Introduction. Transfemoral osseointegration (TFOI) for amputees has substantial literature proving superior quality of life and mobility versus a socketed prosthesis. Some amputees have hip arthritis that would be relieved by a total hip replacement (THR). No other group has reported performing a THR in association with TFOI (THR+TFOI). We report the outcomes of eight patients who had THR+TFOI, followed for an average 5.2 years. Materials & Methods. Our osseointegration registry was retrospectively reviewed to identify all patients who had TFOI and also had THR, performed at least two years prior. Six patients had TFOI then THR, one simultaneous, one THR then TFOI. All constructs were in continuity from hip to prosthetic limb. Outcomes were: complications prompting surgical intervention, and changes in subjective hip pain, K-level, daily prosthesis wear hours, Questionnaire for Persons with a Transfemoral Amputation (QTFA), and Short Form 36 (SF36). All patients had clinical follow-up, but one patient did not have complete mobility and quality of life survey data at both time periods. Results. Four (50%) were male, average age 52.7±14.8 years. Three patients (38%) had amputation for trauma, three for osteosarcoma, one each (13%) infected total knee and persistent infection after deformity surgery. One patient died one year after THR+TOFA from subsequently diagnosed pancreatic cancer. One patient had superficial debridement for infection with implant retention after five years. No implants were removed, no fractures occurred. All patients reported severe hip pain preoperatively versus full relief of hip pain afterwards. K-level improved from 0/8=0% K>2 (six were wheelchair-bound) to 5/8=63% (p=.026). At least 8 hours of prosthesis wear was reported by 2/7=29% before TOFA vs 5/7=71% after (p=.286). The QTFA improved in all categories, but not significantly: Global (40.0±21.6 vs 60.0±10.9, p=.136), Problem (50.2±33.2 vs 15.4±8.4, p=.079), and Mobility (35.9±26.8 vs 58.3±30.7, p=.150). The SF36 also improved minimally and not significantly: Mental (53.6±12.0 vs 54.7±4.6, p=.849) and Physical (32.5±10.9 vs 36.3±11.2, p=.634). Conclusions. THR+TFOI is a successful reconstruction option for amputees who desire relief from severe pain related to hip joint degeneration, and also the opportunity for improved mobility and quality of life that TFOI typically confers. In our cohort, the procedure proved safe: no associated deaths, no removals, one soft tissue debridement. Mobility improved markedly. Quality of life improved, but not to significant thresholds as measured by the surveys. THR+TFOI appears safe and reasonable to offer to transfemoral amputees with painful hip joint degeneration

Introduction. Transtibial osseointegration (TFOI) for amputees has limited but clear literature identifying superior quality of life and mobility versus a socketed prosthesis. Some amputees have knee arthritis that would be relieved by a total knee replacement (TKR). No other group has reported performing a TKR in association with TTOI (TKR+TTOI). We report the outcomes of nine patients who had TKR+TTOI, followed for an average 6.5 years. Materials & Methods. Our osseointegration registry was retrospectively reviewed to identify all patients who had TTOI and who also had TKR, performed at least two years prior. Four patients had TKR first the TTOI, four patients had simultaneous TKR+TTOI, and one patient had 1 OI first then TKR. All constructs were in continuity from hinged TKR to the prosthetic limb. Outcomes were: complications prompting surgical intervention, and changes in daily prosthesis wear hours, Questionnaire for Persons with a Transfemoral Amputation (QTFA), and Short Form 36 (SF36). All patients had clinical follow-up, but two patients did not have complete survey and mobility tests at both time periods. Results. Six (67%) were male, average age 51.2±14.7 years. All primary amputations were performed to manage traumatic injury or its sequelae. No patients died. Five patients (56%) developed infection leading to eventual transfemoral amputation 36.0±15.3 months later, and 1 patient had a single debridement six years after TTOI with no additional surgery in the subsequent two years. All patients who had transfemoral amputation elected for and received transfemoral osseointegration, and no infections occurred, although one patient sustained a periprosthetic fracture which was managed with internal fixation and implant retention and walks independently. The proportion of patients who wore their prosthesis at least 8 hours daily was 5/9=56%, versus 7/9=78% (p=.620). Even after proximal level amputation, the QTFA scores improved versus prior to TKR+TTOI, although not significantly: Global (45.2±20.3 vs 66.7±27.6, p=.179), Problem (39.8±19.8 vs 21.5±16.8, p=.205), Mobility (54.8±28.1 vs 67.7±25.0, p=.356). SF36 changes were also non-significant: Mental (58.6±7.0 vs 46.1±11.0, p=.068), Physical (34.3±6.1 vs 35.2±13.7, p=.904). Conclusions. TKR+TTOI presents a high risk for eventual infection prompting subsequent transfemoral amputation. Although none of these patients died, in general, TKR infection can lead to patient mortality. Given the exceptional benefit to preserving the knee joint to preserve amputee mobility and quality of life, it would be devastating to flatly force transtibial amputees with severe degenerative knee joint pain and unable to use a socket prosthesis to choose between TTOI but a painful knee, or preemptive transfemoral amputation for transfemoral osseointegration. Therefore, TTOI for patients who also request TKR must be considered cautiously. Given that this frequency of infection does not occur in patients who have total hip replacement in association with transfemoral osseointegration, the underlying issue may not be that linked joint replacement with osseointegrated limb replacement is incompatible, but may require further consideration of biological barriers to ascending infection and/or significant changes to implant design, surgical technique, or other yet-uncertain factors

Introduction. Acetabular revision surgery remains a technically demanding procedure with higher failure rates than primary total hip arthroplasty (THA). An acetabular component with three dimensional porous titanium and anatomic screw holes (Figure 1) was designed to allow the cup to be positioned anatomically and provide reliable fixation. Methods. A prospective multicenter study of 193 cases (190 patients) was conducted to assess the midterm clinical outcomes of the revision titanium acetabular shell. Radiographs, demographics, Harris Hip Score (HHS), and Short Form 36 (SF-36) were collected preoperatively, at 6 weeks, 3 months, and annually thereafter to 5 years. The mean duration of follow-up was 3.36 years. The Paprosky classification was assessed intraoperatively. Short Form 6D (SF-6D) utility values were obtained by transforming SF-36 scores through the Brazier method and were analyzed for effect size. Results. At time of surgery, mean patient age was 63.5 years and mean BMI was 28.1. 69 of the 193 cases were graded as 3A or 3B according to the Paprosky classification method. For all cases, Harris Hip Scores improved significantly (p < 0.001) from a preoperative mean score of 53.60 to a mean score of 86.15 at 1 year. These significant gains were maintained through 5 years, with a mean score of 87.35 at the 5-year time point. The Harris Hip Scores for Paprosky 3A and 3B cases also improved significantly (p < 0.001) from a preoperative mean score of 48.11 to a mean score of 85.45 at 1 year. These significant gains were maintained through 5 years, with a mean score of 85.65 at the 5-year time point. Among the radiographs independently reviewed to date, no cup migration or unstable cups have been identified. There were 12 acetabular shell re-revisions reported, for infection (7), aseptic loosening (4) and recurrent dislocation (1). Three of the cases revised for aseptic loosening were Paprosky type 3A, and one was 3B. For all cases, a clinically significant improvement in health utility was achieved by 3 months postoperative, with an effect size of 0.54. Clinically significant scores were maintained throughout the follow-up period, reaching an effect size of 0.64 at 5 years. Effect sizes were larger for cases with Paprosky classifications of 3A and 3B than the overall study population at all time points, reaching clinical significance at 3 months with an effect size of 0.64, and continuing to increase to an effect size of 1.19 at 5 years. Conclusion. Even in patients with severe acetabular defects, next generation highly porous acetabular components with three dimensional porous titanium and anatomic screw holes provide excellent stability, predictable midterm biologic fixation, pain, and reduction, and improved clinical function and health utility

The aim of our review was to assess (health related) quality of life ((HR)QoL) after one-stage or two-stage revision for prosthetic joint infection (PJI). Although it is generally accepted that staged revisions are very strenuous for patients, little is known about the (HR)QoL after these procedures. We compared (HR)QoL scores with normative population scores to assess the magnitude of this problem. Two authors performed a computerized systematic search in Embase, Cochrane and Pubmed. We included articles that reported: validated (HR)QoL questionnaires, one-stage or two-stage revision for PJI after total hip arthroplasty (THA), a minimum follow-up of 24 months and a minimum of ten patients. Methodological quality of all papers was assessed using the MINORS score. The systematic review was conducted according to the PRISMA statement. The search produced 11195 hits. After selection, based on title and abstract, 18 full text papers were reviewed. Six articles were excluded. Twelve papers were selected for final assessment. All papers described two-stage revisions. The mean MINORS score for these studies was 9.8, indicating moderate study quality. Seven articles reported WOMAC scores, with a total of 185 patients (74% response rate) having a mean general score of 73, with a mean follow-up of 65 months. The normative total WOMAC score for the general population (age 60–64) is 82.9, with a score of 100 being the best possible outcome. Four articles described Short Form 36 (SF-36) results on a total of 159 patients (71.9% response rate). In these studies the physical component score (PCS) of the SF-36 was on average 39.6 and the mental component score (MCS) was on average 50.9, with a mean follow-up of 41 months. Normative data for the US population (age 55–64) are a PCS of 47.2 and an MCS of 51.8. Four articles reported Short Form 12 (SF-12) scores on a total of 138 patients, with a mean PCS of 33.6 and a mean MCS of 51.7, with a mean follow up of 72.5 months. Normative data for the Dutch population (age 55–65) are a PCS of 48.3 and an MCS of 52.8. A score of 100 represents best possible health for both SF questionnaires. Patients that underwent two-stage revision for hip PJI have substantially lower (physical component) (HR)QoL scores, when compared to the general population

Background. The factors that are considered to be associated with successful clinical outcome fallowing cervical arthroplasty surgery are patient selection, absence of facet joint changes and lack of pre-operative kyphosis. Even though many studies have cited the pre-operative demographic details of their patient groups, the effect of associated psychological co-morbidities (Depression/Anxiety), smoking history, gender, social benefits and employment status on the clinical outcome measures have not been reported. The aim of the study was to assess the influence of pre-operative patient characteristics on the clinical outcomes following cervical disc replacement. Methods. We included 126 patients who underwent single or multiple level cervical arthroplasty in our unit were included in the study. The clinical outcome measures such as Visual Analogue Score for neck pain (VAS-NP) and arm pain (VAS-AP); Neck disability Index (NDI), Hospital depression and anxiety scale and Bodily pain component of Short Form 36 questionnaires (SF-36 P) were recorded pre and post operatively. Statistical analysis was completed using SPSS 16.0 statistical package (SPSS Inc, Chicago, IL). Results. There were 60 males and 63 females. Average duration of follow up was 18 months (Range 10–51). Out of 123 patients, 37 patients had a history of anxiety/depression, 25 patients gave history of smoking, 64 were actively working at the time of operation and 27 were receiving social benefits. We have found that gender; smoking status, associated co-morbidities, working and benefit status had no statistically significant contribution to clinical outcome measures in the follow up period. Conclusion. This is has been a first ever attempt to analyse the affect these psychosocial factors on the clinical outcomes following cervical arthroplasty. In our study, contrary to studies related lumbar surgeries, we conclude that there is no statistically significant contribution of associated psychosocial factors on the clinical outcomes in the early follow up period

Introduction. In the last decade, single level cervical arthroplasty has proven its efficacy as one of the surgical treatment option for for patients suffering from cervical degenerative disc disease. Recent published reports on multilevel cervical arthroplasty using single implants have shown statistically significant results when compared to single level surgery. The aim of this study is to compare the clinical outcomes of multilevel cervical arthroplasty to single level cervical arthroplasty, when more than one type of implants were used. Methods. This is a prospective study of consecutive patients who presented to our unit in between June 2006 and November 2009. The maximum follow-up period was 51 months (mean=18 months). Several types of cervical arthroplasty devices have been used in this study. The clinical outcome measures such as Visual Analogue Score for neck pain (VAS-NP) and arm pain (VAS-AP); Neck disability Index (NDI) and the Bodily pain component of Short Form 36 questionnaires were recorded pre and post operatively. After confirming the normality of the data appropriate parametric (paired t-test) were used to assess the statistical significance (p< 0.05) between pre and post-operative values. Two sample T-test was used to assess the significance between the differences in mean scores between each group. Results. A total of 105 patients (37 single level, 68 multi-level) were included in the study. Mean age of patients was 51 years (Range 32–80) with Male: Female ratio of 9:10. All clinical outcome measures showed statistically significant improvement in the post-operative period in single as well as multilevel group. However, there was no statistically significant difference in the improvement in between single and multilevel surgeries. Conclusions. Our study results clearly demonstrate that multilevel cervical arthroplasty offers the similar clinical outcome when compared to single level surgery, despite using different type of implant in multilevel surgeries

Objective. To evaluate the effect of claiming compensation on health status for people with mild to moderate injuries sustained in road traffic collisions (RTC). Methods. The design was a prospective cohort study in the Australian Capital Territory (ACT), Australia and a fault based compensation system. The subjects were people with mild to moderate musculoskeletal injuries who presented to the emergency department within 7 days of an RTC. Outcome Measures were Physical Component Score (PCS) and Mental Component Score (MCS) of the Short Form 36 (SF-36) health status measure; Hospital Anxiety and Depression Scale (HADS); and the Functional Rating Index (FRI). These measures were recorded immediately RTC, and at 6 and 12 months. Results. Ninety-five people were enrolled a mean of 8.6 days following RTC; 86% were followed up at 12 months. Mean age was 37 years; 61% were female; and 91% were employed at the time of injury. Compensation was claimed by 33% of enrolled subjects, and 25% engaged a lawyer. There were no significant differences in patient demographics or injury-related factors between the groups. As expected, passengers and people involved in multiple vehicle crashes more frequently claimed compensation. At each time-point, claiming compensation resulted in significantly worse scores for SF-36 PCS (-5.5 (95%CI -8.6 to -2.4), p = 0.001), HADS Anxiety (1.7 (95%CI 0.17 to 3.3), p = 0.048), and FRI (11.2 (95%CI 3.9 to 18.5), p = 0.003). For both groups, health status improved at the same rate, with significant improvement between baseline and 6 months, but no further improvement between 6 and 12 months. Conclusion. Claiming compensation had a significant negative effect on health status following mild to moderate musculoskeletal injuries sustained in RTC. However, whether this negative effect was due to claiming compensation itself or the presence of other unmeasured factors cannot be determined

Purpose. To determine whether there is a difference in the metal ion levels among three different metal-on-metal total hip systems: two monoblock large heads and one modular metal-on-metal total hip replacement system in patients who received these implants in our region. Method. A group of 56 patients were recruited that had either undergone total hip replacement (THR) with a Birmingham resurfacing socket, the Durom resurfacing socket, or a Pinnacle metal-on-metal bearing surface. All patients recruited were at least one year following their surgery in order that their ion levels had reached a steady state. We reviewed every patient clinically, radiographically as well as biochemically. Blood was obtained for cobalt (Co) and chromium (Cr) levels. Current radiographs were arranged to assess the stability and mechanics of the total hip systems. All patients signed an informed consent and completed three questionnaires, The Western Ontario and McMaster Universities (WOMAC) index, the Short Form 36 (SF36) and UCLA activity score. A Harris Hip score was completed in order to assess individual hip function. Statistical analysis was performed on the collected data to assess whether there were any other potential influence on the mean levels of Co and Cr. Results. The blood metal ion levels in the larger non modular acetabular sockets were significantly raised compared to the Pinnacle group. For Co, 1.95 parts per billion (ppb) and 2.70 ppb in the Durom and Birmingham groups respectively compared to only 0.52 ppb in the Pinnacle group (P< 0.001). Cr levels were the same in the two monoblock systems, 1.9 ppb compared to the Pinnacle sockets 1.2 ppb (P<0.001). In all groups however these levels were within an acceptable safe range. The mean head size used in the Birmingham group was 53.2mm (Range 44mm to 56mm), and in the Durom group, 47.1 (Range 42 to 54mm). The mean head size used in the modular group was 37.3mm (Range 36–44mm). There was no difference between the three groups in terms of functional outcome and patient demographics were similar in all three groups. There was no statistical difference between the groups in terms of anteversion and abduction angles. There was also a smaller spread in this group in terms of range of angles. There was also no relationship between these values and the metal ion levels. Conclusion. All three total hip systems demonstrated average metal ion whole blood levels in a safe range. Larger diameter metal on metal bearings had higher ion levels

The primary objective of implanting a total knee prosthesis is to release the patient from pain and to improve the joint mobility at the same time. This leads to an increased quality of life that is optimally kept for the patient's residual lifespan. Joint mobility and stability requires an intra-operative soft-tissue balancing. To reach the goal of a correct implant positioning and well-balanced ligaments two different operative procedures can be used: the so-called “Femur-first”-technique and the “Tibia-first” technique. Since now more than ten years the CT-free navigation is established as a routine procedure in TKA. Studies investigating this innovative technique have shown to lead to a higher precision regarding implant positioning and leg alignment. The present study compares navigated “Femur-first”-technique and “ Tibia-first”-technique. We hypothesised that, due to its better soft-tissue balance, the tibia first technique (T) would allow a flexion improvement of 10° compared to the femur first technique (F). Between February 21, 2008, and October 10, 2009, 116 consecutive patients were implanted a Columbus® non-constrained total knee replacement (Aesculap®, Tuttlingen, Germany) using navigation; they were examined before the operation and 1 year after. The TKAs were performed by 3 surgeons experienced in knee replacement surgery. We used the femur first technique (F) in 63 patients, the tibia first technique (T) in 53 patients. We performed the final flexion measurement one year after the operation using a Goniometer and evaluated standing full-length radiographs. In addition, we took standard varus and valgus stress radiographs to evaluate the stability of the collateral ligaments and determine the relative position of the implants to one another. Finally, to compare the two patient groups, we used the following pain and function scores: Knee Society Score (KSS), Oxford Score, Knee Injury and Osteoarthritic Outcome Score (KOOS), Short Form 36 (SF 36), Tegner Lysholm Score. Concerning maximal flexion as the main parameter, we did not find any significant difference between the F and T groups (maximal flexion in group F: 113.4± 9,8° and in group T: 113.5± 8.4°; p = 0.963); thus we could not confirm our hypothesis. Radiological evaluation of the stability of the collateral ligaments did not reveal any significant difference between the two groups both in the medial and lateral joint cavity (lateral collateral ligament in group F: 3.4± 1.4°, and in group T: 3.9± 1.7°; p = 0.850, and medial collateral ligament in group F: 4.0± 1.4°, and in group T: 4.1± 1.7°; p = 0.086). Concerning the mechanical axis on the standing full-length radiograph as part of the 1-year results, no significant difference was found between the two groups (p = 0.089). Likewise, the pain and function scores did not show any difference between the two groups. Concerning operating time (OP time) and outliers exceeding 3° of varus/valgus deviation from the ideal mechanical axis, trends were identifiable. The number of outliers tended to be higher in the F group, the OP time in group T seemed longer. As a conclusion, we can say that both the tibia first and the femur first techniques yield good clinical and radiological results in combination with navigation. In terms of function and patient satisfaction, we did not find any significant difference