Background. Fractures of the femoral component are well reported complications that present a challenging task in revision total hip arthroplasty. Albeit being uncommon, with an incidence of 0.23–11%, the consequences can be devastating. Its extraction being a demanding undertaking that is potentially detrimental to the remaining host bone. Several techniques have been described to address this complex issue prior to revision: drilling of the exposed part of the femoral stem and attaching a threaded extraction device, surface undercutting with an extraction device wedged in, femoral trephine techniques, creation of a femoral cortical window, an extended femoral osteotomy procedure, as well as extraction by means of retrograde nail impaction. Here we present the modified technique we employed in the revision of a failed cementless extensively porous coated femoral component that had fractured at the neck-stem interface. Technique. The proximal femoral component was visualized and an orthopedic burr and a femoral osteotome employed surrounding the component. Utilizing a Midas Rex® MR7 drill with its metal cutting attachment, a circular recess was created in the shoulder of the femoral component. This facilitated the application of the distal end of a universal slap hammer. The component was retrieved successfully with no associated bone loss negating the need for a femoral osteotomy. Discussion. Revision hip arthroplasty is a perplexing field where unpredictable prosthetic failures require innovation to tackle the unique problems encountered. Our method allows a safe and efficient alternative in retrieving femoral components with no associated complications

Introduction. Augmented glenoid implants provide a new avenue to correct glenoid bone loss and can possibly reconcile current prosthetic failures and improve long-term performance. Biomechanical implant studies have suggested benefits from augmented glenoid components but limited evidence exists on optimal design of these augmented glenoid components. The aim of this study was to use integrated kinematic finite element analysis (FEA) model to evaluate the optimal augmented glenoid design based on biomechanical performance in extreme conditions for failure. Materials and Methods. Computer aided design software (CAD) models of two different commercially available augmented glenoid designs - wedge (Equinox®, Exactech, Inc.) and step (Steptech®, Depuy Synthes) were created per precise manufacturer's dimensions and sizes of the implants. Using FE modeling, these implants were virtually implanted to correct 20° of glenoid retroversion. Two glenohumeral radial mismatches (RM) (3.5/4mm and 10 mm) were evaluated for joint stability and implant fixation to simulate high risk conditions for failure. The following variables were recorded: glenohumeral force ratio, relative micromotion (distraction, translation and compression), and stress on the implant and at the cement mantle interface. Results. The wedged and step designs showed similar force ratio measurements with both RM [(wedge (3.5 mm: 0.69; 10 mm: 0.7) and step (4 mm: 0.72; 10 mm: 0.75)]. Surrogate for micromotion was a combination of distraction, translation and compression. As radial mismatch increased, both implants showed less distraction [wedge design (3.5 mm: 0.042 mm; 10mm: 0.030 mm); step design (4 mm: 0.04 mm; 10 mm: 0.027 mm)]. As radial mismatch increased, both implants showed more translation [wedge design (3.5 mm: 0.058 mm; 10mm: 0.062 mm); step design (4 mm: 0.023 mm; 10 mm: 0.063 mm)]. During compression measurements, the different designs did not follow the same pattern as their conformity setting changed. The wedge one decreased as radial mismatch increased, (at 3.5mm: 0.18 mm; at 10 mm: 0.10 mm) and the step design increased as its radial mismatch increased (at 3.5 mm: 0.19 mm; at 10 mm: 0.25 mm). Quantitatively, the step design showed higher risk of implant instability and loosening. As radial mismatch increased, the stress level on the backside of the implant increased as opposed to the stress levels on the cement mantle which decreased for both designs as the radial mismatch increased [wedged (3.5 mm: 2.9 MPa; 10mm: 2.6 MPa); step (3.5 mm: 4.4 MPa; 10 mm: 4.1 MPa)]. In this situation, the risk of loosening was higher for the step designwhich exceeded the endurance limit of the cement material (4 MPa). Discussion. Implant loosening and wear are associated with increased micromotion and high stress levels. Based on our FEA model, overall increased radial mismatch has an advantage of providing higher glenohumeral stability but not without tradeoffs, such as higher implant and cement mantle stress levels, and micromotion increasing the risk of implant loosening, failure or fracture over time, leading to poorer clinical outcomes and higher revision rates, especially when considering a step augmented glenoid design

Aim. In patients with bone sarcoma, placing mega prostheses in the proximal tibia is associated with high rates of infection. In studies with small numbers of patients and short follow-up periods, silver-coated mega prostheses have been reported to lead to reduced infection rates. To the best of our knowledge, this study is the largest one that has compared the infection rates with titanium versus silver-coated mega prostheses in patients treated for sarcomas in the proximal tibia. Method. The infection rate in 98 patients with sarcoma or giant cell tumour in the proximal tibia who underwent placement of a titanium (n = 42) or silver-coated (n = 56) mega prosthesis. *. was assessed, along with the treatments administered for any infection. Results. As the primary end point of the study, the rates of infection were 16.7% in the titanium group and 8.9% in the silver group, resulting in 5-year prosthesis survival rates of 90% in the silver group and 84% in the titanium group. Overall, seven of 56 patients in the silver group (12.5%) developed periprosthetic infection. Two patients became infected after revision surgery due to mechanical failure of the prosthesis. In the titanium group, one patient developed a periprosthetic infection after revision surgery (which was carried out in 50% of patients) due to a mechanical prosthetic failure, leading to an overall infection rate of 19.0% (eight of 42). Overall, nine of 12 (75%) periprosthetic infections in the two groups occurred within the first 2 years postoperatively, if later revision surgery due to mechanical failure was not necessary. Whereas three of the eight patients in the titanium group (37.5%) ultimately had to undergo amputation due to infected proximal tibia replacement, these mutilating surgical procedures were necessary in the silver group in only one patient (14.3%). In the titanium group, two-stage revision surgery with a temporary antibiotic-impregnated cement spacer was ultimately successful in four of eight patients (50.0%), but this procedure was necessary in only one patient in the silver group (14.3%). Conclusions. The use of silver-coated prostheses reduced the infection rate in a relatively large and homogeneous group of patients. In addition, less aggressive treatment of infection was possible in the group with silver-coated prostheses

Pain following total hip arthroplasty is a relatively rare event. Several series place the incidence of some degree of pain post THA at approximately 5%. A systematic approach to determining etiology will direct treatment. Hip pain can be categorised as:. Extrinsic to the Hip. –. Spine +/− radiculopathy. –. Vascular disease. –. Metabolic (Paget's). –. Malignancy. Intrinsic to the Hip. Intracapsular/Implant. Loosening. Sepsis. Prosthetic failure. Osteolysis. Instability. Thigh pain. Stem tip pain. Hypersensitivity/ALVAL. Extracapsular. Iliopsoas tendonitis. Snapping Hip. Trochanter problems (bursitis). Heterotopic ossification. A full history and appropriate physical exam will direct the clinician. The use of routine radiographs, blood tests, and special tests (i.e., blood metal ions, advanced imaging techniques) will be discussed I detail

Introduction. The development of new megaprosthesis for the treatment of large bone defects has offered important opportunities to orthopedic oncologic surgeons for the replacement of skeletal segments such as the long bones of the upper and lower limbs and the relative joints. Our experience, treating non union and severe bone loss, has brought us, sometimes, to be confronted with the reality of some failures after unsuccessful attempts to reconstruct. Faced with certain radiological and / or clinical drastic situations we wanted to apply the principles of Biological Chamber and oncologic surgery with megaprosthetic replacement solutions. We implanted megaprosthesis with either 1 step or 2 steps (previous antibiotated spacer) technique depending on the septic patient conditions. The aim of this study is to retrospectively evaluate both clinical and radiological outcomes in patients underwented to a lower limb megaprosthesis implant and complications were recorded. Materials and Methods. In total, we treated 58 patients with megaprosthesis mono-and bi-articular subdivided as follows: proximal femur, distal femur, proximal tibia and total femur. The mean follow-up of patients is about 24 months (5 yrs max, min 6 months) with clinical and serial radiographic revaluations with standard methods (X-ray in 45 days, 3–6-12-18-24 months) as well as monitoring of blood parameters of inflammation for at least 2 months. Results. Despite the follow up average is not so long, the first patients have now reached five years of monitoring and in all cases we have had encouraging clinical results with good articulation of the segments, no somato-sensory or motorial defict and acceptable functional recovery. During surgery and, even more, in the pre-operative planning much attention should be given to the evaluation of the extensor apparatus preserving it and, when necessary, reinforcing it with tendon substitutes. Discussion. Megaprosthesis in traumatic and prosthetic failures can therefore be considered, in extreme cases appropriately selected, as a solution available to the orthopedic surgeon? In oncological surgery the opportunity to regive a function, although not ad integrum, to the patient is certainly an element of great fascination for the surgeon and an opportunity for the patient. Unfortunately, the high mortality associated with this disease does not allow us to have long-term follow-up. This then creates a lack of certainty about the survival of this type of prosthesis and the medium and long-term complications that may occur. Nevertheless, the patients treated by us should be considered as a oncologic patient, not because of the disease but for the limited therapeutic options available. Conclusions. We can consider megaprosthesis as a valuable opportunity to restore functionality to patients who are, despite themselves, to deal with highly disabling diseases

Introduction. Up to 2% of total hip arthroplasties (THA) are still complicated by infection. This leads to dissatisfied patients with poor function, and has far-reaching social and economic consequences. The challenge in these cases is the eradication of infection, the restoration of full function and the prevention of recurrence. We report the outcome of early aggressive debridement in the acutely infected THA. Methods. We studied 28 consecutive patients referred with acutely infected THA (18 primaries, 10 revisions) which occurred within 6 weeks of the index operation or of haematogenous spread between 1999 and 2006. Microbiology confirmed bacterial colonisation in all cases with 20 early post-operative infections and 8 cases of acute haematogenous spread. Patients with a cemented THA underwent aggressive open debridement, a thorough synovectomy and exchange of all mobile parts. Uncemented THA were treated as a single stage revision with removal of all implants, aggressive debridement and re-implantation of new prosthesis. Antibiotics were continued in all cases until inflammatory markers and the plasma albumin concentration returned to within normal limits. Results. Ten patients required multiple washouts. 7 patients needed a two stage revision. 21 patients returned to their expected functional level without removal of the implants and with no radiographic evidence of prosthetic failure. At a minimum 2 years follow-up, we had a 75% infection control rate. The outcome was significantly better in patients treated in the first 120 hours after presentation. Discussion and Conclusion. Our data suggests that there is a role for early aggressive open debridement in acute infections after THA with an excellent chance of eradicating infection

Only 0.8% of arthroplasties registered on the National Joint Registry in 2006 are patello-femoral. The Leicester patello-femoral replacement (Corin) has been in use for over 10 years with satisfactory initial results. The indication for use is isolated patello-femoral osteoarthritis with the theoretical benefits of bone preservation, maintenance of normal knee mechanics and easy revision. The implant was only available in one size and the femoral component was uncemented. We reviewed 49 patients managed with this prosthesis with a median follow up of 10 years (range 4-16). The mean age of the patients at time of surgery was 64. 62 arthroplasties were performed.51 were in females and 11 in males giving a 5:1 ratio. Thirteen patients had bilateral procedures. Thirty-nine revisions (62.9%) were performed for progressive tibio-femoral arthritis or prosthetic failure. Mean time to revision was 5 years 3 months. The knees were revised to total knee replacements without the need for stems, wedges or constraint. The unrevised knees had a mean survivorship of 8 years 6 months with a range of 4-14 years. The mean Oxford score for these surviving implants was 22.5. Results of other implants from the literature included the Avon prosthesis with 80% satisfaction rate at 5 years and the Lubinus with 45% satisfaction rate at 7.5 years. The Leicester device showed a pattern of progressive failure with up to 40% revision at 5 years. However those with surviving implants were reasonably happy as shown by the Oxford scores. We concluded that patello-femoral replacement has a role though this is not as well defined as TKR or even UKR. We posed the question as to whether these results were due to poor patient selection or design failings of the Leicester prosthesis. This prosthesis has been successful at reducing pain and improving function and may have been more successful with more sizes of implant, better instrumentation and more rigid patient selection

Purpose. of this study is to analyze the results of a modular reconstructive tumor prosthesis for the lower limb (GMRS. (r). ) with a comparative statistical analysis of primary and secondary implants. Material and methods. From October 2003 to September 2007 at Rizzoli 161 GMRS. (r). prostheses were implanted, most after resection of osteosarcoma (94 cases, 58%). It is a modular system with a rotating hinge mechanism for the knee, cemented and uncemented stems, in titanium and chromium-cobalt-molybdenum, curved and straight-fluted, with or without hydroxyapatite coating. Moreover adaptors are available to revise HMRS. (r). implants. This series includes 88 males and 73 females ranging in age from 9 to 80 years. Sites of reconstruction were 109 distal femurs, 19 proximal femurs, 1 total femur and 32 proximal tibias. There were 149 oncologic and 12 non oncologic diagnoses, including 96 primary reconstructions and 65 revisions after failure of previous implant. A retrospective analysis of imaging and complications was performed and functional results assessed according to MSTS system. Statistical analysis with Kaplan-Meier curves was used to study implant survival. Results. At a mean follow up of 2 yrs. 106 patients are continuously NED, 31 are NED after treatment of one or more local recurrence or metastasis, 7 AWD, 5 DWD. There were 10 major complications: 8 infections (4,7%) (5 in primary and 3 in secondary implants, 2 previously infected) and 2 aseptic loosening (1,2%) (1 each). There were 9 minor complications (4 wound sloughs, 1 stiff joint, 3 disrupted extensor apparatus,1 patellar instability) requiring revision. Comparative statistical analysis of primary and secondary implants survival at major complications shows no statistically significant difference. Functional results were good or excellent in 95% of the evaluated patients, without any poor. Conclusions. Middle term results are promising: good function, very low incidence of major complications, no breakage of implant components. This prosthetic reconstruction is indicated in oncological cases as well as in selected in some non oncological settings, such as challenging revisions of prosthetic failures with massive bone loss or post-radiation non unions or allografts failures. Although a higher incidence of complications was expected in secondary implants, statistical analysis shows similar survival

Unicompartmental knee arthroplasty (UKA) was first described over 30 years ago and allows replacement of a single compartment in patients who have isolated osteoarthritis. However, UKA is more technically challenging than total knee arthroplasty due to limited exposure as a minimally invasive procedure. In addition to component alignment and fixation, ligament balancing plays an important role in implant survival. Some failures of early UKA systems were attributed to a failure to adequately balance the knee. The development of robots to aid in performing the procedure has lead to renewed interest in this surgical technique. The use of a robot-assisted system allows the orthopaedic surgeon to verify that balancing sought pre-operatively correlates with that obtained at surgery. Some studies have shown good post-operative mechanical alignment utilizing this method. The aim of this study was to examine the variation in pre-operative templated ligament balance and that obtained during the operation. Data were prospectively collected on 51 patients (52 knees) undergoing robot-assisted unicompartmental knee arthroplasty by a single surgeon. For pre-operative planning, dynamic ligament balancing was obtained of the operative knee under valgus stress, prior to any bony cuts. Final intra-operative images with the prosthesis in place were taken without valgus stress. Positive values denoted loose ligamentous balancing while negative values indicated ligament tightness. A small variation of less than 1 mm was measured between the pre-operative plan and the final image with the implant in place. At 0 degrees the mean change was −0.26 mm (range, −4.40 to 2.20 mm), at 30 degrees −0.53 mm (range, −5.30 to 1.80 mm), at 60 degrees −0.04 mm (range, −3.10 to 2.30 mm) and at 90 degrees 0.16 mm (range, −2.70 to 2.00 mm). These results show that planned dynamic ligament balancing is accurate to within 0.52 mm. The technological advancements with robotic feedback in orthopaedic surgery can aid in the success of unicompartmental knee replacement surgery. Ensuring that pre-operative templated changes match those performed during surgery is an important predictor of outcome. With proper planning prior to surgery, the use of a robot in UKA can improve ligament balancing. This can be done at various angles, ensuring excellent ligament balancing throughout the entire range of motion. Correct component alignment reduces the risk of prosthetic failure and may increase the length of implant survival. Further fine-tuning of the accuracy of feedback between the robot and the anatomical points will improve the accuracy of UKA

Introduction. Unicompartmental knee arthroplasty (UKA) was first described over 30 years ago and allows replacement of a single compartment in patients who have isolated osteoarthritis. 1. However, UKA is more technically challenging than total knee arthroplasty due to limited exposure as a minimally invasive procedure. In addition to component alignment and fixation, ligament balancing plays an important role in implant survival. 2. Some failures of early UKA systems were attributed to a failure to adequately balance the knee. The development of robots to aid in performing the procedure has lead to renewed interest in this surgical technique. The use of a robot-assisted system allows the orthopaedic surgeon to verify that balancing sought pre-operatively correlates with that obtained at surgery. Some studies have shown good post-operative mechanical alignment utilizing this method. 3. The aim of this study was to examine the variation in pre-operative templated ligament balance and that obtained during the operation. Methods. Data were prospectively collected on 52 patients (51 knees) undergoing robot-assisted unicompartmental knee arthroplasty by a single surgeon. For pre-operative planning, dynamic ligament balancing was obtained of the operative knee under valgus stress, prior to any bony cuts. Final intra-operative images with the prosthesis in place were taken without valgus stress. Positive values denoted loose ligamentous balancing while negative values indicated ligament tightness. Results. A small variation of less than 1 mm was measured between the pre-operative plan and the final image with the implant in place. At 0 degrees the mean change was −0.26 mm (range, −4.40 to 2.20 mm), at 30 degrees −0.53 mm (range, −5.30 to 1.80 mm), at 60 degrees −0.04 mm (range, −3.10 to 2.30 mm) and at 90 degrees 0.16 mm (range, −2.70 to 2.00 mm). These results show that planned dynamic ligament balancing is accurate to within 0.52 mm. Conclusion. The technological advancements with robotic feedback in orthopaedic surgery can aid in the success of unicompartmental knee replacement surgery. Ensuring that pre-operative templated changes match those performed during surgery is an important predictor of outcome. With proper planning prior to surgery, the use of a robot in UKA can improve ligament balancing. This can be done at various angles, ensuring excellent ligament balancing throughout the entire range of motion. Correct component alignment reduces the risk of prosthetic failure and may increase the length of implant survival. Further fine-tuning of the accuracy of feedback between the robot and the anatomical points will improve the accuracy of UKA

Aims

Orthopaedic infection is a potentially serious complication of elective and emergency trauma and orthopaedic procedures, with a high associated burden of morbidity and cost. Optimization of vitamin D levels has been postulated to be beneficial in the prevention of orthopaedic infection. This study explores the role of vitamin D in orthopaedic infection through a systematic review of available evidence.

Aim. Clear differentiation between aseptic failure and prosthetic joint infection remains one of the goals of modern orthopaedic surgery. New diagnostic methods can provide more precise evaluation of the etiology of prosthetic joint failure. With the introduction of sonication an increasing number of culture-negative prosthetic joint infection were detected. The aim of our study was to evaluate culture-negative prosthetic joint infections in patients who were preoperatively evaluated as aseptic failure. Method. For the purpose of the study we included patients planed for revision surgery for presumed aseptic failure. Intraoperatively acquired samples of periprosthetic tissue and explanted prosthesis were microbiologically evaluated using standard microbiologic methods and sonication. If prosthetic joint infection was discovered, additional therapy was introduced. Results. Between October 2010 and till the end of 2014 151 cases were operated (38 revision knee arthroplasty, 113 revision hip arthroplasty). 40 (26,5%) cases had positive sonication and negative periprosthetic tissue samples (knee 7 cases, hips 33 cases), 13 (8,6%) cases had positive tissue samples but negative sonication (knee 7 cases, hips 6 cases), in 13 (8,6%) cases both tests were positive (knee none, hips 13 cases) and in 85 (56,3%) cases all microbiologic tests were negative (knee 24 cases, hips 61 cases). In both groups cases coagulase-negative staphylococci and P.acnes were most common, followed by mixed flora. Conclusions. With the increasing number of patients requiring revision arthroplasty, a clear differentiation between aseptic failure and prosthetic joint infection is crucial for the optimal treatment. Sonication of explanted material is more successful in the isolation of pathogens compared to periprosthetic tissue cultures. Sonication of explanted prosthetic material is helpful in the detection of culture-negative prosthetic joint infections

Clear differentiation between aseptic failure and prosthetic joint infection remains one of the goals of modern orthopaedic surgery. The development of new diagnostic methods enabled more precise evaluation of the etiology of prosthetic joint failure. With the introduction of sonication an increasing number of culture-negative prosthetic joint infection were detected. The aim of our study was to evaluate culture-negative prosthetic joint infections in patients who were preoperatively evaluated as aseptic failure. For the purpose of the study we included patients planed for revision surgery for aseptic failure. Intraoperatively acquired samples of periprosthetic tissue and explanted prosthesis were microbiologicaly evaluated using standard microbiologic methods and sonication. If prosthetic joint infection was discovered, additional therapy was introduced. Between October 2010 and April 2013 54 patients were operated (12 revision knee arthroplasty, 42 revision hip arthroplasty). 10 (18,6%) patients had positive sonication and negative periprosthetic tissue sample, 5 (9,2%) patients had positive tissue samples, but negative sonication, in 9 (16,7%) patients both tests were positive and in 30 (55,5%) patients all microbiologic tests were negative. The microbiologic isolates of sonicate fluid were in 12 cases coagulase-negative staphylococci, in 3 cases P.acnes in 3 cases mixed flora, in 1 case enterococcus and in 1 case SA. From periprosthetic tissue cultures 5 samples have yielded coagulase-negative staphylococci in 5 cases P.acnes in 2 cases mixed flora, in 1 case enterococcus and in 1 case SA were isolated. With the increasing number of patients requiring revision arthroplasty, a clear differentiation between aseptic failure and prosthetic joint infection is crucial for the optimal treatment. Sonication of explanted material is more successful in the isolation of pathogens compared to periprosthetic tissue cultures. Sonication of explanted prosthetic material is helpful in the detection of culture-negative prosthetic joint infections

In order to assess current opinions on the long-term outcome after primary total hip replacement, we performed a multicentre, cross-sectional survey in 22 centres from 12 European countries. Different patient characteristics were categorised into ‘decreases chances’, ‘does not affect chances’, and ‘increases chances’ of a favourable long-term outcome, by 304 orthopaedic surgeons and 314 referring practitioners. The latter were less likely to associate age older than 80 years and obesity with a favourable outcome than orthopaedic surgeons (p < 0.001 and p = 0.006, respectively) and more likely to associate age younger than 50 years with a favourable outcome (p = 0.006). Comorbidity, rheumatoid arthritis, and poor bone quality were thought to be associated with a decreased chance of a favourable outcome. We found important differences in the opinions regarding long-term outcome after total hip replacement within and between referring practitioners and orthopaedic surgeons. These are likely to affect access to and the provision of total hip replacement.