Aims

The Birmingham Hip Resurfacing (BHR) arthroplasty has been used as a surgical treatment of coxarthrosis since 1997. We present 20-year results of 234 consecutive BHRs performed in our unit.

Although good to excellent short-term results of arthroscopic partial limbectomy of the hip have been reported, there is little information on the long-term outcome of the procedure. We report a case with a 16-year follow-up. A 34-year old woman presented with a three-month history of severe pain and limitation of movement of the hip. Plain radiographs and arthrography showed no abnormality. MRI showed an effusion and a deformity of the anterosuperior part of the labrum. This was confirmed as an inverted labral tear that was debrided arthroscopically. At 16 years post-operatively, she remained symptom-free. Plain radiographs showed no abnormality and MRI suggested that the sealing effect of the scar tissue prevented articular damage and degeneration

Aims

Avascular femoral head necrosis in the context of gymnastics is a rare but serious complication, appearing similar to Perthes’ disease but occurring later during adolescence. Based on 3D CT animations, we propose repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension and external rotation as a possible cause of direct vascular damage, and subsequent femoral head necrosis in three adolescent female gymnasts we are reporting on.

Patients from a randomised trial on resurfacing hip arthroplasty (RHA) (n = 36, 19 males; median age 57 years, 24 to 65) comparing a conventional 28 mm metal-on-metal total hip arthroplasty (MoM THA) (n = 28, 17 males; median age 59 years, 37 to 65) and a matched control group of asymptomatic patients with a 32 mm ceramic-on-polyethylene (CoP) THA (n = 33, 18 males; median age 63 years, 38 to 71) were cross-sectionally screened with metal artefact reducing sequence-MRI (MARS-MRI) for pseudotumour formation at a median of 55 months (23 to 72) post-operatively. MRIs were scored by consensus according to three different classification systems for pseudotumour formation. . Clinical scores were available for all patients and metal ion levels for MoM bearing patients. . Periprosthetic lesions with a median volume of 16 mL (1.5 to 35.9) were diagnosed in six patients in the RHA group (17%), one in the MoM THA group (4%) and six in the CoP group (18%). The classification systems revealed no clear differences between the groups. Solid lesions (n = 3) were exclusively encountered in the RHA group. Two patients in the RHA group and one in the MoM THA group underwent a revision for pseudotumour formation. There was no statistically significant relationship between clinical scoring, metal ion levels and periprosthetic lesions in any of the groups. . Periprosthetic fluid collections are seen on MARS-MRI after conventional CoP THA and RHA and may reflect a soft-tissue collection or effusion. . Currently available MRI classification systems seem to score these collections as pseudotumours, causing an-overestimatation of the incidence of pseudotumours. . Cite this article: Bone Joint J 2015;97-B:1175–82

Recent studies about hip stability after total hip arthroplasties (THA) concerned differences regarding bearings: ceramic on ceramic (CoC) presenting less dislocations on the long term compared to metal or ceramic on polyethylene. The hypothesis is a difference in the healing process of periarticular tissues, with a stronger fibrous tissue for the first one, and more foreign body reaction, joint effusion with the others. NMR Imaging of the pelvis showing both hips using novel MR MAVRIC program for metal artefacts suppression, were performed in 10 patients, 15 THA and 2 non-pathological contralateral hips. Eight hips had CoC bearings, 3 of which were impacted cementless bulky ceramic implant, and 5 had a metal back. 7 hips had CoP bearings, 4 of which were cemented. Native capsules showed a mean thickness of 6.6mm. For CoC bearings, capsule thickness ranged from 7mm to 9.6 mm with a mean thickness of 8mm. For CoP bearings, capsule thickness ranged from 3mm to 8.4mm, with a mean thickness of 6.1mm. Neocapsule appeared clearly in all COC bearings observed, while for CoP, sometimes it was less dense with fatty aspect, 3 hips out of 7 having a very thin capsule under 4mm. It is possible to observe and quantify new capsule after THR and measure differences although not significant regarding bearings on limited number of samples. More patients might be included, but the tendencies observed here might explain better long term stability in vivo observed with Coc

Aims

This study aims to assess the relationship between history of pseudotumour formation secondary to metal-on-metal (MoM) implants and periprosthetic joint infection (PJI) rate, as well as establish ESR and CRP thresholds that are suggestive of infection in these patients. We hypothesized that patients with a pseudotumour were at increased risk of infection.

Introduction. Ascertaining the etiology of hip pain in young patients can be challenging. Osteoid osteoma about the hip has only been described in case reports and small case series in this sub-population. This study assessed the clinical course, radiologic findings, and treatment approaches in a large series of pediatric osteoid osteoma cases about the hip. Potential diagnostic and treatment pitfalls were identified. Methods. A single-center tertiary care departmental database was queried for all cases of osteoid osteoma seen between Jan 1, 2003 and December 31, 2015. Medical records were reviewed to identify those with lesions identified within or around the hip joint. Clinical, demographic, and radiologic data were analyzed. Results. Fifty children and adolescents (56% female, mean age 12.4 years, range 3–19 years) were identified with osteoid osteoma about the hip. The femoral neck was the most common lesion location (38%), and pain in the hip was the most common presenting chief complaint (60%). Night pain (90%) and symptom relief with NSAIDs (88%) were extremely common, though not universally reported. Sclerosis and/or cortical thickening was visible in 58% of radiographs, though a lucent nidus was visible in only 42%. Thirty patients (60%) underwent MRI, 27 of which were available for review, with focal peri-lesional edema as a universal finding. Amongst intracapsular lesions (n=17, 63%), common findings included medial retinacular thickening (33%), synovitis (45%) and effusion (76%). In the 43 patients (48%) who underwent CT, a diagnostic lucent nidus was a universal finding. Initial alternative diagnoses were recorded in 46% of cases, including, in order of decreasing frequency, femoro-acetabular impingement, minor trauma, hip synovitis, ‘growing pain’, stress fracture, and infection. Abnormal hip range of motion, positive impingement signs, and global synovitis on MRI scan were found to be associated with alternative diagnosis. On multivariate regression analysis, only abnormal hip ROM was independently predictive of alternative diagnosis. Delay in diagnosis of >6 months was seen in 43% of patients. Three patients underwent preceding operative procedures for other hip diagnoses, but had persistent hip pain until the osteoid osteoma was treated. Forty-one patients (82%) ultimately underwent radiofrequency ablation (RFA), and 1 open osteoid osteoma resection was performed. Of those who underwent RFA, 93% achieved complete symptom resolution, with 2 of 3 patients without symptom resolution undergoing revision RFA procedure, 1 of which led to symptom resolution. Complications of treatment included 1 case of deep infection along an RFA track, requiring operative debridement, 1 case of transient weakness and paresthesias in the involved extremity, and 1 case of fracture at the RFA site, requiring ORIF. Conclusions. Alternative andelayed diagnoses are common in osteoid osteoma about the hip, with femoro-acetabular impingement representing the most common alternative initial diagnosis in our series. While varying presenting complaints and nonspecific MRI findings may contribute to diagnostic uncertainty, night pain was present in the vast majority of cases and CT scans provided definitive diagnosis in all patients who received them. As increasing numbers of young, active patients are being evaluated for various causes of hip pain, such as femoro-acetabular impingement, osteoid osteoma should not be overlooked in the differential diagnosis of pain about the hip

Aims

To establish the survivorship, function, and metal ion levels in an unselected series of metal-on-metal hip resurfacing arthroplasties (HRAs) performed by a non-designer surgeon.

We carried out radial MRI in 30 hips with moderate osteoarthritis and in ten normal hips. On a scout view containing the entire acetabular rim, 12 vertical radial slices were set at 15° intervals. Different appearances were observed in different parts of the joint. In the weight-bearing portion, from 45° anterosuperior to 45° posterosuperior, ‘attenuation’ (n = 16) and ‘disappearance’ (n = 25) were observed as abnormalities of the labrum with ‘capsular stripping’ (n = 29) and ‘extraosseous high signal lesion’ (n = 27) as capsular abnormalities, seen more often in the anterosuperior portion. In all 12 planes there were osteophytes on the acetabular edge (n = 24), femoral head (n = 22) and/or at the central acetabulum (n = 6), a bone cyst on the acetabulum (n = 18) and/or the femoral head (n = 9), irregularity of the articular cartilage (n = 30), and an effusion (n = 28). Our findings indicate that radial MRI may be a useful non-invasive diagnostic method for demonstrating pathology in moderate osteoarthritis of the hip

Aims

The practice of overlapping surgery has been increasing in the delivery of orthopaedic surgery, aiming to provide efficient, high-quality care. However, there are concerns about the safety of this practice. The purpose of this study was to examine the safety and efficacy of a model of partially overlapping surgery that we termed ‘swing room’ in the practice of primary total hip (THA) and knee arthroplasty (TKA).

Aims

Leucocyte esterase (LE) has been shown to be an accurate marker of prosthetic joint infection (PJI), and has been proposed as an alternative to frozen section (FS) histology for intraoperative diagnosis. In this study, the intraoperative assessment of LE was compared with FS histology for the diagnosis of prosthetic hip infection.

Objectives

We have encountered patients who developed large joint fluid collections with massive elevations in chromium (Cr) and cobalt (Co) concentrations following metal-on-metal (MoM) hip arthroplasties. In some cases, retrieval analysis determined that these ion concentrations could not be explained simply by the wear rates of the components. We hypothesized that these effects may be associated with aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL).

Aims

To determine ten-year failure rates following 36 mm metal-on-metal (MoM) Pinnacle total hip arthroplasty (THA), and identify predictors of failure.

We investigated the changes seen on serial metal artefact reduction magnetic resonance imaging scans (MARS-MRI) of metal-on-metal total hip arthroplasties (MoM THAs). In total 155 THAs, in 35 male and 100 female patients (mean age 70.4 years, 42 to 91), underwent at least two MRI scans at a mean interval of 14.6 months (2.6 to 57.1), at a mean of 48.2 months (3.5 to 93.3) after primary hip surgery. Scans were graded using a modification of the Oxford classification. Progression of disease was defined as an increase in grade or a minimum 10% increase in fluid lesion volume at second scan. A total of 16 hips (30%) initially classified as ‘normal’ developed an abnormality on the second scan. Of those with ‘isolated trochanteric fluid’ 9 (47%) underwent disease progression, as did 7 (58%) of ‘effusions’. A total of 54 (77%) of hips initially classified as showing adverse reactions to metal debris (ARMD) progressed, with higher rates of progression in higher grades. Disease progression was associated with high blood cobalt levels or an irregular pseudocapsule lining at the initial scan. There was no association with changes in functional scores. Adverse reactions to metal debris in MoM THAs may not be as benign as previous reports have suggested. Close radiological follow-up is recommended, particularly in high-risk groups.

Cite this article: Bone Joint J 2015;97-B:1328–37.

Aims

There are limited published data detailing the volumetric material loss from tapers of conventional metal-on-polyethylene (MoP) total hip arthroplasties (THAs). Our aim was to address this by comparing the taper wear rates measured in an explanted cohort of the widely used Exeter THA with those measured in a group of metal-on-metal (MoM) THAs.

Aims

The aims of this study were to compare the diagnostic test characteristics of ultrasound alone, metal artefact reduction sequence MRI (MARS-MRI) alone, and ultrasound combined with MARS-MRI for identifying intra-operative pseudotumours in metal-on-metal hip resurfacing (MoMHR) patients undergoing revision surgery.

Aims

Early evidence has emerged suggesting that ceramic-on-ceramic articulations induce a different tissue reaction to ceramic-on-polyethylene and metal-on-metal bearings. Therefore, the aim of this study was to investigate the tissue reaction and cellular response to ceramic total hip arthroplasty (THA) materials in vitro, as well as the tissue reaction in capsular tissue after revision surgery of ceramic-on-ceramic THAs.

Objectives

Legg–Calvé–Perthes’ disease (LCP) is an idiopathic osteonecrosis of the femoral head that is most common in children between four and eight years old. The factors that lead to the onset of LCP are still unclear; however, it is believed that interruption of the blood supply to the developing epiphysis is an important factor in the development of the condition.

Aims

There are many guidelines that help direct the management of patients with metal-on-metal (MOM) hip arthroplasties. We have undertaken a study to compare the management of patients with MOM hip arthroplasties in different countries.

We undertook a retrospective cohort study to determine clinical outcomes following the revision of metal-on-metal (MoM) hip replacements for adverse reaction to metal debris (ARMD), and to identify predictors of time to revision and outcomes following revision. Between 1998 and 2012 a total of 64 MoM hips (mean age at revision of 57.8 years; 46 (72%) female; 46 (72%) hip resurfacings and 18 (28%) total hip replacements) were revised for ARMD at one specialist centre. At a mean follow-up of 4.5 years (1.0 to 14.6) from revision for ARMD there were 13 hips (20.3%) with post-operative complications and eight (12.5%) requiring re-revision.

The Kaplan–Meier five-year survival rate for ARMD revision was 87.9% (95% confidence interval 78.9 to 98.0; 19 hips at risk). Excluding re-revisions, the median absolute Oxford hip score (OHS) following ARMD revision using the percentage method (0% best outcome and 100% worst outcome) was 18.8% (interquartile range (IQR) 7.8% to 48.3%), which is equivalent to 39/48 (IQR 24.8/48 to 44.3/48) when using the modified OHS. Histopathological response did not affect time to revision for ARMD (p = 0.334) or the subsequent risk of re-revision (p = 0.879). Similarly, the presence or absence of a contralateral MoM hip bearing did not affect time to revision for ARMD (p = 0.066) or the subsequent risk of re-revision (p = 0.178).

Patients revised to MoM bearings had higher rates of re-revision (five of 16 MoM hips re-revised; p = 0.046), but those not requiring re-revision had good functional results (median absolute OHS 14.6% or 41.0/48). Short-term morbidity following revision for ARMD was comparable with previous reports. Caution should be exercised when choosing bearing surfaces for ARMD revisions.

Cite this article: Bone Joint J 2014;96-B:1600–9.