Aims. A higher failure rate has been reported in haematogenous periprosthetic joint infection (PJI) compared to non-haematogenous PJI. The reason for this difference is unknown. We investigated the outcome of haematogenous and non-haematogenous PJI to analyze the risk factors for failure in both groups of patients. Methods. Episodes of knee or hip PJI (defined by the European Bone and Joint Infection Society criteria) treated at our institution between January 2015 and October 2020 were included in a retrospective PJI cohort. Episodes with a follow-up of > one year were stratified by route of infection into haematogenous and non-haematogenous PJI. Probability of failure-free survival was estimated using the Kaplan-Meier method, and compared between groups using log-rank test. Univariate and multivariate analysis was applied to assess risk factors for failure. Results. A total of 305 PJI episodes (174 hips, 131 knees) were allocated to the haematogenous (n = 146) or the non-haematogenous group (n = 159). Among monomicrobial infections, Staphylococcus aureus was the dominant pathogen in haematogenous PJI (76/140, 54%) and coagulase-negative staphylococci in non-haematogenous PJI (57/133, 43%). In both groups, multi-stage exchange (n = 55 (38%) in haematogenous and n = 73 (46%) in non-haematogenous PJI) and prosthesis retention (n = 70 (48%) in haematogenous and n = 48 (30%) in non-haematogenous PJI) were the most common surgical strategies. Median duration of antimicrobial treatment was 13.5 weeks (range, 0.5 to 218 weeks) and similar in both groups. After six years of follow-up, the probability of failure-free survival was significantly lower in haematogenous compared to non-haematogenous PJI (55% vs 74%; p = 0.021). Infection-related mortality was significantly higher in haematogenous than non-haematogenous PJI (7% vs 0% episodes; p = 0.001). Pathogenesis of failure was similar in both groups. Retention of the prosthesis was the only independent risk factor for failure in multivariate analysis in both groups. Conclusion. Treatment failure was significantly higher in haematogenous compared to non-haematogenous PJI. Retention of the prosthesis was the only independent risk factor for failure in both groups. Cite this article: Bone Joint J 2023;105-B(12):1294–1302

There is widespread concern regarding the incidence of adverse soft-tissue reactions after metal-on-metal (MoM) hip replacement. Recent National Joint Registry data have shown clear differences in the rates of failure of different designs of hip resurfacing. Our aim was to update the failure rates related to metal debris for the Articular Surface Replacement (ASR). A total of 505 of these were implanted. Kaplan-Meier analysis showed a failure rate of 25% at six years for the ASR resurfacing and of 48.8% for the ASR total hip replacement (THR). Of 257 patients with a minimum follow-up of two years, 67 (26.1%) had a serum cobalt concentration which was greater than 7 μg/l. Co-ordinate measuring machine analysis of revised components showed that all patients suffering adverse tissue reactions in the resurfacing group had abnormal wear of the bearing surfaces. Six THR patients had relatively low rates of articular wear, but were found to have considerable damage at the trunion-taper interface. Our results suggest that wear at the modular junction is an important factor in the development of adverse tissue reactions after implantation of a large-diameter MoM THR

We present the results for 4762 revision total hip arthroplasties with no previous infection in the hip, which were reported to the Norwegian Arthroplasty Register between 1987 and 2003. The ten-year failure rate for revised prostheses was 26% (95% CI 25 to 26). Cox regression analyses were undertaken separately for acetabular and femoral revision components. Cemented revision components without allograft was the reference category. For acetabular components, we found a significantly reduced risk of failure for uncemented revisions both with (relative risk (RR) = 0.66; 95% CI 0.43 to 0.99) and without (RR = 0.37; 95% CI 0.22 to 0.61) allograft. For femoral components, we found a significantly reduced risk of failure for uncemented revisions, both with (RR = 0.27; 95% CI 0.16 to 0.46) and without (RR = 0.22; 95% CI 0.11 to 0.46) unimpacted allograft. This reduced risk of failure also applied to cemented revision components with allograft (RR = 0.53; 95% CI 0.33 to 0.84) and with impaction bone grafting (RR = 0.34; 95% CI 0.19 to 0.62). Revision prostheses have generally inferior results when compared with primary prostheses. Recementation without allograft, and uncemented revision with bone impaction, were associated with worse results than the other revision techniques which we studied

Hypothesis. Cartilage defects pretreated with marrow stimulation techniques will have an increased failure rate. The first 321 consecutive patients treated at one institution with autologous chondrocyte implantation for full-thickness cartilage defects that reached more than two years of follow-up were evaluated by prospectively collected data. Patients were grouped based on whether they had undergone prior treatment with a marrow stimulation technique. Outcomes were classified as complete failure if more than 25% of a grafted defect area had to be removed in later procedures because of persistent symptoms. Results. There were 522 defects in 321 patients (325 joints) treated with autologous chondrocyte implantation. On average, there were 1.7 lesions per patient. Of these joints, 111 had previously undergone surgery that penetrated the subchondral bone; 214 joints had no prior treatment that affected the subchondral bone and served as controls. Within the marrow stimulation group, there were 29 (26%) failures, compared with 17 (8%) failures in the control group. Conclusion. Defects that had prior treatment affecting the subchondral bone failed at a rate three times that of nontreated defects. The failure rates for drilling (28%), abrasion arthroplasty (27%), and microfracture (20%) were not significantly different—possibly because of the lower number of microfracture patients in this cohort (25 of 110 marrow-stimulation procedures). The data demonstrate that marrow stimulation techniques have a strong negative effect on subsequent cartilage repair with autologous chondrocyte implantation and, therefore, should be used judiciously in larger cartilage defects that could require future treatment with autologous chondrocyte implantation. Unlike coventional wisdom, MSTs do ‘burn bridges’

Introduction: Tibial augments are required to replace bone loss in the proximal tibia during revision total knee replacement and can be either a rectangular ‘block’ shape or an angled ‘wedge’ shape. Purpose of study: We have identified a high failure rate with the ‘wedge’ shape currently used in the Co-ordinate (DePuy) revision knee system. Methods: We report a series of revision total knee replacement procedures performed using the Co-ordinate system. All revision ‘angled’ tibial wedge implants were selected from our prospective database containing follow up records for knee replacements. Patients underwent clinical and radiological review at three months following the procedure, on the anniversary of surgery and then on a yearly basis. Those with fewer than 12 months follow-up were excluded. Results: Between December 1993 and February 2006, a total of 34 patients (19 female, 15 male) required revision knee arthroplasty with an ‘angled’ wedged tibial augment. Mean age at surgery was 59.3 years (range 46–93). Five cases were excluded due to absence of follow-up (four requiring further surgery for infection and one due to unrelated medical complications). Of the remaining 29 cases, 16 (55.2%) had no problems with the tibial implant, while 13 (44.8%) exhibited radiological changes on review. Tibial implant migration was seen in 5 cases (17.2%), all within three years of surgery. One of these has needed further revision surgery and the other four are expected to need revision in the future. Seven (24.1%) were found to have a tibial radiolucent zone, which was progressive in four cases. There was one case of stem dissociation. Conclusion: ‘Angled’ tibial wedge implants are associated with a high rate of implant migration and loosening, presumably due to the effect of shear forces. Use of these implants should be reserved for low demand patients

Background. The R3 cementless acetabular system (Smith & Nephew, Memphis, Tennessee, United States) is a modular titanium shell with an asymmetric porous titanium powder coating. It supports cross-linked polyethylene, metal and ceramic liners with several options for the femoral head component. The R3 cup was first marketed in Australia and Europe in 2007. Two recent papers have shown high failure rates of the MoM R3 system with up to 24% (Dramis et al 2014, Hothi et al 2015). There are currently no medium term clinical papers on the R3 acetabular cup. Objectives. The aim of the study is to review our results of the R3 acetabular cup with a minimum of 5 year follow up. Study Design & Methods. Patients who were implanted with the R3 acetabular cup were identified from our centre”s arthroplasty database. Our centre started implanting the R3 acetabular cup in August 2009. For this study, we only included patients with a minimum of 5 year follow up (until June 2011). Over this time period, 293 consecutive THAs were performed in 286 patients, of which 7 were bilateral staged total hip arthroplasties. The primary outcome was revision. The secondary outcomes were the Oxford hip scores and radiographic evaluation. Results. The mean age of the patients was 69.4 years (range 20–100 years). There were 117 males and 169 females in our series. The majority of the total hip arthroplasties in our series were cementless (n=283, 97%) and the rest were hybrid (n=10, 3%). The articulation bearings were as follows: ceramic on ceramic (n=167; 57%), Ceramic on Poly XLPE (n=97; 33%), Oxinium-Poly XLPE (n=19; 6.5%), stainless steel- Poly XLXE (n=10; 3.5%). The mean pre-operative Oxford Hip Score was 23 (range 10–34) and the mean Oxford Hip Score was 40 (range 33–48) at the final follow-up. Radiological evaluation showed an excellent ARA-score in all patients at five years. None of the R3 cups showed osteolysis at final follow up. There were 3 revisions in our series, of which two R3 cup were revised. The risk of revision was 0.28% at 5 years. Using Weibull analysis, it gives a 10-year estimate of 98.8% survival for the R3 cup (95%CI 95.0 to 99.6). Conclusions. Our experience at a district general hospital using the R3 acetabular system with conventional bearings showed high survivorship and is consistent with the allocated Orthopaedic Data Evaluation Panel (ODEP) rating of 5A* as rated in 2015 in the United Kingdom

Purpose: Resurfacing arthroplasty (RA) is becoming popular as an alternative to total hip arthroplasty (THA). Direct to consumer advertising reports good to excellent outcomes and patients sometimes seek RA on the assumption that it provides increased survivorship over THA. We report the 5 year survivorship of 25 RA procedures done at one institution. Method: 25 patients were prospectively followed after receiving a Conserve Plus RA through a direct lateral approach between 2002 and 2005. There were 22 males and 3 females with an mean age at surgery of 42 years. The average length of follow-up was 40 months. Failure was defined as revision of the components or a pending revision. Results: At a mean of 2 years follow-up, 3 patients had been revised and 2 more were scheduled for revision surgery for a failure rate of 20%. Reasons for revision included 1 neck fracture and 2 aseptically loose acetabular components. The 2 patients waiting for revision also had aseptically loose acetabular components. Patients receiving or requiring revision were operated on throughout the series and were not necessarily part of the surgical learning curve. Conclusion: RA of the hip done through a direct lateral approach in this series had an unacceptably high failure rate for aseptic loosening of the acetabular component

Aims

To investigate the outcomes of treatment of streptococcal periprosthetic joint infection (PJI) involving total knee and hip arthroplasties.

Introduction: Although good mid-term results have been reported with some metal on metal hip replacements, reported complications due to metal on metal (MOM) related reactions are a cause for concern. We have assessed the clinical outcome and MRI metallic artefact reduction sequence (MARS) findings in a consecutive series of patients with a large head metal on metal hip replacement. Methods: 62 ASR XL Corail THRs and 17 ASR resurfacings were performed at our hospital between 2005 and 2008. All patients were reviewed and assessed with an Oxford hip score (OHS), a plain radiograph and a MRI imaging was obtained on 76 (96%) hips. Implant position was assessed using Wrightington cup orientation software. Results: At a mean follow up of 32 months, 9 (15%) ASR XL Corail THRs, and 2(12%) ASR resurfacings had been revised. 10 revisions were performed for MRI confirmed MOM related pathology. Histology confirmed a MOM reaction in all 10 cases. Of the 76 hips that were MRI scanned, 27 (36%) had typical features of a MOM reaction. These were classified as mild in 10 (13%), moderate in 13 (17%) and severe in 4 (5%). 78 patients completed an OHS and the mean score was 21. The mean OHS was 29 pre-operatively in those that had been revised, 25 in patients with abnormal MRI findings and 20 in those with a normal MRI. 10 patients with abnormal MRIs had a near perfect OHS (15 or less). Conclusions: The ASR XL Corail THR has an unacceptably high early failure rate. MARS MRI is able to detect metal debris related soft tissue pathology around metal on metal THRs. These lesions are sometimes asymptomatic. We suggest that MARS MRI evaluation should form part of the routine evaluation of all metal on metal THRs, and in particular of this implant

Background

Established hip and knee arthroplasty registers exist in many countries but this is not the case with spinal implants. Moreover, in the case of a rod intended to guide spinal growth in a child and then be removed, the definition of ‘failure’ (revision) used for hip or knee arthroplasty is inappropriate. How can the performance of such spinal implants be judged?

Aims. To systematically review the predominant complication rates and changes to patient-reported outcome measures (PROMs) following osteochondral allograft (OCA) transplantation for shoulder instability. Methods. This systematic review, following PRISMA guidelines and registered in PROSPERO, involved a comprehensive literature search using PubMed, Embase, Web of Science, and Scopus. Key search terms included “allograft”, “shoulder”, “humerus”, and “glenoid”. The review encompassed 37 studies with 456 patients, focusing on primary outcomes like failure rates and secondary outcomes such as PROMs and functional test results. Results. A meta-analysis of primary outcomes across 17 studies revealed a dislocation rate of 5.1% and an increase in reoperation rates from 9.3% to 13.7% post-publication bias adjustment. There was also a noted rise in conversion to total shoulder arthroplasty and incidence of osteoarthritis/osteonecrosis over longer follow-up periods. Patient-reported outcomes and functional tests generally showed improvement, albeit with notable variability across studies. A concerning observation was the consistent presence of allograft resorption, with rates ranging from 33% to 80%. Comparative studies highlighted similar efficacy between distal tibial allografts and Latarjet procedures in most respects, with some differences in specific tests. Conclusion. OCA transplantation presents a promising treatment option for shoulder instability, effectively addressing both glenoid and humeral head defects with favourable patient-reported outcomes. These findings advocate for the inclusion of OCA transplantation in treatment protocols for shoulder instability, while also emphasizing the need for further high-quality, long-term research to better understand the procedure’s efficacy profile. Cite this article: Bone Jt Open 2024;5(7):570–580

This study reports the mid-term results of a large-bearing hybrid metal-on-metal total hip replacement in 199 hips (185 patients) with a mean follow-up of 62 months (32 to 83). Two patients died of unrelated causes and 13 were lost to follow-up. In all, 17 hips (8.5%) have undergone revision, and a further 14 are awaiting surgery. All revisions were symptomatic. Of the revision cases, 14 hips showed evidence of adverse reactions to metal debris. The patients revised or awaiting revision had significantly higher whole blood cobalt ion levels (p = 0.001), but no significant difference in acetabular component size or position compared with the unrevised patients. Wear analysis (n = 5) showed increased wear at the trunnion-head interface, normal levels of wear at the articulating surfaces and evidence of corrosion on the surface of the stem. The cumulative survival rate, with revision for any reason, was 92.4% (95% confidence interval 87.4 to 95.4) at five years. Including those awaiting surgery, the revision rate would be 15.1% with a cumulative survival at five years of 89.6% (95% confidence interval 83.9 to 93.4). This hybrid metal-on-metal total hip replacement series has shown an unacceptably high rate of failure, with evidence of high wear at the trunnion-head interface and passive corrosion of the stem surface. This raises concerns about the use of large heads on conventional 12/14 tapers

This study reports the mid-term results of a large bearing hybrid metal on metal total hip replacement (MOMHTHR) in 199 hips (185 patients) with mean follow up of 62 months. Clinical, radiological, metal ion and retrieval analysis were performed. Seventeen patients (8.6%) had undergone revision, and a further fourteen are awaiting surgery (defined in combination as failures). Twenty one (68%) failures were females. All revisions and ten (71%) awaiting revision were symptomatic. Twenty four failures (86%) showed progressive radiological changes. Fourteen revision cases showed evidence of adverse reactions to metal debris (ARMD). The failure cohort had significantly higher whole blood cobalt ion levels (p=0.001), but no significant difference in cup size (p=0.77), inclination (p=0.38) or cup version (p=0.12) compared to the non revised cohort. Female gender was associated with increased risk of failure (p=0.04). Multifactorial analysis demonstrated isolated raised Co levels in the absence of symptoms or XR changes were not predictive of failure (p=0.675). However the presence of pain (p<0.001) and XR changes (p<0.001) in isolation were significant predictors of failure. Wear analysis (n=5) demonstrated increased wear at the trunnion/head interface (mean out of roundness measurements 34.5 microns (normal range 8–10 microns) with normal wear levels at the articulating surfaces. Macroscopically corrosion was evident at the proximal and distal stem surfaces. Cumulative survival rate, with revision for any reason was 92.4% (95%CI: 87.4–95.4) at 5 years. Including those awaiting surgery, the revision rate would be 15.1% with 89.6% (95% CI: 83.9–93.4). Cumulative survival at 5 years. This MOMHTHR series has demonstrated unacceptable high failure rates with evidence of high wear at the head/trunnion interface and passive corrosion to the stem surface. Female gender was an independent risk factor of failure. Metal ion levels remain a useful aspect of the investigation work up but in isolation are not predictive of failure

Results in patients undergoing total hip arthroplasty (THA) for femoral head osteonecrosis (ON) when compared with primary osteoarthritis (OA) are controversial. Different factors like age, THA type or surgical technique may affect outcome. We hypothesized that patients with ON had an increased revision rate compared with OA. We analysed clinical outcome, estimated the survival rate for revision surgery, and their possible risk factors, in two groups of patients.

In this retrospective cohort analysis of our prospective database, we assessed 2464 primary THAs implanted between 1989 and 2017. Patients with OA were included in group 1, 2090 hips; and patients with ON in group 2, 374 hips. In group 2 there were more men (p<0.001), patients younger than 60 years old (p<0.001) and with greater physical activity (p<0.001). Patients with lumbar OA (p<0.001) and a radiological acetabular shape type B according to Dorr (p<0.001) were more frequent in group 1. Clinical outcome was assessed according to the Harris Hip Score and radiological analysis included postoperative acetabular and femoral component position and hip reconstruction. Kaplan-Meier survivorship analysis was used to estimate the cumulative probability of not having revision surgery for different reasons. Univariate and multivariate Cox regression models were used to assess risk factors for revision surgery.

Clinical improvement was better in the ON at all intervals. There were 90 hips revised, 68 due to loosening or wear, 52 (2.5%) in group 1, and 16 (4.3%) in group 2. Overall, the survival rate for revision surgery for any cause at 22 years was 88.0 % (95% CI, 82-94) in group 1 and 84.1% (95% CI, 69 – 99) in group 2 (p=0.019). Multivariate regression analysis showed that hips with conventional polyethylene (PE), compared with highly-cross linked PEs or ceramic-on-ceramic bearings, (p=0.01, Hazard Ratio (HR): 2.12, 95% CI 1.15-3.92), and cups outside the Lewinnek´s safe zone had a higher risk for revision surgery (p<0.001, HR: 2.57, 95% CI 1.69-3.91).

Modern highly-cross linked PEs and ceramic-on-ceramic bearings use, and a proper surgical technique improved revision rate in patients undergoing THA due to ON compared with OA.

Introduction. Although good mid-term results have been reported with some metal on metal hip replacements, reported complications due to metal on metal (MOM) related reactions are a cause for concern. We have assessed the early clinical outcome and results of routine metal artefact reduction MRI findings in a consecutive series of patients with a modern large head metal on metal hip replacement. Methods. 62 ASR XL Corail total hip replacements (THR) and 17 ASR resurfacings were performed at our hospital between 2005 and 2008. All patients were reviewed and assessed with an Oxford hip score (OHS), a plain radiograph and a MRI imaging was obtained on 76 (96%) hips. Implant position was assessed using Wrightington cup orientation software. Results. At a mean follow-up of 32 months, 8 ASR XL Corail THRs had been revised. 6 revisions were performed for MRI-confirmed MOM-related pathology. Histology confirmed a MOM reaction in all 6 cases. Of the 76 hips that were MRI scanned, 27 (36%) had typical features of a MOM reaction. These were classified as mild in 5 (7%), moderate in 18 (24%) and severe in 4 (5%). 78 patients completed an OHS and the mean score was 21. The mean OHS was 37 pre-operatively in those that had been revised, 19 in patients with abnormal MRI findings and 23 in those with a normal MRI. 10 patients with abnormal MRIs had a near perfect OHS (15 or less). Conclusion. The ASR XL Corail THR has an unacceptably high early failure rate. MRI detected metal debris related soft tissue related reactions were very common and often asymptomatic. We recommend that patients with this implant should be closely followed up and undergo routine metal artefact reduction MRI screening

Marrow stimulation techniques such as drilling or microfracture are first-line treatment options for symptomatic cartilage defects. Common knowledge holds that these treatments do not compromise subsequent cartilage repair procedures with autologous chondrocyte implantation (ACI). We present our experience with ACI after prior marrow stimulation. This study reviewed prospectively collected data for the first 321 consecutive patients treated at our institution with ACI for full-thickness cartilage defects that have reached more than 2 years of follow-up. Patients were grouped based on whether they had undergone prior treatment with a marrow stimulation technique. Outcomes were classified as complete failure if more than 25% of a grafted defect area had to be removed in later procedures due to persistent symptoms. This includes treatment with revision ACI, allograft transplantation, partial or total knee replacement. 522 defects in 321 patients (325 joints) were treated with ACI. Patient average age was 35 (13–60), there were 185 men and 136 women, with a follow-up of 2–12 Years. On average, there were 1.7 lesions per patient (range, 1–5) with a transplant area of 4.8 cm2 per lesion and 8.1 cm2 per knee. 111 of these joints had previously undergone surgery that penetrated the subchondral bone: microfracture (n=25), abrasion chondroplasty (n=33), and drilling (n=53). 214 joints had no prior treatment that affected the subchondral bone and served as control. Within the marrow stimulation group, there were 27 (24%) failures compared with 17 (8%) failures in the control group. In our review of 321 patients, defects that had prior treatment affecting the subchondral bone failed at a rate 3 times that of non-treated defects. These data demonstrate that marrow stimulation techniques have a strong negative effect on subsequent cartilage repair, and should be used judiciously in larger cartilage defects that could require future treatment with ACI.

Introduction

The optimal bearing for hip arthroplasty is still a matter of debate. in younger and more active patients ceramic-on-polyethylene (CoP) bearings are frequently chosen over metal-on-polyethylene (MoP) bearings to reduce wear and increase biocompatibility. However, the fracture risk of ceramic heads is higher than that of metal heads. This can cause serious issue, as ceramic fractures pose a serious complication often necessitating major revision surgery – a complication more frequently seen in ceramic-on-ceramic bearings. To date, there are no long-term data (> 20 years of follow-up) reporting fracture rates of the ceramic femoral heads in CoP bearings.

We report the results of 75 consecutive primary press-fit Kinemax arthroplasties with an average follow-up of 14 months (three to 28). We reviewed 26 cemented and 49 non-cemented tibial components implanted into 72 patients (30 men and 42 women, median age 70 years). At the latest follow-up the overall evaluation (Hospital for Special Surgery knee rating scale) for cemented cases was excellent in 54%, good in 42% and poor in 4%. No cemented prosthesis loosened. Of the non-cemented cases 55% were excellent, 23% good, and 2% fair. Ten tibial implants (20%) loosened and required revision. Residual pain marred the result in 24% of the non-cemented prostheses and in 4% of the cemented group. We do not recommend the press-fit, smooth-surfaced Kinemax prosthesis for non-cemented use.

Background: We have noted a concerning number of early failures (as defined by revision) for Preservation medial mobile-bearing uni-compartmental knee replacements (UKR’s) implanted in our hospital. This study retrospectively reviewed the postoperative radiographs to see if these were as a result of surgical technical failure.

Methods: Between 2003 and 2004, 43 medial mobile-bearing Preservation UKR’s were implanted into 39 patients. The average age of the patients at the time of the index procedure was 61.4 years (range, 46–85), (20 males). The immediate post-operative radiographs were reviewed by 2 independent orthopaedic consultants and a registrar, who were blinded to the patient outcomes, using the radiographic criteria used for the Oxford UKR. We however, particularly tried to identify any medio-lateral offset between femoral and tibial components due to the constrained nature of the prosthesis. A compound error score for all other technical errors was also calculated for each patient.

Results: Six (13.9%) of 43 knees were revised (5 for persistent pain, 1 for tibial component subsidence). Technical errors were few and no correlation was found between post-operative radiographic appearances and the subsequent need for revision. The mean compound error score (maximum value 18) was 4.5 (range, 2–9) in the revision cases and in the non revised cases 3.2 (range, 0–8).

Conclusions: We believe this study gives credence to the opinion that the DePuy Preservation mobile-bearing implant has design faults and is over-constrained leading to early failures in some cases.

Aims

To compare radiographic failure and re-operation rates of anatomical coracoclavicular (CC) ligament reconstructional techniques with non-anatomical techniques after chronic high grade acromioclavicular (AC) joint injuries.