The purpose of this prospective study was to evaluate the long-term clinical and radiological outcomes of revision of the femoral component of a total hip replacement using impaction bone grafting. Femoral revision with an impacted allograft was performed on 29 patients (31 hips). In all, 21 hips (68%) had grade III or IV femoral defects according to the Endo-Klinik classification. A total of 11 patients (12 hips) died before the ten-year follow-up period. Of the remaining patients, 18 patients (19 hips) were followed for 10 to 15 years; three further patients died during this time. None of the 31 stems underwent further revision of their stem. However, four stems showed extensive subsidence (> 15 mm). One of these patients had a femoral fracture that required fixation. Three other patients had a femoral fracture, two of which required fixation and the other was treated conservatively. Patients with a femoral fracture and/or severe subsidence had significantly more grade IV defects (six of seven hips; p = 0.004). One patient needed a closed reduction for dislocation.

Impaction allografting in revision hip surgery gives good long-term results for femora with grades I, II and III Endo-Klinik-classified defects. Extensive subsidence and femoral fractures were seen mainly in patients with grade IV damaged femora.

We previously reported the five to ten-year results of the Birmingham Hip Resurfacing (BHR) implant. The purpose of this study was to evaluate the survivorship, radiographic results, and clinical outcomes of the BHR at long-term follow-up. We retrospectively reviewed 250 patients from the original cohort of 324 BHRs performed from 2006 to 2013 who met contemporary BHR indications. Of these, 4 patients died and 4 withdrew. From the 242 patients, 224 patients (93%) were available for analysis. Modified Harris hip score (mHHS) and University of California, Los Angeles (UCLA) scores were collected and compared to a matched total hip arthroplasty (THA) cohort. Mean follow-up was 14 years. Survivorship free of aseptic revision was 97.4% and survivorship free of any revision was 96.0% at 15 years. Revisions included 3 periprosthetic joint infections, 2 for elevated metal ions and symptomatic pseudotumor, 2 for aseptic femoral loosening, and 1 for unexplained pain. The mean mHHS was 93 in BHR patients at final follow-up, similar to the THA cohort (p=0.44). The UCLA score was significantly higher for BHR patients (p=0.02), however there were equal proportions of patients who remained highly active (UCLA 9 or 10) in both groups, 60.5% and 52.2% (p=0.45) for BHR and THA respectively. Metal ion levels at long term follow-up were low (mean serum cobalt 1.8±1.5 ppb and mean serum chromium 2.2±2.0 ppb). BHR demonstrated excellent survivorship in males less than 60 years of age at time of surgery. Clinical outcomes and activity levels were similar to THA patients. Failures related to the metal-on-metal bearing were rare and metal levels were low at long-term follow-up. Level of evidence: III. Keywords: survivorship; hip arthroplasty; activity; metal-on-metal. Surface Replacement Arthroplasty demonstrates low revision rates and similar activity level compared to total hip arthroplasty at long-term follow-up

Although periacetabular osteotomies are widely used for the treatment of symptomatic acetabular dysplasia, the surgical outcomes after long term follow-up are still limited. Thus, we assessed hip survival and patient-reported outcomes (PROMs) at 20 years after the transposition osteotomy of acetabulum (TOA). Among 260 hips in 238 patients treated with TOA, 172 hips in 160 patients were evaluated at average 20.8 years, excluding patients who died or lost to follow-up. Kaplan-Meier analysis was used to assess survivorship with an end-point of THA. PROMs were evaluated using the VAS satisfaction, VAS pain, Oxford hip score (OHS), and Forgotten joint score (FJS). The thresholds of favorable outcomes of FJS and OHS were obtained using the receiver-operating characteristic curve with VAS satisfaction ≥ 50 and VAS pain < 20 as anchors. Thirty-three hips (19.2%) underwent THA at average 13.3 years after TOA. Kaplan-Meier analysis revealed hip survival rate at 20 years was 79.7%. Multivariate analysis showed the preoperative Tönnis grade significantly influenced hip survival. Survival rates with Tönnis grade 0, grade 1, and grade 2 were 93.3%, 86.7%, and 54.8% at 20 years, respectively. More than 60% of the patients showed favorable PROMs (VAS satisfaction ≥ 50, VAS pain < 20, OHS ≥ 42, FJS ≥ 51). Advanced Tönnis grade at the latest follow-up and higher BMI were significantly associated with unfavorable OHS, but not with other PROMs. This study demonstrated the durability of TOA for hips with Tönnis grade 0–1 and favorable satisfaction in majority of the patients at 20 years after surgery. Current presence of advanced osteoarthritis is associated with the lower hip function (OHS), but not necessarily associated with subjective pain and satisfaction. Higher BMI also showed a negative impact on postoperative function

Aims. We have previously demonstrated raised cobalt and chromium levels in patients with larger diameter femoral heads, following metal-on-polyethylene uncemented total hip arthroplasty. Further data have been collected, to see whether these associations have altered with time and to determine the long-term implications for these patients and our practice. Methods. Patients from our previous study who underwent Trident-Accolade primary total hip arthroplasties using a metal-on-polyethylene bearing in 2009 were reviewed. Patients were invited to have their cobalt and chromium levels retested, and were provided an Oxford Hip Score. Serum ion levels were then compared between groups (28 mm, 36 mm, and 40 mm heads) and over time. Results. Metal ion levels were repeated in 33 patients. When comparing the results of serum metal ion levels over time, regardless of head size, there was a significant increase in both cobalt and chromium levels (p < 0.001). Two patients with larger head sizes had undergone revision arthroplasty with evidence of trunnion damage at surgery. Two patients within the 40 mm subgroup had metal ion levels above the MHRA (Medicines and Healthcare Products Regulatory Agency) threshold for detailed investigation. The increase in cobalt and chromium, when comparing the 36 mm and 40 mm groups with those of the 28 mm group, was not significant (36 mm vs 28 mm; p = 0.092/p = 0.191; 40 mm vs 28 mm; p = 0.200/p = 0.091, respectively). There was no difference, between femoral head sizes, when comparing outcome as measured by the Oxford Hip Score. Conclusion. This study shows an increase in cobalt and chromium levels over time for all modular femoral head sizes in patients with metal-on-polyethylene bearings, with two patients demonstrating ion levels above the MHRA threshold for failure, and a further two patients requiring revision surgery. These results may have clinical implications regarding longer term follow-up of patients and future implant choice, particularly among younger patients. Cite this article: Bone Joint J 2020;102-B(7):832–837

Introduction. Femoroacetabular impingement(FAI) is a relatively common cause causes of hip pain and dysfunction in active young adults. The concept of FAI was popularized by Ganz et al in early 2000s. Surgical treatment for FAI has been widely employed over the last two decades. The long term outcome of femoroacetabular osteoplasty (FAO) and risk factors for long-term failure of FAO is less studied. The goal of this single surgeon series is to identify the long term outcome of FAO (minimum 10-year follow-up) and risk factors for surgical treatment failure in these patients. Methods. The prospective database on hip joint preservation identified 1,120 patients who have undergone FAO between January 2005-June 2019. Of these 164 patients (178 hips) have a minimum 10-year follow-up (range, 10–14). The database collects detailed information on patient demographics, clinical history, radiographic and cross sectional imaging findings, intraoperative findings (site and size of chondral lesion, labral tear, subchondral cyst, size of cam lesion, etc), and patient outcome using the modified HHS, SF-36, and UCLA activity score. Patients are contacted on an annual basis and the functional outcome instruments administered. Of 1,120 patients, 122 patients have been lost to follow-up. Results. The mean age of patients in the cohort is 34.3±10.4 years and 39.6% of patients are female. FAO resulted in an improvement in mean mHHS (58.2±3.9 to 86.4±3.2) and SF-36(60.4±4 to 85±4.1) in 89% of patients. At the latest follow up 8.1% of patients have undergone THA. The study found that older age, longer preoperative symptomatic period, higher preoperative alpha angle, presence of hip dysplasia and acetabular retroversion, inability to repair acetabular labrum, and full thickness acetabular chondral lesion were associated with higher risk of failure of treatment. Conclusion. Patients with symptomatic FAI who undergo surgery experience pain relief and functional improvement that appears to endure over a decade in the majority. This study on a large cohort with long term follow-up has also identified patients who are at higher risk of failure. The study has also shed light on some interesting findings such as labral tear being very common in patients without hip symptoms and others that will be presented. For any tables or figures, please contact the authors directly

We investigated the preliminary results of femoral head necrosis treated by modified femoral neck osteotomy through surgical hip dislocation in young adults. 33 patients with femoral head osteonecrosis received modified femoral neck osteotomy through surgical hip dislocation from March 2015. 14 patients who had minimal 12 months of follow-up were reviewed radiographically and clinically (mean follow-up:16 months, 12–36 months). The mean age of the patients 32 years at the time of surgery (ranged from 16 to 42years). There were 6 women and 8 men. The cause of the osteonecrosis was steroid administration in 6, alcohol abuse in 4, trauma in 3, and no apparent risk factor in 1. According to the Ficat staging system, 1 hips was stage II, 9 hips III, and 4 hips stage IV. The posterior or anterior rotational angle was 90–180° with a mean of 143°. Clinical evaluation was performed in terms of pain, walk and range of motion on the basis of Merle d'Aubigné hip scores: 17–18 points are excellent, 15–16 are good, 13–14 are fair, 12 or less are poor. Recollapse of the final follow-up anteroposterior radiograph was prevented in 13 hips. One patient got 1 mm recollapse 18 months after surgery. No patient got progressive joint space narrowing. The Merle d'Aubigné score was excellent in 7 hips, good in 5, fair in 2. The preliminary results suggest that modified femoral neck osteotomy through surgical hip dislocation is in favor of young patients. But longer term follow-up is necessary

Introduction. Patients under the age of 50 who undergo a total hip arthroplasty (THA) are at high risk for wear-related complications due to their higher activity level. Previous studies have shown that highly crosslinked polyethylene (HXLPE) is more durable with no evidence of loosening compared to conventional polyethylene due to its improved wear characteristics. Unfortunately, there are few studies with long term follow-up of HXLPE in this patient population. The purpose of this study was to evaluate two questions related to this population of patients undergoing THA. First, what were the clinical outcomes for HXLPE in patients 50 years or younger at an average follow-up of 15 years? Second, was osteolysis observed in any of these hips?. Methods. Between November 1999 and April 2005, 105 THAs were performed for 90 patients 50 years of age or younger (mean, 42 years; range, 20–50 years). The mean body mass index (BMI) was 30 kg/m2 (range, 17–51 kg/m2). The mean follow-up was 15.25 years (range, 12–19 years). Eight patients (two bilateral) were lost to follow-up, which left 82 patients with 95 hips for analysis. HXLPE was the acetabular bearing for all hips. Harris Hip Scores were collected from all patients. Radiographs were obtained on all patients to evaluate for wear and osteolysis. Results. Clinical outcomes show excellent results in 81 hips, good results in ten, fair results in three, and a poor result in one hip using the Harris Hip Score. There have been no revisions, infections, or dislocations in this cohort of patients. Fourteen hips developed radiolucent lines in zone I, II, or III of the acetabulum, but none were circumferential. Two hips developed radiolucent lines in zones I and VII in the femur. None of the hips in our study developed osteolysis. Conclusions. The use of HXLPE in patients under the age of 50 who undergo THA shows excellent clinical and radiographic results at an average of 15 years follow-up

The goal of periacetabular osteotomy (PAO) is to delay or prevent osteoarthritic development in dysplastic hips. However, it is unclear whether the surgical goals are achieved and if so in which patients. This information is essential to select appropriate patients for a durable PAO that achieves its goals. We therefore (1) determined hip survival rates; (2) determined how many preserved hips were functionally successful after PAO; and (3) identified demographic, clinical, and radiographic factors predicting failure after PAO. We reviewed 316 patients (401 hips) who had PAO. We evaluated radiographic parameters and obtained WOMAC scores. Through inquiry to the National Registry of Patients, we identified conversions to THA. Risk factors for conversion to THA were assessed. Mean followup was 8 years (range, 4–12 years). We conclude that PAO can be performed with a good outcome at medium to long term follow-up, suggesting that it may be applied by experienced surgeons with satisfactory results. To further improve the outcome, focus should be on the potential negative influence of parameters that are easily assessed, such as the patients age (>45) preoperative grade of osteoarthritis, incongruency, and severe acetabular dysplasia. Perioperatively, the surgeon should attempt to achieve hip congruence and a CE angle between 30° to 40° to improve the durability of PAO. Level II, prognostic study

Introduction. Reverse hybrid total hip replacement (THR) offers significant theoretical benefits but is uncommonly used. Our primary objective was to evaluate implant survival with all cause revision and revision for aseptic loosening of either component as endpoints. Patients/Materials & Methods. Data was collected prospectively on 1, 088 (988 patients) consecutive reverse hybrid THRs. Mean patient age was 69.3 years (range, 21–94) and mean follow-up was 8.2 years (range, 5–11.3). No patients were lost to follow-up. Overall, 194 (17.8%) procedures were performed in patients under 60 years, 666 (61.1%) were performed in female patients and 349 (32.1%) were performed by a trainee. Acetabular components were ultra-high molecular weight polyethylene in 415 (38.1%) hips, highly cross-linked polyethylene in 669 (61.5%) hips and vitamin E stabilised polyethylene in 4 (0.4%) hips. Femoral stems were collared in 757 (69.7%) hips and collarless in 331 (30.3%) hips. Femoral head sizes were 28 mm in 957 (87.9%) hips and 32 mm in 131 (12.1%) hips. Survival analysis was performed using Kaplan Meier methodology. Log rank tests were used to asses differences in survival by age, gender, head size and surgeon grade. Results. Ten-year implant survival (122 hips at risk) was 97.2% (95% CI 95.8–98.1%) for all cause revision (Figure 1), 100% for aseptic acetabular loosening and 99.6% (95% CI 99.0–99.9%) for aseptic stem loosening (Figure 2). There was no difference in implant survival by age (p = 0.39), gender (p = 0.68), head size (p = 0.76) or surgeon grade (p = 0.20) for all cause revision. There was no difference in survival by gender (p = 0.12), head size (p = 0.38) or surgeon grade (p = 0.76) for stem revision. Four (0.4%) stems failed at mean 2.5 years (range, 0.6–4.8) because they were undersized. These were associated with patient age under 60 years (p = 0.015). Discussion. This is the largest reported study on the outcomes of reverse hybrid THR in a consecutive series of patients at medium to long term follow-up. Cemented acetabular components are less costly than uncemented cups and offer other significant benefits such as improved fixation in osteoporotic or pathological bone, reduced risk of intraoperative periprosthetic fracture, easier revision and local antibiotic delivery which can reduce deep infection rates. Advantages of uncemented stems over cemented stems include biological fixation, shorter operating times, fewer adverse pulmonary events and reduced proximal stress shielding. Our results indicate high implant survival rates at ten-year follow-up with low rates of aseptic loosening (0.4%). Meticulous surgical technique is required to avoid stem undersizing which may lead to early failure particularly in younger patients. Conclusion. This study confirms that reverse hybrid THR offers highly successful outcomes, irrespective of age, gender, head size and surgeon grade. For any figures and tables, please contact the authors directly

We undertook a randomised prospective follow-up study of changes in peri-prosthetic bone mineral density (BMD) after hip resurfacing and compared them with the results after total hip replacement. A total of 59 patients were allocated to receive a hip resurfacing (n = 29) or an uncemented distally fixed total hip replacement (n = 30). The BMD was prospectively determined in four separate regions of interest of the femoral neck and in the calcar region corresponding to Gruen zone 7 for the hip resurfacing group and compared only to the calcar region in the total hip replacement group. Standardised measurements were performed pre-operatively and after three, six and 12 months. The groups were well matched in terms of gender distribution and mean age. The mean BMD in the calcar region increased after one year to 105.2% of baseline levels in the resurfaced group compared with a significant decrease to 82.1% in the total hip replacement group (p < 0.001) by 12 months. For the resurfaced group, there was a decrease in bone density in all four regions of the femoral neck at three months which did not reach statistical significance and was followed by recovery to baseline levels after 12 months. Hip resurfacing did indeed preserve BMD in the inferior femoral neck. In contrast, a decrease in the mean BMD in Gruen zone 7 followed uncemented distally fixed total hip replacement. Long term follow-up studies are necessary to see whether this benefit in preservation of BMD will be clinically relevant at future revision surgery

Aims

This study uses prospective registry data to compare early patient outcomes following arthroscopic repair or debridement of the acetabular labrum.

Aims

There is a paucity of long-term studies analyzing risk factors for failure after single-stage revision for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). We report the mid- to long-term septic and non-septic failure rate of single-stage revision for PJI after THA.

Aims

Optimal exposure through the direct anterior approach (DAA) for total hip arthroplasty (THA) conducted on a regular operating theatre table is achieved with a standardized capsular releasing sequence in which the anterior capsule can be preserved or resected. We hypothesized that clinical outcomes and implant positioning would not be different in case a capsular sparing (CS) technique would be compared to capsular resection (CR).

Aims

Complex total hip arthroplasty (THA) with subtrochanteric shortening osteotomy is necessary in conditions other than developmental dysplasia of the hip (DDH) and septic arthritis sequelae with significant proximal femur migration. Our aim was to evaluate the hip centre restoration with THAs in these hips.

Aims

To compare long-term survival of all-cemented and hybrid total hip arthroplasty (THA) using the Exeter Universal stem.

Aims

We report on the outcome of the Synergy cementless femoral stem with a minimum follow-up of 15 years (15 to 17).

In developmental dysplasia of the hip (DDH), a bone defect is often observed superior to the acetabulum after the reconstruction at the level of the true acetabulum during total hip replacement (THR). However, the essential amount of uncemented acetabular component coverage required for a satisfactory outcome remains controversial. The purpose of this study was to assess the stability and function of acetabular components with a lack of coverage > 30% (31% to 50%). A total of 760 DDH patients underwent THR with acetabular reconstruction at the level of the true floor. Lack of coverage above the acetabular component of > 30% occurred in 56 patients. Intra-operatively, autogenous morcellised bone grafts were used to fill the uncovered portion. Other than two screws inserted through the acetabular shell, no additional structural supports were used in these hips. In all, four patients were lost to follow-up. Therefore, 52 patients (52 hips, 41 women and 11 men) with a mean age of 60.1 years (42 to 78) were available for this study at a mean of 4.8 years (3 to 7). There were no instances of prosthesis revision or marked loosening during the follow-up. The Harris hip score improved from a mean of 40.7 points (sd 12.2) pre-operatively to 91.1 (sd 5.0) at the last follow-up. Radiological analysis with medical imaging software allowed us to calculate the extent of the uncoverage in terms of the uncovered arc of the implant as viewed on the anteroposterior pelvic radiograph. From this we propose that up to 17 mm of lateral undercoverage in the presence of a stable initial implantation in the presence of bone autografting, with an inclination angle of the acetabular component between 40° and 55°, is acceptable. This represents undercoverage of ≤ 50%.

Cite this article: Bone Joint J 2013;95-B:1178–83.

Options for the treatment of subcapital femoral neck fractures basically fall into two categories: internal fixation or arthroplasty (either hemiarthroplasty or total hip arthroplasty). Historically, the treatment option has been driven by a diagnosis-related approach (non-displaced neck fractures versus displaced neck fractures). More recently, the traditional paradigm has changed. Instead of a diagnosis-related approach, it has become more of a patient-related approach. Treatment options take in to consideration the patient’s age, functional demands, and individual risk profile. A simple algorithm can be helpful in terms of directing the treatment. Non-displaced fractures, regardless of age of the patient, should be treated with closed reduction and internal fixation. For displaced femoral neck fractures, the treatment differs depending on the age of the patient. The younger patient should be treated with urgent ORIF with the goal of an anatomic reduction. For displaced femoral neck fractures in the elderly, cognitive function should be determined. For those who are cognitively functioning, total hip arthroplasty appears to be the best option. In the cognitively dysfunctional, a bipolar hemiarthroplasty or a total hip arthroplasty with use of larger heads (32 mm or 36 mm) and/or constrained sockets are a viable option.

Revision total hip arthroplasty (THA) is projected to increase by 137% from the years 2005 to 2030. Reconstruction of the femur with massive bone loss can be a formidable undertaking. The goals of revision surgery are to create a stable construct, preserve bone and soft tissues, augment deficient host bone, improve function, provide a foundation for future surgery, and create a biomechanically restored hip. Options for treatment of the compromised femur include: resection arthroplasty, allograft prosthetic composite (APC), proximal femoral replacement, cementless fixation with a modular tapered fluted stem, and impaction grafting. The purpose of this article is to review the treatment options along with their associated outcomes in the more severe femoral defects (Paprosky types IIIb and IV) in revision THA.

We have reviewed the rate of revision of fully cemented, hybrid and uncemented primary total hip replacements (THRs) registered in the New Zealand Joint Registry between 1999 and December 2006 to determine whether there was any statistically significant difference in the early survival and reason for revision in these different types of fixation. The percentage rate of revision was calculated per 100 component years and compared with the reason for revision, the type of fixation and the age of the patients.

Of the 42 665 primary THRs registered, 920 (2.16%) underwent revision requiring change of at least one component. Fully-cemented THRs had a lower rate of revision when considering all causes for failure (p < 0.001), but below the age of 65 years uncemented THRs had a lower rate (p < 0.01). The rate of revision of the acetabular component for aseptic loosening was less in the uncemented and hybrid groups compared with that in the fully cemented group (p < 0.001), and the rate of revision of cemented and uncemented femoral components was similar, except in patients over 75 years of age in whom revision of cemented femoral components was significantly less frequent (p < 0.02). Revision for infection was more common in patients aged below 65 years and in cemented and hybrid THRs compared with cementless THRs (p < 0.001). Dislocation was the most common cause of revision for all types of fixation and was more frequent in both uncemented acetabular groups (p < 0.001). The experience of the surgeon did not affect the findings.

Although cemented THR had the lowest rate of revision for all causes in the short term (90 days), uncemented THR had the lowest rate of aseptic loosening in patients under 65 years of age and had rates comparable with international rates of aseptic loosening in those over 65 years.