Aims. The aim of this study was to report the long-term follow-up of cemented short Exeter femoral components when used in primary total hip arthroplasty (THA). Methods. We included all primary 394 THAs with a cemented short Exeter femoral component (≤ 125 mm) used in our tertiary referral centre between October 1993 and December 2021. A total of 83 patients (21%) were male. The median age of the patients at the time of surgery was 42 years (interquartile range (IQR) 30 to 55). The main indication for THA was a childhood hip disease (202; 51%). The median follow-up was 6.7 years (IQR 3.1 to 11.0). Kaplan-Meier survival analyses were performed to determine the rates of survival with femoral revision for any indication, for septic loosening, for fracture of the femoral component and for aseptic loosening as endpoints. The indications for revision were evaluated. Fractures of the femoral component were described in detail. Results. The 20-year rate of survival was 85.4% (95% confidence interval (CI) 73.9 to 92.0) with revision for any indication, 96.2% (95% CI 90.5 to 98.5) with revision for septic loosening and 92.7% (95% CI 78.5 to 97.6) with revision for fracture of the femoral component. No femoral components were revised for aseptic loosening. There were 21 revisions of the femoral component; most (seven) as part of a two-stage management of infection. Fracture of the femoral component occurred in four THAs (1.0%) at 6.6, 11.6, 16.5, and 18.2 years of follow-up, respectively. Three of these were transverse fractures and occurred at the level of the lesser trochanter. In one THA, there was a fracture of the neck of the component. Conclusion. THAs using cemented short Exeter femoral components showed acceptable rates of survival of the femoral component at long-term follow-up, in this young cohort of patients. Although fracture is a rare complication of these components, surgeons should be aware of their incidence and possible risk factors. Cite this article: Bone Joint J 2024;106-B(3 Supple A):137–142

Aims. The purpose of this study was to compare the clinical outcomes, mortalities, implant survival rates, and complications of total knee arthroplasty (TKA) in patients with or without hepatitis B virus (HBV) infection over at least ten years of follow-up. Methods. From January 2008 to December 2010, 266 TKAs were performed in 169 patients with HBV (HBV group). A total of 169 propensity score–matched patients without HBV were chosen for the control group in a one-to-one ratio. Then, the clinical outcomes, mortalities, implant survival rates, and complications of TKA in the two groups were compared. The mean follow-up periods were 11.7 years (10.5 to 13.4) in the HBV group and 11.8 years (11.5 to 12.4) in the control group. Results. The mean Knee Society scores in the HBV and control groups improved from 37.1 (SD 5.6) and 38.4 (SD 5.4) points preoperatively to 78.1 (SD 10.8) and 81.7 (SD 10.2) points at final follow-up (p = 0.314), while the mean function scores in the HBV and control groups improved from 36.2 and 37.3 points preoperatively to 77.8 and 83.2 points at final follow-up (p = 0.137). Nine knees in the HBV group required revision surgery, including seven due to septic loosening and two due to aseptic loosening. Four knees in the control group required revision surgery, including three due to septic loosening and one due to aseptic loosening. Kaplan–Meier survivorship analysis with the revision of either component as an endpoint in the HBV and control groups estimated 96.6% and 98.5% chances of survival for ten years, respectively (p = 0.160). Conclusion. TKA in patients with HBV infection resulted in good clinical outcomes and survivorship. However, there was a higher revision rate over a minimum ten-year follow-up period compared to TKA in patients without HBV infection. Cite this article: Bone Jt Open 2022;3(6):470–474

In this study of 41 patients, we used proteomic, Western blot and immunohistochemical analyses to show that several reactive oxygen species scavenging enzymes are expressed differentially in patients with primary osteoarthritis and those with non-loosening and aseptic loosening after total hip replacement (THR). The patients were grouped as A (n = 16, primary THR), B (n = 10, fixed THR but requiring revision for polyethylene wear) and C (n = 15, requiring revision due to aseptic loosening) to verify the involvement of the identified targets in aseptic loosening. When compared with Groups A and B, Group C patients exhibited significant up-regulation of transthyretin and superoxide dismutase 3, but down-regulation of glutathione peroxidase 2 in their hip synovial fluids. Also, higher levels of superoxide dismutase 2 and peroxiredoxin 2, but not superoxide dismutase 1, catalase and glutathione perioxidase 1, were consistently detected in the hip capsules of Group C patients.

We propose that dysregulated reactive oxygen species-related enzymes may play an important role in the pathogenesis and progression of aseptic loosening after THR.

Aims. This study reports updates the previously published two-year clinical, functional, and radiological results of a group of patients who underwent transfibular total ankle arthroplasty (TAA), with follow-up extended to a minimum of five years. Methods. We prospectively evaluated 89 patients who underwent transfibular TAA for end-stage osteoarthritis. Patients’ clinical and radiological examinations were collected pre- and postoperatively at six months and then annually for up to five years of follow-up. Three patients were lost at the final follow-up with a total of 86 patients at the final follow-up. Results. A total of 86 patients were evaluated at a mean follow-up of 65.4 months (60 to 90). At five-year follow-up, statistically significant improvements (p < 0.001) were found in the mean American Orthopaedic Foot & Ankle Society Ankle Hindfoot Score (from 33.8 (SD 14.3) to 86.1 (SD 8.8)), visual analogue scale for pain (from 8.5 (SD 1.7) to 1.5 (SD 1.2)), Short Form-12 Physical and Mental Component Scores (from 29.9 (SD 6.7) and 43.3 (SD 8.6) to 47.3 (SD 7.5) and 52.2 (SD 8.0), respectively), and mean ankle dorsiflexion and plantarflexion (from 6.2° (SD 5.5°) and 9.6° (SD 5.8°) to 23.9° (SD 7.7°) and 16.9° (SD 7.2°), respectively). Radiologically, the implants maintained neutral alignment without subsidence. Tibial or talar radiolucency was found in eight patients, but none of these patients was symptomatic. At five-year follow up, 97.7% of implants (95% confidence interval 91.2 to 99.4) were free from revision or removal with 84 implants at risk. We recorded two cases (2.3%) of failure for septic loosening. Conclusion. Transfibular TAA is safe and effective with a high survival rate at mid-term follow-up and satisfactory clinical and radiological results. Further studies are required to determine the long-term performance of these implants. Cite this article: Bone Joint J 2022;104-B(4):472–478

Although data on uncemented short stems are available, studies on cemented short-stemmed THAs are limited. These cemented short stems may have inferior long-term outcomes and higher femoral component fracture rates. Hence, we examined the long-term follow-up of cemented short Exeter stems used in primary THA. Within the Exeter stem range, 7 stems have a stem length of 125 mm or less. These stems are often used in small patients, in young patients with a narrow femoral canal or patients with anatomical abnormalities. Based on our local database, we included 394 consecutive cemented stems used in primary THA (n=333 patients) with a stem length ≤125 mm implanted in our tertiary referral center between 1993 and December 2021. We used the Dutch Arthroplasty Registry (LROI) to complete and cross-check the data. Kaplan-Meier survival analyses were performed to determine 20-year survival rates with stem revision for any reason, for septic loosening, for aseptic loosening and for femoral component fracture as endpoints. The proportion of male patients was 21% (n=83). Median age at surgery was 42 years (interquartile range: 30–55). The main indication for primary THA was childhood hip diseases (51%). The 20-year stem survival rate of the short stem was 85.4% (95% CI: 73.9–92.0) for revision for any reason and 96.2% (95%CI: 90.5–98.5) for revision for septic loosening. No stems were revised for aseptic femoral loosening. However, there were 4 stem fractures at 6.6, 11.6, 16.5 and 18.2 years of follow-up. The stem survival with femoral component fracture as endpoint was 92.7% (CI: 78.5–97.6) at 20 years. Cemented short Exeter stems in primary THA show acceptable survival rates at long-term follow-up. Although femoral component fracture is a rare complication of a cemented short Exeter stem, orthopaedic surgeons should be aware of its incidence and possible risk factors

Aims. The aim of this meta-analysis was to compare the outcome of total elbow arthroplasty (TEA) undertaken for rheumatoid arthritis (RA) with TEA performed for post-traumatic conditions with regard to implant failure, functional outcome, and perioperative complications. Materials and Methods. We completed a comprehensive literature search on PubMed, Web of Science, Embase, and the Cochrane Library and conducted a systematic review and meta-analysis. Nine cohort studies investigated the outcome of TEA between RA and post-traumatic conditions. The preferred reporting items for systematic reviews and meta-analysis (Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)) guidelines and Newcastle-Ottawa scale were applied to assess the quality of the included studies. We assessed three major outcome domains: implant failures (including aseptic loosening, septic loosening, bushing wear, axle failure, component disassembly, or component fracture); functional outcomes (including arc of range of movement, Mayo Elbow Performance Score (MEPS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), and perioperative complications (including deep infection, intraoperative fracture, postoperative fracture, and ulnar neuropathy). Results. This study included a total of 679 TEAs for RA (n = 482) or post-traumatic conditions (n = 197). After exclusion, all of the TEAs included in this meta-analysis were cemented with linked components. Our analysis demonstrated that the RA group was associated with a higher risk of septic loosening after TEA (odds ratio (OR) 3.96, 95% confidence interval (CI) 1.11 to 14.12), while there was an increased risk of bushing wear, axle failure, component disassembly, or component fracture in the post-traumatic group (OR 4.72, 95% CI 2.37 to 9.35). A higher MEPS (standardized mean difference 0.634, 95% CI 0.379 to 0.890) was found in the RA group. There were no significant differences in arc of range of movement, DASH questionnaire, and risk of aseptic loosening, deep infection, perioperative fracture, or ulnar neuropathy. Conclusion. The aetiology of TEA surgery appears to have an impact on the outcome in terms of specific modes of implant failures. RA patients might have a better functional outcome after TEA surgery. Cite this article: Bone Joint J 2019;101-B:1489–1497

Aims. The purpose of this study is to report our updated results at a minimum follow-up of 30 years using a first generation uncemented tapered femoral component in primary total hip arthroplasty (THA). Methods. The original cohort consisted of 145 consecutive THAs performed by a single surgeon in 138 patients. A total of 37 patients (40 hips) survived a minimum of 30 years, and are the focus of this review. The femoral component used in all cases was a first-generation Taperloc with a non-modular 28 mm femoral head. Clinical follow-up at a minimum of 30 years was obtained on every living patient. Radiological follow-up at 30 years was obtained on all but four. Results. Seven femoral components (18%) required revision, and none for septic loosening. Four well fixed stems were removed during acetabular revision and three were revised for late infection. One femoral component (3%) was loose by radiological criteria. The mean Harris Hip Score improved from 47 points (SD 4.62) preoperatively to 83 points (SD 9.27) at final follow-up. With revision for any reason as the endpoint, survival of the femoral component was 80% (95% confidence interval (CI) 61% to 90%) at 32 years. With revision for aseptic loosing femoral component, survival was 99% (95% CI 93% to 99%). Conclusion. With regards to aseptic loosening, the Taperloc femoral component provides excellent fixation at a mean follow-up of 32 years. Cite this article: Bone Jt Open 2023;4(2):79–86

THA in patients with acetabular bone defects is associated with a high risk of dislocation. Dual mobility (DM) cups are known to prevent and treat chronic instability. The aim of this study was to evaluate the dislocation rate and survival of jumbo DM cups. This was a retrospective, continuous, multicenter study of all the cases of jumbo DM cup implantation between 2010 and 2017 in patients with acetabular bone loss (Paprosky 2A: 46%, 2B: 32%, 2C: 15% and 3A: 6%). The indications for implantation were revisions for aseptic loosening of the cup (n=45), aseptic loosening of the femoral stem (n=3), bipolar loosening (n=11), septic loosening (n=10), periprosthetic fracture (n=5), chronic dislocation (n=4), intraprosthetic dislocation (n=2), cup impingement (n=1), primary posttraumatic arthroplasty (n=8), and acetabular dysplasia (n=4). The jumbo cups used were COPTOS TH (SERF), which combines press-fit fixation with supplemental fixation (acetabular hook, two superior flanges with one to four screws, two acetabular pegs). A bone graft was added in 74 cases (80%). The clinical assessment consisted of the Harris hip score. The primary endpoint was surgical revision for aseptic acetabular loosening or the occurrence of a dislocation episode. In all, 93 patients were reviewed at a mean follow-up of 5.3 ± 2.3 years [0, 10]. As of the last follow-up, the acetabular cup had been changed in five cases: three due to aseptic loosening (3.2%) and two due to infection (2.1%). The survivorship free of aseptic loosening was 96.8%. Three patients (3%) suffered a dislocation. At the last follow-up visit, the mean HSS scores were 72.15, (p < 0.05). Use of a jumbo DM cup in cases of acetabular bone defects leads to satisfactory medium-term results with low dislocation and loosening rates

The reconstruction of peri-acetabular defects after severe bone loss or pelvic resection for tumor is among the most challenging surgical intervention. The Lumic® prosthesis (Implantcast, Buxtehude, Germany) was first introduced in 2008 in an effort to reduce the mechanical complications encountered with the classic peri-acetabular reconstruction techniques and to improve functional outcomes. Few have evaluated the results associated with the use of this recent implant. A retrospective study from five Orthopedic Oncology Canadian centers was conducted. Every patient in whom a Lumic® endoprosthesis was used for reconstruction after peri-acetabular resection or severe bone loss with a minimal follow-up of three months was included. The charts were reviewed and data concerning patients’ demographics, peri-operative characteristics and post-operative complications was collected. Surgical and functional outcomes were also assessed. Sixteen patients, 11 males and five females, were included and were followed for 28 months [3 – 60]. Mean age was 55 [17–86], and mean BMI reached 28 [19.6 – 44]. Twelve patients (75%) had a Lumic® after a resection of a primary sarcoma, two following pelvic metastasis, one for a benign tumor and one after a comminuted acetabular fracture with bone loss. Twelve patients (75%) had their surgery performed in one stage whereas four had a planned two-stage procedure. Mean surgical time was 555 minutes [173-1230] and blood loss averaged 2100 mL [500-5000]. MSTS score mean was 60.3 preoperatively [37.1 – 97] and 54.3 postoperatively [17.1-88.6]. Five patients (31.3%) had a cemented Lumic® stem. All patients got the dual mobility bearing, and 10 patients (62.5%) had the largest acetabular cup implanted (60 mm). In seven of these 10 patients the silver coated implant was used to minimize risk of infection. Five patients (31.3%) underwent capsular reconstruction using a synthetic fabric aiming to reduce the dislocation risk. Five patients had per-operative complications (31.3%), four were minor and one was serious (comminuted iliac bone fracture requiring internal fixation). Four patients dislocated within a month post-operatively and one additional patient sustained a dislocation one year post-operatively. Eight patients (50%) had a post-operative surgical site infection. All four patients who had a two-stage surgery had an infection. Ten patients (62.5%) needed a reoperation (two for fabric insertion, five for wash-outs, and three for implant exchange/removal). One patient (6.3%) had a septic loosening three years after surgery. At the time of data collection, 13 patients (81.3%) were alive with nine free of disease. Silver coating was not found to reduce infection risk (p=0.2) and capsuloplasty did not prevent dislocation (p=1). These results are comparable to the sparse data published. Lumic® endoprosthesis is therefore shown to provide good functional outcomes and low rates of loosening on short to medium term follow-up. Infection and dislocation are common complications but we were unable to show benefits of capsuloplasty and of the use of silver coated implants. Larger series and longer follow-ups are needed

The reconstruction of peri-acetabular defects after severe bone loss or pelvic resection for tumor is among the most challenging surgical intervention. The Lumic® prosthesis (Implantcast, Buxtehude, Germany) was first introduced in 2008 in an effort to reduce the mechanical complications encountered with the classic peri-acetabular reconstruction techniques and to improve functional outcomes. Few have evaluated the results associated with the use of this recent implant. A retrospective study from five Orthopedic Oncology Canadian centers was conducted. Every patient in whom a Lumic® endoprosthesis was used for reconstruction after peri-acetabular resection or severe bone loss with a minimal follow-up of three months was included. The charts were reviewed and data concerning patients’ demographics, peri-operative characteristics and post-operative complications was collected. Surgical and functional outcomes were also assessed. Sixteen patients, 11 males and five females, were included and were followed for 28 months [3 – 60]. Mean age was 55 [17-86], and mean BMI reached 28 [19.6 – 44]. Twelve patients (75%) had a Lumic® after a resection of a primary sarcoma, two following pelvic metastasis, one for a benign tumor and one after a comminuted acetabular fracture with bone loss. Twelve patients (75%) had their surgery performed in one stage whereas four had a planned two-stage procedure. Mean surgical time was 555 minutes [173-1230] and blood loss averaged 2100 mL [500-5000]. MSTS score mean was 60.3 preoperatively [37.1 – 97] and 54.3 postoperatively [17.1-88.6]. Five patients (31.3%) had a cemented Lumic® stem. All patients got the dual mobility bearing, and 10 patients (62.5%) had the largest acetabular cup implanted (60 mm). In seven of these 10 patients the silver coated implant was used to minimize risk of infection. Five patients (31.3%) underwent capsular reconstruction using a synthetic fabric aiming to reduce the dislocation risk. Five patients had per-operative complications (31.3%), four were minor and one was serious (comminuted iliac bone fracture requiring internal fixation). Four patients dislocated within a month post-operatively and one additional patient sustained a dislocation one year post-operatively. Eight patients (50%) had a post-operative surgical site infection. All four patients who had a two-stage surgery had an infection. Ten patients (62.5%) needed a reoperation (two for fabric insertion, five for wash-outs, and three for implant exchange/removal). One patient (6.3%) had a septic loosening three years after surgery. At the time of data collection, 13 patients (81.3%) were alive with nine free of disease. Silver coating was not found to reduce infection risk (p=0.2) and capsuloplasty did not prevent dislocation (p=1). These results are comparable to the sparse data published. Lumic® endoprosthesis is therefore shown to provide good functional outcomes and low rates of loosening on short to medium term follow-up. Infection and dislocation are common complications but we were unable to show benefits of capsuloplasty and of the use of silver coated implants. Larger series and longer follow-ups are needed

The aim of the study to analyze the circulating white blood cells including the intensity expression of surface receptors and cytoplasmic molecules in patients underwent total hip replacement, with either aseptic or septic loosening of hip prostheses in order to identify cell-surface and cytoplasmic markers that could be indicative of early loosening. Flow cytometry was performed in whole peripheral blood samples of 20 patients with loosening (10 septic and 10 aseptic). Ten healthy individuals served a control group. The CD62L, CD18, CD11a, CD11b and CD11c expressions were evaluated. The mean fluorescence intensity (MFI) of CD 18 was decreased on all leukocytes subsets compared to control group. For patients with aseptic loosening we demonstrated an increase of MFI for CD11b in granulocytes and for CD11c in monocytes and granulocytes compared to control group. In patients with septic loosening an increase of MFI for CD 11c was observed in monocytes compared to control group. The comparison between aseptic and septic loosening showed a statistically significant lower CD18 MFI value in granulocytes for aseptic loosening. A trend towards lower MFI values of CD 62L in lymphocytes and granulocytes were observed in aseptic but not in septic loosening patients compared to control group. The present study is the first study in published literature to demonstrate cell surface and cytoplasmic markers in peripheral blood indicative of loosening of THAs by means of flow cytometry

Aims. Prosthetic joint infection (PJI) and aseptic loosening in total hip arthroplasty (THA) can present with pain and osteolysis. The Musculoskeletal Infection Society (MSIS) has provided criteria for the diagnosis of PJI. The aim of our study was to analyze the utility of F18-fluorodeoxyglucose (FDG) positron emission tomography (PET) CT scan in the preoperative diagnosis of septic loosening in THA, based on the current MSIS definition of prosthetic joint infection. Patients and Methods. A total of 130 painful unilateral cemented THAs with a mean follow-up of 5.17 years (. sd. 1.12) were included in this prospective study. The mean patient age was 67.5 years (. sd. 4.85). Preoperative evaluation with inflammatory markers, aspiration, and an F18 FDG PET scan were performed. Diagnostic utility tests were also performed, based on the MSIS criteria for PJI and three samples positive on culture alone. Results. The mean erythrocyte sedimentation rate, C-reactive protein, and white cell count were 47.83 mm/hr, 25.21 mg/l, and 11.05 × 10. 9. /l, respectively. The sensitivity, specificity, accuracy, negative predictive value, and false-positive rate of FDG PET compared with MSIS criteria were 94.87%, 38.46 %, 56.38%, 94.59 %, and 60.21%, respectively. The false-positive rate of FDG PET compared with culture alone was 77.4%. Conclusion. FDG PET has a definitive role in the preoperative evaluation of suspected PJI. This the first study to evaluate its utility based on MSIS criteria and compare it with microbiology results alone. However, FDG PET has a high false-positive rate. Therefore, we suggest that F18 FDG PET is useful in confirming the absence of infection, but if positive, may not be confirmatory of PJI. Cite this article: Bone Joint J 2019;101-B:910–914

Aims: The symptoms of aseptic and septic prosthetic joint loosening may be similar, and identification of low-grade prosthetic infection based only on clinical history and physical examination has a reported low sensitivity. In a prospective study we explored to what extent a thorough examination of the patient’s history of sickness and a standardized preoperative clinical examination could help the surgeon to identify cases of septic loosening. Methods: We included 54 patients undergoing revision surgery due to loosening of a total hip or knee prosthesis. Preoperatively a standardized form which included data regarding the patient’s history of sickness was obtained and a physical examination was performed. Postoperatively a final diagnose was made based on microbiological testing, which in addition to routine culture, included sonication of the prosthesis and nucleic acid based diagnostics (PCR). Data from the preoperative examination was evaluated in relation to the final diagnose (chi-square test and Student’s t-test), and the sensitivity and specificity for diagnosing a septic loosening was calculated for each preoperative finding. Results: According to the final diagnose, 21 patients had a septic loosening and 33 patients had an aseptic loosening. In the septic group and aseptic group the following anamnestic data was registered: Pain during rest: 16/21 vs. 7/33 (p < 0.001). Prior history of soft tissue debridement: 11/21 vs. 4/33 (p = 0.001). Prior prosthetic revision surgery: 13/21 vs. 8/33 (p = 0.006). Time from index operation to revision: 45 (5 – 144) moths vs. 159 (22–390) moths, (p = 0.02). Time from index operation to debut of prosthetic assosiated dyscomfort: 10 (0–110) moths vs. 120 (0–240) moths, (p < 0.001). The calculated sensitivity (se) and spesifisity (sp) for the pre-operative findings were: Existence of prosthetic related pain during rest: 79% se, 79% sp; history of soft tissue revision in the affected joint 52% se, 88% sp; history of prior exchange prosthetic revision in the affected joint 62% se, 76% sp, respectively. Conclusion: We advise a carefully obtained history from every patient presenting with loosening of implanted prosthetic components for identification of a potential low grade infection. In particular, pain during rest has a notable sensitivity and specificity. A prior history of soft tissue revision also strongly indicates a septic prosthetic loosening

INTRODUCTION. Conventional surgical exposures are usually inadequate for 2-stage revision knee replacement ofinfected implants. Reduced range of motion, extensor mechanism stiffness, peripatellar contracture and soft tissue scarring make patellar eversion difficult and forced eversion places the integrity of the extensor mechanism at risk. On the contrary, a wide exposure is fundamental to allow complete cement spacer removal, soft tissue balancing, management of bone loss and reimplantation without damaging periarticular soft tissues. OBJECTIVES. To compare the long-term clinical, functional and radiographic results and the reinfection rate of the quadriceps snip approach and the tibial tubercle osteotomy in 2-stage revision knee replacement performed for septic loosening of the primary implant. METHODS. In our department, 87 patients had a 2 stage revision knee replacement for septic loosening of the primary implant between 1996 and 2008. In all patients, first stage consisted of primary implant removal, extensive soft tissue debridement and positioning of a static antibiotic loaded cement spacer. The timing for reimplantation was decided basing on negative clinical and laboratory (ESR, CRP) signs and negative Leukoscan results. For reimplantation, a quadriceps snip was used in patients with an intraoperative flexion >90° (Group A) while a tibial tubercle osteotomy (Group B) was used in patients with an intraoperative flexion <90°. RESULTS. At observation point, 4 patients died for reasons unrelated to surgery, leaving 42 patients in Group A and 41 in Group B. We had a total amount of 10 recurrent infections (11%) after reimplantation, 7 patients in Group A and 3 patients in Group B (p<0.005). Patients with a reinfection in Group A were treated with a knee fusion in 4 cases, a rerevision in 2 cases and an amputation above the knee in 1 case, while all those with a reinfection in Group B had a knee fusion. According to HSS score, 11 patients were rated as Excelent/Good in Group A and 9 patients in Group B (p=n.s.). Three patients had a major complication in Group A and 0 patients in Group B (p=0.005). No differences were found between the two groups regarding range of motion and subjective satisfaction. CONCLUSION. Tibial tubercle osteotomy is a safe procedure to obtain a wide exposure in 2-stage revision knee replacement performed for septic loosening of the primary implant and it is effective in reducing reinfection rate without compromising clinical results and range of motion

Introduction. Revision TKA can be a difficult and complex procedure. Bone quality is commonly compromised and stem fixation is required in many cases to provide stability of the prosthetic construct. However, utilization of diaphyseal engaging stems adds complexity to the case and can present technical challenges to the surgeon. Press fit metaphyseal sleeves can provide stable fixation of the construct without the need for stems and allows for biologic ingrowth of the prosthesis. Metaphyseal sleeves simplify the revision procedure by avoiding the need to prepare the diaphysis for stems, alleviating the need for offset stems and decreasing the risk of intra-operative complications. The ability to obtain biologic fixation in the young patient is also appealing. This study reports on the author's mid-term experience with this novel technique. Methods. Between May 2007 and June 2009 the author performed 17 revisions TKA that utilized press-fit metaphyseal sleeves without stems on either the tibial side of the joint, the femoral side of the joint or both. Twenty six sleeves were implanted altogether (13 tibial, 13 femoral). Patients were limited to touch down weight bearing for 6 weeks post-operatively. The patients were followed prospectively with clinical and radiographic follow-up at routine intervals. Results. Average clinical and radiographic F/U for the cohort was 57 months (range 30 – 77). Fourteen of seventeen patients had a minimum of 4 years F/U. Average age at the time of surgery was 58 years (range 46–72) and average BMI was 32.4. Indications for the index revision included nine knees with aseptic loosening and / or osteolysis, two knees for septic loosening, two knees for instability and 4 knees for pain / stiffness or other causes. ROM at pre-op and latest F/U averaged 2–108 deg and 0–117 deg respectively. Knee Society Scores at pre-op and latest F/U averaged 35 and 86 respectively (range 57–100). Survivorship analysis revealed 25 of 26 sleeves (96%) to still be in situ at latest F/U. One tibial sleeve was revised at 30 months for septic loosening. Radiographic analysis revealed 22 of the remaining 25 sleeves (88%) to be ingrown. Two tibial sleeves and one femoral sleeve exhibit stable fibrous fixation and are asymptomatic. Conclusions. Press-fit metaphyseal sleeves utilized without stems appear to provide excellent stability of the revision TKA construct at mid-term F/U. Biologic fixation appears to be present in the majority of cases. This ability to obtain reliable osseointegration of the revision construct is appealing, especially in the younger revision patient. The sleeves have proven easy to use and there have been no intra-operative complications. This technique appears to provide a simple, but robust alternative when compared to revision TKA with stems in appropriate cases. Further F/U of this cohort is necessary to evaluate long term results

We present an update of the clinical and radiological results of 62 consecutive acetabular revisions using impacted morsellised cancellous bone grafts and a cemented acetabular component in 58 patients, at a mean follow-up of 22.2 years (20 to 25). The Kaplan-Meier survivorship for the acetabular component with revision for any reason as the endpoint was 75% at 20 years (95% confidence interval (CI) 62 to 88) when 16 hips were at risk. Excluding two revisions for septic loosening at three and six years, the survivorship at 20 years was 79% (95% CI 67 to 93). With further exclusions of one revision of a well-fixed acetabular component after 12 years during a femoral revision and two after 17 years for wear of the acetabular component, the survivorship for aseptic loosening was 87% at 20 years (95% CI 76 to 97). At the final review 14 of the 16 surviving hips had radiographs available. There was one additional case of radiological loosening and four acetabular reconstructions showed progressive radiolucent lines in one or two zones. Acetabular revision using impacted large morsellised bone chips (0.5 cm to 1 cm in diameter) and a cemented acetabular component remains a reliable technique for reconstruction, even when assessed at more than 20 years after surgery

We evaluated the outcome of 104 consecutive primary cemented Exeter femoral components in 78 patients (34 men, 44 women) under the age of 40 years who underwent total hip replacement between October 1993 and May 2004. The mean age at operation was 31 years (16 to 39). No hip was lost to follow-up, but three patients (four hips) died. None of the deaths were related to the surgery. At a mean follow-up of 6.2 years (2 to 13), three femoral components had been revised for septic loosening. Using Kaplan-Meier survival analysis, the seven-year survival of the component with revision for any reason as the endpoint was 95.8% (95% confidence interval 86.67 to 98.7). The seven-year survival with aseptic femoral loosening as the endpoint was 100% (95% confidence interval 100). The cemented Exeter femoral component in patients under the age of 40 shows promising medium-term results. As it is available in a wide range of sizes and offsets, we could address all types of anatomical variation in this series without the need for custom-made components

We prospectively reviewed 1000 consecutive patients who underwent a cementless, hydroxyapatite-coated, stemless, total knee replacement over a period of nine years. Regular post-operative clinical follow-up was performed using the Knee Society score. The mean pre-operative score was 96, improving to 182 and 180 at five and ten years, respectively. To date, there have been seven (0.5%) cases which required revision, primarily for septic loosening (four cases), with low rates of other post-operative complications. The cumulative survival at ten years with revision as the end-point, was 99.14% (95% confidence interval 92.5 to 99.8). These results support the use of hydroxyapatite in a cementless total knee replacement since it can give reliable fixation with an excellent clinical and functional outcome

At our institution between 1994 and 2003 a total of 36 revision total elbow Arthroplasties were performed in 34 patients. We clinically reviewed 25 patients and reviewed the notes and x-rays of all of them. Of eleven who were not reviewed clinically seven had died from an unrelated cause and four were unable to attend because of illness but we were able to include them as sufficient data were available in the notes. There were 24 female and 12 male, Average age was 67 years and twelve had elbow Arthroplasty in a non-dominant side. The average follow up was 6 years (range 5–13 years). The mean period between the primary and revision surgery was sixty three months (range 3–240 months). The indication for surgery was mainly for aseptic loosening in 15 cases, followed by septic loosening in twelve. All cases of septic loosening had two stage revisions. Other reasons for revision in this series include unstable elbows, implant fracture and peri-prosthetic fractures. Twelve of these revisions had a further revision for a variety of reasons at an average period of twenty eight months. Seven patients had thirteen complications in this series, two radial nerve palsies (one recovered), one distal humeral fracture, five cortical perforations and five triceps weakness. Most of the patients are satisfied with their elbows. The mean Mayo elbow Performance Score was 79 points. We conclude that revision Elbow Arthroplasty is a specialized surgery which is technically demanding, with high risk of complications and high re-revision rate and therefore, should be done in a specialised centres

Girdlestone’s arthroplasty is often used to treat septic loosening of hip prostheses. Although this operation provides goodresults with regards to pain and loosening, it causes instability and in the hip and limb shortening that force the patient to use walking aids. From 1990 to 1999 we treated ten cases of revisionhip arthroplasty after Girdlestone’s arthroplasty. Girdleston e’sarthroplasty was carried out in all cases due to sepsis in the previousimplant. Preoperatively all patients underwent granulocyte-labeledscintigraphy. For clinical evaluation we used the Merle D’Aubignè score. From 1990 to 1999 we treated ten cases of revisionhip arthroplasty after Girdlestone’s arthroplasty. Girdleston e’sarthroplasty was carried out in all cases due to sepsis in the previousimplant. Preoperatively all patients underwent granulocyte-labeledscintigraphy. For clinical evaluation we used the Merle D’Aubignè score. Girdlestone’s arthroplasty is very effective for treating septic loosening of hip prostheses, but it causes severe walking impediment. Revision surgery restores limb length and walking. Patients that undergo this treatment should be checked for residual sepsis, which may jeopardize the operation. Currently we are experimenting with spacers with antibiotics and our initial results are promising

Introduction: Hip replacement prosthesis infection is a severe complication of ever increasing incidence. Currently there is controversy as to whether prosthetic revision surgery should be carried out in one or two stages and whether cemented or uncemented prostheses should be used. Materials and methods: This is a retrospective study of 17 cases of chronic infections of hip replacements that were revised in one-stage procedures between 1996 and 2005 in our center. Mean follow-up is 3.4 years. We analyzed the functional status of the hips before and after revision using the Merle D’Aubigne scale, x-rays, and supplementary tests for diagnosis and decisions on treatment. Results: The functional score at the end of the follow-up was 16.17 (Merle D’Aubigne scale). The most common pathogen is coagulase-negative staphylococci. Acute phase reactive elements reached normal levels. X-ray control does not show any alterations or signs of loosening. No subsequent revisions have been performed. Conclusions: The diagnosis and treatment of prosthetic revision requires correct preoperative assessment and planning. Differential diagnosis of aseptic versus septic loosening in chronic infections is complex; in some cases it is necessary to wait for definite culture results for a surefire diagnosis. We think that in selected chronic cases of septic loosening of the hip due no non-multi-resistant organisms, one-stage revision using a Wagner osteotomy for diaphyseal cleaning combined with a hydoxyapatite-coated stem makes it possible to achieve good functional results and control infection, decreasing the morbidity and cost of a two-stage revision

Numerous techniques are used for the fusion of failed TAR. We wish to report our results of the revision of failed TAR to fusion. Between July 2005 and February 2011 the senior author had performed 20 arthrodeses in 19 patients (13 male and 6 female) who had failed total ankle arthroplasty (TAR). Their mean age was 63.5 years. All of them had the AES total ankle replacement. (Biomet UK). The mean period from the original TAR to fusion was 51 months (6 to72). The indication for revision of TAR to fusion was septic loosening in 4 patients and osteolysis and or aseptic loosening in 16 cases. Three types of fusion techniques were used. The mean follow-up was 15 months. All 3 tibiotalar arthrodeses with screws alone fused successfully. Of the 13 patients where the fusion was augmented with an Ilizarov frame, 4 were done for septic loosening. There were 2 non unions of which one was stable without pain and the other required a further revision fusion with a frame and subsequently fused. Of the 9 patients who had a fusion with a frame for osteolysis and or aseptic loosening, there was one non union which was revised to a tibiotalocalacaneal fusion with a hind foot nail. The nail fractured at the level of the posterior oblique screw hole. The patient subsequently developed a relatively pain free non-union of the tibiotalar joint and not required further surgical intervention. The remaining 8 ankles fused at a mean of 5 months. The average time of frame removal was 17 weeks. There was four pin-site infection all of which settled with oral antibiotics. 5 patients had tibiotalocalacaneal fusion with a hind foot nail. The indication for the hind foot nail was significant osteolysis and loss of talar bone stock. The average shortening as a result of the fusion for the failed TAR was 1.5cms. Our results were comparable to the previous reports of arthrodesis for failed total ankle replacement. We recommend the use of tibiotalocalcaneal fusion with a hind foot nail in the presence of severe osteolysis or accompanying subtalar arthritis. In the presence of good bone stock an ankle fusion supplemented with a circular frame gives a good predictable outcome

Aims: To test the outcome of acetabular revisons with impacted morsellized bone grafts and a cemented cup at a minimum follow-up of 15 years. Methods: Between 1979–1986 62 acetabular revisions (58 patients) were performed with impacted bone grafts and a cemented cup. Two cases (2 hips) were lost to FU. The average age at operation was 59.1 years. The indication was aseptic in 56 and septic loosening in 4 hips. Defects were AAOS-classiþed as ñcavitaryñ in 37 and ñcombinedñ 23 cases. Femoral-head allografts were used. Acetabular re-revisions were determined, the HHS obtained and radiographs analyzed. Results: Nineteen cases (20 hips) died within þfteen years after the operation, none had a re-revision. Eleven acetabular re-revisions were performed: 2 septic loosenings (3 and 6 years p.o.), 7 aseptic loosenings (6, 9, 11, 12, 13, 14, 14 year p.o.) and two for cup wear (12 and 17 yrs p.o.). The average HHS at follow-up was 86 (50–100). There were no additional radiographic failures. Using Kaplan-Meier analysis the survival with endpoint revision for any reason was 79% at 15 years and 71% at 20 years; for aseptic loosening of the cup 84% at 15 years and 84% at 20 years. Conclusions: This technique is attractive to reconstruct acetabular bone stock loss

Aim. In two-stage replacements for septic loosening, some studies have suggested that associate bacterial colonization of spacers had a worse result in relation to the control of the infection and a higher rate of complications after the implantation of the definitive prosthesis. The aim of our study was to determine the reoperation rate of patients undergoing two-stage revision surgery according to the results of spacer sonication. Method. A retrospective observational study was conducted in which 56 hip or knee spacers implanted at our center from 2010 to 2017 were analysed. Patients were grouped into three categories:. Patients with positive spacer sonication fluid culture, with or without positive cultures from the rest of the samples. Patients with negative spacer sonication culture and negative second-stage intraoperative cultures. Patients with negative spacer sonication culture but positive cultures of the rest of intraoperative samples. Results. Of the 56 patients analysed, 11 were included in group A, 32 in group B and 13 in group C. The reoperation rate was 36%, 34% and 54% respectively. Reoperation rate due to infection was 9%, 25% and 46% respectively. In only two cases (both in group C), the reoperation was caused by infection by a previously isolated microorganism. Spacers were colonized in all cases by low virulence microorganisms (coagulase negative staphylococci, P. acnes or Candida). Within group A, six patients also had other positive cultures. Conclusions. In our study, bacterial colonization of the spacer is not associated with a higher rate of reoperations in the short-medium term. The group of patients with positive cultures in the second stage surgery was the one with the highest rate of reoperations

Introduction: In case of massive bone defect, femoral stem revision may cause significant problems to the orthopaedic surgeons. The periprosthetic infection introduces a further element of complication which often leads to complex surgical strategies. The aim of this study was to assess the preliminary results of femoral revision with modular resection femoral stems in a selected group of patients with infected total hip arthroplasty and extensive bone defect. Materials and Methods: The study group included five patients (three women – two men) with an average age of 72 years (range 62–81 years). From 2006 to 2008 the patients underwent a prosthetic femoral revision with resection modular stems to treat a septic loosened primary hip prosthesis (one case) or revision hip prosthesis (four cases). The bacteria responsible for the infection were MRSE in three cases, MSSE and Str. Agalactie in one case, Proteus Mirabilis in one case. Three patients were treated in election for septic loosening of hip implant and two were admitted in our Department as emergency for a periproshtetic femoral fracture (Duncan type B3). In all the patients the femoral bone defect was grade III-B according to Paprosky classification of femoral bone deficiency. One patient with periproshtetic femoral fracture underwent a one-stage prosthetic revision and four patients sustained a two-stage prosthetic revision. In one patient a local flap was performed and Vaacum Assisted Therapy was applied in order to treat an associated loss of substance. The patients underwent periodical clinical controls in which the result has been evaluated by means of Merle-d’Aubigné hip score. Results: The follow-up period ranged from 10 to 28 months. We observed one case of recurrence of infection in the patient treated with a one-stage revision. At present, we did not observe signs of infection in the remaining four patients who underwent a two-stage revision. As for functional result, four patients walked with supports and one without them. No patient referred moderate or severe residual pain. Discussion: The preservation of bone stock is one of the most important goals in prosthetic revision procedures. In some circumstances the amount of femoral bone loss can be so wide to prevent the application of conventional or modular uncemented femoral stems. In these selected cases cemented modular resection femoral stems may represent the only available option for femoral reconstruction. In our clinical experience this solution offered altogether successful outcomes. In our opinion two-stage revision is the preferable surgical choice

Purpose: We report a series of 78 total hip arthroplasty revisions using a locked femoral stem, Ultime. Material and methods: These patients presented aseptic loosening (88%) and septic loosening (12%). Fracture was associated in 17%. The preoperative Postel Merle d’Aubligné (PMA) score was 10.2 points. Using the Vives-SOFCOT classification, 29% of the loosenings were stage I, 37% stage II, 24% stage III, and 10% stage IV. All fractures were associated with lossening. We used a femoral window in 57% and trochanterotomy in 14 cases. The first eight patients in this series had an allograft (impacted piecemeal). Most of the patients resumed weight bearing the first week. The PMA score was used to assess outcome. AP and lateral views were used to evaluate stem-bone contact and cortical thickness at three levels. Results: Early complications were phlebitis (n=1) and superficial haematoma (n=5). Late complications were dislocation (n=6), stem fracture (n=2), deep infection (n=3). At last follow-up, 81% of the aseptic loosenings, 77% of the septic loosenings, and 70% of the fractures on stem had a good or excellent PMA score with a mean gain of 4, 5, and 1 points respectively. Bone reconstruction showed an increase in internal cortical (2 to 4.4 mm) and stem-bone contact increased in the lower two-thirds of the stem. Allografts did not improve results. Furthermore, 28% of the patients had hip pain which could not be related to clinical findings or implant characteristics. Half of the patients were reoperated. Conclusion: In this series, functional improvement was similar to that in published series. The femoral window facilitated the procedure and decreased intraoperative complications. The Ultime prosthesis met the objectives set by the manufacturer, i.e. primary stability and bone reconstruction authorising subsequent revision

The Kent hip is a distally-locked femoral stem which was developed to address severe proximal bone loss, severe bony deformity and peri-prosthetic fracture. We reviewed the results of 145 consecutive Kent hips implanted into 141 patients between 1987 and 2000. The indications for implantation were aseptic loosening (75 hips), septic loosening (two), peri-prosthetic and prosthetic fracture (37), severe bony deformity (24), and fracture through a proximal femoral metastasis (seven). The median time to full weight-bearing after surgery was two days and the mean length of follow-up was 5.1 years (2 to 15). Further revisions were required for 13 femoral stems. With removal of the stem for any reason as an end-point, the cumulative survival at five, ten and 15 years was 93%, 89% and 77%, respectively. In patients aged ≥ 70 years, the cumulative survival at 15 years was 92%, compared with 68% in those aged < 70 years. Because of these findings, we recommend the use of interlocking stems in patients aged ≥ 70 years, particularly in those with a peri-prosthetic fracture, for whom alternative methods are limited. Outcome scores and survival data, compared with other systems, indicate that the Kent hip should be used with caution in younger patients

Purpose: The aim of this work was to assess retrospectively osteofixation and survival of a long custom-made femoral stem with complete hydroxyapatite coating and without locking for replacement of the femoral implant. Material and methods: From 1990 to 1999, 89 stems were implanted for revision total hip arthroplasty. Seventy-five hips were reviewed at one to ten years (mean four years). Radiographic analysis searched for bone damage, osteofixation and implant migration. All measures were taken on the AP views postoperatively and at last follow-up. Results: Revision was performed for aseptic loosening in 75%, for septic loosening in 12%, for fracture in 11% and for instability in 2%. Destruction was SOFCOT stage I in 36%, stage II in 44%, stage III in 17% and could not be assessed in 3%. The femorotomy approach was used in 60% and trochanterotomy in 32% and endofemoral assess in 8%. There were 18% intraoperative fractures, 4.8% postoperative infections and 2.4% dislocations. At last follow-up, the Postel Merle d’Aubigné score was 15.3 and the Harris Hip Score was 77.9. Thigh pain was present in 4%. Bone fixation was considered good in 48%, partial but better than 50% contact in 36% and could not be interpreted in 16%. Complete metaphyseal reconstruction was present in 8%. A piecemeal allograft was used in 89%. Between the postoperative and last follow-up films, 16% of the stems descended a mean 11 mm. Five percent of the stems were removed for infection and one (1.3%) for non-fixation. At five years, 95% of the stems was still in place and 80% at ten years, including removals for infection. All revisions for septic loosening had comparable clinical and radiological results in this series and did not develop secondary infection. Discussion: These results demonstrate the usefulness of the uncemented stems for replacement compared with cemented stems which have a 10% revision rate at five years (SOFCOT 1999). The complete hydroxyapatite coating improves distal fixation of the stem in a healthy zone without compromising secondary proximal fixation and authorising spontaneous metaphyseal bone reconstructions. This may explain the low rate of painful thighs. Modularity and locking could improve the primary fixation and limit descent

Purpose: The purpose of this work was to assess the quality of the bone reconstruction in contact with the long hydroxyapatite-coated locked femoral stem used in a consecutive series of patients undergoing revision total hip arthroplasty (RTHA). Material and methods: This series of 20 patients underwent RTHA for aseptic loosening (n=15) or septic loosening (n=5) of an AURA prosthesis. Mean age was 70.5 years. Mean time between insertion of the first stem and revision was 11 years for the aseptic patients and 2.6 years for the septic patients. Bony lesions of the femur were assessed with the SOFCOT classification: grade I=5, grade II=4, grade III=4, and grade IV=1. A transfemoral approach with a floating femoral segment was used in 14 patients and an endofemoral approach in six. The septic loosenings were reconstructed in two operative times in four patients and in one operation in one patient. An AURA reconstruction stem was used in 15 cases and a revision stem in five. A complementary cancellous bone graft with the endofemoral approach was used in six patients. Results: Two patients died. All others were reviewed at a mean follow-up of 26 months (range 12–46 months) for clinical and radiographic assessment (five patients also had a supplementary scan at more than three years follow-up). We had three dislocations at 15 days with no recurrence and one case of sepsis at three months which cured after wash out and adapted antibiotics. All the femoral segments healed starting on the tenth week. The PMA score improved from 9.1 to 15.66 and the Harris score from 43.5 to 85.5. At last follow-up, all femoral lesions had moved to a lower SOFCOT score. There was a tight contact between the AURA stem and the femur on the last follow-up scan which showed an increase in the cortical index from 1 to 8 cm from the metaphyseal spine of the stem. None of the patients experienced secondary unlocking or required revision for a shorter stem. Discussion: Revision after femoral failure with bone destruction using a non-cemented hydroxyapatite-coated stem allows immediate prosthetic mechanical stability and intimate bone reconstruction in the metaphyseal diaphyseal region. This reconstruction is real even if a graft is not used and appears to be favoured by the femorotomy. Implantation of the long stem is not particularly difficult and can even make the operation easier. Femorotomy has a real advantage, particularly for the revision of septic stems or in the event of difficult explantation

Total hip arthroplasty (THA) in patients under 30 years remains a challenge. The long-term survival data are often disappointing. In our institution, we have always used cemented components in all patients under 30 years, combined with acetabular impaction bone grafting (IBG), if necessary. We reviewed 139 consecutive patients (180 hips) treated between 1986 to 2014. Mean age at time of surgery was 24 (13–30.0) years. Acetabular IBG was applied in 127 (71%) cases. AAOS cavitary defect was seen in 26 (14%) cases, a AAOS segmental defect in 51 (28%) and a combination in 17 (9%). The mean preoperative HHS improved from 47 (20–81) to 87 (28–100) at review. During follow-up 26 hips have been revised (23 cups and 11 stems). Indications for revision were aseptic loosening (n=15), septic loosening (n=5), recurrent dislocation (n=3), wear (n=1), and stem fracture (n=1). The 10-year Kaplan-Meier survival of any component with endpoint revision for any reason was 87% (95% CI 79%–92%) and for aseptic loosening 92% (84%–96%). The 15-year survival of any component with revision for any reason as the endpoint was 77% (65%–86%) and for aseptic loosening 84% (71%–92%). Cemented THA and, if needed with impaction bone grafting, in patients under 30 years provides satisfying long-term results up to 15 years after surgery. Probably this biological approach with IBG may facilitate the inevitable revisions in the future in these young patients because of more bone stock

The advent of trabecular metal (TM) augments has revolutionized the management of severe bone defects during acetabular reconstruction. The purpose of this study was to evaluate patients undergoing revision total hip arthroplasty (THA) with the use of TM augments for reconstruction of Paprosky 3A, 3B defects and defects associated with pelvic discontinuity. A retrospective study was conducted of the cases performed at four centers between August 2007 and January 2015. Patients treated with TM augments for Paprosky 3A, 3B or chronic pelvic discontinuity were included in the study. All surgeries were performed through a posterior approach. A total of 57 patients (Male 34 (69%), Female 23(31%)), mean age 54 years (range, 28–94 years), with minimum follow up of one-year were included and evaluated using intention to treat analysis. There were 44 (77%) patients with a 3A defect, 11(19%) patients with a 3B defect (6 had an associated pelvic discontinuity), and 2 (3.5%) with a 2C defect and associated pelvic discontinuity. The mean follow-up was 37 months (range, 12–96 months). One (2%) patient died after 8 years of unrelated causes. Three (5.5%) patients had acetabular component loosening requiring revision; Two failures were (3.5%) due to aseptic loosening and one (2%) due to septic loosening. Fifty-four patients had a radiologically stable integration of the components at latest follow-up - survivorship was 94.7%. The results of this multi-center study demonstrate encouraging short and mid-term results for the use of TM augments in the management of Grade 3A and 3B defects, and defects associated with a chronic pelvic discontinuity

We reviewed 25 patients in whom a MUTARS megaprosthesis with a conical fluted stem had been implanted. There were three types of stem: a standard stem was used in 17 cases (three in the proximal femur, nine in the distal femur and five proximal tibia), a custom-made proximal femoral stem in four cases and a custom-made distal femoral stem in four cases. The mean age of the patients was 40.1 years (17 to 70) and the mean follow-up was for 2.5 years (0.9 to 7.4). At follow-up two patients had died from their disease: one was alive with disease and 22 were disease-free. One of 23 prostheses had been removed for infection and another revised to a cemented stem. The mean Musculoskeletal Tumor Society score was 24.9 (12 to 30) and the mean Karnofsky index was 82% (60% to 100%). There was no radiological evidence of loosening or subsidence. Stem stress shielding was seen in 11 patients and was marked in five of these. There were five complications, rupture of the extensor mechanism of the knee after extra-articular resection in two patients, deep venous thrombosis in one, septic loosening in one, and dislocation of the hip in one. The survival rate after seven years was 87% (95% confidence interval (CI) 83 to 91) for the patients and 95% (95% CI 91 to 99) for the megaprosthesis. A longer follow-up is needed to confirm these encouraging results

With increasing burden of revision hip arthroplasty, one of the major challenge is the management of bone loss associated with previous multiple surgeries. Proximal femoral replacement (PFR) has already been popularised for tumour surgeries. The inherent advantages of PFR over allograft –prosthesis system, which is the other option for addressing severe bone loss include, early weight bearing and avoidance of non-union and disease transmission. Our study explores PFR as a possible solution for the management of complex hip revisions. Thirty consecutive hips (29 patients) that underwent PFR between January 2009 and December 2015 were reviewed retrospectively for their clinical and radiological outcomes. The Stanmore METS system was used in all these patients. Mean age at the index surgery (PFR) was 72.69 years (range 50–89) with number of previous hip arthroplasties ranging from 1–5. At mean follow up of 32.27 months, there were no peri-prosthetic fractures and no mechanical failure of the implants. Clearance of infection was achieved in 80% of cases. There was 1 early failure due to intra-operative perforation of femoral canal needing further revision and two were revised for deep infection. Instability was noted in 26.7% (8) of the hips, of which, 87.5% (7) needed further revision with constrained sockets. Out of these 8 hips with instability, 5 had pre-operative infection. Deep infection was noted in 20% (6) of the hips, of which, 5 were primarily revised with PFR for septic loosening. However, further surgeries were essential for only 3 patients. One patient has symptomatic aseptic acetabular loosening and 1 had asymptomatic progressive femoral side loosening (lost to follow up). Severe proximal femoral bone loss in complex revision arthroplasties has necessitated the use of PFR prosthesis. Our study supports the fact that PFR is probably a mechanically viable option for complex revisions. Significant numbers of dislocations and infections could be attributed to the poor soft tissue envelope around the hip. Further surgical techniques in the form use of dual mobility cups and silver coated PFR implants need to be explored

The main causes of total hip arthroplasty (THA) revisions are loosening and instability. Use of a dual mobility cup cemented in a acetabular reconstruction cage device limits the risk of instability and does not hinder the acetabular fixation during THA revisions. The objective of this study was to analyse a retrospective series of 123 THA revisions with antiprotusio cage and dual mobility socket. Patients and methods: At a mean follow-up of 10 years, we analysed a continuous series of 123 revisions using a reconstruction device (87 Kerboull cross-plates, 12 Burch-Schneider antiprotrusio cages, 24 custom-fit Novae ARM cages associated in all cases with a Novae Stick dual mobility cup cemented into the cage). There were 80 women and 43 males. The mean age at the surgery was 69.2 years old. PMA score increased from 9.6 +/− 3.06 preoperatively to 14.2 +/− 2. at the follow-up. 9 early dislocations occurred and one late dislocation. At the last follow-up, the X-rays showed nine hardware failures, including one cross-plate fracture, one hook fracture, and one flange fracture. Analysis of the radiological position of the cup showed a mean lowering of 13 mm and a 7 mm lateralisation compared to the preoperative position. 2 revisions for aseptic loosening and 3 for septic loosening were performed. This study confirms the advantage of dual mobility cups during acetabular reconstruction cemented in antiprotrusio cages as a way to limit, without eliminating, the risk of dislocation. Therefore cemented fixation of dual mobility cups in cages appears to be a reliable short-term option

Aims

The aim of this study was to determine the outcome of all primary total hip arthroplasties (THAs) and their subsequent revision procedures in patients aged under 50 years performed at our institution.

Aims

Pelvic discontinuity is a rare but increasingly common complication of total hip arthroplasty (THA). This single-centre study evaluated the performance of custom-made triflange acetabular components in acetabular reconstruction with pelvic discontinuity by determining: 1) revision and overall implant survival rates; 2) discontinuity healing rate; and 3) Harris Hip Score (HHS).

Introduction. The mid- or long-term results of acetabular revision total hip arthroplasty (THA) in Korea are rare. The purpose of this study is to report the mid-term radiographic results (> 5 years) of acetabular revision THA with porous-coated cementless Trilogy. ®. cup (Zimmer, Warsaw, IN, USA). Materials and Methods. Between 1999 and 2010, 77 patients (79 hips) had underwent acetabular revision THA with Trilogy. ®. cup. Eight patients (8 hips) were excluded due to death before 5-year follow-up, and 22 patients (23 hips) were excluded due to less than 5-year follow-up or follow-up loss. Forty-seven patients (48 hips) were included in our study. The mean age was 57.9 years (range, 36 to 76 years) and the mean follow-up was 9.8 years (range 5.0 to 16.2 years). The causes of revision were aseptic loosening in 40 hips, and septic loosening in 8 hips, respectively. Both acetabular and femoral revisions were performed in 14 hips and isolated acetabular revision was done in 34 hips. Preoperetive acetabular bone defect according to Paprosky classification was; 1 in type I, 6 in IIA, 11 in IIB, 9 in IIC, 15 in IIIA, and 6 in IIIB. Results. Radiolucent lines less than 2mm were found in 2 hips; one in zone I, another in zone I, II, III. Four hips (1 in type IIC, 1 in IIIA and 2 in IIIB) showed cup migration greater than 5 mm accompanying change of position greater than 5 degrees. However, these patients did not complain pain and showed fixation by secondary stabilization. The Kaplan-Meier survivorship with aseptic loosening as the end point at 10 years was 92.6% (95% confidence interval [CI], 82.6 – 100) and at 15 years was 83.8 % (95% CI, 69.1 – 98.6), respectively. Non-recurrent dislocations occurred in 4 hips. There were no other complication such as sciatic nerve palsy, infection and deep vein thrombosis. Conclusion. Mid-term radiographic results (>5 years) of acetabular revision THA with porous-coated cementless Trilogy. ®. cup showed durable longevity. However, other options such as anti-protrusio cage or cup-cage construct should be considered in severe acetabular bone defect

In spite of its incidence decreasing to 1% nowadays, prosthesis-related infections remain a research, diagnostic, therapeutic and cost-related problem. Early diagnosis, selection of an appropriate surgical strategy, accurate identification of the responsible microorganisms and construction of an appropriate antibiotic regimen are essential elements of any management strategy. Our study aim was firstly to compare the diagnostic accuracy of conventional periprosthetic tissue culture and culture of fluid derived from vortexing and bath sonication of the explanted hardware and secondly to investigate the role of possible metabolic factors affecting the sensitivity of the sonication method. We investigated 70 patients undergoing revision hip or knee arthroplasty because of loosening of the prostheses, at our institution, between October 2011 and November 2013. Patients’ medical history and demographic characteristics were recorded. We compared the culture of samples obtained by sonication of explanted hip and knee prostheses with conventional culture of periprosthetic tissue for the microbiological diagnosis of prosthetic-joint infection. Infectious Diseases Society of America (IDSA) Guidelines were used for the definition of prosthetic-joint infection. Thirty-two patients had septic loosening and 38 aseptic loosening (48 hip prostheses and 22 knee prostheses). The sensitivity of sonication fluid culture was 81.25% and the sensitivity of conventional tissue cultures was 56.25% (p-value = 0.043). The sensitivity of the sonication method was statistically higher in obese, diabetic patients, with age above 60, in uncemented arthroplasties and in arthroplasties because of primary osteoarthritis (p-values < 0.05). The sonication method represents a reliable test for the diagnosis of prosthetic – joint infections with a greater sensitivity than the conventional periprosthetic tissue cultures, especially in obese, diabetic patients, with age above 60, in uncemented arthroplasties and in arthroplasties because of primary osteoarthritis

Aims

The aim of this study was to evaluate the survival of a collarless, straight, hydroxyapatite-coated femoral stem in total hip arthroplasty (THA) at a minimum follow-up of 20 years.

Failure of the femoral component after a primary or revision THA is commonly associated with some degree of femoral bone loss. Depending on the quantity and quality of the remaining host bone, femoral stem revision can be challenging. Twenty patients with severe proximal femoral bone loss due to prosthetic loosening were treated by Wagner cementless self-locking revision stems with a mean follow up of 24 months (range 18–36 months). The indication of revision surgery was aseptic loosening in 16 patients and septic loosening in 4 cases. At the end of the follow up the mean Harris hip score increased from 35 to 86 points. Definite radiographic evidence of bone regeneration in the bony defects was achieved within 3 months in all patients. Implantation of a Wagner cementless selflocking revision stem provided satisfactory results. The Wagner SL Revision prosthesis, firmly and rotationally stable fixed in the medullary cavity of the healthy bone distal from the original prosthetic bed, with its conical longitudinal ribs and cementless anchorage, bridges the defective prosthetic bed and hereby leads to a condition of relative mechanical stability. With time, there is active ossification in the old prosthetic bed, replacing lost bone

Introduction. The legacy constrained condylar knee prosthesis (LCCK, Zimmer.) is designed for primary and revision total joint arthroplasties that need additional stability due to ligament deficiency and to compensate for bone defects. In this follow-up we present our mid term results. Methods and Material. Between November 1999 and January 2006 59 patients were provided with 67 LCCK knee endoprotheses. 38 prostheses were implanted in cases of revision surgery and 29 as primary implants. The mean patient age was 76 years (range 22–93). Indications for revisions were 20 aseptic loosenings, 11 late infections, 7 instabilities (5 cases due to polyethylene wear). Indications for primary arthroplasties were 16 severe valgus and 7 severe varus deformities, 5 cases of osteoarthritis after infection and 1 posttraumatic deformity. 36 femur components (54%) and 34 tibia components (51%) were augmented. 31 stems were fixed cementless, 15 stems were cemented (6 with an intermedullary plug). We evaluated the results prospectively with a clinical inspection and x-ray. Clinical rating systems used were the Knee society, SF-36 Quality of life and Womac score. The mean follow up was 5.6 years. 42 patients were examined, 10 questioned on the telephone, 3 deceased, 12 had to be revised and 2 were lost for follow-up. Results. We had an increase in ROM from 93° to 110°. The Knee Society score improved from 40 to 75 and the function score improved from 46 to 72. The early complications included 1 peroneal lesion, 1 intraoperative fracture, 7 limitations in movement, 10 wound healing problems and 1 thrombosis. 12 revisions had to be performed. 1 septic loosening, 1 synovectomy, 4 aseptic loosenings, 3 secondary patella replacements, 1 traumatic rupture of the quadriceps muscle, 1 chondrosacroma and 1 revision performed in another clinic. 25 (80%) uncemented stems, 3 (33%) cemented stems and 1 (17%) of the stems cemented with an intramedullary plug showed radiolucencies. Conclusion. The LCCK prosthesis can be recommended as a primary implant and for revisions in cases of severe instability or severe bone loss. Due to the bad general health of the patients and preoperative situation of the knee joints the results are satisfactory. All revisions due to aseptic loosening had to be performed on LCCKs with uncemented stems

Aims

The aim of this study is to report the long-term outcomes of instrumented femoral revisions with impaction allograft bone grafting (IBG) using the X-change femoral revision system at 30 years after introduction of the technique.

Aims

Safety concerns surrounding osseointegration are a significant barrier to replacing socket prosthesis as the standard of care following limb amputation. While implanted osseointegrated prostheses traditionally occur in two stages, a one-stage approach has emerged. Currently, there is no existing comparison of the outcomes of these different approaches. To address safety concerns, this study sought to determine whether a one-stage osseointegration procedure is associated with fewer adverse events than the two-staged approach.

Aims

The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry.

INTRODUCTION. Wear, aseptic loosening, dislocation, corrosion and prosthetic joint infection (PJI) are major factors leading to revision of THA. The effect of using ceramic components to address these issues was investigated to determine their behaviour and potential benefit. METHODS. a) Wear determination in off-normal conditions. A series of CoC articulations (32mm) was evaluated using a hip simulator (ISO 14242) up to 4 million cycles in presence of fine alumina particles (48mg/ml). Wear was measured gravimetrically. b) Friction moment determination. Friction moments were measured in a hip simulator with 25% newborn calf serum as lubricant. CoC, CoPE, MoPE, MoXLPE and CoXLPE with articulating diameters ranging between 28 and 40mm were used. The cup was inclined to a constant angle of 33° and rotated ±20° sinusoidally around a horizontal axis at 1Hz. Peak friction moments were measured around the cup rotation axis during a constant joint force period of 1700N between 200 and 210 seconds. c) Infections. Four databases were analysed and additionally data from registers and literature were reviewed to determine the risk of revision for prosthetic joint infection (PJI) dependence on the bearing. Only data for cementless THA were used. Several studies also included analysis of several confounding factors like age at surgery, BMI, pathology, etc. using Cox multivariate analysis. RESULTS. a) Wear determination in off-normal conditions. Loading the test medium with alumina particles didn't produces detectable wear. Opaque areas appeared only after 3 million load cycles, but the wear-rate remained within the gravimetric measurement detection limit (about 0.1–0.2mg) indicating the still extremely low wear-rate of the tested couplings. b) Friction moment determination. The highest moments were measured for metal heads; the lowest for CoC bearings. 40mm CoC bearing showed a similar friction moment like 28mm bearings when coupled with a XLPE liner. c) Infections. The rate of revisions for PJI for 500'749 patients from various studies was in the range of 0.2 to 1.1%. Age at surgery and BMI did not influence septic loosening, while the bearing did; sometimes significant. The trend was identical for all seven sources and ceramic components resulted in a lower incidence of revisions for up to 60%. CONCLUSION. The wear of CoC articulations is extremely low even in a heavily contaminated environment with fine hard particles. Such high scratch resistance makes CoC the preferable revision solution in THA. Friction moments with CoC are the lowest, even with large diameter bearings. The low friction moments of ceramics lower the stresses at the modular and also bone interface and can affect the outcome of THA. Revisions due to infection seem to be also dependent on the bearing couple with a positive influence of ceramic components. Although due to the complex reasons for infections only a trend, CoP and CoC has been identified to mitigate the risk of PJI

Introduction. The dual mobility cup was introduced in the 1970s to allow extensive range of motion associated with great stability thanks to double articulation; the first between the head and polyethylene, the second between the polyethylene and the cup. The original plan was to install a stainless-steel uncemented cup coated with a thin layer of alumina and a metal head of 22,2 mm with a polyethylene liner of first generation. Long term follow-up case studies are cited in the literature showing excellent results in reducing dislocations; however wearing and aseptic loosening are noted. The new dual-mobility cups, with reticular polyethylene and titanium and hydroxyapatite coating are proving as reliable as the older ones in terms of stability whilst they appear to be more durable. Furthermore, cemented dual-mobility cups are available, these are the topic of this study. One of the most frequent complications in the major revisions of hip replacement is dislocation. This study summarises our experience gathered in the use of dual-mobility cups during revisions of complex cases (GIR III-IV femoral or acetabular). Materials and Methods. Between July 2014 to March 2015, we have implanted 13 cemented cups with dual-mobility (Avantage® Biomet) each in different patients, who have undergone revision with severe ostheolysis (GIR III-IV femoral or acetabular). The mean age of patients was 71.5 years old (46 to 89). Indications for revisions were: aseptic loosening in 7 patients (two at third surgery), recurrent dislocation in 3 patients, 1 septic loosening, 1 revision after spacer removal e 1 post-traumatic. We used dual-mobility cup in revision surgery when implant stability could have been compromised due to difficult positioning of acetabular component in cases of walls defects or muscolar laxity. The patients have been evaluated clinically and radiographically. Results. In most difficult cases with a severe lack of acetabular walls (9 patients), and thus difficulties in correct cup positioning, we have choosen to implant a cemented cup inside a Burch-schneider® (Zimmer) ring; in those cases where acetabular morphology was still sufficient, a dual-mobility cup was directly cemented to the bone. No dislocations occured during the folllow-up, neither infections, neurological events or DVT. Discussion. Dual mobility cups are often used both as primary implant or as a revision cup. Dislocation rate in primary total hip replacement is comparable to other kind of cup normally used, while in revision cases, the incidence of dislocation decrease from a range of 5–30% to 1,1–5,5%. Our results are not yet comparable to those in literature due to short follow-up, but first impressions are comforting thanks to the lack of dislocation even in really severe cases. Conclusions. The dual-mobility cup in acetabular revisions, is one of the possible choice to keep in mind in more complex cases, where obtaining stability is difficult or impossible using other revision implants. In the literature, the available follow up are not yet long enough to be sure of implant longevity and so it's important to pay attention to use this cup in those patients with long life expectancy

Trabecular metal (TM) augments are a relatively new option for reconstructing segmental bone loss during acetabular revision. We studied 34 failed hip replacements in 34 patients that were revised between October 2003 and March 2010 using a TM acetabular shell and one or two augments. The mean age of the patients at the time of surgery was 69.3 years (46 to 86) and the mean follow-up was 64.5 months (27 to 107). In all, 18 patients had a minor column defect, 14 had a major column defect, and two were associated with pelvic discontinuity. The hip centre of rotation was restored in 27 patients (79.4%). The Oxford hip score increased from a mean of 15.4 points (6 to 25) before revision to a mean of 37.7 (29 to 47) at the final follow-up. There were three aseptic loosenings of the construct, two of them in the patients with pelvic discontinuity. One septic loosening also occurred in a patient who had previously had an infected hip replacement. The augments remained stable in two of the failed hips. Whenever there was a loose acetabular component in contact with a stable augment, progressive metal debris shedding was evident on the serial radiographs. Complications included another deep infection treated without revision surgery. Good clinical and radiological results can be expected for bone-deficient acetabula treated by a TM cup and augment, but for pelvic discontinuities this might not be a reliable option. Cite this article: Bone Joint J 2013;95-B:166–72

Background. Revision THA presents significant challenges for the surgeon when the proximal femur is deficient or mechanically unreliable. The aim of this study is to assess the clinical and functional results of the use of tumor enndoprosthesis to reconstruct the proximal femur when there is massive bone loss. Patients and Methods. A prospective study was conducted involving 10 cases. The follow up of the cases ranged from 12 months to 30 months with a mean period of an average of 23months. The indications for revision surgery were aseptic loosening in 9 cases and septic loosening in one case Harris hip score was used for pre and postoperative clinical evaluation of the patients. Results. At the latest follow up the Harris Hip scores improved from a preoperative average of 16 (range, 3-47), to a postoperative average of 75.6 (range, 66-94). The complications that we encountered in the study included one case of superficial wound infection, another case developed sciatic nerve palsy postoperatively. No other complications were reported. Conclusion. Revision hip replacement in proximally compromised femurs presents a significant surgical challenge. When there is massive proximal femoral bone loss proximal fitting revision stems do not achieve adequate fixation hence the use of tumor prosthesis is indicated

Introduction. Total hip arthroplasty in young patients is still associated with high failure rates, especially at the acetabular side. Purpose of this study was to evaluate the long-term results of the Alloclassic cementless Zweymüller total hip prosthesis in patients younger than 50 years at the time of surgery. Methods. Between 1987 and 1994, 73 Zweymüller total hip arthroplasties with a titanium threaded cup were placed in 67 patients younger than 50 years. Mean age at surgery was 43 years (23–49 years). Patients were followed clinically with use of the HHS, revisions were determined and radiographs were analyzed. Kaplan-meier analysis was used to determine survival for different endpoints. Results. Three hips were revised for septic loosening, 3 cups for aseptic loosening and 1 hip because of periprosthetic fracture. Four patients (4 hips) died and 8 patients (9 hips) were lost to follow-up without any revision. 48 patients with 53 prostheses could be evaluated after a mean follow-up of 208 (170–253) months and the mean HHS was 90 (52–100). Cumulative survival analysis with endpoint revision for any reason was 89% (C.I. 85–93) at 17 years. With endpoint aseptic loosening, survival was 95% (C.I. 91–98) at 17 years. Conclusion. Alloclassic Zweymüller total hip arthroplasty with a titanium threaded cup showed good long-term results, even in this group of patients younger than 50 years