With increasing burden of revision hip arthroplasty, one of the major challenge is the management of bone loss associated with previous multiple surgeries. Proximal femoral replacement (PFR) has already been popularised for tumour surgeries. The inherent advantages of PFR over allograft –prosthesis system, which is the other option for addressing severe bone loss include, early weight bearing and avoidance of non-union and disease transmission. Our study explores PFR as a possible solution for the management of complex hip revisions. Thirty consecutive hips (29 patients) that underwent PFR between January 2009 and December 2015 were reviewed retrospectively for their clinical and radiological outcomes. The Stanmore METS system was used in all these patients. Mean age at the index surgery (PFR) was 72.69 years (range 50–89) with number of previous hip arthroplasties ranging from 1–5. At mean follow up of 32.27 months, there were no peri-prosthetic fractures and no mechanical failure of the implants. Clearance of infection was achieved in 80% of cases. There was 1 early failure due to intra-operative perforation of femoral canal needing further revision and two were revised for deep infection. Instability was noted in 26.7% (8) of the hips, of which, 87.5% (7) needed further revision with constrained sockets. Out of these 8 hips with instability, 5 had pre-operative infection. Deep infection was noted in 20% (6) of the hips, of which, 5 were primarily revised with PFR for septic loosening. However, further surgeries were essential for only 3 patients. One patient has symptomatic aseptic acetabular loosening and 1 had asymptomatic progressive femoral side loosening (lost to follow up). Severe proximal femoral bone loss in complex revision arthroplasties has necessitated the use of PFR prosthesis. Our study supports the fact that PFR is probably a mechanically viable option for complex revisions. Significant numbers of dislocations and infections could be attributed to the poor soft tissue envelope around the hip. Further surgical techniques in the form use of dual mobility cups and silver coated PFR implants need to be explored

Objectives. To examine patient mortality, implant survivorship, and complication profiles of proximal femoral replacement (PFR) as compared to revision total hip arthroplasty (REV) or open reduction internal fixation (ORIF) in the treatment of acute periprosthetic fractures of the proximal femur. Methods. We performed a retrospective controlled chart review at our tertiary center from from 2000–2010, identifying 97 consecutive acute periprosthetic proximal femoral fractures. Patients were stratified into three treatment groups: PFR (n=21), REV (n=19), and ORIF (n=57). Primary outcome measures included death, implant failure, and reoperation. We also recorded patient demographics, medical comorbidities, fracture type, treatment duration, time to treatment, and complication profiles. Statistical analyis included competing risks survival, which allows independent survival analysis of competing failure mechanisms such as death and implant failure. Results. Competing Risks survival analysis of overall mortality during the mean 35-month follow-up showed no difference between the three groups (p=0.65; 12 and 60 month mortality for PFR: 37%, 45%; REV: 16%, 46%; ORIF: 14%, 100%). Implant survival was worse for the PFR group (p=0.03, 12 and 60-month implant failure rate for PFR: 5%, 39%; REV: 93%, 93%; ORIF 98%, 98%). Comparing PFR to REV and ORIF, PFR had a trend towards higher dislocation (19% vs. 5% vs. 4%, p=0.06). There was no difference between groups with regard to summary non-death complications including DVT, infection, dislocation, and other measures (30% vs. 40% vs. 34%, p=0.80). Operative times were not different between groups (172 min. vs. 162 min. vs. 168 min, p=0.92). Conclusions. In treating difficult periprosthetic fractures, PFR as compared with REV or ORIF has worse medium-term implant survival, primarily due to instability and dislocation. The groups had similar perioperative complication rates, similar short and long term mortality, and similar operative times

Custom 3D printed implants can be anatomically designed to assist in complex surgery of the bony pelvis in both orthopaedic oncology and orthopaedic reconstruction surgery. This series includes patients who had major pelvic bone loss after initially presenting with tumours, fractures or infection after previous total hip arthroplasty. The extent of the bone loss in the pelvis was severe and therefore impossible to be reconstructed by conventional ‘off –the-shelve’ implants. The implant was designed considering the remaining bony structures of the contra-lateral hemi- pelvis, to provide an anatomical, secured support for the reconstructed hip joint. The latter was realised by strategically orientated screws and by porous structures (an integral part of the implant), which stimulates osseointegration. A custom pelvic implant was designed, manufactured and 3D printed. Reconstruction of the pelvis was performed together with a cemented (bipolar bearing) acetabular cup. In some cases, a proximal femoral replacement was also necessary to compensate for bony defects. All patients had sufficient range of motion (ROM) at the hip with post-operative stability. It has been verified, at six and twelve months postoperatively, that there is a strong hold of the implant due to osseointegration. Additionally, in patients whose posterior acetabular wall was missing, it was discovered that the implant assisted in bone formation and covered the entire posterior surface of the implant. All patients in this study managed with this novel treatment option, proved to have a stable pelvic reconstruction with restoration of leg lengths, improvement of strength and independent ambulation at short and medium term follow-up

Resection of the proximal femur raises several challenges to the orthopedic oncology surgeon. Among these is the re-establishment of the abductor mechanism that might impacts on hip function. Extent of tumor resection and surgeons’ preferences dictate the reconstruction method of the abductors. While some surgeons advocate the necessity of greater trochanter (GT) preservation whenever possible, others attempt direct soft tissues reattachment to the prosthesis. Sparse data in the literature evaluated the outcomes of greater trochanter fixation to the proximal femur megaprosthesis. This is a retrospective monocentric study. All patients who received a proximal femoral replacement after tumor resection between 2005 and 2021 with a minimum follow-up of three months were included. Patients were divided into two groups: (1) those with preserved GT reattached to the megaprosthesis and (2) those with direct or indirect (tenodesis to fascia lata) abductor muscles reattachment. Both groups were compared for surgical outcomes (dislocation and revision rates) and functional outcomes (Trendelenburg gait, use of walking-assistive device and abductor muscle strength). Additionally patients in group 1 were subdivided into patients who received GT reinsertion using a grip and cables and those who got direct GT reinsertion using suture materials and studied for GT displacement at three, six and 12 months. Time to cable rupture was recorded and analyzed through a survival analysis. Fifty-six patients were included in this study with a mean follow-up of 45 months (3-180). There were 23 patients with reinserted GT (group 1) and 33 patients with soft tissue repair (group 2). Revision rate was comparable between both groups(p=0.23); however, there were more dislocations in group 2 (0/23 vs 6/33; p=0.037). Functional outcomes were comparable, with 78% of patients in group 1 (18/23) and 73% of patients in group 2 (24/33) that displayed a Trendelenburg gait (p=0.76). In group 1, 70% (16/23) used walking aids compared to 79% of group 2 (27/33) (p=0.34). Mean abductor strength reached 2.7 in group 1 compared to 2.3 in group 2 (p=0.06). In group 1, 16 of the 23 patients had GT reinsertion with grip and cables. Median survival of cables for these 16 patients reached 13 months in our series. GT displacement reached a mean of two mm, three mm, and 11 mm respectively at three, six and 12 months of follow-up in patients with grip and cables compared to 12 mm, 24 mm and 26 mm respectively at the same follow-up intervals in patients with GT stand-alone suture reinsertion(p<0.05). Although GT preservation and reinsertion did not improve functional outcomes after proximal femur resection and reconstruction with a megaprosthesis, it was significantly associated with lower dislocation rate despite frequent cable failure and secondary GT migration. No cable or grip revision or removal was recorded. Significantly less displacement was observed in patients for whom GT reattachment used plate and cables rather than sutures only. Therefore we suggest that GT should be preserved and reattached whenever possible and that GT reinsertion benefits from strong materials such as grip and cables

Introduction:. Endoprosthetic replacement of the proximal femur is common in the management of bone tumours and failed revision arthroplasty. This study seeks to compare those patients undergoing acetabular resurfacing at the time of femoral replacement with those patients where the native acetabulum was preserved. Methods:. All proximal femoral replacements from 2004 to 2009 with a five year follow up were included. Case files were interrogated to identify those that had either revision surgery or dislocation of the hip. Results:. 87 patients met the inclusion criteria with an average age of 53 years. 25 operations were for failed revision arthroplasty, 61 for tumours and 1 for osteomyelitis. In 60 patients the acetabulum was resurfaced at surgery, and in 27 patients the acetabulum was preserved. 36 of 60 patients (60%) undergoing immediate resurfacing of the acetabulum had tumours. In patients who did not undergo acetabular resurfacing at surgery 4 sustained dislocations; 1 had surgery for failed revision arthroplasty and 3 tumour resections. Dislocations were significantly lower in the group undergoing immedicate resurfacing p<0.05. There were no dislocations in the acetabular resurfacing cohort p=0.0034. Eighteen of the 87 patients underwent revision surgery (20.7%) although none of these were for recurrent dislocation. 9 of the 27 patients (33.3%) that had a native acetabulum went on to have revision surgery in comparison with 9 (15%) revisions performed in those undergoing acetabular resurfacing at the time of surgery p= 0.02. 83% of revisions were for acetabular wear p<0.05. Conclusions:. Revision and dislocation rates for proximal femoral replacement are significantly lower in those who undergo resurfacing of the acetabulum

The rate of fracture and subsequent nonunion after radiation therapy for soft-tissue sarcomas and bone tumors has been demonstrated to quite high. There is a paucity of data describing the optimal treatment for these nonunions. Free vascularized fibular grafts (FVFG) have been used successfully in the treatment of large segmental bone defects in the axial and appendicular skeleton, however, their efficacy with respect to treatment of radiated nonunions remains unclear. The purpose of the study was to assess the 1) union rate, 2) clinical outcomes, and 3) complications following FVFG for radiation-induced femoral fracture nonunions. We identified 24 patients who underwent FVFG for the treatment of radiation-induced femoral fracture nonunion between 1991 and 2015. Medical records were reviewed in order to determine oncologic diagnosis, total preoperative radiation dose, type of surgical treatment for the nonunion, clinical outcomes, and postoperative complications. There were 11 males and 13 females, with a mean age of 59 years (range, 29 – 78) and a mean follow-up duration of 61 months (range, 10 – 183 months). Three patients had a history of diabetes mellitus and three were current tobacco users at the time of FVFG. No patient was receiving chemotherapy during recovery from FVFG. Oncologic diagnoses included unspecified soft tissue sarcomas (n = 5), undifferentiated pleomorphic sarcoma (UPS) (n = 3), myxofibrosarcoma (n = 3), liposarcoma (n = 2), Ewing's sarcoma (n = 2), lymphoma (n = 2), hemangiopericytoma, leiomyosarcoma, multiple myeloma, myxoid chondrosarcoma, myxoid liposarcoma, neurofibrosarcoma, and renal cell carcinoma. Mean total radiation dose was 56.3 Gy (range, 39 – 72.5), given at a mean of 10.2 years prior to FVFG. The average FVFG length was 16.4 cm. In addition to FVFG, 13 patients underwent simultaneous autogenous iliac crest bone grafting, nine had other cancellous autografting, one received cancellous allograft, and three were treated with synthetic graft products. The FVFG was fixed as an onlay graft using lag screws in all cases, additional fixation was obtained with an intramedullary nail (n = 19), dynamic compression plate (n = 2), blade plate (n = 2), or lateral locking plate (n = 1). Nineteen (79%) fractures went on to union at a mean of 13.1 months (range, 4.8 – 28.1 months). Musculoskeletal Tumor Society scores improved from eight preoperatively to 22 at latest follow-up (p < 0.0001). Among the five fractures that failed to unite, two were converted to proximal femoral replacements (PFR), two remained stable pseudarthroses, and one was converted to a total hip arthroplasty. A 6th case did unite initially, however, subsequent failure lead to PFR. Seven patients (29%) required a second operative grafting. There were five additional complications including three infections, one wound dehiscence, and one screw fracture. No patient required amputation. Free vascularized fibular grafts are a reliable treatment option for radiation-induced pathologic femoral fracture nonunions, providing a union rate of 79%. Surgeons should remain cognizant, however, of the elevated rate of infectious complications and need for additional operative grafting procedures

Failed total hip arthroplasty (THA) can require novel designs of revision implants that present unique risks as well as benefits. One of our patients endured a series of hip and knee revisions. In her twenties, she experienced a failed THA, became infected and all implants removed. In her early fifties (2008), she had a proximal femoral replacement incorporating a FreedomTM cup (Biomet, Warsaw, IN). She lacked hip musculature, was a dislocation risk, and cup constraint was necessary. Our choice of Freedom cup provided a 36mm head for enhanced stability and range-of-motion, plus the polyethylene liner was not as encompassing as other constrained designs, and the external clamping ring came pre-installed. This unique design allows for ease of head insertion during surgery. Our patient also had a CompressTM fixator combined knee-arthroplasty (Biomet). This knee fixation failed in 2013 and we installed a total femur combined hinge-knee arthroplasty. The Freedom cup was kept and post-op results were satisfactory. Follow-up appeared satisfactory in 2014. Some liner eccentricity was apparent but the patient had no complaints. Radiographs in February 2016 indicated cup's locking-mechanism was possibly failing but patient had no complaints. By December follow-up of 2016, the patient claimed she had 3 falls, and her x-rays indicated a displaced head and dislodged liner. At revision, the liner appeared well-seated inside the acetabular shell. However, about 50% of the polyethylene rim was missing and the large detached circumferential fragment represented the other 50%. A new Freedom liner was installed and her follow-up appears satisfactory to date. The fractured liner was sectioned through the thinnest wall (under detached rim fragment). The most critical design section was at site of the external locking ring, this wall thickness appearing < 3mm, whereas eccentric cup dome was 7.5–8mm thick. Under the detached rim fragment, wall thickness had been reduced (in vivo) to < 1mm. Given the robust rim profile, it seemed unlikely that the liner could have been spinning. The more likely scenario was that with repeated impingement, attempted subluxations by the femoral head stressed the contra- polyethylene rim, resulting in cold flow, thinning, and rim fragmentation. Two exemplar liners were compared, one similar to our patient's and one in a thicker design. Comparison of the sectioned retrieval to the new liners confirmed major loss of circumferential polyethylene. Our learning experience was threefold; (i) if we had been aware of the thin wall limitation, possibly we could have inserted the thicker liner (larger shell), (ii) we could have been more alert to the impending liner failure (x- ray imaging), and (iii) positioning the cup in a more horizontal orientation may have been an alternate solution, i.e. more coverage (but perhaps more impingement). Use of a 32mm head would have facilitated a thicker liner but this option was unavailable. In conclusion, it was notable that this constrained liner functioned very well for 7 years in our complex case and was easily revised at 8 years to another Freedom liner

The Vancouver classification separates periprosthetic femur fractures after THA into three regions (A - trochanteric, B - around or just below the stem, and C - well below the stem), with fractures around or just below the stem further separated into those with a well-fixed (B1) or loose stem and good (B2) or poor (B3) bone stock. Trochanteric fractures may be associated with osteolysis and require treatment that addresses osteolysis as well as ORIF of displaced fractures. Fractures around a well-fixed stem can be treated with ORIF using cerclage or cable plating, while those around a loose stem require implant revision usually to a longer cementless tapered or distally porous coated cementless stem. Fractures around a loose stem with poor bone stock in which salvage of the proximal femur is not possible require replacement of the proximal femur with an allograft prosthetic composite or proximal femoral replacement. Fractures well below the stem can be treated with conventional plating methods. Periprosthetic acetabular fractures are rare and usually occur in the early post-operative period or late as a result of osteolysis or trauma. These can generally be separated into those with a stable acetabular component which can be treated non-operatively, and those with an unstable component often with discontinuity or posterior column instability which require complex acetabular reconstruction utilizing plating or revision to a cup-cage

Revision of the failed femoral component can be challenging. Multiple reconstructive options are available and the procedure is technically difficult and thus meticulous pre-operative planning is required. The Paprosky Femoral Classification is useful as it helps the surgeon determine what bone stock is available for fixation and hence, which type of femoral reconstruction is most appropriate. Type 1 Defect: This is essentially a normal femur and reconstruction can proceed as the surgeon would with a primary femur. Type 2 Defect: The metaphysis is damaged but still supportive and hence a stem that gains primary fixation in the metaphysis can be used. Type 3 Defect: The metaphysis is damaged and non-supportive and hence a stem that gains primary fixation in the diaphysis is required. Broken down into types “A” and “B” based on the amount of intact isthmus available for distal fixation. Type 3A Defect: >4 cm of intact femoral isthmus is present. Can be managed with a fully porous coated stem, so long as the diameter is <18 mm and torsional remodeling is not present. Type 3B Defect: There is < 4 cm of intact femoral isthmus and based on lower rates of osseointegration if a fully porous coated stem is used, a modular titanium tapered stem is recommended. Type 4 Defect: The most challenging to manage as there is no isthmus available for distal fixation. Can be managed with proximal femoral replacement if uncontained and impaction grafting if contained. We have also successfully used modular titanium tapered stems that appear to gain “3-point fixation” in this type of defect

Peri-prosthetic fractures of the femur around a THA remain challenging injuries to treat. The Vancouver Classification helps to guide decision making, and is based on fracture location, implant fixation status, and remaining bone quality. It is critical to determine fixation status of the implant, even if surgical dislocation is necessary. Type A fractures involve the trochanters, and are usually due to osteolysis. Revision of the bearing surface and bone grafting of the lesions can be effective. Type B1 fractures occur around a well fixed stem, typically at the stem tip. Internal fixation with laterally based locked cable plates is effective. Optimising proximal fixation is important, typically with locked screws and cables. Allograft struts are probably unnecessary with modern angle stable plates. Type B2 and B3 fractures are treated with revision, either with a fully coated cylindrical or a modular fluted tapered titanium stem. Distal fixation should be optimised, while preserving vascularity to proximal bony fragments. The « internal scaffold » technique has been described with excellent results. Rarely, a proximal femoral replacement is necessary. Careful attention to detail and clear knowledge of stem fixation status is necessary for a good outcome

As the incidence of total hip arthroplasty (THA) rises, an increasing prevalence of peri-prosthetic femur fractures has been reported. This is likely due to the growing population with arthroplasties, increasing patient survival and a more active life-style following arthroplasty. It is the 3rd most common reason for THA reoperation (9.5%) and 5th most common reason for revision (5% with fracture risk after primary THA reported at 0.4%-1.1% and after revision at 2.1%-4%). High quality radiographs are usually sufficient to classify the fracture and plan treatment. Important issues in treatment include stem fixation status and fracture location relative to the stem. Additional comorbidities will also influence treatment choices, of which the most critical is the presence of infection and the quality of bone stock. The most commonly studied, and reported classification system is the Vancouver. Type A are peri-trochanteric fractures with AL at the lesser and AG at the greater trochanter. B fractures are those around the stem with B1 fractures having a well-fixed stem, B2 a loose stem with adequate bone stock, and B3 representing loose stem and inadequate bone stock. C fractures are distal to the stem. Type A) Trochanteric Fractures: These are usually associated with lysis. Displaced fractures can be managed adequately with cerclage fixation and cancellous allograft to fill osteolytic defects. Undisplaced fractures usually heal well with symptomatic treatment. Type B) Fractures Around the Stem: The B1 type has a well-fixed component and is usually treated with extramedullary fixation plus graft. Contemporary plates have been designed specifically for these fractures. Strut allograft may be used to provide a more rigid construct. Spiral and long oblique fractures can be cerclaged while short oblique or transverse fractures require fixation anterior and lateral with cable plates and cortical strut grafts. Screws can be used distal to the implant, and cables used proximally. The B2 type has a loose prosthesis but otherwise good bone stock. In this setting, the fracture line may be extended on the lateral cortex of the femur as an extended osteotomy to provide easy access for cement removal. These fractures can be managed with an extensively coated stem if rotational stability can be obtained in the distal segment. If rotational stability over a 4 cm scratch interference fit of the stem isn't possible, then a fluted tapered modular stem should be used. Strut allografts improve initial stability. The B3 type has both a loose prosthesis and poor bone stock and in the younger patient restoration of bone stock should be a priority. Bulk femoral grafts may be needed. The elderly or low functional demand patient may be treated with a proximal femoral replacement. Because of soft-tissue deficiencies, a constrained acetabular liner may be needed to prevent instability. Type C) Fractures Distal to the Stem: These usually accompany a stable stem and many fixation devices are available. Locking plates have become most popular and should be secured with cerclage wires proximally around the component with screws distally. Retrograde nails may be employed if there is adequate bone distal to the stem tip and above the fracture

Vancouver A: If minimal displacement and prosthesis stable can treat nonoperatively. If displacement is unacceptable and/or osteolysis is present consider surgery. AL: Rare, avulsions from osteopenia and lysis. If large, displaced and include large portion of calcar-can destabilise stem and prompt femoral revision. AG: More common. Often secondary to lysis. Does not usually affect implant stability. Minimal displacement. Treat closed × 3 months. Revise later is needed to remove the particle generator, debride defects and bone graft. Displaced with good host bone stock. Consider early ORIF and bone grafting. Vancouver B:. B1: Rarely non-operative. ORIF with femoral component retention. Need to carefully identify stem fixation. B2's classified as B1's are doomed to fail. B1's correctly identified treated with plate, allograft struts or both. High union rates with component retention. B2: Femoral revision +/− strut allograft. Best results seen with patients revised with uncemented, extensively porous coated femoral stems. May use modular, fluted taper stems. B3: Proximal femoral replacement - Tumor prosthesis, Allograft Prosthetic Composite (APC). Uncemented femoral stem - Extensively porous coated, Fluted, tapered stem, Allograft strut. Vancouver C: Treat with standard fracture techniques. These fractures are away from the femoral prosthesis. Rarely nonoperative. Fixation options – Cerclage, Strut Allograft, Plate fixation, Retrograde IM nail, or a Combination thereof. Avoid stress risers between implants. Bypass (overlap) fixation. Consider allowing 2.5 cortical diameters between devices

Introduction. The Western Infirmary/Gartnavel General Hospital orthopaedic department is geographically located next to the Beatson Oncology Centre, a specialist regional oncology unit. Pathological femoral fractures are the commonest reason for surgical intervention in patients referred from the Beatson and we have used them as a model to establish the demographic data, referral patterns, treatment results, and survival characteristics in such a group of patients. Methods. We have collected prospective data for the last 4 years on referrals from patients under the care of oncology services. Results. 52 patients with 53 pathological fractures and 2 impending pathological fractures of the femur during a 4 year period have been treated with a surgical intervention. The surgery included locked reconstruction femoral nailing, long stem hemiarthroplasty with distal locking and proximal femoral replacement with or without acetabular augmentation/reconstruction. 34 patients were female, 18 were male reflecting the most common primary diagnosis of breast carcinoma (30 patients). The mean age was 64 years (range 31 to 82). Post-operative complications include one death at 48 hours, 4 pulmonary emboli, a symptomatic DVT and one sciatic nerve palsy. No dislocations have occurred and there have been no implant failures at a mean of 1.2 years (range 2-26 months). We present survival characteristics based on primary tumour type and indicators of poor prognosis. Discussion. The benefits of timely orthopaedic intervention in patients with pathological fractures is well established and this study provides further insight to aid informed decisions and provides information on surgical provision required

Infected periprosthetic fractures around total hip arthroplasties are increasingly common and extremely challenging problem. The purpose of the study was to review the experience of two tertiary referral units managing infected periprosthetic femoral fractures using interlocking long-stem femoral prostheses either as temporary functional spacers or as definitive implants. Methods. A prospective review of 19 patients managed at two tertiary referral units between 2000 and 2011. Each patient was diagnosed and managed according to similar institutional protocols. Investigation through aspiration and biopsy of periprosthetic tissue supplemented haematological tests to confirm infection. The Cannulock uncoated stem was used in 14 cases, and the Kent hip prosthesis in 5 cases. Allograft struts were used in patients with deficient bone stock. Results. The mean follow-up for the series was a 53 months (range, 24–99 months). 13 patients underwent definitive revision within 7.9 months (range, 6–10 months; SD, 2.2 months). In 6 cases we implanted an extensively porous-coated stem, in 4 cases a tapered distally fixed cementless stem was used, and in 3 cases a proximal femoral replacement was used. There were no reinfections after the second stage revisions in these patients. 2 patients were offered further staged surgery due to persistently raised inflammatory markers but being mobile and relatively painfree declined. They are being managed in the community on oral antibiotics. Satisfactory outcome was noted in all cases, and in 13 cases, revision to a definitive stem was undertaken after successful control of infection and fracture union. The average postoperative Harris Hip score was 83 (range 79–89). All patients returned to their low to moderate premorbid functional state after discharge. Discussion. The use of interlocking stems offers a relatively appealing solution for a complex problem and avoids the complications associated with resection of the entire femur or the use of large quantities of bone cement

Introduction. The aim of this study is to report the results of Revision hip arthroplasty using large diameter, metal on metal bearing implants- minimum 2 year follow up. Methods. A single centre retrospective study was performed of 22 consecutive patients who underwent acetabular revision surgery using metal on metal bearing implants between 2004 and 2007. Birmingham hip resurfacing (BHR) cup was used in all patients - monoblock, uncemented, without additional screws in 16 cases and cemented within reinforcement or reconstruction ring in 6 cases. Femoral revisions were carried out as necessary. Results. There were 16 men and 6 women with a mean age of 71 years (51-83). Revision surgery was performed for aseptic loosening in 10, infected primary hip arthroplasty in 8, infected Hemiarthroplasty in 1 and Peri-prosthetic fracture with loosening in 3 patients. A 2-stage revision was performed for all infected hips. One patient died and the remaining 21 patients had clinical and radiological assessment at a mean 35 months (24-60). The mean Harris hip score was 75 (23-98) with 50% good to excellent results. Only 1 patient had further revision to a proximal femoral replacement and constrained cup in 2 stages for recurrent infection at 24 months. There were 2 recurrent infections (both revised for septic loosening) and 1 non-union of trochanteric osteotomy. There were no dislocations in the group. No radiological loosening of implants or metal ion complications have been seen at last follow up. Conclusions. We believe this is the first reported series on the use of large diameter metal on metal bearing surfaces for revision hip arthroplasty. Our series shows satisfactory short to medium term results in this complex group of patients with no component loosenings, despite monoblock cups and no dislocations

Introduction. To report the short to medium term results of acetabular reconstruction using reinforcement/reconstruction ring, morcellised femoral head allograft and cemented metal on metal cup. Methods. Single centre retrospective study of 6 consecutive patients who underwent acetabular reconstruction for revision hip surgery. The acetabulum was reconstructed using morcellised femoral head allograft and reinforcement or reconstruction ring fixed with screws. The Birmingham cup – designed for cementless fixation, was cemented into the ring in all cases. The uncemented Echelon stem with metal on metal modular head was used for reconstructing the femur. Data from our previous in-vitro study had shown good pull out strength of a cemented Birmingham cup. Results. There were 2 men and 4 women with a mean age of 75 years(57-83). Revision was performed for aseptic loosening in 2, septic loosening in 2 and peri-prosthetic fracture with loosening in 2 patients. All patients were reviewed clinically and radiographically at a mean of 36 months follow-up(range 24 - 42 months). Revision was not necessary in any patient for failure of acetabular or femoral fixation. However, 1 patient had revision to a proximal femoral replacement and constrained cup for recurrent infection and osteomyelitis at 24 months. This patient was excluded from the final analysis. The mean Harris hip score at last follow up was 79(range 70-89). Radiographic analysis revealed good graft incorporation and no signs of loosening or cup/ring migration. No dislocations or metal ion problems were recorded in this series. Conclusions. To the best our knowledge, this is the first series using cemented metal on metal cups within a reinforcement/reconstruction ring for revision hip arthroplasty. Excellent cemented fixation of the cup, manufactured for cementless fixation, was obtained at surgery with no evidence of loosening, and no dislocations at minimum 24 months follow up

Periprosthetic fractures in total hip arthroplasty lead to considerable morbidity in terms of loss of component fixation, loss of bone and subsequent functional deficits. We face an epidemic of periprosthetic fractures as the number of cementless implants inserted continues to rise and as the number of revisions continues to increase. The management of periprosthetic fractures requires careful preoperative imaging, planning and templating, the availability of the necessary expertise and equipment, and knowledge of the potential pitfalls so that these can be avoided both intra-operatively and in follow-up. There is a danger that these cases fall between the expertise of the trauma surgeon and that of the revision arthroplasty surgeon. The past decade has afforded us clear treatment algorithms based on fracture location, component fixation and the available bone stock. We still nevertheless face the enduring challenge of an elderly population with a high level of comorbidity who struggle to rehabilitate after such injuries. Perioperative optimisation is critical as we have seen prolonged hospital stays, high rates of systemic complications and a significant short term mortality in this cohort. We have also been presented with new difficult fracture patterns around anatomic cementless stems and in relation to tapered cemented and cementless stems. In many cases, fixation techniques are biomechanically and biologically doomed to fail and intramedullary stability, achieved through complex revision is required. The treatment of unstable peri-prosthetic femur fractures can be technically challenging due to the weak non-supportive bone stock. We have seen an increase in the frequency of Type B3 fractures that require complex reconstruction with modular tapers, interlocking implants and proximal femoral replacements. Our reconstructive practice has evolved; the aims of femoral reconstruction include rotational and axial stability of the stem, near normal hip biomechanics and preserving as much femoral bone as possible. The advent of modular prostheses that gain distal fixation but have proximal options has extended the scope of this type of fixation. We now favor modular tapered stems that afford us the opportunity to reconstruct such femora whilst attempting to preserve the proximal bone. In effect, distal cone or taper fixation provides the initial stability required for the procedure to be successful but the proximal modular implant subsequently load shares to decrease stress shielding, distribute stress more evenly through the femur and minimise the risk of stem fracture. Such systems provide the intraoperative versatility that these cases require. The use of interlocking stems with coated ingrowth surfaces offers a relatively appealing solution for some complex fractures and avoids the complications that would be associated with unstable fixation or resection of the proximal femur. Periprosthetic acetabular fractures are also increasingly recognised. This is in part due to the popularity of press fit components, which increase fracture risk both at the time of insertion and later due to medial wall stress shielding and pelvic osteolysis, and partly due to the increasing frequency of severe defects encountered at the time of revision surgery. These can present a very difficult reconstructive challenge and may require porous metal, cup-cage or custom reconstruction. Periprosthetic fractures continue to cause problems worldwide. The sequelae of periprosthetic fractures include the financial cost of fixation or revision surgery, the associated morbidity and mortality in an elderly frail population, the difficulty with mobilisation if the patient cannot fully weight bear and a poor functional outcome in a proportion of cases. The battle over which patients or fractures require fixation and which require revision surgery continues

Introduction. Extensive bone loss and poor residual bone quality can make implant fixation difficult to achieve in revision of failed megaprostheses. While newer porous components are available to address various periarticular cavitary and segmental defects, diaphyseal fixation remains challenging without resorting to cemented techniques, or cementless fully-coated stems that achieve fixation over long segments of bone. In cases of previous infection, it may be advantageous to avoid the use of such devices as they can be difficult to remove and may result in even greater bone loss if the infection were to persist. Compressive osseointegration technology has been become a valuable device in the management of these challenging situations. Objectives. We aimed to evaluate the short-term results of compressive osseointegration when used for reconstruction of massive diaphyseal and segmental bone defects. We believe that compressive osseointegration provides predictable, strong endoprosthesis fixation in the short-term and that osseointegration can be evaluated radiogrphically. Methods. We retrospectively reviewed a total of 32 implants (spindles) in 28 patients with failed prior megaprosthetic reconstructions. Procedures were performed at two institutions by six surgeons. Data recorded included patient demographics, indication for surgery, diaphyseal segment and joint reconstructed, and any complications. Results. Average patient age and body mass index at time of surgery were 48 years (range 14–68) and 28.1 m2 (range 17–58), respectively. Indications included aseptic loosening (18), loosening and infection (11), and allograft-prosthetic composite nonunion (3). The reconstructions consisted of distal femoral replacement (16), proximal femoral replacement (10), distal humeral replacement (4) and proximal ulnar replacement (2). There were five spindle failures in 4 patients. Three were converted to a Compress device, two were successful one converted to a cemented stem and another patient was also converted to a cemented stem. Other complications that required repeat surgery included hinge failure (2), arthrofibrosis (1), segment taper adapter fracture (2), persistent chronic deep wound infection (1)and superficial wound infection (1). Fixation at the bone-implant interface remained intact in each of these cases. There was 1 deep infection in this series in spite of a large number of index infected megaprostheses. Twenty-six of twenty-eight patients (92.8%) achieved stable osteointegration and we had an overall spindle osteointegration failure rate of 15.6% (5 of 32) at a mean follow-up length of 16.7 months (range 0.5–57.4). The cortex/spindle ratio of these increased from 0.33 (SD 0.9) immediately postoperatively to 0.53 (SD 0.15) at final follow-up (p < 0.001). At most recent follow-up, these patients reported satisfaction and painless function of the operative limb. Conclusion. Use of compressive osseointegration for revision of failed massive segmental bone defects (See Fig 1 and 2) provides reliable short term fixation, and may prove to be bone conserving in cases that require future re-revision. The cortex/spindle ratio reliably increases over time as fixation is achieved. It has become our device of choice for failed limb salvage reconstructions

Aims

Elective surgery has been severely curtailed as a result of the COVID-19 pandemic. There is little evidence to guide surgeons in assessing what processes should be put in place to restart elective surgery safely in a time of endemic COVID-19 in the community.