Despite considerable legacy issues, Girdlestone's Resection Arthroplasty (GRA) remains a valuable tool in the armoury of the arthroplasty surgeon. When reserved for massive lysis in the context of extensive medical comorbidities which preclude staged or significant surgical interventions, and / or the presence of pelvic discontinuity, GRA as a salvage procedure can have satisfactory outcomes. These outcomes include infection control, pain control and post-op function. We describe a case series of 13 cases of GRA and comment of the indications, peri, and post-operative outcomes.

We reviewed all cases of GRA performed in our unit during an 8 year period, reviewing the demographics, indications, and information pertaining to previous surgeries, and post op outcome for each. Satisfaction was based on a binary summation (happy/unhappy) of the patients’ sentiments at the post-operative outpatient consultations.

13 cases were reviewed. They had a mean age of 75. The most common indication was PJI, with 10 cases having this indication. The other three cases were performed for avascular necrosis, pelvic osteonecrosis secondary to radiation therapy and end stage arthritis on a background of profound learning disability in a non-ambulatory patient. The average number of previous operations was 5 (1-10). All 13 patients were still alive post girdlestone. 7 (54%) were satisfied, 6 were not. 3 patients were diabetic. 5 patients developed a sinus tract following surgery.

With sufficient pre-op patient education, early intensive physiotherapy, and timely orthotic input, we feel this procedure remains an important and underrated and even compassionate option in the context of massive lysis and / or the presence of pelvic discontinuity / refractory PJI. GRA should be considered not a marker of failure but as a definitive procedure that gives predictability to patients and surgeon in challenging situations.

Studies on the migration of an implant may be the only way of monitoring the early performance of metal-on-metal prostheses. The Ein Bild Roentgen Analyse - femoral component analysis (EBRA-FCA) method was adapted to measure migration of the femoral component in a metal-on-metal surface arthroplasty of the hip using standard antero-posterior radiographs. In order to determine the accuracy and precision of this method a prosthesis was implanted into cadaver bones. Eleven series of radiographs were used to perform a zero-migration study. After adjustment of the femoral component to simulate migration of 3 mm the radiographs were repeated. All were measured independently by three different observers. The accuracy of the method was found to be ± 1.6 mm for the x-direction and ± 2 mm for the y-direction (95% percentile). The method was validated using 28 hips with a minimum follow-up of 3.5 years after arthroplasty. Seventeen were sound, but 11 had failed because of loosening of the femoral component. The normal (control) group had a different pattern of migration compared with that of the loose group. At 29.2 months, the control group showed a mean migration of 1.62 mm and 1.05 mm compared with 4.39 mm and 4.05 mm in the failed group, for the centre of the head and the tip of the stem, respectively (p = 0.001). In the failed group, the mean time to migration greater than 2 mm was earlier than the onset of clinical symptoms or radiological evidence of failure, 19.1 versus 32.2 months (p = 0.001) and 24.8 months (p = 0.012), respectively. EBRA-FCA is a reliable and valid tool for measuring migration of the femoral component after surface arthroplasty and can be used to predict early failure of the implant. It may be of value in determining the long-term performance of surface arthroplasty

Administration of perioperative antibiotic prophylaxis (AP) reduces the risk of prosthetic joint infection (PJI) following primary total hip (THA) and knee (TKA) arthroplasty. The optimal type of antibiotic used, and duration of prophylaxis are subject to debate. We compared the risk of revision surgery for PJI in the first year following THA and TKA by AP regimen. A national survey collecting information on hospital-level AP regimen policy was conducted across the Netherlands and linked to data from the LROI arthroplasty registry for 2011–2015. PJI status was defined using the surgical indication reported at revision by surgeons in the registry form. Restricted cubic splines Poisson model adjusted for hospital clustering were used to conduct the comparisons on 130,712 THAs and 111,467 TKAs performed across 99 institutions. These included 399 THAs and 303 TKAs revised for an indication of PJI. Multiple shot of Cefazolin (MCZ), of cefuroxime (MCX) and single shot of Cefazolin (SCZ) were respectively administrated to 87%, 4% and 9% of patients. For THA, the rates of revision for PJI were respectively 31/10,000 person-years 95%CI[28, 35], 39[25, 59] and 23[15, 34] in the groups which received MCZ, MCX and SCZ; respectively, the rates for TKA were 27[24, 31], 40[24, 62] and 24[16, 36]. No evidence of difference between AP regimens was found in the unadjusted and adjusted model (age, gender, BMI and ASA grade). Further work is advocated to confirm whether there is an association between AP regimen collected at patient-level and the risk of subsequent revision for PJI.

Finite element analysis was used to examine the initial stability after hip resurfacing and the effect of the procedure on the contact mechanics at the articulating surfaces. Models were created with the components positioned anatomically and loaded physiologically through major muscle forces. Total micromovement of less than 10 μm was predicted for the press-fit acetabular components models, much below the 50 μm limit required to encourage osseointegration. Relatively high compressive acetabular and contact stresses were observed in these models. The press-fit procedure showed a moderate influence on the contact mechanics at the bearing surfaces, but produced marked deformation of the acetabular components. No edge contact was predicted for the acetabular components studied.

It is concluded that the frictional compressive stresses generated by the 1 mm to 2 mm interference-fit acetabular components, together with the minimal micromovement, would provide adequate stability for the implant, at least in the immediate post-operative situation.

This edition of Cochrane Corner looks at some of the work published by the Cochrane Collaboration, covering pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic, and long bone fractures; interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews; and pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews

Abstract. There are numerous advantages of discharging patients early after any surgery. Day case arthroplasty in hip and knee is already brought into practice at many centres. We present our journey towards discharging elective shoulder arthroplasty patient on same after their surgery. An initial retrospective study of patients who underwent elective shoulder replacement between 2017 and 2020 were studied. It was identified that a selected group of patients could be discharged on the same of their surgery. The criteria to select a patient for this service was laid down that include ASA 1 or 2, good family support on discharge, personal wishes of patients and early identification of potential patients in the clinic and planning for day case shoulder arthroplasty56 consecutive patients underwent elective arthroplasty of shoulder. Among them 22 patients were discharges on the next day of surgery. The potential patients those could discharged on same were identified to be 11 out of 22 were under ASA 2 and had good family support at home on discharge. Average length of stay after surgery was 2.17 days. We have prospectively discharged 2 patients following the new criteria. This study demonstrates how outpatient elective shoulder could be implemented at other centres. Patient participation and selection with proper planning is key for success here. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Background. Fractures of the femoral neck occurring outside the capsule of the hip joint are assumed to have an intact blood supply and hence their conventional management is by fixation rather than arthroplasty. The dynamic hip screw and its variants have been used over many years to fix such fractures but have inherent vulnerabilities; they require an intact lateral femoral cortex, confer a relatively long moment arm to the redistribution of body weight and may cause a stress riser due to the plate with which they are fixed to the femur. Intramedullary devices for fixation of proximal femoral fractures have a shorter moment arm, can be distally locked with reduced perforation of the femoral cortex and are believed to be inherently more stable. For these reasons, a number of surgeons believe them to be superior to the DHS for all extracapsular fractures and their use is now widespread. In this study, we present the usage trends of both devices in extracapsular fractures over the last five years and set these results in the context of patient demographics. Methods. Our departmental electronic patient management system was used to identify all patients undergoing surgery coded as either DHS or its variants or intramedullary fixation of hip fracture. The patients’ age, sex and American Society of Anaesthesiologists grading were recorded. Comparison between groups was made using appropriate tests in SPSS. Results. Our unit has seen a steady move towards the use of intramedullary fixation of extracapsular fractures over five years, from 28.2% to 45.2% of operations, without a change in demographics of the population or a change in surgical outcomes at the most basic level. Conclusion. The move towards intramedullary fixation without evidence of improved outcomes, given the significantly higher cost, requires urgent research. Level of Evidence. IV

Introduction. seeking full compliance with the Tissue Sparing Surgery principles, we introduced this new surgical approach to the coxa-femoral joint via the medial inguinal region. Patients/Materials and Methods. we performed total hip arthroplasty on 20 patients suffering from hip arthritis while 15 cases of medial femoral fracture received hemiarthroplasty with bipolar prostheses implants. Results. reduced surgery times, lower blood loss, zero complications and significantly speedier recovery were observed in all the above cases. Discussion/ Conclusion. this new surgical approach we devised enables a quick, safe and easy replacement of the hip. The muscles of the hip remain totally unharmed; maximum exposure is gained, with visualization of the acetabulum, directly fronting the surgeon, at its very best, favourably comparing with any other known approach. No particular equipment is needed and no special operating table. And it does not in the least imply a steep learning curve. Dislocation risks are non-existent allowing the patient any position in bed immediately after surgery. It is aesthetically preferable, the scar remaining almost invisible in between the inguinal skin lines. The patient can at once resume a steady walk, Canadian crutches being needed only for the first few days. It is the authors' opinion that such a technique, thanks to its being safe, fast, economical and easy to replicate, results in undoubted benefits for the patient, not least because it requires much shorter and far easier rehabilitation; and it can be counted as a valid alternative for surgeons to the most common approaches currently in use

Osteoarthritis (OA) is a prevalent, age-related joint disease, characterized by diverse progressive changes in articular cartilage and subchondral bone. Disease management is severely hampered by the absence of tools to classify patients based on underlying disease mechanisms. For that matter, increased BMI is a known risk factor for OA in the weight bearing knee joint, but also for hand OA. 1. The increased risk for OA is therefore thought to be influenced by systemic factors accompanying BMI. It was hypothesized that differences in metabolic state could be underlying OA phenotypes. In the current study we set out to explore the potential role of a large range of metabolites in blood as sensitive biomarker of OA. Plasma samples were taken from the Rotterdam Study, CHECK-, GARP/NORREF- and the LUMC-arthroplasty cohorts. OA was defined as having had arthroplasty for primary OA, stratified per location (any, hip or knee). In total 647 persons with Total Joint Arthroplasty (TJA) were included and 2125 persons were considered as controls (i.e. they had a Kellgrenn-Lawrence Score of <2 indicating no radiographic OA was present) in any of the studied joints. A total of 231 different metabolites were assessed by using the BrainShake NMR platform. Since parts of the metabolites were highly correlated, we used Principal Component Analyses (PCA) to reduce the data. 23 factors were identified, accounting for 91,4% of the variance in the data. Logistic regression models were applied to investigate the identified factors for their association to arthroplasty for primary OA, independent of age, sex, BMI and cholesterol-lowering medication (statins). The models showed two different factors robustly associated to arthroplasty as result of primary OA. A table represents the associations of these factors to arthroplasty adjusted for age, sex and BMI, as the information on statin-use was not known for all subjects. Analyses showed that additional correction for statins did not change the results. When stratifying the arthroplasty phenotypes for joint location, factor 11, characterized by e.g. linoleic acid, was found to be associated to arthroplasty in the hip (THA). Similarly, Factor 22, representing saturated fatty acids and degree of unsaturation, was consistently associated with arthroplasty, independent of the site. When analyzing the metabolites involved in the factors individually these associations were confirmed for most contributors of the factors, except the ratio of saturated fatty acids to total fatty acids. Our preliminary analyses showed that persons with arthroplasty for primary OA compared to controls have different values for factors composed for fatty acids. The identification of groups of fatty acid metabolites as being connected to OA phenotypes indicates an inflammation driven pathway which might give a better understanding of the mechanisms behind OA

We investigated the antibiotic concentration in fresh-frozen femoral head allografts harvested from two groups of living donors. Ten samples were collected from patients with osteoarthritis of the hip and ten from those with a fracture of the neck of the femur scheduled for primary arthroplasty. Cefazolin (1 g) was administered as a pre-operative prophylactic antibiotic. After storage at −80°C for two weeks the pattern of release of cefazolin from morsellised femoral heads was evaluated by an in vitro broth elution assay using high-performance liquid chromatography. The bioactivity of the bone was further determined with an agar disc diffusion and standardised tube dilution bioassay. The results indicated that the fresh-frozen femoral heads contained cefazolin. The morsellised bone released cefazolin for up to four days. The concentration of cefazolin was significantly higher in the heads from patients with osteoarthritis of the hip than in those with a fracture. Also, in bioassays the bone showed inhibitory effects against bacteria. We concluded that allografts of morsellised bone from the femoral head harvested from patients undergoing arthroplasty of the hip contained cefazolin, which had been administered pre-operatively and they exhibited inhibitory effects against bacteria in vitro

We report the survival, functional and radiological outcome of a series of Birmingham hip resurfacing procedures performed by a single surgeon at a district general hospital. The aim of this study was to retrospectively report the medium term outcome and survival of our patients. There were 45 hip resurfacings performed in 38 patients between 2004 and 2010. Patients were followed for a mean duration of four years. Mean age of 52.6 years (range 26 to 65). Although no patients were lost to follow up, four did not complete the oxford hip scoring assessment. The median Oxford hip score was 16.25 points (range 12–39 points, standard deviation 5.9) at 48 months follow up (range 11.5–84.2 months). The mean acetabular inclination was 46.9 (range 40.9–59.9) in the 45 hip resurfacings post operatively. There was one patient with varus subsidence of the prosthesis and one patient with persistent hip pain post operatively under investigation currently. There was no definite radiological evidence of loosening or of narrowing of the femoral neck. No cases were revised and no cases developed any other complications. These medium-term results from a district general hospital are comparable to the other studies performed. Few independent studies have reported the outcome of resurfacing arthroplasty of the hip in a district general hospital. Further evaluation and follow up of these patients is required to address the concerns raised by other centers related to fracture and metal debris

Bone surface strains were measured in cadaver femora during loading prior to and after resurfacing of the hip and total hip replacement using an uncemented, tapered femoral component. In vitro loading simulated the single-leg stance phase during walking. Strains were measured on the medial and the lateral sides of the proximal aspect and the mid-diaphysis of the femur. Bone surface strains following femoral resurfacing were similar to those in the native femur, except for proximal shear strains, which were significantly less than those in the native femur. Proximomedial strains following total hip replacement were significantly less than those in the native and the resurfaced femur. These results are consistent with previous clinical evidence of bone loss after total hip replacement, and provide support for claims of bone preservation after resurfacing arthroplasty of the hip

Summary Statement. The chemistry, amount, morphology, and size distribution of wear debris from silicon nitride coatings generated in the bearing surface can potentially reduce the negative biological response and increase the longevity compared to conventional materials in joint replacements. Introduction. Total hip implants have a high success rate at 15 years of implantation, but few survive over 25 years. At present, revisions are mostly due to aseptic loosening, believed to mainly be caused by the biological response to wear debris generated in the joint bearing. For the polymer liners the size of the wear debris determines the biological response, while for metal bearing surfaces a limitation is the metal ion release. When ceramics are used, the wear debris is in general small and mechanical factors may be the main cause for failure. A more recent, experimental alternative is to let the well-known metallic substrate serve as the soft, tough bulk, and additionally apply a hard and smooth ceramic coating. In this way a lower wear rate and reduced metal ion release could be obtained. Furthermore, the chosen composition, silicon nitride (SixNy), contains no detrimental ions, and silicon nitride debris has been shown to slowly dissolve in aqueous medium. Altogether, it can potentially increase the longevity of the implant. However, the debris from SixNy coatings has not yet been characterised. In this study, a wear model test was performed to generate wear debris from SixNy coatings. The debris was characterised using scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDS) in combination with computational calculations. Methods. Silicon nitride coatings deposited on flat cobalt chromium alloy (ASTM F75) were worn in a reciprocating ball on disc setup in a 25% serum solution at 37°C against an alumina ball with a load of 1.5 N. Wear debris was separated using serum digestion with hydrochloric acid (ISO 17853:2011) and examined in SEM in combination with EDS. As reference polyethylene (PE) was used to verify that relevant particles sizes were achieved. The SEM images were processed using a modified MATLAB-script originating from Cervera Gontard et al. [1], identifying the particles and calculating their size. Results. Particles generated from SixNy coatings (n=62) a size distribution D50 [D10-D90] of 0.29 µm [0.16–0.69] and were round to oval in shape. The PE particles (n=70) had a size distribution of 0.29 µm [0.13–1.3], shaped similar to the SixNy particles or with a more elongated shape. Discussion and conclusions. PE wear debris has been reported to lie in the size range of nm up to several μm in vivo, with a large proportion within the critical size for macrophage activation (0.2 to 0.8 μm). The model test reports relevant sizes and shape of PE debris, confirming the validity of the method. Particles generated from the SixNy coatings showed a smaller size range than PE, however most particles were within the critical size range for biological activation. In conclusion, this model test could be used to generate what we believe are relevant sizes and shapes of PE and SixNy wear debris and to learn more at an early stage of prediction of wear debris. Further dissolution studies as well as studies on the in vitro and in vivo cell response to these types of particles will be performed. The authors thank the Swedish Foundation for Strategic Research (SSF) through MS2E and FP7 NMP project LifeLongJoints for financial support, as well as Linköping University for the coating facilities and expertise

Infection rates following arthroplasty surgery are between 1–4%, with higher rates in revision surgery. The associated costs of treating infected arthroplasty cases are considerable, with significantly worse functional outcomes reported. New methods of infection prevention are required. HINS-light is a novel blue light inactivation technology which kills bacteria through a photodynamic process. The aim of this study was to investigate the efficacy of HINS-light for the inactivation of bacteria isolated from infected arthroplasty cases. Specimens from hip and knee arthroplasty infections are routinely collected to identify causative organisms. This study tested a range of these isolates for sensitivity to HINS-light. During testing, bacterial suspensions were exposed to increasing doses of HINS-light of (123 mW/cm. 2. irradiance). Non-light exposed control samples were also set-up. Bacterial samples were then plated onto agar plates and incubated at 37°C for 24 hours before enumeration. Complete inactivation (greater than a 4-log reduction) was achieved for all of the clinical isolates from infected arthroplasty cases. The typical inactivation curve showed a slow initial reaction followed by a period of rapid inactivation. The doses of HINS-light exposure required ranged from 118–2214 J/cm. 2. respectively. Gram-positive bacteria were generally found to be more susceptible than Gram-negative. This study has demonstrated that HINS-light successfully inactivated all clinical isolates from infected arthroplasty cases. As HINS-light utilises visible-light wavelengths it can be safely used in the presence of patients and staff. This unique feature could lead to possible applications such as use as an infection prevention tool during surgery and post-operative dressing changes

Aims

The intra-articular administration of tranexamic acid (TXA) has been shown to be effective in reducing blood loss in unicompartmental knee arthroplasty and anterior cruciate reconstruction. The effects on human articular cartilage, however, remains unknown. Our aim, in this study, was to investigate any detrimental effect of TXA on chondrocytes, and to establish if there was a safe dose for its use in clinical practice. The hypothesis was that TXA would cause a dose-dependent damage to human articular cartilage.

Objectives

Osteophytes are products of active endochondral and intramembranous ossification, and therefore could theoretically provide significant efficacy as bone grafts. In this study, we compared the bone mineralisation effectiveness of osteophytes and cancellous bone, including their effects on secretion of growth factors and anabolic effects on osteoblasts.

Aims

Osteoporosis and abnormal bone metabolism may prove to be significant factors influencing the outcome of arthroplasty surgery, predisposing to complications of aseptic loosening and peri-prosthetic fracture. We aimed to investigate baseline bone mineral density (BMD) and bone turnover in patients about to undergo arthroplasty of the hip and knee.

The cortical strains on the femoral neck and proximal femur were measured before and after implantation of a resurfacing femoral component in 13 femurs from human cadavers. These were loaded into a hip simulator for single-leg stance and stair-climbing. After resurfacing, the mean tensile strain increased by 15% (95% confidence interval (CI) 6 to 24, p = 0.003) on the lateral femoral neck and the mean compressive strain increased by 11% (95% CI 5 to 17, p = 0.002) on the medial femoral neck during stimulation of single-leg stance. On the proximal femur the deformation pattern remained similar to that of the unoperated femurs.

The small increase of strains in the neck area alone would probably not be sufficient to cause fracture of the neck However, with patient-related and surgical factors these strain changes may contribute to the risk of early periprosthetic fracture.

The effects of the method of fixation and interface conditions on the biomechanics of the femoral component of the Birmingham hip resurfacing arthroplasty were examined using a highly detailed three-dimensional computer model of the hip. Stresses and strains in the proximal femur were compared for the natural femur and for the femur resurfaced with the Birmingham hip resurfacing. A comparison of cemented versus uncemented fixation showed no advantage of either with regard to bone loading. When the Birmingham hip resurfacing femoral component was fixed to bone, proximal femoral stresses and strains were non-physiological. Bone resorption was predicted in the inferomedial and superolateral bone within the Birmingham hip resurfacing shell. Resorption was limited to the superolateral region when the stem was not fixed. The increased bone strain observed adjacent to the distal stem should stimulate an increase in bone density at that location. The remodelling of bone seen during revision of failed Birmingham hip resurfacing implants appears to be consistent with the predictions of our finite element analysis.