral deficiency. Tapered stems have proved to be a useful alternative in revision total hip arthroplasty across the spectrum of femoral bone deficiency