Introduction. Varus alignment of the femoral component in total hip arthroplasty (THA) is thought to be a risk factor for implant loosening and early revision surgery. The purpose of this study was to evaluate whether the Exeter stem tolerates varus alignment and assess if this theoretical malalignment has an influence on clinical outcomes. Methods. A total of 4126 consecutive THAs were reviewed for patients between 2006 and 2012 to allow for a minimum five-year follow-up. To determine the effects of the stem alignment on results, the hips were classified into 3 groups on the basis of stem alignment in initial postoperative anteroposterior radiographs. The alignment of the stem was defined as neutral, valgus (≥ 3° of lateral deviation), or varus (≥ 3° of medial deviation). The primary outcome was all cause revision with patient related outcomes assessed with Oxford hip score pre and post-operatively. Results. The mean follow-up period was 8.6 years. 3803 (92.2%), 48 (1.2%), and 275 (6.7%) hips were assessed as neutral, valgus, and varus alignment, respectively. Assessment of outcomes showed that 75 revision surgeries (1.8%) were performed during follow-up for a variety of causes but there was no significant difference in the revision rate among the 3 alignment groups. No stems were revised for aseptic loosening in any of the three groups. Oxford Hip scores were obtained at a mean of 4.6 years post-operatively and no significant difference in patient reported outcome was identified between the different alignment groups. Conclusion. This study suggests that the Exeter stem tolerates varus alignment well with no demonstrable effect on revision rate or patient reported outcome. This tolerance of malposition compared to the negative results reported in the literature with other stem designs can be of reassurance to surgeons using the Exeter system

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

Aims. The diversity of femoral morphology renders femoral component sizing in total hip arthroplasty (THA) challenging. We aimed to determine whether femoral morphology and femoral component filling influence early clinical and radiological outcomes following THA using fully hydroxyapatite (HA)-coated femoral components. Methods. We retrospectively reviewed records of 183 primary uncemented THAs. Femoral morphology, including Dorr classification, canal bone ratio (CBR), canal flare index (CFI), and canal-calcar ratio (CCR), were calculated on preoperative radiographs. The canal fill ratio (CFR) was calculated at different levels relative to the lesser trochanter (LT) using immediate postoperative radiographs: P1, 2 cm above LT; P2, at LT; P3, 2 cm below LT; and D1, 7 cm below LT. At two years, radiological femoral component osseointegration was evaluated using the Engh score, and hip function using the Postel Merle d’Aubigné (PMA) and Oxford Hip Score (OHS). Results. CFR was moderately correlated with CCR at P1 (r = 0.44; p < 0.001), P2 (r = 0.53; p < 0.001), and CFI at P1 (r = − 0.56; p < 0.001). Absence of spot welds (n = 3, 2%) was associated with lower CCR (p = 0.049), greater CFI (p = 0.017), and lower CFR at P3 (p = 0.015). Migration (n = 9, 7%) was associated with lower CFR at P2 (p = 0.028) and P3 (p = 0.007). Varus malalignment (n = 7, 5%), predominantly in Dorr A femurs (p = 0.028), was associated with lower CFR at all levels (p < 0.05). Absence of spot welds was associated with lower PMA gait (p = 0.012) and migration with worse OHS (p = 0.032). Conclusion. This study revealed that femurs with insufficient proximal filling tend to have less favourable radiological outcomes following uncemented THA using a fully HA-coated double-tapered femoral component. Cite this article: Bone Joint Res. 2020;9(4):182–191

Aims. The aim of this study was to determine the association between knee alignment and the vertical orientation of the femoral neck in relation to the floor. This could be clinically important because changes of femoral neck orientation might alter chondral joint contact zones and joint reaction forces, potentially inducing problems like pain in pre-existing chondral degeneration. Further, the femoral neck orientation influences the ischiofemoral space and a small ischiofemoral distance can lead to impingement. We hypothesized that a valgus knee alignment is associated with a more vertical orientation of the femoral neck in standing position, compared to a varus knee. We further hypothesized that realignment surgery around the knee alters the vertical orientation of the femoral neck. Methods. Long-leg standing radiographs of patients undergoing realignment surgery around the knee were used. The hip-knee-ankle angle (HKA) and the vertical orientation of the femoral neck in relation to the floor were measured, prior to surgery and after osteotomy-site-union. Linear regression was performed to determine the influence of knee alignment on the vertical orientation of the femoral neck. Results. The cohort included 147 patients who underwent knee realignment-surgery. The mean age was 51.5 years (SD 11). Overall, 106 patients underwent a valgisation-osteotomy, while 41 underwent varisation osteotomy. There was a significant association between the orientation of the knee and the coronal neck-orientation. In the varus group, the median orientation of the femoral neck was 46.5° (interquartile range (IQR) 49.7° to 50.0°), while in the valgus group, the orientation was 52.0° (IQR 46.5° to 56.7°; p < 0.001). Linear regression analysis revealed that HKA demonstrated a direct influence on the coronal neck-orientation (β = 0.5 (95% confidence interval (CI) 0.2 to 0.7); p = 0.002). Linear regression also showed that realignment surgery was associated with a significant influence on the change in the coronal femoral neck orientation (β = 5.6 (95% CI 1.5 to 9.8); p = 0.008). Conclusion. Varus or valgus knee alignment is associated with either a more horizontal or a more vertical femoral neck orientation in standing position, respectively. Subsequently, osteotomies around the knee alter the vertical orientation of the femoral neck. These aspects are of importance when planning osteotomies around the knee in order to appreciate the effects on the adjacent hip joint. The concept may be of even more relevance in dysplastic hips. Cite this article: Bone Jt Open 2021;2(12):1057–1061

Introduction. Cemented femoral fixation has been shown to carry a lower risk of peri-prosthetic fracture (PPF). The aim of this study was to determine whether adequate (1) stem position and (2) cement mantle (i.e. factors associated with outcome of cemented stems) can be achieved with the anterior approach as compared to the posterior approach. Methods. This is a prospective, multi-surgeon, single center, consecutive, case-matched series. Twenty patients/hips (age: 76±SD 14) that underwent cemented fixation of their femoral component via an anterior approach (AA) were matched with twenty hips that received the same cemented femoral components via the posterior approach by the same surgeons. Outcome measures of interest included Barrack classification (A, B, C or D), Coronal alignment defined as Varus (>5º), mild varus (3–5º), neutral, mild valgus (3–5º) and valgus (>5º) of the stem and sagittal component alignment defined as anterior to posterior, neutral, posterior to anterior (±3 degrees) and cement mantle thickness in all Gruen zones. Results. There was no difference between groups in the Barrack classification (DAA: A:12,B:7, D:1); (Posterior: A:13, B:7) [p=0.56]. Coronal alignment (DAA: 15 neutral, 5 mild varus/valgus); (Post:15 neutral, 3 mild varus/valgus, 2 valgus) [p=0.27] and sagittal alignment was similar between groups [p=0.07]. Cement mantle thickness per Gruen zone was also similar between groups in all zones with particular interest zones 8 [P=0.68] and 12 [p=0.3] confirming comparable sagittal cement mantle thickness. Conclusion. This study demonstrates that equivalent stem alignment and cement mantle quality can be achieved with both approaches. As such, patients undergoing the AA approach can benefit from a quick recovery and lower risk of peri-prosthetic femur fracture

Aims. The aim of this study was to identify patient- and surgery-related risk factors for sustaining an early periprosthetic fracture following primary total hip arthroplasty (THA) performed using a double-tapered cementless femoral component (Bi-Metric femoral stem; Biomet Inc., Warsaw, Indiana). Patients and Methods. A total of 1598 consecutive hips, in 1441 patients receiving primary THA between January 2010 and June 2015, were retrospectively identified. Level of pre-operative osteoarthritis, femoral Dorr type and cortical index were recorded. Varus/valgus placement of the stem and canal fill ratio were recorded post-operatively. Periprosthetic fractures were identified and classified according to the Vancouver classification. Regression analysis was performed to identify risk factors for early periprosthetic fracture. Results. The mean follow-up was 713 days (1 to 2058). A total of 48 periprosthetic fractures (3.0%) were identified during the follow-up and median time until fracture was 16 days, (interquartile range 10 to 31.5). Patients with femoral Dorr type C had a 5.2 times increased risk of post-operative periprosthetic fracture compared with type B, while female patients had a near significant two times increased risk over time for post-operative fracture. Conclusion. Dorr type C is an independent risk factor for early periprosthetic fracture, following THA using a double tapered cementless stem such as the Bi-Metric. Surgeons should take bone morphology into consideration when planning for primary THA and consider using cemented femoral components in female patients with poor bone quality. Cite this article: Bone Joint J 2017;99-B:451–7

Aims

The Exeter short stem was designed for patients with Dorr type A femora and short-term results are promising. The aim of this study was to evaluate the minimum five-year stem migration pattern of Exeter short stems in comparison with Exeter standard stems.

Introduction. Undersizing of an uncemented femoral stem is a post-operative description of a radiograph with unclear clinical importance. It may not always translate into a suboptimal clinical outcome. Aim. To describe a novel classification system of undersizing in a fully hydroxyapatite coated femoral implant, assess if it could be reliably reported between observers, and describe a simple way to assess the degree of undersizing on an AP radiograph. Methods. A retrospective review of 1000 consecutive total hip arthroplasties was conducted. Two investigators reviewed post-operative radiographs independently for stem undersizing. The data was tested for inter and intra-observer agreement using the Kappa method. Results. Undersizing was classified as:. Varus - Stem in contact proximally with medial calcar, and distally with lateral cortex. Valgus - Stem in contact proximally with lateral cortex, and distally with medial cortex. Uniform - Continuous margin around the stem of at least one-half tip width of the stem throughout. Champagne flute - Distal stem fills the narrow diaphysis with insufficient bony contact at the wide metaphysis. If varus or valgus undersizing was present we described the formation of two triangles of excess cancellous space around the implant, each having overlapping apices signifying undersizing by at least two sizes. 32% of the stems were undersized with Kappa demonstrating very good (89%) to good (86%) inter and intra observer agreement respectively. 50% of undersized stems were uniformly undersized, 36% were varus, 6% valgus, and 8% were in a champagne fluted shaped femur. A higher percentage of the lateralised (KLA) stems were undersized compared to other neck configurations (40%). 54% of these were varus undersized and this increased the offset up to 2cm. Conclusion. We describe a classification system for undersizing in hip arthroplasty. KLA stems have an increased tendency to be undersized in varus, thereby increasing the overall offset

Aims

Refobacin Bone Cement R and Palacos R + G bone cement were introduced to replace the original cement Refobacin Palacos R in 2005. Both cements were assumed to behave in a biomechanically similar fashion to the original cement. The primary aim of this study was to compare the migration of a polished triple-tapered femoral stem fixed with either Refobacin Bone Cement R or Palacos R + G bone cement. Repeated radiostereometric analysis was used to measure migration of the femoral head centre. The secondary aims were evaluation of cement mantle, stem positioning, and patient-reported outcome measures.

Aims

Although there are various pelvic osteotomies for acetabular dysplasia of the hip, shelf operations offer effective and minimally invasive osteotomy. Our study aimed to assess outcomes following modified Spitzy shelf acetabuloplasty.

Aims

Highly polished stems with force-closed design have shown satisfactory clinical results despite being related to relatively high early migration. It has been suggested that the minimal thickness of cement mantles surrounding the femoral stem should be 2 mm to 4 mm to avoid aseptic loosening. The line-to-line cementing technique of the femoral stem, designed to achieve stem press-fit, challenges this opinion. We compared the migration of a highly polished stem with force-closed design by standard and line-to-line cementing to investigate whether differences in early migration of the stems occur in a clinical study.

Aims

The aim of this study was to radiologically evaluate the quality of cement mantle and alignment achieved with a polished tapered cemented femoral stem inserted through the anterior approach and compared with the posterior approach.

Aims

Femoral bone preparation using compaction technique has been shown to preserve bone and improve implant fixation in animal models. No long-term clinical outcomes are available. There are no significant long-term differences between compaction and broaching techniques for primary total hip arthroplasty (THA) in terms of migration, clinical, and radiological outcomes.

Aims

The prevalence of combined abnormalities of femoral torsion (FT) and tibial torsion (TT) is unknown in patients with femoroacetabular impingement (FAI) and hip dysplasia. This study aimed to determine the prevalence of combined abnormalities of FT and TT, and which subgroups are associated with combined abnormalities of FT and TT.

Aims

The Exeter V40 cemented polished tapered stem system has demonstrated excellent long-term outcomes. This paper presents a systematic review of the existing literature and reports on a large case series comparing implant fractures between the Exeter V40 series; 125 mm and conventional length stem systems.

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Cement-in-cement revision of the femoral component represents a widely practised technique for a variety of indications in revision total hip arthroplasty. In this study, we compare the clinical and radiological outcomes of two polished tapered femoral components.

Objectives

Different criteria for assessing the reduction quality of trochanteric fractures have been reported. The Baumgaertner reduction quality criteria (BRQC) are relatively common and the Chang reduction quality criteria (CRQC) are relatively new. The objectives of the current study were to compare the reliability of the BRQC and CRQC in predicting mechanical complications and to investigate the clinical implications of the CRQC.

Aims

This study aimed to evaluate implant survival of reverse hybrid total hip arthroplasty (THA) at medium-term follow-up.

Aims

The classical longitudinal incision used for the direct anterior approach (DAA) to the hip does not follow the tension lines of the skin and can lead to impaired wound healing and poor cosmesis. The purpose of this retrospective study was to determine the satisfaction with the scar, and functional and radiographic outcomes comparing the classic longitudinal incision with a modified skin crease ‘bikini’ when the DAA is used for total hip arthroplasty (THA).

Aims

The widely used and well-proven Palacos R (a.k.a. Refobacin Palacos R) bone cement is no longer commercially available and was superseded by Refobacin bone cement R and Palacos R + G in 2005. However, the performance of these newly introduced bone cements have not been tested in a phased evidence-based manner, including roentgen stereophotogrammetric analysis (RSA).