Introduction. Re-revision due to instability and dislocation can occur in up to 1 in 4 cases following revision total hip arthroplasty (THA). Optimal placement of components during revision surgery is thus critical in avoiding re-revision. Computer-assisted navigation has been shown to improve the accuracy and precision of component placement in primary THA; however, its role in revision surgery is less well documented. The purpose of our study was to evaluate the effect of computer-assisted navigation on component placement in revision total hip arthroplasty, as compared with conventional surgery. Methods. To examine the effect of navigation on acetabular component placement in revision THA, we retrospectively reviewed data from a multi-centre cohort of 128 patients having undergone revision THA between March 2017 and January 2019. An imageless computer navigation device (Intellijoint HIP®, Intellijoint Surgical, Kitchener, ON, Canada) was utilized in 69 surgeries and conventional methods were used in 59 surgeries. Acetabular component placement (anteversion, inclination) and the proportion of acetabular components placed in a functional safe zone (40° inclination/20° anteversion) were compared between navigation assisted and conventional THA groups. Results. Mean inclination decreased post-operatively versus baseline in both the navigation (44.9°±12.1° vs. 43.0°±6.8°, p=0.65) and control (45.8°±19.4° vs. 42.8°±7.1°, p=0.08) groups. Mean anteversion increased in both study groups, with a significant increase noted in the navigation group (18.6°±8.5° vs. 21.6°±7.8°, p=0.04) but not in the control group (19.4°±9.6° vs. 21.2°±9.8°, p=0.33). Post-operatively, a greater proportion of acetabular components were within ±10° of a functional target (40° inclination, 20° anteversion) in the navigation group (inclination: 59/67 (88%), anteversion: 56/67 (84%)) than in the control group (49/59 (83%) and 41/59, (69%), respectively). Acetabular component precision in both study groups improved post-operatively versus baseline. Variance in inclination improved significantly in both control (50.6° vs. 112.4°, p=0.002) and navigation (46.2° vs. 141.1°, p<0.001) groups. Anteversion variance worsened in the control group (96.3° vs. 87.6°, p=0.36) but the navigation group showed improvement (61.2° vs. 72.7°, p=0.25). Post-operative variance amongst cup orientations in the navigation group (IN: 46.2°; AV: 61.2°) indicated significantly better precision than that observed in the control group (IN: 50.6°, p=0.36; AV: 96.3°, p=0.04). Discussion. Re-revision is required in up to 25% of revision THA cases, of which 36% are caused by instability. This places a significant burden on the health care system and highlights the importance of accurate component placement. Our data indicate that the use of imageless navigation in revision THA – by minimizing the likelihood of outliers – may contribute to lower rates of re-revision by improving component orientation in revision THA. Conclusion. Utilizing imageless navigation in revision THAs results in more consistent placement of the acetabular component as compared to non-navigated revision surgeries

Background. Standard preoperative protocols in total joint arthroplasty utilize the International Normalized Ratio (INR) to determine patient coagulation profiles. However, the relevance of preoperative INR values in joint arthroplasty remains controversial. Acceptable INR cutoff values for joint replacement are inconsistent, and are often based on studies of primary arthroplasty, or even non-orthopedic procedures. This analysis examined the relationship between preoperative INR values and post-operative outcomes in revision total hip arthroplasty (rTHA). Optimal cutoff INR values correlated with specific outcomes were subsequently determined. Methods. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was retrospectively queried for revision total hip arthroplasty procedures performed between 2006 and 2017. Patients with a preoperative INR collected no later than 1 day prior to surgery were further stratified for analysis. INR values which correlated with specific outcomes were determined using receiver operating characteristics (ROC) curves for each outcome of interest. The optimal cutoff INR value for each outcome was then obtained using univariate and multivariate models which determined INR values that maximized both sensitivity and specificity. Results. There were a total of 11,393 patients who underwent a revision total hip arthroplasty from 2006–2017 recorded in NSQIP. Of the 2,012 patients who met inclusion and exclusion criteria, 858 had an INR < 1.0, 931 had an INR > 1.0 to 1.25, 175 had an INR > 1.25 to 1.5, and 48 patients had an INR > 1.5. Patients with progressively higher INR values had a significantly different risk of mortality within 30 days (p=0.005), bleeding requiring transfusion (p< 0.001), sepsis (p=0.002), stroke (p<0.001), failure to wean from ventilator within 48 hours (p=0.001), readmission (p=0.01), and hospital length of stay (p< 0.001). Similar results were obtained when utilizing optimal INR cutoff values. When correcting for other factors, the following poor outcomes were significantly associated with the respective INR cutoff values (Estimate, 95% CI, p value): LOS (1.67, 1.34–2.08, p <0.001), bleeding requiring transfusion (1.65, 1.30–2.09, p<0.001), sepsis (2.15, 1.11–4.17, p 0.02), and any infection (1.82, 1.01–3.29, p 0.04). Conclusions. INR values >1.65, >1.67, >1.82, and >2.15 were correlated with increased transfusion requirements, LOS, any infection, and sepsis respectively. Therefore, even subtherapeutic elevations in INR may predict poor outcomes following revision total joint replacement. Surgeons and perioperative medical specialists should consider more stringent INR goals when optimizing patients prior to revision arthroplasty. Level of Evidence. Prognostic Level IV. For any figures or tables, please contact authors directly

Instability and aseptic loosening are the two main complications after revision total hip arthroplasty (rTHA). Dual-mobility (DM) cups were shown to counteract implant instability during rTHA. To our knowledge, no study evaluated the 10-year outcomes of rTHA using DM cups, cemented into a metal reinforcement ring, in cases of severe acetabular bone loss. We hypothesized that using a DM cup cemented into a metal ring is a reliable technique for rTHA at 10 years, with few revisions for acetabular loosening and/or instability. This is a retrospective study of 77 rTHA cases with severe acetabular bone loss (Paprosky ≥ 2C) treated exclusively with a DM cup (NOVAE STICK; SERF, DÉCINES-CHARPIEU, FRANCE) cemented into a cage (Kerboull cross, Burch-Schneider, or ARM rings). Clinical scores and radiological assessments were performed preoperatively and at the last follow-up. The main endpoints were revision surgery for aseptic loosening or recurring dislocation. With a mean follow-up of 10.7 years [2.1-16.2], 3 patients were reoperated because of aseptic acetabular loosening (3.9%) at 9.6 years [7-12]. Seven patients (9.45%) dislocated their hip implant, only 1 suffered from chronic instability (1.3%). Cup survivorship was 96.1% at 10 years. No sign of progressive radiolucent lines were found and bone graft integration was satisfactory for 91% of the patients. The use of a DM cup cemented into a metal ring during rTHA with complex acetabular bone loss was associated with low revision rates for either acetabular loosening or chronic instability at 10 years. That's why we also recommend DM cup for all high risk of dislocation situations

Background. Failed ingrowth and subsequent separation of revision acetabular components from the inferior hemi-pelvis constitutes a primary mode of failure in revision total hip arthroplasty (THA). Few studies have highlighted other techniques than multiple screws and an ischial flange or hook of cages to reinforce the ischiopubic fixation of the acetabular components, nor did any authors report the use of porous metal augments in the ischium and/or pubis to reinforce ischiopubic fixation of the acetabular cup. The aims of this study were to introduce the concept of extended ischiopubic fixation into the ischium and/or pubis during revision total hip arthroplasty [Fig. 2], and to determine the early clinical outcomes and the radiographic outcomes of hips revised with inferior extended fixation. Methods. Patients who underwent revision THA utilizing the surgical technique of extended ischiopubic fixation with porous metal augments secured in the ischium and/or pubis in a single institution from 2014 to 2016 were reviewed. 16 patients were included based on the criteria of minimum 24 months clinical and radiographic follow-up. No patients were lost to follow-up. The median duration of follow-up for the overall population was 37.43 months. The patients' clinical results were assessed using the Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and Short form (SF)-12 score and satisfaction level based on a scale with five levels at each office visit. All inpatient and outpatient records were examined for complications, including infection, intraoperative fracture, dislocation, postoperative nerve palsy, hematoma, wound complication and/or any subsequent reoperation(s). The vertical and horizontal distances of the center of rotation to the anatomic femoral head and the inclination and anteversion angle of the cup were measured on the preoperative and postoperative radiographs. All the postoperative plain radiographs were reviewed to assess the stability of the components. Results. At the most recent follow-up, 11 (68.8%) patients rated their satisfaction level as “very satisfied” and 4 (25.0%) were “satisfied.” The median HHS improved significantly and the WOMAC global score decreased significantly at the latest follow-up (? 0.001). No intraoperative or postoperative complications were identified. All constructs were considered to have obtained bone ingrowth fixation. The median vertical distance between the latest postoperative center of rotation to the anatomic center of the femoral head improved from 14.7±10.05 mm preoperatively to 6.77±9.14 mm at final follow-up (p=0.002). The median horizontal distance between the latest postoperative center of rotation to the anatomic center of femoral head improved from 6.3±12.07 mm laterally preoperatively to 2.18±6.98 mm medially at the most recent follow-up (p=0.013) postoperatively. The median acetabular cup abduction angle improved from 55.04°±10.11° preoperatively to 44.43°± 5.73° at the most recent follow-up postoperatively (p=0.001). However, there was no difference in the median cup anteversion angles preoperatively (9.15°±5.36°) to postoperatively (9.66°±3.97°) (P=0.535). Conclusions. Early follow-up of patients reconstructed with the technique of extended ischiopubic fixation with porous metal augments demonstrated satisfactory clinical outcomes, restoration of the center of rotation and adequate biological fixation. For any figures or tables, please contact the authors directly

Aim. The aim of this study is to evaluate if obesity negatively affects: (1) complication rate, (2) reoperation and revision rate and (3) functional outcome (based on patient reported outcome measures, PROMs) in revision total hip arthroplasty (rTHA). To our knowledge this is the only recent study to prospectively review these three aspects in what might be considered challenging rTHA. Methods. 444 rTHAs (cup, stem, both, n= 265, 57, 122 respectively), performed in a specialized high-volume orthopaedic center from 2013 to 2015, were prospectively followed. Complications and Oxford Hip Score (OHS) were evaluated at 4 months, 1 year and 2 years. Thirtyfour patients had a BMI >35 kg/m2 (obese), of which thirteen patients with a BMI >40 kg/m2 (morbidly obese). Results. Infection following rTHA was more common in obese patients (8/34: 24%) and in morbidly obese patients (5/13: 38%) than in non-obese patients (15/410: 4%; p's < 0.001). No differences between obese and non-obese groups for other complications were observed (aseptic loosening, dislocation, periprosthetic fractures, thromboembolic events). Reoperation and revision rates were similar overall (p = 0.067 / 0.303 respectively) and due to infection (p = 0.469 / 0.879 respectively) for obese and non-obese groups. Scores on the OHS improved from 42 ±13 at baseline to 27±12 at 1 and 2 year follow-up (p < 0.001). Obese patients had overall poorer OHS scores than non-obese patients (p < 0.001), but improvement of OHS did not differ between obese and non-obese patients (p = 0.198). Conclusion. Obesity is associated with an increased risk of infection following revision THA. Patients with high BMI should be counselled appropriately before surgery

Acetabular reconstruction of extensive bone defect is troublesome in revision total hip arthroplasty (rTHA). Kerboull or Kerboull type reinforcement acetabular device with allobone grafting has been applied since 1996. Clinical results of the procedure were evaluated. Patients. One hundred and ninety-two consecutive revision total hip arthroplasties were performed with allograft bone supported by the Kerboull or Kerboull type reinforcement acetabular device from 1996 to 2009. There were 23 men and 169 women. Kerboull plates were applied to 18 patients, and Kerboull type plates to 174. The mean follow up of the whole series was 8 years (4–18years). Surgical Technique. The superior bone defect was reconstructed principally by a large bulky allo block with plate system. Medial bone defect was reconstructed by adequate bone chips and/or sliced bone plates. After temporally fixation of bulky bone block with two 2.0mm K-wires, it was remodeled by reaming to fit the gap between host bone and plate, followed by fixation to the iliac bone by screws. Finally, residual space of the defect between host bone and the fixed plated was filled up with morselized cancellous bones, bone chips, and/or wedged bony fragments with impaction. This method was sufficiently applicable to AAOS Typeâ�, II, and III bone defects. In case of AAOS Typeâ�£, the procedure was also available after repairing discontinuation between distal and proximal bones by reconstrusion plate or allografting with tibial bone plates or sliced femoral head. Results. Nine patients (4.7%) required revision surgery (infection 5, breakage 3, and malalignment 1). The plate breakage was observed in 8 joints (4.2%). Three patients had no symptoms after the breakage. Three required revision, but the other cases were carefully observed without additional surgical intervention. Ten-year survival rate by Kaplan-Meier method was 96.6% when the endpoint was set revision by asceptic loosning. Conclusions. This study indicated that acetabular allograft reconstructions reinforced by Kerboull or Kerboull type acetabular device were able to recover bone stock with anatomic reconstruction of femoral head center, thus providing satisfactory clinical results in middle term period

Introduction. Highly cross-linked polyethylene has been introduced to decrease osteolysis secondary to polyethylene wear debris generation, but there are few long-term data on revision total hip arthroplasty using highly cross-linked polyethylene liners. The purpose of this study was to report the long-term radiographic and clinical outcomes of a highly cross-linked polyethylene liner in revision total hip arthroplasty. Materials & Methods. We analyzed 63 revision total hip arthoplasties that were performed in 63 patients using a highly cross-linked polyethylene liner between April 2000 and February 2005. Of these, nine died and four were lost to follow-up before the end of the 10-year evaluation. Thus, the final study cohort consisted of 50 patients (50 hips). There were 26 males and 24 females with a mean age at time of revision total hip arthoplasty of 53 years (range, 27–75 years). Mean duration of follow-up was 11 years (range, 10–14 years). Results. Mean Harris hip score improved from 44 points preoperatively to 85 points at final follow-up. No radiographic evidence of osteolysis was found in any hip. One hip required re-revision surgery for acetabular cup loosening at 6.5 years postoperatively. One required re-revision with a constrained liner because of recurrent dislocation. Three sustained deep infections requiring additional surgical procedures. Kaplan-Meier survivorship with an end point of re-revision for any reason was 91.0% and for aseptic cup loosening was 97.9% at 11 years (Figs. 1 and 2). Conclusions. At a minimum of 10 years, the highly cross-linked polyethylene liners showed excellent clinical performance and implant survivorship, and were not associated with osteolysis in our group of patients with revision total hip arthoplasties

Introduction. Modular tapered implants have been suggested as the optimal treatment in patients with severe femoral bone loss undergoing revision total hip arthroplasty (THA). The purpose of this study is to describe minimum 2 year follow up of patients treated with modular tapered prostheses for Paprosky type IIIB and IV femoral bone loss in revision THA. Methods. 44 Consecutive patients with Paprosky type IIIB (23) or IV (21) femurs undergoing revision total hip arthroplasty to cementless modular tapered prostheses were studied. Harris Hip Scores were obtained prior to revision on all patients except those presenting with acute implant failure or periprosthetic fracture. 10 Patients were deceased within 2 years of surgery; the remaining 18 were followed for an average of 42 months (range 25-69 months). Clinical outcomes were measured using the Harris Hip Score, and radiographs were assessed for signs of stem loosening or subsidence >4mm. Results. No further revisions were required in patients who were deceased within 2 years. In those with >2 year follow up, there were 4 additional revisions: 1 for infection, 2 for instability, and 1 for periprosthetic fracture. In patients with surviving implants, the mean Harris Hip Score improved from 33 (range 11-49) pre-operatively to 77 (range 55-100), and there was no radiographic evidence of loosening or subsidence at time of final follow up. Conclusions. These outcomes support the use of modular tapered implants as a safe and effective option for revision arthroplasty of type IIIB and IV femurs

Aims. Severe, superior acetabular bone defects are one of the most challenging aspects to revision total hip arthroplasty (THA). We propose a new concept of “superior extended fixation” as fixation extending superiorly 2 cm beyond the original acetabulum rim with porous metal augments, which is further classified into intracavitary and extracavitary fixation. We hypothesized that this new concept would improve the radiographic and clinical outcomes in patients with massive superior acetabular bone defects. Patients and Methods. Twenty eight revision THA patients were retrospectively reviewed who underwent reconstruction with the concept of superior extended fixation from 2014 to 2016 in our hospital. Patients were assessed using the Harris Hip Score (HHS) and the Western Ontario and McMaster Universities Osteoarthritis Index score (WOMAC). In addition, radiographs were assessed and patient reported satisfaction was collected. Results. At an average follow-up of 28 months (range 18 – 52 months), the postoperative HHS and WOMAC scores were significantly improved at the last follow-up (p < 0.001). The postoperative horizontal and vertical locations of the COR from the interteardrop line were significantly improved from the preoperative measurements (p < 0.001). One (3.6 %) patient was dissatisfied due to periprosthetic joint infection. Conclusion. Extracavitray and intracavitary superior extended fixation with porous metal augments and cementless cups are effective in reconstructing severe superior acetabular bone defects, with promising short-term clinical and radiographic outcome

Aims. Revision total hip arthroplasty is a common operation. The MP Link (Waldemar Link, Hamburg, Germany) system is a distally loading, modular, tapered femoral stem component for revision hip surgery. MP Link in revision total hip arthoplasty was investigated clinically, radiologically and with Oxford hip scores. Methods. A prospective study was conducted of 43 patients undergoing revision total hip arthroplasty with MP Link prostheses between 2004 and 2010. The patients were operated upon by one of the senior authors (JM, JS, RC). Outcome data was collected in clinic and via patient questionnaires. Results. Of the 43 patients, 18 were males. The mean age at surgery was 70.88 years (range 37–97 years). The mean follow up was 33.1 months (range 10–61 months). Indications for revision surgery ranged from aseptic loosening in 34 patients (79.1%), infection in 7 (16.3%), periprosthetic fractures in 1 (2.3%) and recurrent dislocations in 1 (2.3%). None of the patients were lost to follow up. 4 patients died with asymptomatic, well-fixed stems. 2 patients requested to have their follow up referred to their local hospital after 6 and 28 months respectively. 1 patient developed a post-operative pulmonary embolus which was treated with warfarin and caused no further problems. The average Birmingham hip score following the revision surgery was 13.5/48. 100% of the patients had osteointegration of the stem and there were no cases of loosening or osteolysis. There was no radiographic evidence of distal migration of the stems. One patient who underwent revision for infection, became re-infected and underwent further revision surgery. Kaplan-Meier survivorship was 98%. Discussion. The early to mid term results of the uncemented, modular femoral MP link prosthesis are encouraging in complex revision total hip arthoplasty. Long term results are awaited

Introduction. As the proximal femoral bone is generally compromised in failed total hip arthroplasty, achievement of solid fixation with a new component can be technically demanding. Clinical studies have demonstrated good medium-term results after revision total hip arthroplasty using modular fluted and tapered distal fixation stems, but, to our knowledge, long-term outcomes have been rarely reported in the literature. The purpose of this study was to report the minimum ten-year results of revision total hip arthroplasty using a modular fluted and tapered distal fixation stem. Materials & Methods. We analyzed 40 revision THAs performed in using a modular fluted and tapered distal fixation stem (Fig. 1) between December 1998 and February 2004. There were 11 men (12 hips) and 28 women (28 hips) with a mean age of 59 years (range, 38 to 79 years) at the time of revision THA. According to the Paprosky classification of femoral defects, 5 were Type II, 24 were Type IIIA, and 11 were Type IIIB. An extended trochanteric osteotomy was carried out in 21 (52%) of the 40 hips. Patients were followed for a mean of 11.7 years (range, 10 to 15 years). Results. The mean Harris hip score improved from 41 points preoperatively to 85 points at the time of the latest follow-up. A total of 4 hips required additional surgery. One hip had two-stage reconstruction due to deep infection, one had liner and head exchange for ceramic head fracture, one had isolated cup re-revision for aseptic loosening, and one had constrained component revision for recurrent dislocation. No repeat revision was performed due to aseptic loosening of femoral stem. There was no stem fracture at the modular junction. Kaplan-Meier survivorship with an end point of stem re-revision for any reason was 98.1% at 11.7 years (Fig. 2), and, for aseptic stem loosening, the best-case scenario was 100% and the worst-case scenario was 91.9% at 11.7 years (Fig. 3). Conclusions. A modular fluted and tapered distal fixation stem continued to provide a reliable fixation at a minimum ten years after revision THA and can therefore be recommended as a promising option for challenging revision situations with femoral bone defects

THA in patients with acetabular bone defects is associated with a high risk of dislocation. Dual mobility (DM) cups are known to prevent and treat chronic instability. The aim of this study was to evaluate the dislocation rate and survival of jumbo DM cups.

This was a retrospective, continuous, multicenter study of all the cases of jumbo DM cup implantation between 2010 and 2017 in patients with acetabular bone loss (Paprosky 2A: 46%, 2B: 32%, 2C: 15% and 3A: 6%). The indications for implantation were revisions for aseptic loosening of the cup (n=45), aseptic loosening of the femoral stem (n=3), bipolar loosening (n=11), septic loosening (n=10), periprosthetic fracture (n=5), chronic dislocation (n=4), intraprosthetic dislocation (n=2), cup impingement (n=1), primary posttraumatic arthroplasty (n=8), and acetabular dysplasia (n=4). The jumbo cups used were COPTOS TH (SERF), which combines press-fit fixation with supplemental fixation (acetabular hook, two superior flanges with one to four screws, two acetabular pegs). A bone graft was added in 74 cases (80%). The clinical assessment consisted of the Harris hip score. The primary endpoint was surgical revision for aseptic acetabular loosening or the occurrence of a dislocation episode.

In all, 93 patients were reviewed at a mean follow-up of 5.3 ± 2.3 years [0, 10]. As of the last follow-up, the acetabular cup had been changed in five cases: three due to aseptic loosening (3.2%) and two due to infection (2.1%). The survivorship free of aseptic loosening was 96.8%. Three patients (3%) suffered a dislocation. At the last follow-up visit, the mean HSS scores were 72.15, (p < 0.05).

Use of a jumbo DM cup in cases of acetabular bone defects leads to satisfactory medium-term results with low dislocation and loosening rates.

BACKGROUND. During revision hip arthroplasty, removal of a well-fixed, ingrown metal acetabular component may not be possible. Therefore, a new polyethylene liner can be cemented into the existing shell via the cement locking mechanism. We report the indications, technique, and results of cementing an acetabular liner into a well-fixed cementless acetabular shell. PATIENTS AND METHODS. All patients were given informed consent to participate in this study, and the study was approved by our hospital institutional review board. Of 95 revision total hip arthroplasty (THA) between 2005 and 2014, five hips in 5 patients (4 female and a male) were operated by the cemented socket into metal shell technique. The mean age was 70.6 years (range, 59–84 years) (Table 1). Operative Technique. All operations were performed with the patient in the lateral decubitus position and using a posterolateral approach without osteotomy of the greater trochanter. After removal of broken polyethylene liner, an all-polyethylene socket (manufactured by Kyocera Corporation, Osaka, Japan) was cemented in the metal shell. In case of small metal shell, bone bed around the shell were augmented by the use of an impaction morselized allogeneic bone grafting, and the socket was cemented both in the metal shell and in the bone bed (Fig. 1). Postoperative Regimen. On the third postoperative day, the patients began a rehabilitation programmed by clinical path under the supervision of a physiotherapist. The use of crutches for ambulation was begun on the 10th to 14th postoperative day, with progressive weight-bearing as tolerated. Time to full weight-bearing was 3 to 4 weeks postoperatively. RESULTS. All of the cemented sockets functioned well and there were no failure cases during average follow-up period of 5 years (range, 0.7–9.5 years). DISCUSSION. Cementation of polyethylene liners into well-fixed metal shells has become a popular option during revision total hip arthroplasty (THA). Failure was always observed at the metal shell/cement interface whenever it did occur. The cement locking mechanism can be strengthened by roughening the backside of a smooth polyethylene liner to improve the cement-polyethylene interface, or by using an all-polyethylene acetabular component that is designed to be used with cement. Saw roughening of the polyethylene liner strengthens the poly-cement interface. We have used the all-polyethylene acetabular component with macrotexture anchoring form to cement fixation. To perform this procedure, an adequate shell diameter is necessary to accept an acetabular liner that will enable 2 mm of cement mantle around it. If an oversized polyethylene liner is cemented into a small acetabular metal shell, then there is the theoretical risk that the increased shear force will damage the cement locking mechanism, thus leading to failure of the construct. The case 1 in the current series, the hips had this situation, but no loosening occurred at final follow-up of 9.5 years postoperatively (Fig. 1). CONCLUSIONS. We reported good results with the use of a “cemented cup in cementless cup” technique in revision THAs, although follow-up periods were short-term to midterm. To view tables/figures, please contact authors directly

Revision of fractured ceramic-on-ceramic total hip replacements with a cobalt-chromium (CoCr) alloy-on-polyethylene articulation can facilitate metallosis and require further expensive revision surgery [1–3]. In the present study, a fifty-two year old male patient suffered from fatal cardiomyopathy after undergoing revision total hip arthroplasty. The patient had received a polyethylene-ceramic acetabular liner and a ceramic femoral head as his primary total hip replacement. The polyethylene-ceramic sandwich acetabular liner fractured in vivo after 58 months and the patient underwent his first revision surgery where he received a Vitamin E stabilized acetabular Polyethylene (PE) liner and a CoCr alloy femoral head with documented synovectomy at that time. After 15 months, the patient was admitted to hospital in cardiogenic shock, with retrieval of the bearing components. Before the second revision surgery, peak serum cobalt levels measured 6,521 μg/L, 78-times greater than serum cobalt levels of 83μg/L associated with cobalt poisoning [4]. Serum titanium levels found in the patient measured 17.5 μg/L) normal, healthy range 0–1.4 μg/L). The retrieved CoCr alloy femoral head had lost a total of 28.3g (24% or an estimated amount of 102 × 10. −9. wear particles (∼2 μm diameter) [1]) within 16 months of in vivo service. Despite initiating a cobalt chelating therapy, the patients' cardiac left ventricular ejection fraction remained reduced at 6%. This was followed by multi-organ failure, and ultimately the patient passed away shortly after being taken off life support. Embedded ceramic particles were found on the backside and articular surfaces of the Vitamin E-stabilized PE acetabular liner. Evidence of fretting wear on the titanium (Ti) alloy acetabular shell was present, possibly explaining the increased serum Ti levels. Scanning electron microscopy and energy dispersive X-ray analyses confirmed Ti alloy transfer on the embedded ceramic particles on the backside PE liner surface and CoCr alloy transfer on the embedded ceramic particles on the articular PE liner surface. A fractured ceramic-on-ceramic total hip replacement should not be revised to a CoCr alloy-on-polyethylene articulation irrespective of concurrent synovectomy [5] as it can cause severe, third-body wear to the CoCr alloy femoral head that can lead to metallosis with fatal, systemic consequences

Introduction. The goal of revision total hip arthroplasty (THA) for acetabular defects is to achieve the best stability and fixation with available host bone. Tritanium is a highly porous metal construct with a titanium matrix coating. We are reporting our experience of utilizing this material in patients with major acetabular defects. Methods. Between February 2007 and August 2010, 24 consecutive hips (23 patients) underwent acetabular reconstruction using the Tritanium cups. The acetabular defects were assessed using the Paprosky classification. Anteroposterior and lateral radiographs were analyzed at follow-up based for the presence of radiolucent lines more than 2 mm in any of the 3 zones. Results. Mean follow-up was 3.6 ± 1.1 years (range 1.5–5 years). There were 12 males and 11 females. The acetabular defects were type 2a (2 hips), 2b (3 hips), 2c (5 hips), 3a (8 hips), and 3b (6 hips). Two patients had pelvic dissociation. Mean anteversion and abduction angles were 43 ± 4.6 and 19.5 ± 4.4 degrees respectively. All hips had radiographic evidence of osteointegration. Four hips had small demarcation at zones 1 and 3 (<1 mm), however, there were no hips with circumferential or more than 2 mm demarcation. There was no intra-operative fracture or post-operative dislocation, instability, or infection. Discussion and Conclusion. The short-term results of titanium cups in major acetabular defects are encouraging. Our results demonstrate excellent safety and efficacy of this material in revision THA

Revision total hip arthroplasty (THA) is a challenging scenario following complex primary THA for developmental dysplasia of hip (DDH). Our study envisages the long-term outcomes of revision DDH and the role of lateral structural support in socket fixation in these young patients who may require multiple revisions in their life-time. Hundred and eighteen consecutive cemented revision THAs with minimum follow up of 5 years following primary diagnosis of DDH operated between January 1974 and December 2012 were analysed for their clinical and radiological outcomes. The mean follow-up of 118 patients was 11.0 years (5.1–39.6 years). The Kaplan Mier survivorship at 11 years with end point as revision for any reason was 89.8% (CI 81.1–98.4). Of 118 revisions, 88 acetabular revisions were for aseptic loosening. Out of the acetabular revisions, 21 had pre-existing structural bone grafts from primary surgery, of which only 3 needed structural re-grafting during revision. Amongst the remaining 18 hips, the lateral support from the previous graft facilitated revision with no requirement of additional structural graft. Sixty-three hips did not have any form of grafting during primary operation. Amongst them, 35 had bone grafting in revision surgery (18 structural grafting). This study reports the largest number of revision THAs with primary diagnosis of DDH with the longest follow up. In our experience, the lateral support from the structural graft done in primary operation appears to have provided benefit in subsequent revision socket fixation

Introduction. Previous studies of ceramic-on-polyethylene (C-PE) and ceramic-on-ceramic (COC) hip bearings have focused on outcomes following primary surgery. Less is known about the utilization or outcomes of ceramic bearings in revision total hip arthroplasty (R-THA) for the Medicare population in the US. We asked (1) what is the utilization of ceramic bearings for R-THA in the Medicare population and how has it evolved over time; (2) does the use of C-PE bearings influence outcomes following R-THA as compared with metal-on-polyethylene (M-PE); and (3) does the use of COC bearings influence outcomes following R-THA as compared with M-PE?. Methods. A total of 31,809 Medicare patients (aged > 65y) who underwent R-THA between 2005 and 2013 with known bearing types were identified from the Medicare 100% inpatient sample administrative database. Outcomes of interest included relative risk of readmission (90 days) or infection, dislocation, rerevision, or mortality at any time point after revision. Propensity scores were developed to adjust for selection bias in the choice of bearing type at revision surgery. Cox regression incorporating propensity score stratification (10 levels) was then used to evaluate the impact of bearing surface selection on outcomes, after adjusting for patient-, hospital-, and surgeon-related factors. Results. The utilization of C-PE and COC bearings in RHA increased from 5.3% to 26.6% and from 1.8% to 2.5% between 2005 and 2013, respectively. For R-THA patients treated with C-PE bearings, there was reduced risk of 90-day readmission (Hazard Ratio, HR: 0.90, 95% CI: 0.84–0.96, p=0.007). We also observed a trend for reduced risk of infection with C-PE (HR: 0.88, 95% CI: 0.74–1.04) that did not reach statistical significance (p = 0.14). For R-THA patients treated with COC, there was reduced risk of dislocation (Hazard Ratio, HR: 0.76, 95% CI: 0.58–0.99, p=0.04). There was no significant difference in risk of rerevision or mortality for either the C-PE or COC bearing cohorts when compared with M-PE. Discussion. The results indicate that, after adjusting for selection bias and various confounding patient-, surgeon-, and hospital-related factors, Medicare patients treated in a revision scenario with ceramic bearings exhibit similar risk of rerevision, infection, or mortality as those treated with M-PE bearings. Conversely, we found an association between the use of specific ceramic bearings in R-THA and reduced risk of readmission (C-PE) and dislocation (COC). The findings of this study support further research into the association between ceramic bearings in R-THA and lower risk of hospital readmission, dislocation, and, potentially, infection

To review prospectively collected data on patients undergoing femoral revision arthroplasty for failed cemented or cementless primary stems. Materials & Methods. All patients undergoing primary and revision joint replacement surgery at our institution are prospectively entered into a database which includes history and physical examination, radiology, WOMAC and SF-36 scores. These investigations are repeated 3 months, 6 months, 1 year and yearly thereafter at each patient visit. This database identified all patients undergoing femoral revision arthroplasty over the last 10 years. Results. There were a total of 231 patients with 248 revision procedures performed. There were 127 female and 104 male patients and the mean age at the time of revision surgery was 69.4 years. Twenty-two of these patients had had at least one prior revision operation on the index hip. Thirty hips were treated with a cemented Echelon stem and 218 treated with a cementless Echelon stem. Of the 248 hips 14 patients were lost to follow-up (14 hips) and 9 patients (9 hips) are deceased. The average follow-up was 5.9 years. Of the 225 hips remaining in the follow-up series there was a single case of aseptic loosening confirmed radiologically. Twenty-one hips were diagnosed with infection (9.3%); 6 of those patients had had at least one prior revision procedure and 4 additional patients had a prior diagnosis of infection. Therefore, 10 of the 21 hips were either definitely or probably infected at the time of their revision operation on which we are reporting. Nine patients (4%) had multiple dislocations post-operatively. These were patients who had undergone multiple revisions or whose primary revision operation was for instability. An additional 18 patients (8%) had a single dislocation treated by closed reduction requiring no further treatment. There were 6 hips with intra-operative fracture requiring immediate re-revision plus fracture fixation and a further 12 hips (5.3%) who sustained a peri-prosthetic fracture some time after their revision procedure. Despite the number of complications the majority of patients required no further surgical treatment. Eleven hips (4.8%) required re-revision of the femoral component. Therefore the overall survival rate at 5.9 years of the Echelon revision stem was 95.2%. Discussion. Femoral revision total hip arthroplasty is a difficult operation with uncertain outcome. All series recognize a significant complication rate primarily as a consequence of infection, instability or intra-operative or peri-operative fractures secondary to poor bone quality. Our experience with the Echelon revision stem demonstrates excellent incorporation of the implant with a negligible rate of re-revision for failure of bone ingrowth; the other complications are consistent with those reported in other series. Conclusions. Although the complication rate in this group of patients is high only 4.8% of the hips required re-revision of the femoral component Of significance was the lack of re-revision necessitated by aseptic loosening of this revision stem

Introduction. The mid- or long-term results of acetabular revision total hip arthroplasty (THA) in Korea are rare. The purpose of this study is to report the mid-term radiographic results (> 5 years) of acetabular revision THA with porous-coated cementless Trilogy. ®. cup (Zimmer, Warsaw, IN, USA). Materials and Methods. Between 1999 and 2010, 77 patients (79 hips) had underwent acetabular revision THA with Trilogy. ®. cup. Eight patients (8 hips) were excluded due to death before 5-year follow-up, and 22 patients (23 hips) were excluded due to less than 5-year follow-up or follow-up loss. Forty-seven patients (48 hips) were included in our study. The mean age was 57.9 years (range, 36 to 76 years) and the mean follow-up was 9.8 years (range 5.0 to 16.2 years). The causes of revision were aseptic loosening in 40 hips, and septic loosening in 8 hips, respectively. Both acetabular and femoral revisions were performed in 14 hips and isolated acetabular revision was done in 34 hips. Preoperetive acetabular bone defect according to Paprosky classification was; 1 in type I, 6 in IIA, 11 in IIB, 9 in IIC, 15 in IIIA, and 6 in IIIB. Results. Radiolucent lines less than 2mm were found in 2 hips; one in zone I, another in zone I, II, III. Four hips (1 in type IIC, 1 in IIIA and 2 in IIIB) showed cup migration greater than 5 mm accompanying change of position greater than 5 degrees. However, these patients did not complain pain and showed fixation by secondary stabilization. The Kaplan-Meier survivorship with aseptic loosening as the end point at 10 years was 92.6% (95% confidence interval [CI], 82.6 – 100) and at 15 years was 83.8 % (95% CI, 69.1 – 98.6), respectively. Non-recurrent dislocations occurred in 4 hips. There were no other complication such as sciatic nerve palsy, infection and deep vein thrombosis. Conclusion. Mid-term radiographic results (>5 years) of acetabular revision THA with porous-coated cementless Trilogy. ®. cup showed durable longevity. However, other options such as anti-protrusio cage or cup-cage construct should be considered in severe acetabular bone defect

Introduction. Failure of acetabular components has been reported to lead to large bone defects, which determine outcome and management after revision total hip arthroplasty (THA). Although Kerboull-type (KT) plate (KYOCERA Medical Corporation, Kyoto, Japan) has been used for compensating large bone loss, few studies have identified the critical risk factors for failure of revision THA using a KT plate. Therefore, the aim of this study is to evaluate the relationship between survival rates for radiological loosening and the results according to bone defect or type of graft. Patients and methods. This study included patients underwent revision THA for aseptic loosening using cemented acetabular components with a KT plate between 2000 and 2012. Bone defects were filled with beta Tricalcium phosphate (TCP) granules between 2000 and 2003 and with Hydroxyapatite (HA) block between 2003 and 2009. Since 2009, we have used femoral head balk allografts. Hip function was evaluated by using the Japanese Orthopaedic Association (JOA) score and University of California, Los Angeles (UCLA) activity. Acetabular defects were classified according to the American Academy of Orthopedic Surgeons (AAOS) classification. The postoperative and final follow-up radiographs were compared to assess migration of the implant. Kaplan–Meier method for cumulative probabilities of radiographic failure rate, and the comparison of survivorship curves for various subgroups using the log-rank test were also evaluated. Logistic regression was performed to examine the association of such clinical factors as the age at the time of operation, body mass index, JOA score, UCLA activity score, and AAOS classification with radiographic failure. Odds ratios (ORs) and 95% CIs were calculated. Multivariate analysis was performed to adjust for potential confounders by clinical factors. Values of p < 0.05 were considered significant. Results. The patient background is shown in Table 1. The JOA score at the final follow-up increased significantly (p < 0.001). Radiographic failure was evaluated for revision THA with beta-TCP, HA, and bulk allografts. These survival rates are shown in Table 2 and the rate in the AAOS type IV group was significantly lower than that in the type III group (p = 0.033). The survival curves were significantly different between beta -TCP group and bulk allograft group (p = 0.036) (Table 3). Multivariate analysis showed that AAOS type IV defect was found to be a risk factor for radiographic failure (radiographic failure: OR: 15.5, 95% CI: 1.4–175.4, p = 0.032). Discussion. Our results of survival rate are similar to those reported by previous studies. However, by comparing the survival rates between beta-TCP group and bulk allograft group, beta-TCP is not suitable for bone graft reconstruction of acetabular bone defects with a KT plate. We also found that AAOS type IV to be a risk factor for failure of revision THA. Therefore, bone defect size is the critical risk factor for failure of revision THA using a KT plate. New devices and techniques for KT plates are needed to improve the treatment of pelvic discontinuity