Most hip fractures treated with modern internal fixation techniques will heal. However, failures occasionally occur and require revision procedures. Salvage strategies employed during revision are based on whether the fixation failure occurs in the femoral neck, or in the intertrochanteric region. Patient age and remaining bone stock also influence decision making. For fractures in young patients, efforts are generally focused on preserving the native femoral head via osteotomies and repeat internal fixation. For failures in older patients, some kind of hip replacement is usually selected. Disuse osteopenia, deformity, bone loss, and stress-risers from previous internal fixation devices all pose technical challenges to successful reconstruction. Attention to detail is important in order to minimise complications. In the majority of cases, good outcomes have been reported for the various salvage strategies. Cite this article: Bone Joint J 2013;95-B, Supple A:7–10

The aim of this study was to systemically review the evidence for the use of intra-operative cell salvage (ICS) among patients undergoing revision hip arthroplasty, and synthesis the available data to quantify any associated reduction in allogeneic blood transfusion. An electronic database search of MEDLINE (PubMed), EMBASE, Scopus and the Cochrane Library was completed from the date of inception to 9. th. February 2021, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were (i) adult patients >18 years, (ii) ICS utilised in one study group, (iii) revision hip arthroplasty performed. Exclusion criteria were (i) pre-donation of red blood cells, (ii) mixed reporting without dedicated subgroup analysis for revision hip arthroplasty. Screening for eligibility, and quality assessment of included studies, was performed independently by two authors (TW and DH), and any disputes settled by third author (AK). Of the 187 records identified, 11 studies were included in the qualitative analysis, and 5 studies suitable for quantitative meta-analysis. Across the included studies there were 1856 participants, with a mean age of 63.86 years and a male: female ratio of 0.90. Quality assessment demonstrated low or medium risk of bias only. For revision hip arthroplasty patients receiving ICS, 37.07% required ABT with a mean transfusion of 1.92 units or 385ml per patient. For patients treated without ICS, 64.58% required ABT with a mean transfusion of 4.02 units or 803ml per patient. This difference achieved statistical significance (p < 0.05). This study has demonstrated a significant reduction in the need for allogenic blood transfusion associated with intra-operative cell salvage use among patients undergoing revision hip arthroplasty. This study therefore supports the routine use of ICS in this patient group. However, a major limitation is the lack of clinical outcomes reported by the available studies. Further research is required to determine whether this effect is associated with sub-groups of revision arthroplasty procedure, and whether ICS impacts clinical outcomes such as length of stay, rehabilitation progress and mortality

Aims. The optimal management of intracapsular fractures of the femoral neck in independently mobile patients remains open to debate. Successful fixation obviates the limitations of arthroplasty for this group of patients. However, with fixation failure rates as high as 30%, the outcome of revision surgery to salvage total hip arthroplasty (THA) must be considered. We carried out a systematic review to compare the outcomes of salvage THA and primary THA for intracapsular fractures of the femoral neck. . Patients and Methods. We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) compliant systematic review, using the PubMed, EMBASE and Cochrane libraries databases. A meta-analysis was performed where possible, and a narrative synthesis when a meta-analysis was not possible. Results. Our analyses revealed a significantly increased risk of complications including deep infection, early dislocation and peri-prosthetic fracture with salvage THA when compared with primary THA for an intracapsular fracture of the femoral neck (overall risk ratio of 3.15). Functional outcomes assessment using EuroQoL (EQ)-5D were not significantly different (p = 0.3). Conclusion. Salvage THA carries a significantly higher risk of complications than primary THA for intracapsular fractured neck of femur. Current literature is still lacking well designed studies to provide a full answer to the question. Take home message: Salvage THA is associated with more complications than primary THA for intracapsular neck of femur fractures. . Cite this article: Bone Joint J 2016;98-B:452–60

We carried out a retrospective case-control study in 80 patients who underwent a revision total hip replacement. Group A (40 patients) received tranexamic acid and intra-operative cell salvage. Group B (40 patients) was a matched control group and did not receive this management. Each group was divided into four subgroups: revision of both components, revision of both components with bone grafting, revision of the acetabular component with or without bone graft, and revision of the femoral component with or without bone graft. In group A the total number of units transfused was 52, compared with 139 in group B, representing a reduction in blood usage of 62.5%. The mean amount of blood transfused from cell salvage in each group was 858 ml (113 to 2100), 477 ml (0 to 2680), 228 ml (75 to 315) and 464 ml (120 to 1125), respectively. There was a significant difference in the amount of blood returned between the groups (p < 0.0001). In group A, 22 patients needed transfusion and in group B, 37 (p < 0.0001). A cost analysis calculation showed a total revenue saving of £70 000 and a potential saving throughout our facility of £318 288 per year. Our results show that a significant reduction in blood transfusion can be made using combined cell salvage and tranexamic acid in revision surgery of the hip

The benefits of cell salvage autotransfusion are well reported. There is a common non-evidenced belief amongst revision arthroplasty surgeons that auto-transfusion is potentially contraindicated in infected revisions. The aim is to study the immediate and delayed outcomes of using cell saver on patients undergoing PJI surgery. Prospective cohort service evaluation registered with the local audit department. 20 PJI cases in 18 patients where cell saver was used over a period of 4 years. Intraoperative fluid and tissue samples were taken for culture. Blood culture from salvaged blood pre and post leucodepletion filter were sent for microbiological analysis. Data on type of surgery, blood loss, further allogenic transfusion and SIRS response was collected. Success of infection clearance was assessed using 2019 MSIS ORT. Five patients receiving autologous blood in non-infection cases were used as controls. Mean age for the PJI group was 67.7 years, 67% female. 11 patients (67%) had 1st stage surgery and 5 (25%) underwent 2nd stage whereas 4 patients had single stage surgery. The mean calculated blood loss was 1398 mls (range 400–3000mls). 6 Patients required further allogenic transfusion. 16 patients received blood via a leuco-depletion filter. The same organism grown from tissues was identified in post-filter blood in 8/17 patients (47%). 2/20 have grown a different organism in post-filtered blood, _P.Acne._. 2 patients developed SIRS upon auto-transfusion, however one was thought to be secondary to cementing. The control group had 443 mls mean amount of blood loss and 1 patient developed a SIRS response. 14/20 (70%) patients had successful clearance of infection (tier 1) 2 patients died prior to undergoing 2nd stage. Using cell saver did not impact main outcome of infection clearance in PJI surgery. We would advocate its routine usage whilst avoiding direct collection of heavily contaminated blood

The management of femoral bone loss is challenging during revision hip arthroplasty. In patients with Paprosky grade IIIB and IV defects, obtaining fixation and rotational stability using traditional surgical constructs is difficult. The use of a custom-made internal proximal femoral replacement prostheses has been proposed as a solution in patients, with severe femoral bone stock loss. However, there is a paucity in the literature on their use and long-term outcomes. We report on the clinical and radiological results of our cohort. We retrospectively reviewed all patients who underwent internal proximal femoral replacement for revision hip arthroplasty between April 1996 and April 2019. All patients had at least 2 years of follow-up time. 160 patients underwent limb salvage at our institution using internal proximal femoral replacement. The mean follow-up was 79.7 months (S.D 41.3). Indications for revision included periprosthetic fractures, aseptic loosening, and deep infection. The mean Oxford hip score increased from 13.8 (0–22) to 31.5 (18–43) (paired t-test, p < 0.001). Kaplan-Meier prosthesis survival analysis with revision as the endpoint was 87% at 5 years. None required revision of the femoral stem. There were four dislocations (5%) and there was failure to eradicate the deep infection in four. This technique allows instant distal fixation, allowing for early mobilisation. Long-term clinical and radiological outcomes are encouraging and the complication rates are acceptable for this patient group

This large UK multicentre study evaluates clinical outcomes and identifies factors associated with local complication following PFR for non-oncological conditions. 132 patients across four UK centres underwent PFR from 01/08/2004-28/03/2023 with median follow-up of 1.9 (Q10.5-Q34.2) years. 75 (56.8%) patients were female and the mean age was 74.0 (SD 11.7) years. 103 (78%) patients had Charleston Comorbidity Index ≥3. ASA class was III or IV in 66.6%. Indications were infected revision (39, 29.5%), periprosthetic fracture (36, 27.3%), acute trauma (30, 22.7%), aseptic revision (17, 12.9%), failed trauma (nine, 6.8%) and complex primary arthroplasty (one, 0.8%). The primary outcome was the local complication rate. Secondary outcomes were systemic complications, reoperation and mortality rates. Comparisons were made with t-tests and Chi2 tests to investigate patient and surgical factors associated with local complication. Statistical significance was p<0.05. There were 37(28.0%) local complications. These were 18 (13.6%) dislocations, eight (6.1%) prosthetic joint infections, four (3.0%) haematomas, three (2.3%) superficial infections, one (0.8%) wound dehiscence, one (0.8%) sciatic nerve palsy and one (0.8%) femoral perforation. Dislocation mostly occurred in conventional articulations (12, 9.1%) followed by dual-mobility cups (three, 2.3%), constrained cups (two, 1.5%) and hemiarthroplasty (one, 0.8%). Median time to local complication was 30 (Q14-Q3 133) days. Seven (5.3%) patients developed a systemic complication. Thirty-three (25.0%) patients underwent reoperation. Thirty-day and one-year mortality rates were 3.8% and 12.1%, respectively. Longer surgical waiting times (7.9 \[SD 16.9) versus 2.6 \[SD 4.4\] days, p<0.001) and longer operating times (212.5 \[SD 71.8\] versus 189.4 \[SD 59.3\] mins, p=0.0450) were associated with local complication. Due to its high complication rate, PFR should be a salvage option when performed for non-oncological indications. Conventional articulations should be avoided. PFR should be delivered in a timely manner and ideally as dual-consultant cases to reduce operating time

Proximal femoral replacements are commonly used in oncologic limb salvage procedures. Recently, these megaprostheses have been utilized in complex revision arthroplasties where proximal femoral bone is compromised. The purpose of this study is to evaluate the clinical and radiographic survivorship of proximal femoral replacements as a salvage treatment for bone loss after hip arthroplasty. We retrospectively reviewed the clinical and radiographic outcomes of 31 proximal femoral replacements of a single design between 2004 and 2013 at a single institution. The mean age at time of index surgery was 62 years, 58% were female, and mean BMI was 28.1 Kg/m. 2. The indications and complications associated with megaprosthesis implantation were collected. Average follow-up was 60 months (range 24–120 months). Kaplan-Meier survivorship assessed clinical and radiographic survivorship. Indication for revision, use of a constrained liner and construct length were assessed as risk factors for construct failure. The indications for proximal femoral replacement were periprosthetic infection (n=12, 38.7%), aseptic loosening (n=10, 32.3%), periprosthetic fracture (n=6, 19.3%), and non-union (n=3, 9.7%). A constrained liner was used in 22 hips (71%). The average length of bone resection was 148 cm (range 81–240 cm). There were nine revisions (29.2%): 3 for infection (9.7%) 2 for dislocation (6.5%), 2 for aseptic loosening (6.5%), and 2 for periprosthetic fracture (6.5%). Two of the 3 infections were in patients treated for infection. Overall survivorship was at 70.8%. There was no relation between the length of the bone resection, indication for revision and failure rate. Proximal femoral replacement in non-oncologic revision hip arthroplasty demonstrated a high failure rate at 2–10 year follow-up. Despite the high failure rate, the benefits of this salvage construct are that they allow full weight-bearing and allow rapid mobilization with minimal morbidity

Aims. The aims of this study were to review the surgical technique for a combined femoral head reduction osteotomy (FHRO) and periacetabular osteotomy (PAO), and to report the short-term clinical and radiological results of a combined FHRO/PAO for the treatment of selected severe femoral head deformities. Patients and Methods. Between 2011 and 2016, six female patients were treated with a combined FHRO and PAO. The mean patient age was 13.6 years (12.6 to 15.7). Clinical data, including patient demographics and patient-reported outcome scores, were collected prospectively. Radiologicalally, hip morphology was assessed evaluating the Tönnis angle, the lateral centre to edge angle, the medial offset distance, the extrusion index, and the alpha angle. Results. The mean follow-up was 3.3 years (2 to 4.6). The modified Harris Hip Score improved by 33.0 points from 53.5 preoperatively to 83.4 postoperatively (p = 0.03). The Western Ontario McMasters University Osteoarthritic Index score improved by 30 points from 62 preoperatively to 90 postoperatively (p = 0.029). All radiological parameters showed significant improvement. There were no long-term disabilities and none of the hips required early conversion to total hip arthroplasty. Conclusion. FHRO combined with a PAO resulted in clinical and radiological improvement at short-term follow-up, suggesting it may serve as an appropriate salvage treatment option for selected young patients with severe symptomatic hip deformities

Aims

The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome.

Background. Surgical treatment for osteonecrosis of the femoral head (ONFH) includes both joint-preserving techniques and joint replacement. Joint preservation is more effective in early-stage ONFH; thus, prompt diagnosis when the femoral head is still salvageable is an important clinical goal. We report a 20-year retrospective study that summarizes the proportion of patients diagnosed with early-stage versus late-stage ONFH at initial presentation to our practice. Methods. Our institutional database was reviewed to identify patients 18–65 years of age who were diagnosed with atraumatic ONFH in our clinic between 1998–2018. The Association Research Circulation Osseous (ARCO) system was used to stage ONFH, based on available imaging. Patients with prior surgical treatment for ONFH were excluded. Results. Four-hundred and thirteen patients and 642 hips with ONFH were identified. At initial presentation, 93 (23%) patients and 229 (37%) hips were diagnosed with stage I or II osteonecrosis. Three hundred and twenty patients (77%) and 403 hips (63%) were diagnosed with stage III or stage IV osteonecrosis. Fifty-eight percent of patients were male, and 56% of patients had bilateral involvement. Average age at presentation was 44 years. Treatments included nonoperative treatment (35%), joint preservation surgery (19%), hip resurfacing (1%), and total hip replacement (45%). Conclusions. More than three-quarters of patients with femoral head ONFH were diagnosed at a late stage. Efforts to improve early detection and prompt referral to orthopaedic surgeons may enable more patients to be diagnosed with early-stage ONFH and improve the success of hip preservation techniques. For any tables or figures, please contact the authors directly

Aims

Periprosthetic joint infections (PJIs) with prior multiple failed surgery for reinfection represent a huge challenge for surgeons because of poor vascular supply and biofilm formation. This study aims to determine the results of single-stage revision using intra-articular antibiotic infusion in treating this condition.

Aims. Loss or absence of proximal femoral bone in revision total hip arthroplasty (THA) remains a significant challenge. While the main indication for the use of proximal femoral replacements (PFRs) is in the treatment of malignant disease, they have a valuable role in revision THA for loosening, fracture and infection in patients with bone loss. Our aim was to determine the clinical outcomes, implant survivorship, and complications of PFRs used in revision THA for indications other than malignancy. Patients and Methods. A retrospective review of 44 patients who underwent revision THA using a PFR between 2000 and 2013 was undertaken. Their mean age was 79 years (53 to 97); 31 (70%) were women. The bone loss was classified as Paprosky IIIB or IV in all patients. The mean follow-up was six years (2 to 12), at which time 22 patients had died and five were lost to follow-up. Results. The mean Harris Hip Score improved from 42.8 (25.9 to 82.9) pre-operatively to 68.5 (21.0 to 87.7) post-operatively (p = 0.0009). A total of two PFRs had been revised, one for periprosthetic infection eight years post-operatively and one for aseptic loosening six years post-operatively. The Kaplan-Meier survivorship free of any revision or removal of an implant was 86% at five years and 66% years at ten years. A total of 12 patients (27%) had a complication including six with a dislocation. Conclusion. PFRs provide a useful salvage option for patients, particularly the elderly with massive proximal femoral bone loss who require revision THA, with significant clinical improvement. While the survivorship of the implant is good at five years, dislocation continues to be the most common complication. The judicious use of larger femoral heads, dual-mobility constructs, or constrained liners may help to minimise the risk of dislocation. Cite this article: Bone Joint J 2017;99-B:325–9

Aims

With increasing burden of revision hip arthroplasty (THA), one of the major challenges is the management of proximal femoral bone loss associated with previous multiple surgeries. Proximal femoral arthroplasty (PFA) has already been popularized for tumour surgeries. Our aim was to describe the outcome of using PFA in these demanding non-neoplastic cases.

Aims. Cephalomedullary nails (CMNs) are commonly used for the treatment of intertrochanteric hip fractures. Total hip arthroplasty (THA) may be used as a salvage procedure when fixation fails in these patients. The aim of this study was to analyze the complications of THA following failed intertrochanteric hip fracture fixation using a CMN. Patients and Methods. Patients who underwent THA were identified from the 5% subset of Medicare Parts A/B between 2002 and 2015. A subgroup involving those with an intertrochanteric fracture that was treated using a CMN during the previous five years was identified and compared with the remaining patients who underwent THA. The length of stay (LOS) was compared using both univariate and multivariate analysis. The incidence of infection, dislocation, revision, and re-admission was compared between the two groups, using multivariate analysis adjusted for demographic, hospital, and clinical factors. Results. The Medicare data yielded 56 522 patients who underwent primary THA, of whom 369 had previously been treated with a CMN. The percentage of THAs that were undertaken between 2002 and 2005 in patients who had previously been treated with a CMN (0.346%) more than doubled between 2012 and 2015 (0.781%). The CMN group tended to be older and female, and to have a higher Charlson Comorbidity Index and lower socioeconomic status. The mean LOS was 1.5 days longer (5.3 vs 3.8) in the CMN group (p < 0.0001). The incidence of complications was significantly higher in the CMN group compared with the non-CMN group: infection (6.2% vs 2.6%), dislocation (8.1% vs 4.5%), revision (8.4% vs 4.3%), revision for infection (1.1% vs 0.37%), and revision for dislocation (2.2% vs 0.6%). Conclusion. The incidence of conversion to THA following failed intertrochanteric hip fracture fixation using a CMN continues to increase. This occurs in elderly patients with increased comorbidities. There is a significantly increased risk of infection, dislocation, and LOS in these patients. Patients with failed intertrochanteric hip fracture fixation using a CMN who require THA should be made aware of the increased risk of complications, and steps need to be taken to reduce this risk. Cite this article: Bone Joint J 2019;101-B(6 Supple B):91–96

Objectives. A possible solution for the management of proximal femoral bone loss is a modular femoral endoprosthesis (EPR). Although the outcome of EPRs in tumour surgery has been well described, the outcome of their use in revision hip surgery has received less attention. The aim of this study was to describe the outcome of using EPR for non-neoplastic indications. Methods. A retrospective review of 79 patients who underwent 80 EPRs for non-neoplastic indications was performed, including the rates of complication and survival and the mean Oxford Hip Scores (OHS), at a mean of five years post-operatively. The mean age at the time of surgery was 69 years (28 to 93) and the mean number of previous operations on the hip was 2.4 (0 to 17). The most common indications for EPR implantation were periprosthetic joint infection (PJI) (n = 40), periprosthetic fracture (n = 12) and failed osteosynthesis of a proximal femoral fracture or complex trauma (n = 11). Results. Salvage was achieved in all patients. A total of 25 patients (25 EPRs, 31.6%) had a complication, the most common being infection (n = 9) and dislocation (n = 3). Further surgery was required for 18 EPRs (22%), nine of which were revision procedures. The five year survival of the EPR was 87% (95%CI: 76% to 98%). The mean OHS was 28 (4 to 48). Inferior survival and outcomes were seen in EPRs which were performed for the treatment of infection. However, the eradication of infection was achieved in 33 of the 40 (82.5%) which were undertaken for this indication. Conclusion. We recommend the continued use of proximal femoral EPRs for non-neoplastic indications, including PJI. Cite this article: Bone Joint J 2016;98-B:1463–70

Introduction. Cephalomedullary nails (CMN) are commonly used for the treatment of intertrochanteric (IT) hip fractures. Total hip arthroplasty (THA) is commonly used as a salvage procedure for failed IT hip fractures that progress to post-traumatic arthritis. This study analyzed the complications of THA following treatment of failed IT hip fractures with cephalomedullary nails. Methods. Patients who had a primary THA were identified from the 5% subset of Medicare Parts A/B from 2002–2015. A subgroup with previous CMN for IT hip fracture within the previous 5 years was identified and compared to the remaining THA patients without prior CMN. Length of stay (LOS) was compared using both univariate and multivariate analysis. Infection, dislocation, revision, and readmission were compared between those with and without prior CMN, using multivariate analysis (adjusted for demographic, hospital, and clinical factors). Results. 5% subset of the Medicare data yielded 56,522 primary THA, with 369 treated with prior CMN. The percentage of primary THA from 2002–2005 with prior cephalomedullary nails (0.346%) more than doubled in 2012–2015 (0.781%). The prior CMN group tended to be older, female, higher CCI, and lower socioeconomic status. Mean LOS was 1.5 days longer (5.3 vs 3.8) in the prior CMN group (p<0.0001). The percentage of postoperative complications was significantly higher in the prior CMN group compared to non-CMN cohort: infection (6.2% vs 2.6%), dislocation (8.1% vs 4.5%), revision (8.4% vs 4.3%), revision for infection (1.1% vs 0.37%), and revision for dislocation (2.2% vs 0.6%). Discussion. Conversion from failed IT hip fractures with cephalomedullary nails to total hip arthroplasty continues to increase. These cases occur in elderly patients with increased comorbidities. There is a significantly increased risk of infection, dislocation and LOS in the CMN group. Patients with failed IT hip fractures undergoing THA should be made aware of the increased complication risk and further steps need to be undertaken to diminish the elevated risk

Introduction. Hip abductor tendon tears have been referred to as “rotator cuff tears of the hip,” and are a recognized etiology for persistent, often progressive, lateral hip pain, weakness, and limp. Multiple repair techniques and salvage procedures for abductor tendon tears have been reported in the literature; however, re-tear remains a frequent complication following surgical repair. This study compares the short-term outcomes of open abductor tendon repairs with decortication and suture fixation (DSF) compared to a modified technique repair into a bone trough (BT), to determine best surgical results for large abductor tendon avulsions. Additionally, surgical treatment of small tears versus large tears was examined. Methods. The outcomes of 37 consecutive hip abductor tendon repairs treated between January 2009 and December 2017 were retrospectively reviewed. Large tears were defined as detachment of 33–100% of the gluteus medius insertion. There were 15 DSF and 10 BT cases. Postoperative pain, ability to perform single leg stance, hip abduction, and Trendelenburg lurch, were examined. Small tears (12 cases) were defined as having no gluteus medius avulsion from the trochanteric insertion and were comprised of longitudinal tears (repaired side-by-side) and isolated gluteus minimus tears (repaired by tenodesis to the overlying gluteus medius). Standard statistical analyses were utilized. Type I error for all analyses was set at α=0.05. Results. When comparing large tear repair outcomes, repairs into a BT had superior outcomes to repairs with DSF: 0 (BT) versus 6 (DSF, 40%) failure rate (p<0.05), and greater reductions in pain at one-year post surgery (Δ VAS: BT, −5.70±0.97 | DSF: −2.73±0.69; p<0.01), ability to perform a single leg stance and hip abduction (90% and 100% vs 47% and 73%) (p<0.05). Clinical strength ratings were higher for repairs into a BT, but this did not reach statistical significance. When comparing large to small tear repair outcomes, small tears were found to have lower VAS pain scores and higher clinical strength ratings during both the pre-op and 1-year post-op time points (p<0.05). A higher percentage of those with small tears were able to perform a single leg stance and hip abduction (100%) compared to those with large tears (64% and 78% respectively) (p<0.05). A significantly higher frequency of residual lurch was also observed for those with large tears; 56% compared to small tears at 0%. Conclusions. Utilizing a BT repair significantly improved surgical results for large abductor tendon avulsions. Level of evidence: Therapeutic level IV case series

Background. Fully constrained liners are used to treat recurrent dislocations or patients at high risk after total hip replacements. However, they can cause significant morbidities including recurrent dislocations, infections, aseptic loosening and fractures. We examine long term results of 111 patients with tripolar constrained components to assess their redislocation and failure rate. Questions/purposes. The purpose of this study was to assess survivorship, complications and functional outcomes at a minimum 10 years after the constrained tripolar liners used in our institute. Methods. We retrospectively identified 111 patients who had 113 revision tripolar constrained liners between 1998 and 2008. Eighty-nine were revised due to recurrent dislocations, 11 for pseudotumor with deficient abductors, and 13 for periprosthetic infection with loss of soft tissue stabilizers. All patients had revision hip arthroplasty before the constrained liner was used: 13 after the first revision, 17 after the second, 38 after the third, and 45 had more than 3 revisions. We extracted demographics, implant data, rate of dislocations and incidence of other complications. Kaplan Meier curves were used to assess dislocation and failure for anything reason. WOMAC was used to assess quality of life. Results. At 10 years, the survival free of dislocation was 95.6% (95%CI 90– 98), and at 20 years to 90.6% (95% CI 81.0– 95.5). Eight patients (7.1%) had dislocations of their constrained liners: 1 patient had simultaneous periprosthetic infection identified at the time of open reduction, and 1 patient sustained stem fracture 3 months prior to the liner dislocation. At 10 years, the survival to any further surgery was 89.4% (95% CI 82–93.8), and at 20 years, this was 82.5 (95% CI 71.9–89.3). Five patients (4.4%) had deep infection: 4 of these had excision arthroplasty due to failure to control infection, while 1 patient was treated successfully with debridement, exchange of mobile components and intravenous antibiotics. Two patients (1.8%) had dissociated rings that required change of liner, ring and head. Two patients (1.8%) had periprosthetic femoral fractures that were treated by revision stems and exchange of constrained liners. The mean WOMAC functional and pain scores were 66.2 and 75.9 of 100, respectively. Conclusions. Constrained tripolar liners in our institute provided favourable results in the long term for recurrent dislocation hip arthroplasty with dysfunctional hip stabilizers. Infection in these patients can prove to be difficult to treat due to their poor soft tissue conditions from repeated surgeries. Comparing long term results from other types of constrained liners is essential to evaluate these salvage liners

Aims

One-stage exchange for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) is gaining popularity. The outcome for a repeat one-stage revision THA after a failed one-stage exchange for infection remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat one-stage exchange, and to investigate the association between the Musculoskeletal Infection Society (MSIS) staging system and further infection-related failure.