There are no recent studies comparing cable with wire for the fixation of osteotomies or fractures in total hip replacement (THR). Our objective was to evaluate the five-year clinical and radiological outcomes and complication rates of the two techniques. We undertook a review including all primary and revision THRs performed in one hospital between 1996 and 2005 using cable or wire fixation. Clinical and radiological evaluation was performed five years post-operatively. Cables were used in 51 THRs and wires in 126, and of these, 36 THRs with cable (71%) and 101 with wire (80%) were evaluated at follow-up. The five-year radiographs available for 33 cable and 91 wire THRs revealed rates of breakage of fixation of 12 of 33 (36%) and 42 of 91 (46%), respectively. With cable there was a significantly higher risk of metal debris (68% vs 9%; adjusted relative risk (RR) 6.6; 95% confidence interval (CI) 3.0 to 14.1), nonunion (36% vs 21%; adjusted RR 2.0; 95% CI 1.0 to 3.9) and osteolysis around the material, acetabulum or femur (61% vs 19%; adjusted RR 3.9; 95% CI 2.3 to 6.5). Cable breakage increased the risk of osteolysis to 83%. There was a trend towards foreign-body reaction and increased infection with cables. Clinical results did not differ between the groups. In conclusion, we found a higher incidence of complications and a trend towards increased infection and foreign-body reaction with the use of cables

Aims. When performing revision total hip arthroplasty using diaphyseal-engaging titanium tapered stems (TTS), the recommended 3 to 4 cm of stem-cortical diaphyseal contact may not be available. In challenging cases such as these with only 2 cm of contact, can sufficient axial stability be achieved and what is the benefit of a prophylactic cable? This study sought to determine, first, whether a prophylactic cable allows for sufficient axial stability when the contact length is 2 cm, and second, if differing TTS taper angles (2° vs 3.5°) impact these results. Methods. A biomechanical matched-pair cadaveric study was designed using six matched pairs of human fresh cadaveric femora prepared so that 2 cm of diaphyseal bone engaged with 2° (right femora) or 3.5° (left femora) TTS. Before impaction, three matched pairs received a single 100 lb-tensioned prophylactic beaded cable; the remaining three matched pairs received no cable adjuncts. Specimens underwent stepwise axial loading to 2600 N or until failure, defined as stem subsidence > 5 mm. Results. All specimens without cable adjuncts (6/6 femora) failed during axial testing, while all specimens with a prophylactic cable (6/6) successfully resisted axial load, regardless of taper angle. In total, four of the failed specimens experienced proximal longitudinal fractures, three of which occurred with the higher 3.5° TTS. One fracture occurred in a 3.5° TTS with a prophylactic cable yet passed axial testing, subsiding < 5 mm. Among specimens with a prophylactic cable, the 3.5° TTS resulted in lower mean subsidence (0.5 mm (SD 0.8)) compared with the 2° TTS (2.4 mm (SD 1.8)). Conclusion. A single prophylactic beaded cable dramatically improved initial axial stability when stem-cortex contact length was 2 cm. All implants failed secondary to fracture or subsidence > 5 mm when a prophylactic cable was not used. A higher taper angle appears to decrease the magnitude of subsidence but increased the fracture risk. The fracture risk was mitigated by the use of a prophylactic cable. Cite this article: Bone Jt Open 2023;4(7):472–477

Aims. Femoral bone preparation using compaction technique has been shown to preserve bone and improve implant fixation in animal models. No long-term clinical outcomes are available. There are no significant long-term differences between compaction and broaching techniques for primary total hip arthroplasty (THA) in terms of migration, clinical, and radiological outcomes. Methods. A total of 28 patients received one-stage bilateral primary THA with cementless femoral stems (56 hips). They were randomized to compaction on one femur and broaching on the contralateral femur. Overall, 13 patients were lost to the ten-year follow-up leaving 30 hips to be evaluated in terms of stem migration (using radiostereometry), radiological changes, Harris Hip Score, Oxford Hip Score, and complications. Results. Over a mean follow-up period of 10.6 years, the mean stem subsidence was similar between groups, with a mean of -1.20 mm (95% confidence interval (CI) -2.28 to -0.12) in the broaching group and a mean of -0.73 mm (95% CI -1.65 to 0.20) in the compaction group (p = 0.07). The long-term migration patterns of all stems were similar. The clinical and radiological outcomes were similar between groups. There were two intraoperative fractures in the compaction group that were fixed with cable wire and healed without complications. No stems were revised. Conclusion. Similar stem subsidence and radiological and clinical outcomes were identified after the use of compaction and broaching techniques of the femur at long-term follow-up. Only the compaction group had intraoperative periprosthetic femur fractures, but there were no long-term consequences of these. Cite this article: Bone Jt Open 2021;2(12):1035–1042

Periprosthetic femoral fractures are a challenging problem to manage. In the literature various constructs have been designed and tested, most requiring cables for proximal fixation. The Synthes Locking Attachment Plate (LAP) has been designed to achieve proximal fixation without the use of cables. The aim of this study was to biomechanically evaluate the LAP construct in comparison to a Cable plate construct, for the fixation of periprosthetic femoral fractures after cemented total hip arthroplasty (THA). Twelve synthetic femora were tested in axial compression, lateral bending and torsion to determine initial stiffness, and stiffness following fixation of a simulated midshaft fracture with and without a bone gap. Two different fracture fixation constructs (six per group) were assessed. Each construct incorporated a broad curved LCP with bi-cortical locking screws for distal fixation. In the Cable construct, 2 cables and 2 uni-cortical locking screws were used for proximal fixation. In the LAP construct, the cables were replaced by a LAP with 4 bicortical locking screws. Axial, lateral bending and torsional stiffness were assessed using intact specimen values as a baseline. Axial load to failure was also measured. The LAP construct was significantly stiffer than the cable construct under axial load with a bone gap (simulating a comminuted fracture) (p=0.01). There were no significant differences between the two constructs in any of the other modalities tested. Loading to failure resulted in no significant differences between constructs, in either initial stiffness or peak load. In conclusion the LAP construct enables bi-cortical screw fixation around a prosthesis. Compared to cables, this was stiffer when there was a bone gap and thus should offer improved proximal fixation of Vancouver B1 proximal femoral fractures in cemented THA

Introduction. Iliopsoas tendonitis after total hip arthroplasty (THA) can be a considerable cause of pain and patient dissatisfaction. The optimal cup position to avoid iliopsoas tendonitis has not been clearly established. Implant designs have also been developed with an anterior recess to avoid iliopsoas impingement. The purpose of this cadaveric study was to determine the effect of cup position and implant design on iliopsoas impingement. Materials. Bilateral THA was performed on three fresh frozen cadavers using oversized (jumbo) offset head center revision acetabular cups with an anterior recess (60, 62 and 66 mm diameter) and tapered wedge primary stems through a posterior approach. The relatively large shell sizes were chosen to simulate THA revision cases. At least one fixation screw was used with each shell. A 2mm diameter flexible stainless steel cable was inserted into the psoas tendon sheath between the muscle and the surrounding membrane to identify the location of the psoas muscle radiographically. Following the procedure, CT scans were performed on each cadaver. The CT images were imported in an imaging software for further analysis. The acetabular shells, cables as well as pelvis were segmented to create separate solid models of each. To compare the offset head center shell to a conventional hemispherical shell in the same orientation, the offset head center shell was virtually replaced with an equivalent diameter hemispherical shell by overlaying the outer shell surfaces of both designs and keeping the faces of shells parallel. enabled us to assess the relationship between the conventional shells and the cable. The shortest distance between each shell and cable was measured. To determine the influence of cup inclination and anteversion on psoas impingement, we virtually varied the inclination (30°/40°/50°) and anteversion (10°/20°/30°) angles for both shell designs. Results. The CT analysis revealed that the original orientation (inclination/anteversion) of the shells implanted in 3 cadavers were as follows: Left1: 44.7°/23.3°; Right1: 41.7°/33.8°; Left2: 40.0/17; Right2: 31.7/23.5; Left3: 33.0/2908; Right3: 46.7/6.3. For the offset center shells, the shell to cable distance in all the above cases were positive indicating that there was clearance between the shells and psoas. For the hemispherical shells, in 3 out of 6 cases, the distance was negative indicating impingement of psoas. With the virtual implantation of both shell designs at orientations 40°/10°, 40°/20°, 40°/30° we found that greater anteversion helped decrease psoas impingement in both shell designs. When we analyzed the influence of inclination angle on psoas impingement by comparing wire distances for three orientations (30°/20°, 40°/20°, 50°/20°), we found that the effect was less pronounced. Further analysis comparing the offset head center shell to the conventional hemispherical shell revealed that the offset design was favored (greater clearance between the shell and the wire) in 17 out of 18 cases when the effect of anteversion was considered and in 15 out of 18 cases when the effect of inclinations was considered. Discussion. Our results indicate that psoas impingement is related to both cup position and implant geometry. For an oversized jumbo cup, psoas impingement is reduced by greater anteversion while cup inclination has little effect. An offset head center cup with an anterior recess was effective in reducing psoas impingement in comparison to a conventional hemispherical geometry. In conclusion, adequate anteversion is important to avoid psoas impingement with jumbo acetabular shells and an implant with an anterior recess may further mitigate the risk of psoas impingement

There is a paucity of available literature to guide the surgeon treating postoperative fractures of the greater trochanter after femoral component revision. Between 2009 and 2016, 133 patients underwent femoral component revision by the senior author utilizing a modular tapered fluted titanium stem. 17 patients died or had inadequate follow-up. Therefore, 116 patients were included in the final analysis. There were 58 males and 58 females with a mean age of 64 (range 23 to 91 years old). Clinical and radiographic data were analyzed for postoperative greater trochanteric fracture (GTfx). Mean clinical follow up was 21 months (range 3 to 77 mos). Age, BMI, preoperative diagnosis, comorbidities, reason for revision, use of Extended Trochanteric Osteotomy (ETO), fixation method of ETO, presence of prior hardware, post-operative trauma (falls), femoral component size and offset, change in leg length were analyzed to determine potential risk factors for postoperative GT fracture. There were 7 postoperative greater trochanteric fractures in 7 patients (6%). Of these, 1 occurred as a result of a postoperative fall, 1 occurred after dislocation, and 1 occurred after a fall with a subsequent dislocation. The mean time to diagnosis of the fracture was 10.7 weeks postoperatively (range one day to 37.4 weeks). 52 of 116 patients had their revision performed through an ETO. Of those, 6 had a postoperative fracture of the GT. The use of an ETO significantly increased the likelihood of postoperative GT fx (p=0.035). Regarding femoral component size, use of a longer proximal body (+10 or greater) was associated with an increased risk of postoperative GT fx (p=0.07). Two fractures were minimally (<1cm) or non-displaced and were treated non-operatively. Of these fractures, 1 united. The other fracture further displaced and resulted in recurrent instability. This was treated with excision of the fragment and a constrained liner. 5 fractures were displaced and were treated with ORIF. 3 were fixed with a cable grip device, 1 was plated, and 1 was treated with a cable grip device and a constrained liner. Of those treated with some form of ORIF, all 5 healed. Of those that underwent surgical fixation initially, 3 reported residual trochanteric pain and 1 patient had their hardware removed (trochanteric claw). 2 of these patients have a residual limp and require a cane for use as a gait aid. The patient treated non-surgically required a cane as did the patient that failed non-surgical treatment. Post-operative greater trochanteric fractures are a rare complication of femoral component revision. The use of an ETO significantly increased the rate of post of GTfx. The mean time to diagnosis of was 11 weeks. Displaced fractures of the greater trochanter treated with ORIF all healed, both cable grip devices and plates were effective. Residual limp requiring gait aids and residual trochanteric pain were common outcomes after fixation of these fractures despite successful union

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

Aims

Revision hip arthroplasty for femoral stem loosening remains challenging due to significant bone loss and deformities requiring specialized revision stems. The aim of this study was to evaluate the clinical and radiological outcomes, and survival, of a consecutive series of femoral revisions performed using a primary cementless stem with tapered geometry and rectangular cross-section at medium-term follow-up.

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.

Aims

Instability is a common cause of failure after total hip arthroplasty. A novel reverse total hip has been developed, with a femoral cup and acetabular ball, creating enhanced mechanical stability. The purpose of this study was to assess the implant fixation using radiostereometric analysis (RSA), and the clinical safety and efficacy of this novel design.

Introduction. The Vancouver Classification System presents a systematic approach to classification of periprosthetic fractures of the proximal femur (PFPFs) that has been validated in previous studies. However, with the introduction of tapered fluted stems and cable plates since the introduction of the Vancouver System, the connection between fracture class and the preferred method of treatment is often unclear. The present study was undertaken to identify fracture patterns surrounding contemporary femoral stems and the relationship between the current method of treatment and the Vancouver Class of the periprosthetic fracture. Methods. Three experienced joint surgeons collected plain radiographs (AP and lateral) and CT/MR scans (n=40) from 72 cases of Vancouver A or B periprosthetic fractures performed over the period 2016–2018. We identified the mode of primary stem fixation and the Vancouver grade of the fracture (A, B1, B2 or B3). Two independent investigators examined all imaging studies and the intraoperative records and recorded: (i) and the location and distribution of the fracture surfaces, and (ii) the presence of incomplete cortical fractures that had initiated within the femoral cortex without completing propagation and (iii) the method of operative treatment. These data were analyzed to examine the incidence of fractures within more than one femoral zone and differences in the fracture patterns corresponding to each Vancouver class. Results. One fifth (21%) of fractures were Type A with the remainder consisting predominantly of Type B2 (39%), with approximately equal proportions of Type B1 (22%) and B3 (18%) fractures. In almost half of Type B2 fractures (a loose femoral stem and a fracture adjacent to the prosthesis), fractures were also present within the metaphysis (ie. Type A+B). In the presence of a cementless femoral stem, fractures often occurred adjacent to the uncoated surface of the stem distal to the proximal ingrowth surface. Type B2 and B3 femurs had similar fracture patterns and degrees of comminution, though their method of treatment differed significantly. Incomplete fractures were identified in every Vancouver class (entire sample: 22%), especially in association with loose stems in poor quality bone (Type B3; 38% of cases). Conclusions. Approximately two-thirds of periprosthetic femoral fractures involve a loose femoral component (ie Types B2 and B3), though bone quality impacts operative treatment. In cementless stems, Vancouver Type B fractures often occur in the unbonded diaphysis between the distal edge of the ingrowth surface and immediately below the stem tip. Incomplete fractures are present in a surprising proportion of cases, suggesting that careful examination of imaging studies is needed to prevent fracture propagation due to inadequate fixation. CT scans are a useful adjunct to supplement plain radiographs. For any tables or figures, please contact the authors directly

Aims

Implant waste during total hip arthroplasty (THA) represents a significant cost to the USA healthcare system. While studies have explored methods to improve THA cost-effectiveness, the literature comparing the proportions of implant waste by intraoperative technology used during THA is limited. The aims of this study were to: 1) examine whether the use of enabling technologies during THA results in a smaller proportion of wasted implants compared to navigation-guided and conventional manual THA; 2) determine the proportion of wasted implants by implant type; and 3) examine the effects of surgeon experience on rates of implant waste by technology used.

Standard practice in revision total hip replacement (THR) for periprosthetic fracture (PPF) is to remove all cement from the femoral canal prior to implantation of a new component. This can make the procedure time consuming and complex. Since 1991 it has been our practice to preserve the old femoral cement where it remains well fixed to bone, even if the cement mantle is fractured, and to cement a new component into the old mantle. We have reviewed the data of 48 consecutive patients, treated at our unit between 1991 and 2009, with a first PPF around a cemented primary THR stem where a cement in cement revision was performed. 8 hips were revised to a standard length stem, 39 hips to a long stem & 1 patient had the same stem reinserted. All fractures were reduced and held with cerclage wires or cables and four had supplementary plate fixation. Full clinical and radiographic follow up was available in 38 patients & clinical or radiographic follow up in a further 6 patients. The other 4 patients. without follow up but whose outcome is known, have suffered no complications and are pain free. Of the remaining 44 patients, forty-two went on to union of the fracture and two have required further surgery for non-union. One patient has ongoing undiagnosed hip pain. Our long term experience with cement in cement revision for periprosthetic femoral fractures shows that this is a viable technique with a low complication rate and high rate of union (95%) in what is generally regarded as a very difficult condition to treat

Aims

The aim of this study was to determine both the incidence of, and the reoperation rate for, postoperative periprosthetic femoral fracture (POPFF) after total hip arthroplasty (THA) with either a collared cementless (CC) femoral component or a cemented polished taper-slip (PTS) femoral component.

Aims

The Birmingham Hip Resurfacing (BHR) was introduced in 1997 to address the needs of young active patients using a historically proven large-diameter metal-on-metal (MoM) bearing. A single designer surgeon’s consecutive series of 130 patients (144 hips) was previously reported at five and ten years, reporting three and ten failures, respectively. The aim of this study was to extend the follow-up of this original cohort at 25 years.

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The objectives of this study were to investigate the patient characteristics and mortality of Vancouver type B periprosthetic femoral fractures (PFF) subgroups divided into two groups according to femoral component stability and to compare postoperative clinical outcomes according to treatment in Vancouver type B2 and B3 fractures.

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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.

Aims

The prevalence of ipsilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) is rising in concert with life expectancy, putting more patients at risk for interprosthetic femur fractures (IPFFs). Our study aimed to assess treatment methodologies, implant survivorship, and IPFF clinical outcomes.

Aims

The aim of this study was to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter).

Aims

We aimed to compare the implant survival, complications, readmissions, and mortality of Vancouver B2 periprosthetic femoral fractures (PFFs) treated with internal fixation with that of B1 PFFs treated with internal fixation and B2 fractures treated with revision arthroplasty.