Revision hip arthroplasty presents a challenge in the setting of femoral bone loss. Tapered stems are susceptible to subsidence which leads to leg length inequality, hip instability and may necessitate repeat femoral revision surgery. The purpose of this study was to compare radiographic outcomes in two modular tapered revision systems with different distal stem geometries. We sought to establish the minimum postoperative stem bi-cortical contact length that predicts subsidence for tapered stems. This study examined revision total hip arthroplasties between 2009 and 2016 in a European university affiliated major trauma center. Modular stem A has a taper of 3 degrees whereas modular stem B has a taper of 2 degrees. Radiologic assessment compared x-rays at two time points: immediately post-surgery and most recent x-ray available at a minimum follow up of two years. Leg length discrepancy, subsidence and postoperative bi cortical contact was assessed. Descriptive summary statistics calculated clinical factors (i.e. age, gender, Paprosky classification). 122 arthroplasties were completed. Complete data was available for 112. Revisions were carried out for Paprovski grade 3a/ 3b femoral deficits. Post-operative bi-cortical contact of the proximal stem < 20mm was associated with higher subsidence rates (P = 0.047). Subsidence rates for implant A and B system were 4.27mm (0.12–25.62mm) and 3.43 mm (0.3–11.1 mm) respectively. Significant subsidence was noted in 9.8% (n=8) in implant A and 5.2%(n=2) in implant B. We conclude that immediate postoperative bi-cortical stem contact of <20mm was associated with significantly higher subsidence rates in this study

Aim of this study was to identify reoperation rates in patients with short oblique and transverse fractures around a well fixed cemented polished taper slip stem and to determine any associations with treatment failure.

Retrospective cohort study of 31 patients with AO transverse or short oblique Vancouver B1 PFFs around THA (total hip arthroplasty) cemented taper slip stems: 12 male (39%); mean age 74±11.9 (range 44–91); mean BMI 28.5±1.4 (range 16–48); and median ASA 3. Patient journeys were assessed, re-interventions reviewed. The primary outcome measure was reoperation.

Time from primary THA to fracture was 11.3±7.8yrs (0.5–26yrs). Primary surgical management was fixation in 27/31 and rTHA (revision total hip arthroplasty) in 4/31. 10 of 31 (32%) patients required reoperation, 9 within 2 years of fracture: 1 following rTHA and 8 following ORIF. The commonest mode of failure was non-union (n=6). No significant associations with reoperation requirement were identified. Kaplan-Meier free from reoperation was 67.4% (49.8–85.0 95% CI) at 2 years and this was unaffected by initial management with ORIF or rTHA (Log rank 0.898). Of those reoperated, 6/10 required multiple reoperations to obtain either bony union or a stable revision construct and 13% ultimately required proximal femoral endoprostheses. The relative risk of 1 year mortality was 1.6 (0.25 to 10.1 95%CI) among patients who required reoperation compared to those who did not.

These are difficult fractures to manage, should not be underestimated and patients should be counselled that there is a 30% risk of reoperation and 20% of requiring multiple reoperations.

The aim of the study was to report the survival of open reduction and internal fixation (ORIF) of Vancouver B fractures associated with the Exeter Stem (ES) at a minimum of 5 years.

This retrospective cohort study assessed 129 consecutive patients with Vancouver B type fractures treated with ORIF from 2008-2016 at a minimum of 5 years. Patient records were examined, and the following recorded: details of primary prosthesis, details of injury, Vancouver classification, details of operative management, complications, and requirement for reoperation. Data was analysed using SPSS. Survival analysis was undertaken using the endpoint ‘reoperation for any reason’.

Mean age at fracture was 78.2 (SD10.6, 46-96) and 54 (43%) were female. Vancouver subclassifications were: 24% B1, 70.5% B2 and 5.5% B3. For all Vancouver B fractures, Kaplan Meier analysis demonstrated a 5 year survival free from reoperation of 88.8% (82.0-94.7 95%CI). Fourteen patients required reoperation, most commonly within the first year for non-union and plate fracture (5.4%). Five-year survival for any reoperation differed significantly according to fracture type (p=0.016) and was worst in B1s: B1 76.6% (61.3-91.9); B2 92.6% 986.9-98.3); and 100% of B3. Univariate analysis identified B1 type (p=0.008) and a transverse fracture pattern (p=0.003) to be significantly associated with the need for reoperation.

Adopting a strategy of fixation of all Vancouver B fractures involving the ES where the fracture was anatomically reducible and the bone cement interface was well-fixed was associated with a 5 year survival, free from reoperation of 88.8%.

To investigate predictors of periprosthetic fracture level (around stem (Vancouver B) or distal to stem (Vancouver C/D) in cemented polished tapered femoral stems.

Retrospective cohort study of 188 patients (mean age 79 (range 30–91); 99 (53%) male) with unilateral periprosthetic femoral fractures associated with CPT stems. Medical notes were reviewed and the following recorded: patient demographics, past medical history, drug history, date of prosthesis insertion, and date of injury. Radiographs analysis included Vancouver classification, cement restrictor type, cement mantle to implant tip distance, cortical thickness, femoral diameter and DORR classification. Univariate, multivariate and ROC curve analysis was performed.

Fractures occurred at mean 7.5 years following primary procedure: 152 (83%) were B fractures; and 36 (19%) C/D. On univariate analysis female gender, lower BMI, osteoporosis, NSAID use, Bisphosphonate therapy, cortical thickness, distal cement mantle length and distal cement mantle length:femoral diameter ratio were significantly associated with C level fractures (p<0.05). Distal cement mantle lengths of >19.6mm (AUC 0.688, p<0.001) were associate with C level fractures. Multivariate analysis demonstrated female gender and distal cement mantle length:femoral diameter ratio to be independent predictors of C level periprosthetic fractures.

Though female sex is the largest independent predictor of periprosthetic fractures distal to a CPT femoral stem, the relationship between cortical thickness and distal cement mantle length appears significant. As fractures distal to the stem are invariably managed by ORIF, whereas fractures around the stem frequently require revision arthroplasty, this has relevance at primary surgery in osteoporotic females to reduce the need for complex revisions.

We present our results of cementless total hip arthroplasty with a tapered, rectangular stem made of titanium-aluminum-niobium alloy. This implant is used since 1979 with only minor modifications. The design of the femoral component achieves primary stability through precision rasping and press-fit implantation.

Between October 1986 and November 1987, two hundred consecutive patients (208 hips) underwent total hip arthroplasty with this tapered, rectangular stem. In all cases the acetabular component was a threaded cup made of titanium.

At a minimum follow-up of twenty years eighty-seven patients were still alive. Sixty-seven patients (69 hips) were available for clinical and radiographic follow-up. The probability of survival of the stem was 0.96 (95% confidence interval, 0.91 to 0.98) and that of the cup was 0.72 (0.62 to 0.80). The probability of survival of both the stem and the acetabular component with revision for any reason as the end point was 0.71 (0.61 to 0.78).

Two stems have been revised due to aseptic loosening. We found various degrees of osteolysis around the acetabular and femoral component (61,7%). At the time of the 20-year follow-up no stem was deemed at risk for loosening.

The key findings of our twenty-year follow-up are the very low rate of revisions of the femoral component and the low rate of distal femoral osteolysis associated with this stem. Our data show that femoral fixation of the stem continues to be secure at a follow-up of twenty years.

Introduction

Total Hip Arthroplasty (THA) in patients after proximal femoral osteotomy remains a major challenge. Inferior survival for both cementless and cemented THA has been reported in this subgroup of patients.

Introduction

Modern cementless press fit stems rely on early fixation and stability for osteointegration and longterm success with early migration increasing the risk of failure. The Ein Bild Roentegen Analyse Femoral Component Analysis (EBRA-FCA) methods allow accurate measurement of femoral stem subsidence without the need for Tantalum markers. The degree of subsidence of femoral stems in the first two years has been shown to be highly predictive of failure when using the cut off value of 1.5 mm. We aimed to measure the early migration pattern of a titanium alloy, tapered, plasma and hydroxyapatite coated femoral stem and any factors associated with subsidence.

Introduction

The origins of the uncemented tapered wedge hip stem design currently offered by several orthopaedic device companies can be linked back to the cemented Straight Mueller type stem design first used in 1977. The design, a wedge shape with a taper angle of 6 degrees, maintains a single medial curvature for all sizes and increases laterally in the width to accommodate different size femurs. Although evolutionary improvements have been made over the years the basic body geometry of the stem has stayed mainly unchanged with excellent clinical survivorship. Over the past decade, the demographics of hip replacement have changed, with a large increase in younger male patients in the age range of 40 to 60 years. In this study the femoral fit of a novel tapered stem, designed to fit a wide array of patient types, is compared to a standard predicate tapered stem design.

Vancouver B fractures around a cemented polished tapered stem (CTPS) are often treated with revision arthroplasty. Results of osteosynthesis in these fractures are poor as per current literature. However, the available literature does not distinguish between fractures around CTPS from those around other stems.

The aim of our study was to assess the clinical and radiological outcome of open reduction and internal fixation in Vancouver B fractures around CTPS using a broad non-locking plate.

Patients treated with osteosynthesis between January 1997 and July 2011 were retrospectively reviewed. All underwent direct reduction and stabilisation using cerclage wires before definitive fixation with a broad DCP. Bicortical screw fixation was obtained in the proximal and distal fragments. We defined failure of treatment as revision for any cause.

101 patients (42 men and 59 women, mean age 79) were included. 70 had minimum follow-up of 6 months. 63 of these went on to clinical and radiological union. Three developed infected non-union. 7 had failure of fixation. Lack of anatomical reduction was the commonest predictor of failure followed by inadequate proximal fragment fixation and infection. 14 patients dropped at least 1 mobility grade from their preoperative status.

This is the largest series of a very specific group of periprosthetic fractures treated with osteosynthesis. Patients who develop these fractures are often frail and “high risk” for major revision surgery. We recommend osteosynthesis for patients with Vancouver B periprosthetic fractures around CTPS provided these fractures can be anatomically reduced and adequately fixed.