Aims. Large-diameter metal-on-metal (MoM) total hip arthroplasty (THA) has demonstrated unexpected high failure rates and pseudotumour formation. The purpose of this prospective cohort study is to report ten-year results in order to establish revision rate, prevalence of pseudotumour formation, and relation with whole blood cobalt levels. Methods. All patients were recalled according to the guidelines of the Dutch Orthopaedic Association. They underwent clinical and radiographical assessments (radiograph and CT scan) of the hip prosthesis and whole blood cobalt ion measurements. Overall, 94 patients (95 hips) fulfilled our requirements for a minimum ten-year follow-up. Results. Mean follow-up was 10.9 years (10 to 12), with a cumulative survival rate of 82.4%. Reason for revision was predominantly pseudotumour formation (68%), apart from loosening, pain, infection, and osteolysis. The prevalence of pseudotumour formation around the prostheses was 41%, while our previous report of this cohort (with a mean follow-up of 3.6 years) revealed a 39% prevalence. The ten-year revision-free survival with pseudotumour was 66.7% and without pseudotumour 92.4% (p < 0.05). There was poor discriminatory ability for cobalt for pseudotumour formation. Conclusion. This prospective study reports a minimum ten-year follow-up of large-head MoM THA. Revision rates are high, with the main reason being the sequelae of pseudotumour formation, which were rarely observed after five years of implantation. Blood ion measurements show limited discriminatory capacity in diagnosing pseudotumour formation. Our results evidence that an early comprehensive follow-up strategy is essential for MoM THA to promptly identify and manage early complications and revise on time. After ten years follow-up, we do not recommend continuing routine CT scanning or whole cobalt blood measurements, but instead enrolling these patients in routine follow-up protocols for THA. Cite this article: Bone Jt Open 2022;3(1):61–67

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.

Aims

The aim of this study was to evaluate blood metal ion levels, leucocyte profiles, and serum cytokines in patients with a total hip arthroplasty (THA) involving modular dual-mobility components.

Between January 1984 and January 1986, 131 porous-coated anatomic total hip replacements were performed in 119 consecutive patients. Of these, 100 patients (110 hips) who were alive at a minimum of 18 years after replacement were included in the study. The mean age of the patients at surgery was 48.4 years and that of surviving patients at the latest follow-up was 67.8 years. The mean duration of the clinical and radiological follow-up was 19.4 years (18 to 20).

The mean Harris hip score initially improved from 55 points before to 95 points at two years after operation, but subsequently decreased to 91 points after six years, 87 points after 11.2 years, and 85 points after 19.4 years. At the final follow-up, 23 hips (18%) of the entire cohort and 21% of survivors had undergone revision because of loosening or osteolysis of the acetabular component and eight hips (6%) of the entire cohort and 7% of survivors for loosening or osteolysis of the femoral component. Only four femoral components (4%) were revised for isolated aseptic loosening without osteolysis and two (2%) for recurrent dislocation. On the basis of these long-term results, the porous-coated anatomic femoral component survived for a minimum of 18 years after operation while the acetabular component was less durable. The findings identify the principles of uncemented joint replacement which can be applied to current practice.

In a frail elderly patient a pathological fracture of the femur at the lower end of a loose femoral stem was treated by the retrograde insertion of an intramedullary nail over the tip of the prosthesis.

We have followed up for a period of seven to nine years 100 consecutive arthroplasties of the hip in which an entirely HA-coated implant had been used.

The clinical results were excellent and bony incorporation was extensive in all components. No stem became loose or subsided but five cups were revised because of loosening after 3.8 to 5.5 years, having functioned painlessly and shown radiological ingrowth.

Revision procedures because of excessive polyethylene wear have been performed on 18 hips and are planned for six more. Two eroded metal backings with worn-through polyethylene were exchanged; six hips showed metallosis without polyethylene wear-through. There were two cases of granulomatous cysts in the groin and 66 hips had osteolysis located periarticularly, in the greater trochanter or in the acetabulum.

We enrolled 98 patients (107 hips) with a mean age of 47 years (SD 8.6) into a prospective study of the Madreporic Lord THR; 34 hips had primary and 73 secondary osteoarthritis.

After ten years, the survival rate using revision as the endpoint for failure was 70% (±9) for the cup and 98% (±0.3) for the stem. The combined clinical and radiological survival rates were 46% (±11) and 81% (±10), respectively. Osteoporosis due to stress-shielding was observed in the proximal femur. Hips with radiologically dense bone postoperatively showed the most pronounced bone loss.

We recommend continued radiological follow-up of patients with this type of implant to allow revision to be performed before there is severe bony destruction of the pelvis.

In this meta-analysis we included 32 English-language articles published between January 1975 and June 2004 on the diagnostic performance of plain radiography, subtraction arthrography, nuclear arthrography and bone scintigraphy in detecting aseptic loosening of the femoral component, using criteria based on the Cochrane systematic review of screening and diagnostic tests.

The mean sensitivity and specificity were, respectively, 82% (95% confidence interval (CI) 76 to 87) and 81% (95% CI 73 to 87) for plain radiography and 85% (95% CI 75 to 91) and 83% (95% CI 75 to 89) for nuclear arthrography. Pooled sensitivity and specificity were, respectively, 86% (95% CI 74 to 93) and 85% (95% CI 77 to 91) for subtraction arthrography and 85% (95% CI 79 to 89) and 72% (95% CI 64 to 79) for bone scintigraphy. Although the diagnostic performance of the imaging techniques was not significantly different, plain radiography and bone scintigraphy are preferred for the assessment of a femoral component because of their efficacy and lower risk of patient morbidity.

The early failure and revision of bimodular primary total hip arthroplasty prostheses requires the identification of the risk factors for material loss and wear at the taper junctions through taper wear analysis. Deviations in taper geometries between revised and pristine modular neck tapers were determined using high resolution tactile measurements. A new algorithm was developed and validated to allow the quantitative analysis of material loss, complementing the standard visual inspection currently used.

The algorithm was applied to a sample of 27 retrievals (in situ from 2.9 to 38.1 months) of the withdrawn Rejuvenate modular prosthesis. The mean wear volumes on the flat distal neck piece taper was 3.35 mm³ (0.55 to 7.57), mainly occurring in a characteristic pattern in areas with high mechanical loading. Wear volume tended to increase with time to revision (r² = 0.423, p = 0.001). Implant and patient specific data (offset, stem size, patient’s mass, age and body mass index) did not correlate with the amount of material loss observed (p >  0.078). Bilaterally revised implants showed higher amounts of combined total material loss and similar wear patterns on both sides. The consistent wear pattern found in this study has not been reported previously, suggesting that the device design and materials are associated with the failure of this prosthesis.

Cite this article: Bone Joint J 2015;97-B:1350–7.

Aims. There is evidence that prior lumbar fusion increases the risk of dislocation and revision after total hip arthroplasty (THA). The relationship between prior lumbar fusion and the effect of femoral head diameter on THA dislocation has not been investigated. We examined the relationship between prior lumbar fusion or discectomy and the risk of dislocation or revision after THA. We also examined the effect of femoral head component diameter on the risk of dislocation or revision. Methods. Data used in this study were compiled from several Finnish national health registers, including the Finnish Arthroplasty Register (FAR) which was the primary source for prosthesis-related data. Other registers used in this study included the Finnish Health Care Register (HILMO), the Social Insurance Institutions (SII) registers, and Statistics Finland. The study was conducted as a prospective retrospective cohort study. Cox proportional hazards regression and Kaplan-Meier survival analysis were used for analysis. Results. Prior lumbar fusion surgery was associated with increased risk of prosthetic dislocation (hazard ratio (HR) = 2.393, p < 0.001) and revision (HR = 1.528, p < 0.001). Head components larger than 28 mm were associated with lower dislocation rates compared to the 28 mm head (32 mm: HR = 0.712, p < 0.001; 36 mm: HR = 0.700, p < 0.001; 38 mm: HR = 0.808, p < 0.140; and 40 mm: HR = 0.421, p < 0.001). Heads of 38 mm (HR = 1.288, p < 0.001) and 40 mm (HR = 1.367, p < 0.001) had increased risk of revision compared to the 28 mm head. Conclusion. Lumbar fusion surgery was associated with higher rate of hip prosthesis dislocation and higher risk of revision surgery. Femoral head component of 32 mm (or larger) associates with lower risk of dislocation in patients with previous lumbar fusion. Cite this article: Bone Joint J 2020;102-B(8):1003–1009

Aims

Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications.

Aims

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.

Aims

Our objective was describing an algorithm to identify and prevent vascular injury in patients with intrapelvic components.

Aims

Young adults undergoing total hip arthroplasty (THA) largely have different indications for surgery, preoperative function, and postoperative goals compared to a standard patient group. The aim of our study was to describe young adult THA preoperative function and quality of life, and to assess postoperative satisfaction and compare this with functional outcome measures.

Aims

The aims of this study were to determine if an increasing serum cobalt (Co) and/or chromium (Cr) concentration is correlated with a decreasing Harris Hip Score (HHS) and Hip disability and Osteoarthritis Outcome Score (HOOS) in patients who received the Articular Surface Replacement (ASR) hip resurfacing arthroplasty (HRA), and to evaluate the ten-year revision rate and show if sex, inclination angle, and Co level influenced the revision rate.

Introduction. We aimed to identify genes associated with the development of ALVAL at relatively low levels of wear. Methods. At our unit all patients undergoing revision of a MoM hip prosthesis have periprosthetic tissue samples graded for ALVAL. Explants undergo volumetric wear testing of the bearing and taper surfaces. We identified patients with moderate/severe ALVAL who had been exposed to lower than the median wear rate of all recorded patients who had developed ALVAL (<3mm. 3. /year). This was termed the “ALVAL” group. We then identified all patients whose tissues had shown no signs of ALVAL. The patients in the two groups were sent buccal DNA collection kits. DNA was examined using next generation sequencing. Alleleic frequencies in the two groups were compared using Fisher's test and compared to a background UK population group (n=8514). We then conducted binary logistic regression with patient age, sex, primary source of debris (taper/bearing) and HLA genotype as the predictors. With the hypothesis that a cobalt/albumin metalloprotein acts as the epitope, we used validated binding prediction software to determine the relative affinities of the binding grooves created by different DQA1/DQB1 genetic combinations for albumin derived peptides. Given the protection that male sex and younger age appears to confer against ALVAL, we hypothesized that testosterone peptides may compete for these binding sites. Results. 28 ALVAL and 37 non ALVAL patients returned their samples for testing. The frequencies of DQA1∗05:05 and DQB1∗03:01 were significantly greater in the ALVAL groups(p=0.018). The variables positively associated with ALVAL were female sex(0.021), increasing age(0.003) and DQA1/DQB1 combinations with greater binding affinity for albumin fragments(0.03). Greater binding affinities for testosterone peptides were inversely related to ALVAL(0.05). Discussion. Common immune genotypes are associated with a greater risk of ALVAL. Conclusion. The evidence base on which MoM follow up protocols are based should be re-evaluated in light of these findings and future studies designed accordingly

Aims

Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors.

Aim. Left sided hip fractures are more common but no obvious cause has been identified. Left handedness has previously been associated with an increased risk of fracture for a number of sites but to the best of our knowledge no association between handedness and hip fracture has previously been reported. Methods. 2 separate 6-month prospective reviews of hip fracture patients aged over 65 years-of-age were conducted at 2 different hospitals. Handedness was dete2rmined at the time of admission. The second review focused on the use of walking aids. Patients with a previous cerebrovascular accident, neurological condition or contralateral hip prosthesis were excluded due to increased balance problems and falls risk. Results. Hand dominance was recorded for 339 patients; 304 right and 35 left. 91 patients were excluded. Of the remaining 248 patients more than twice as many (2.06 times) fractured their hip on the side of their non-dominant hand. For left handed individuals this increased to 4.6 times. Walking aid use was recorded for 102 patients. For patients using no walking aids, a Zimmer frame or 2 walking sticks; equal numbers of patients sustained right and left hip fractures. While 97.7% of patients using 1 walking stick did so in their dominant hand, sustaining 84% contralateral hip fractures. Conclusions. The direction in which people fall and the causes of hip fractures are clearly multi-factorial. However there is a clear association between hand dominance and the side of hip fracture, particularly in left handed individuals. Walking aids also play a role with 97.7% of patients using a walking stick in their dominant hand resulting in 84% contralateral hip fractures. By being aware of this association it may be possible to target both patient education and physiotherapy potentially reducing the number of patient falls and associated hip fractures

The reported success rate after treatment with debridement, antibiotics and implant retention (DAIR) of hip prosthesis infections has been found variable. We evaluated all reoperations performed because of infection and reported to Swedish Hip Arthroplasty Register (SHAR) between 1999 and 2016. The analyses were separated into reoperations performed for the first time and those which had been preceded by at least one previous reoperation performed because of the same reason. The outcome was repeated reoperation performed because of infection. 1,882 were first-time procedures (Group I) and 2,275 had been preceded by at least one reoperation due to infection (Group II). Head and/or liner exchange had been performed in 47% of the cases in group I, and in 22% in Group II. The mean age varied between 70 and 71 years and there was a dominance of males in all groups (52–59%). Compared to all primary THR performed during this period (n=319,813) patients with inflammatory disease, idiopathic femoral head necrosis and sequel after childhood disease were overrepresented for this type of procedure. Between 1999 and 2016 the number of DAIR procedures increased from 29 to 383 per year corresponding to 21 and 72 % of all reoperations performed due to infection. In first time reoperations the survival was 74.5±3.1% if the head/liner had been exchanged and 46.2±3.2% if only irrigation and synovectomy had been performed. In patients reoperated at least one time previously due to infection the survival rates dropped to 68.6±4.6% and 34.5±2.4%. Compared to first time reoperation with exchange of femoral and/or liner, synovectomy and irrigation without exchange of any implant part(s) resulted in an almost tripled risk of a second reoperation due to same reason (Hazard Ratio: 2.8, 95% confidence interval: 2.4–3.3). In cases previously reoperated because of infection (Group II) exchange of head/liner and debridement had a 28% increased risk of failure compared to the corresponding first time reoperations (1.28 1.02–1.6). If none of the components were replaced in Group II, the risk ratio for a new failure increased almost 4 times (3.8 3.3–4.4). Presence of a cemented stem increased the risk for further reoperations due to infection (1.14 1.02–1.28), but not presence of a cemented cup (1.06 0.92–1.19). All hazard ratios were adjusted for age, gender, diagnosis and type of fixation. The comparatively good results observed after exchange of head and liner might indicate that this is necessary to perform a sufficiently radical debridement. This observation could also be biased by a surgeon related factor suggesting that component exchange mainly is performed by surgeons with long experience of revision surgery

Aims

Total hip arthroplasty (THA) in patients with post-polio residual paralysis (PPRP) is challenging. Despite relief in pain after THA, pre-existing muscle imbalance and altered gait may cause persistence of difficulty in walking. The associated soft tissue contractures not only imbalances the pelvis, but also poses the risk of dislocation, accelerated polyethylene liner wear, and early loosening.