Introduction. The obesity epidemic is a growing problem and must be considered with the projected increased demand for total hip arthroplasty (THA). Previous studies have reported increased complication rates after THA in the obese population, which has led to hesitation in offering surgery to this population. Moreover, some insurers are denying coverage for morbidly obese patients. While many consider obesity a “modifiable” risk factor, very few patients with advanced osteoarthritis have successfully lost substantial weight. The experience of centers that utilize systematic preoperative risk stratification tools and standardized postoperative total joint pathways may be underrepresented in prior studies. The aim of this study is to describe one surgeon's experience performing THA in morbidly and super-obese patient populations using an institutional preoperative Risk Stratification Tool (RST) and total joints pathway. Methods. We conducted a retrospective review of patients undergoing primary THA between May 2014 and December 2017 performed by a single surgeon at a tertiary care referral center. All patients were assessed preoperatively using an institutional RST and had a minimum of 90-day postoperative follow up. Patients were stratified by body mass index (BMI, kg/m. 2. ): non-obese (BMI < 30), obese (30–34), severely obese (35–39), morbidly obese (40–44), and super-obese (≥ 45). Primary outcomes were inpatient and 90-day complications. Continuous and binary parameters were analyzed by Kruskal-Wallis and Fisher exact tests. Logistic regression was additionally utilized to evaluate outcomes by BMI cohort. Results. A consecutive series of 368 patients met inclusion criteria across all BMI cohorts. There was significant variation with respect to age (P=0.001), BMI (P<0.001), diabetes (P=0.008), ASA class (P<0.001), and anesthesia type (P=0.003) (Table 1). Variation among BMI cohorts was also identified for several operative and postoperative parameters, including longer operative and in-room time and greater length of stay (P<0.001) (Table 2). Compared to non-obese patients, super-obese patients had 20.1 greater odds of return to OR within 90 days for superficial surgical site infection (SSI) or prolonged round drainage (P=0.008) (Table 3). Notably, morbidly and super-obese patients were not at significantly increased risk for inpatient intensive care unit (ICU) transfer, blood transfusion, 90-day emergency room visit, or 90-day readmission compared to their non-obese counterparts. For patients in whom 1-year follow-up was available, these differences between BMI cohorts remained insignificant. Conclusions. Patients with BMI>40 are more likely than non-obese patients to have increased postoperative rehabilitation needs but are not at increased risk for in-hospital complications. Super-obese patients have greater risk of superficial SSI or prolonged wound drainage than non-obese patients but are not at increased risk for revision or deep infection in any cohort. Use of a preoperative RST may help to mitigate postoperative complications and readmissions previously associated with morbid and super-obesity. We conclude that THA can be safely performed in super-obese patients and therefore care should not be denied to this population. Summary sentence. Total hip arthroplasty (THA) can be safely performed in morbidly and super-obese patients with the use of a preoperative risk stratification tool (RST) and total joints pathway. For any tables or figures, please contact the authors directly

Aims. The prevalence of obesity is increasing substantially around the world. Elevated BMI increases the risk of complications following total hip arthroplasty (THA). We sought to evaluate trends in BMI and complication rates of obese patients undergoing primary THA over the last 30 years. Methods. Through our institutional total joint registry, we identified 15,455 primary THAs performed for osteoarthritis from 1990 to 2019. Patients were categorized according to the World Health Organization (WHO) obesity classification and groups were trended over time. Cox proportional hazards regression analysis controlling for confounders was used to investigate the association between year of surgery and two-year risk of any reoperation, any revision, dislocation, periprosthetic joint infection (PJI), venous thromboembolism (VTE), and periprosthetic fracture. Regression was stratified by three separate groups: non-obese; WHO Class I and Class II (BMI 30 to 39 kg/m. 2. ); and WHO Class III patients (BMI ≥ 40 kg/m. 2. ). Results. There was a significant increase in the proportion of all obesity classes from 1990 to 2019, and the BMI values within each WHO class significantly increased over time. Risk of any reoperation did not change over time among non-obese or WHO Class I/II patients, but increased for WHO Class III patients (hazard ratio (HR) 1.04; p = 0.044). Risk of dislocation decreased over time for non-obese (HR 0.96; p < 0.001) and WHO Class I/II (HR 0.96; p = 0.002) patients, but did not change over time for WHO Class III (HR 0.94; p = 0.073) patients. Risks of any revision and PJI did not change over time for any group. Conclusion. The proportion of patients undergoing THA who are obese has increased dramatically at our institution between 1990 and 2019. Despite BMI values increasing within all WHO classes over time, two-year complication risks have remained stable or decreased in WHO Class I/II patients. However, continued efforts will be required to mitigate risks in the heaviest WHO Class III patients. Cite this article: Bone Joint J 2024;106-B(11):1223–1230

Majority of ultra-high molecular weight polyethylene (UHMWPE) medical devices used in total joint arthroplasty are crosslinked using gamma radiation to improve wear resistance. Alternative methods of crosslinking are urgently needed to replace gamma radiation due to rapid decline in its supply. Peroxide crosslinking is a candidate method with widespread industrial applications. Oxidative stability and biocompatibility, which are critical requirements for medical device applications, can be achieved using vitamin-E as an additive and by removing peroxide by-products through high temperature melting, respectively. We investigated compression molded UHMWPE/vitamin-E/di-cumyl peroxide blends followed by high-temperature melting in inert gas as a material candidate for tibial knee inserts. Wear resistance increased and mechanical properties remained largely unchanged. Oxidation induction time was higher than most of the other clinically available formulations. The material passed the local-end point biocompatibility tests per ISO 10993. Compounds found in exhaustive extraction were of no concern with margin-of-safety values well above the accepted level, indicating a desirable toxicological risk profile. Peroxide crosslinked, vitamin-E stabilized, and high temperature melted UHMWPE has recently been cleared for clinical use in tibial knee inserts. With all the salient characteristics needed in a material that can provide superior long-term performance in total joint patients, peroxide crosslinking can replace gamma radiation crosslinking of UHMWPE for use in all total joint replacement implant including acetabular liners

Arthroplasties are widely performed to improve mobility and quality of life for symptomatic knee/hip osteoarthritis patients. With increasing rates of Total Joint Replacements in the United Kingdom, predicting length of stay is vital for hospitals to control costs, manage resources, and prevent postoperative complications. A longer Length of stay has been shown to negatively affect the quality of care, outcomes and patient satisfaction. Thus, predicting LOS enables us to make full use of medical resources. Clinical characteristics were retrospectively collected from 1,303 patients who received TKA and THR. A total of 21 variables were included, to develop predictive models for LOS by multiple machine learning (ML) algorithms, including Random Forest Classifier (RFC), K-Nearest Neighbour (KNN), Extreme Gradient Boost (XgBoost), and Na¯ve Bayes (NB). These models were evaluated by the receiver operating characteristic (ROC) curve for predictive performance. A feature selection approach was used to identify optimal predictive factors. Based on the ROC of Training result, XgBoost algorithm was selected to be applied to the Test set. The areas under the ROC curve (AUCs) of the 4 models ranged from 0.730 to 0.966, where higher AUC values generally indicate better predictive performance. All the ML-based models performed better than conventional statistical methods in ROC curves. The XgBoost algorithm with 21 variables was identified as the best predictive model. The feature selection indicated the top six predictors: Age, Operation Duration, Primary Procedure, BMI, creatinine and Month of Surgery. By analysing clinical characteristics, it is feasible to develop ML-based models for the preoperative prediction of LOS for patients who received TKA and THR, and the XgBoost algorithm performed the best, in terms of accuracy of predictive performance. As this model was originally crafted at Ashford and St. Peters Hospital, we have naturally named it as THE ASHFORD OUTCOME

Angular proximal femoral deformities increase the technical complexity of primary total hip arthroplasties (THAs). The goals were to determine the long-term implant survivorship, risk factors, complications, and clinical outcomes of contemporary primary THAs in this difficult cohort. Our institutional total joint registry was used to identify 119 primary THAs performed in 109 patients with an angular proximal femoral deformity between 1997 and 2017. The deformity was related to previous femoral osteotomy in 85%, and developmental or metabolic disorders in 15%. 53% had a predominantly varus angular deformity. The mean age was 44 years, mean BMI was 29 kg/m. 2. , and 59% were female. An uncemented metaphyseal fixation stem was used in 30%, an uncemented diaphyseal fixation stem in 28%, an uncemented modular body stem with metaphyseal fixation sleeve in 24%, and a cemented stem in 18%. Simultaneous corrective femoral osteotomy was performed in 18%. Kaplan-Meier survivorships and Harris hip scores were reported. Mean follow-up was 8 years. The 10-year survivorships free of femoral loosening, aseptic femoral revision, any revision, and any reoperation were 95%, 93%, 90% and 88%, respectively. Revisions occurred in 13 hips for: aseptic femoral component loosening (3), stem fracture (2), dislocation (2), aseptic acetabular loosening (2), polyethylene liner exchange (2), and infection (2). Preoperative varus angular deformities were associated with a higher risk of any revision (HR 10, p=0.03), and simultaneous osteotomies with a higher risk of any reoperation (HR 3.6, p=0.02). Mean Harris hip scores improved from 52 preoperatively to 82 at 10 years (p<0.001). In the largest series to date of primary THAs in patients with angular proximal femoral deformities, we found a good 10-year survivorship free from any revision. Varus angular deformities, particularly those treated with a simultaneous osteotomy due to the magnitude or location of the deformity, had a higher reoperation rate. Keywords: Proximal femoral deformity; dysplasia; femoral osteotomy; survivorship; revision. Level of evidence: Level III, comparative retrospective cohort

The last two decades have seen remarkable technological advances in total hip arthroplasty (THA) implant design. Porous ingrowth surfaces and highly crosslinked polyethylene (HXLPE) have been expected to dramatically improve implant survivorship. The purpose of the present study was to evaluate survival of contemporary cementless acetabular components following primary THA. 16,421 primary THAs performed for osteoarthritis between 2000 and 2019 were identified from our institutional total joint registry. Patients received one of 12 contemporary cementless acetabular designs with HXLPE liners. Components were grouped based on ingrowth surface into 4 categories: porous titanium (n=10,952, mean follow-up 5 years), porous tantalum (n=1223, mean follow-up 5 years), metal mesh (n=2680, mean follow-up 6.5 years), and hydroxyapatite (HA) coated (n=1566, mean follow-up 2.4 years). Kaplan-Meier analyses were performed to assess the survivorship free of acetabular revision. A historical series of 182 Harris-Galante-1 (HG-1) acetabular components was used as reference. The 15-year survivorship free of acetabular revision was >97% for all 4 contemporary cohorts. Compared to historical control, porous titanium (HR 0.06, 95% CI 0.02–0.17, p<0.001), porous tantalum (HR 0.09, 95%CI 0.03–0.29, p<0.001), metal mesh (HR 0.11, 95%CI 0.04–0.31, p<0.001), and HA-coated (HR 0.14, 95%CI 0.04–0.48, p=0.002) ingrowth surfaces had significantly lower risk of any acetabular revision. There were 16 cases (0.1%) of acetabular aseptic loosening that occurred in 8 (0.07%) porous titanium, 5 (0.2%) metal mesh, and 3 (0.2%) HA-coated acetabular components. 7 of the 8 porous titanium aseptic loosening cases occurred in one known problematic design. There were no cases of aseptic loosening in the porous tantalum group. Modern acetabular ingrowth surfaces and HXLPE liners have improved on historical results at the mid-term. Contemporary designs have extraordinarily high revision-free survivorship, and aseptic loosening is now a rare complication. At mid-term follow-up, survivorship of contemporary uncemented acetabular components is excellent and aseptic loosening occurs in a very small minority of patients

Aims

Dislocation remains a leading cause of failure following revision total hip arthroplasty (THA). While dual-mobility (DM) bearings have been shown to mitigate this risk, options are limited when retaining or implanting an uncemented shell without modular DM options. In these circumstances, a monoblock DM cup, designed for cementing, can be cemented into an uncemented acetabular shell. The goal of this study was to describe the implant survival, complications, and radiological outcomes of this construct.

Aims

Contemporary outcomes of primary total hip arthroplasties (THAs) with highly cross-linked polyethylene (HXLPE) liners in patients with inflammatory arthritis have not been well studied. This study examined the implant survivorship, complications, radiological results, and clinical outcomes of THA in patients with inflammatory arthritis.

Introduction. Patient demand for hip and knee arthroplasty continues to rise. Information sources providing data on the volume and cost of Medicare total joint arthroplasty by hospital are of use to patients and healthcare professionals. Data have demonstrated that higher volume surgeons are associated with lower cost, morbidity, and mortality. The current study assesses if the same is true for hospitals. Methods. The Limited Data Set (LDS) from the Centers for Medicare and Medicaid (CMS) were used for this study. All elective, DRG 470 Total Hip Arthroplasties (THA) reported by CMS from the first quarter of 2013 through the second quarter of 2016 were included. Volume and part A Medicare payments over a 90-day period for the 20 highest volume hospitals in the US were analyzed. Cost associated with initial hospital stay and post discharge skilled nursing, home health, long term acute care, inpatient rehabilitation facilities, and readmission was aggregated and analyzed. For each episode, demographic information (age, sex, and race), geographic location, and Elixhauser comorbidities were calculated to control for major confounding factors in the regression. Results. For the 20 highest volume centers in the US, total joint volume for CMS insured patients varied from 1104 to 5069. Average cost varied from $16,974 to $22,094. For the 20 highest volume cities in the US, total joint volume for CMS insured patients varied from 1,501 to 6,727. Average Medicare part A payment varied from $14,255 to $21,125. Readmission % varied from 3.9% to 8.2%. 90-day mortality varied from 0.0% to 0.57%. DISCUSSION AND CONCLUSION. The variation in volume between the top 20 centers in the US varies by more than a factor of 4 with the highest volume hospital having almost twice the volume as the second highest hospital. Part A payments, readmissions, and mortality also varied widely. Within the top 20 hospitals by volume, there does not appear to be a correlation between volume and cost

Aims

Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors.

Background. Uncemented dual-tapered stems are a popular choice for primary total hip arthroplasty (THA). The purpose of this study was to examine long-term outcomes after primary THA utilizing a single dual-tapered stem. Patients and Methods. Utilizing our total joint registry, we retrospectively identified 1215 THAs (1055 patients) performed with an uncemented dual-tapered stem from 1998 to 2009. Mean age was 55 years, 70% were male, and mean BMI was 30 kg/m. 2. Mean follow-up was 10 years. Analysis included implant survivorship, clinical outcomes, and radiographic results. Results. Survivorship from stem revision for any reason was 99.0% at 5 years postoperatively and 98.4% at both 10 and 15 years. Survivorship from stem revision for aseptic loosening was 99.9% at 5-, 10-, and 15-years postoperatively. Survivorship from stem revision for periprosthetic fracture was 99.7%, 99.1%, and 98.9% at 5, 10, and 15 years postoperatively, respectively. In total, 18 (1.5%) stems underwent revision. Revisions were performed for periprosthetic fracture (10, 0.82%), infection (7, 0.58%), and aseptic loosening (1, 0.08%). Intraoperative fracture occurred in 58 (4.77%) THAs treated with cerclage wiring (52, 89.66%) or no treatment (6, 10.34%) and insertion of a standard prosthesis. At mean radiographic follow-up of 10 years, only 4 of 1084 (0.37%) stems with 1-year radiographic follow-up had any radiolucency around the proximal ongrowth coating, and only 1 (0.10%) of these had a circumferential radiolucent line (Gruen zones 1–14). Conclusions. This uncemented dual-tapered femoral stem is associated with excellent survivorship, reasonably low intraoperative fracture rate, and extremely low rates of revision for aseptic loosening, periprosthetic fracture, and infection when used for primary THA at long-term follow up. For any tables or figures, please contact the authors directly

Aims

The Forgotten Joint Score-12 (FJS-12) is a validated patient-reported outcome measure (PROM) tool designed to assess artificial prosthesis awareness during daily activities following total hip arthroplasty (THA). The patient-acceptable symptom state (PASS) is the minimum cut-off value that corresponds to a patient’s satisfactory state-of-health. Despite the validity and reliability of the FJS-12 having been previously demonstrated, the PASS has yet to be clearly defined. This study aims to define the PASS of the FJS-12 following primary THA.

Aims

Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA.

Introduction. There is renewed interest in dislocation after surgical approach with popularization of the direct anterior approach. The purported advantage of both the lateral and direct anterior approaches is decreased risk of dislocation. The purpose of this study was to assess the risk of dislocation by approach following modern primary THA. Methods. All primary THAs at a single academic institution from 2010 to 2017 were analyzed through our institutional total joint registry. There were 7023 THAs including 3754 posterior, 1732 lateral, and 1537 direct anterior. Risk of dislocation was assessed against the competing risks of revision surgery and death as well as by individual patient and surgical factors including surgical approach. Risk of revision surgery was considered as a secondary outcome. Step-wise selection was utilized to develop multivariable models. Clinical outcomes were documented with the Harris Hip Score (HHS). Mean age was 63 years, 51% were female, and mean body mass index (BMI) was 30 kg/m. 2. Minimum follow-up was 2 years. Results. The cumulative incidence of dislocation at 1-year and 5-years by approach was as follows: posterior (2.1%; 3.0%), lateral (0.7%; 0.7%), direct anterior (0.4%; 0.4%) (p<0.001) (Figure 1). Compared to the posterior cohort, the adjusted risk of dislocation was decreased for the lateral (hazard ratio [HR]=0.28, p<0.001) and direct anterior cohorts (HR=0.18, p<0.001). The cumulative incidence of revision for instability at 1-year and 5-years by approach was as follows: posterior (0.8%; 1.0%), lateral (0.6%; 0.6%), direct anterior (0%; 0%) (p=0.09). The adjusted risk of all-cause revision surgery was increased among the lateral cohort compared to posterior (HR=1.75, p=0.003) and direct anterior (HR=2.44, p=0.002) and among patients with diagnoses other than osteoarthritis (HR=2.89, p<0.001). Among patients who dislocated, 69 (83%) had anteversion >25° (Figure 2). Mean increase in HHS from preoperative assessment to final follow-up was greatest among direct anterior patients (37 points), followed by posterior patients (33 points), followed by lateral patients (29 points) (p<0.05, all comparisons). Conclusions. This study documents the risk of dislocation by surgical approach among a large contemporary cohort undergoing primary THA. The risk of dislocation was higher following the posterior approach, whereas all-cause revision surgery was found to be higher following the lateral approach. For any tables or figures, please contact the authors directly

Aims

Septic arthritis of the hip often leads to irreversible osteoarthritis (OA) and the requirement for total hip arthroplasty (THA). The aim of this study was to report the mid-term risk of any infection, periprosthetic joint infection (PJI), aseptic revision, and reoperation in patients with a past history of septic arthritis who underwent THA, compared with a control group of patients who underwent THA for OA.

Introduction. The infection rate after total joint arthroplasty (TJA) has been shown to be 1–2% in multiple series and registry data. Irrigation, debridement, and polyethylene exchange (IDPE) is a common first line treatment in many cases of acute prosthetic joint infection (PJI). The reinfection rate in open IDPE procedures is variable with studies showing reinfection rates of 10–70% depending on various patient and microbial factors. Our pilot study aimed to determine if the bacterial load in infected total joints was sufficiently reduced by IDPE to allow for the use of post-debridement cultures as an independent marker of procedural success. Methods. 46 prosthetic joint infections underwent irrigation and debridement using 6L of normal saline and 3L of a normal saline and bacitracin mixture prior to the insertion of a new polyethylene liner. This protocol utilized a single equipment setup with all surgical members donning new gloves prior to polyethylene exchange. Between 3 and 5 intraoperative cultures were obtained both prior to and after debridement as per the surgeon's standard protocol. A two-tailed student's t-test was used to evaluate for any differences in the rate of positive culture between these two groups. Results. Of all pre- and post-debridement cultures sampled 66.5% and 60.7% of cultures were positive respectively. No significant difference in the rate of positive intraoperative culture was found between pre-debridement and post-debridement groups (p = 0.52). In 32 of 46 (69%) cases there was no difference in the total number of positive cultures despite a thorough debridement. Conclusions. Our data shows that open debridement of PJI does not provide a sterile environment, and post-debridement cultures should not be used as an independent marker of procedural success. The role of an irrigation and debridement to reduce the bacterial burden and potentiate the clearance of an infection is established but its efficacy is unclear, and the inability to create a post-debridement sterile environment is a concern

Introduction. Historically, the most common indications for re-revision of a total hip arthroplasty (THA) have been aseptic loosening, instability, infection, and peri-prosthetic fracture. As revision implants and techniques have evolved and improved, understanding why contemporary revision THAs fail is important to direct further improvement and innovation. As such, the goals of this study were to determine the implant survivorship of contemporary revision THAs, as well as the most common indications for re-revision. Methods. We retrospectively reviewed 2568 aseptic revision THAs completed at our academic institution between 2005 and 2015 through our total joint registry. There were 34% isolated acetabular revisions, 18% isolated femoral revisions, 28% both component revisions, and 20% modular component exchanges. The mean age at index revision THA was 66 years, and 46% were males. The most common indications for the index revision THA were aseptic loosening (21% acetabular, 15% femoral, 5% both components), polyethylene wear and osteolysis (18%), instability (13%), fracture (11%), and other (17%). Mean follow-up was 6 years. Results. There were 211 re-revision THAs during the study period in this cohort. The overall survivorship free of any re-revision at 2, 5, and 10 years was 94%, 92%, and 88%, respectively. The most common reasons for re-revision were hip instability (52%), peri-prosthetic fracture (11%), femoral aseptic loosening (10%), acetabular aseptic loosening (8%), infection (6%), polyethylene wear (3%), and other (10%). A pre-revision diagnosis of instability had the worst survivorship free of revision at 10 years (79%). Conclusion. Compared to historical series, the 88% survivorship free of any re-revision at 10 years in a difficult revision cohort is notably improved. As implant fixation has improved, aseptic loosening has become much less common after revision THA, and instability has come to account for more than half of re-revisions. Methods to further mitigate this risk may be emphasized during index revision THA

The infection rate after total joint arthroplasty (TJA) has been shown to be 1–2% in multiple series and registry data. Irrigation, debridement, and polyethylene exchange (IDPE) is a common first line treatment in many cases of acute prosthetic joint infection (PJI). The reinfection rate in open IDPE procedures is variable with studies showing reinfection rates of 10–70% depending on various patient and microbial factors. Our pilot study aimed to determine if the bacterial load in infected total joints was sufficiently reduced by IDPE to allow for the use of post-debridement cultures as an independent marker of procedural success. 46 prosthetic joint infections underwent irrigation and debridement using 6L of normal saline and 3L of a normal saline and bacitracin mixture prior to the insertion of a new polyethylene liner. This protocol utilized a single equipment setup with all surgical members donning new gloves prior to polyethylene exchange. Between 3 and 5 intraoperative cultures were obtained both prior to and after debridement as per the surgeon's standard protocol. A two-tailed student's t-test was used to evaluate for any differences in the rate of positive culture between these two groups. Of all pre- and post-debridement cultures sampled 66.5% and 60.7% of cultures were positive respectively. No significant difference in the rate of positive intraoperative culture was found between pre-debridement and post-debridement groups (p = 0.52). In 32 of 46 (69%) cases there was no difference in the total number of positive cultures despite a thorough debridement. Our data shows that open debridement of PJI does not provide a sterile environment, and post-debridement cultures should not be used as an independent marker of procedural success. The role of an irrigation and debridement to reduce the bacterial burden and potentiate the clearance of an infection is established but its efficacy is unclear, and the inability to create a post-debridement sterile environment is a concern

Highly porous tantalum cups have been used in complex acetabular revisions for nearly 20 years but reports of long term results are limited. This study was designed to report ten year results of revision using a single porous tantalum cup design with special attention to re-operation for any reason, all-cause revision, and revision for aseptic loosening. Retrospective review of all revision THA cases performed from 1999–2006 using a highly porous tantalum acetabular component design with multiple screw holes and a cemented polyethylene liner (Zimmer Biomet, Warsaw, IN). Our institutional medical record and total joint registry were used to assess follow-up and xrays were reviewed. The Paprosky classification system was used to rate acetabular bone loss. Radiographic loosening was defined as new/progressive radiolucencies in all 3 acetabular zones, or cup migration (>2mm). Kaplan-Meier survivorship was used to assess survivorship free of cup revision/removal for any reason, and free of revision for aseptic loosening. Between 1999 and 2006 this tantalum cup was used in 916 revisions. Mean age: 66 (±6), BMI: 29 (±6), and male: 42%. Indications for revision: aseptic loosening 346 (38%), osteolysis 240 (26%), and infected arthroplasty 168 (18%). Large (3A or 3B) bone defects were present in 260, and pelvic discontinuity in 61. Reoperation for any reason: 133 (15%), but 84 of 133 cases did not require cup revision for instability (38) or femoral failure (24). Tantalum cup removal/revision was required in 49 (5.3%) for deep infection (39) and recurrent dislocation (6), and aseptic loosening (4). 10 year survivorship free of cup revision for any reason: 95% and for aseptic loosening: 99%. Radiographic review (mean 10 years): suspicious for aseptic loosening in another 4 cups. A highly porous tantalum acetabular component with multiple screws and a cemented polyethylene insert provided durable long term fixation for an array of acetabular revision problems. Long term aseptic loosening was very rare (<1%) and cup removal was mainly related to deep infection, and rarely dislocation

Aims

Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method.