Aims. We aimed to report the mid- to long-term rates of septic and aseptic failure after two-stage revision surgery for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). Methods. We retrospectively reviewed 96 cases which met the Musculoskeletal Infection Society criteria for PJI. The mean follow-up was 90 months (SD 32). Septic failure was assessed using a Delphi-based consensus definition. Any further surgery undertaken for aseptic mechanical causes was considered as aseptic failure. The cumulative incidence with competing risk analysis was used to predict the risk of septic failure. A regression model was used to evaluate factors associated with septic failure. The cumulative incidence of aseptic failure was also analyzed. Results. There were 23 septic failures at final follow-up, with a cumulative incidence of 14% (95% confidence interval (CI) 8% to 22%) at one year, 18% (95% CI 11% to 27%) at two years, 22% (95% CI 14% to 31%) at five years, and 23% (95% CI 15% to 33%) at ten years. Having at least one positive culture (hazard ratio (HR) 2.38 (interquartile range (IQR) 1.19 to 4.74); p = 0.013), or a positive intraoperative frozen section (HR 2.55 (IQR 1.06 to 6.15); p = 0.037) was significantly associated with septic failure after reimplantation. With dislocation being the most common cause of aseptic revision (5.2%), the cumulative incidence of aseptic failure was 1% (95% CI 0% to 5%) at one year, 6% (95% CI 1% to 8%) at five years, and 8% (95%CI 3% to 17%) at ten years. Conclusion. If there is no recurrent infection in the five years following reimplantation, the chances of further infection thereafter are remote. While the results of a frozen section may be a reliable guide to the timing of reimplantation, intraoperative culture has, currently, only prognostic value. Surgeons should be aware that instability remains a potential indication for further revision surgery. Cite this article: Bone Joint J 2021;103-B(1):79–86

A growing number of recent investigations on the human genome, gut microbiome, and proteomics suggests that the loss of mucosal barrier function, particularly in the gastrointestinal tract, may substantially affect antigen trafficking, ultimately influencing the close bidirectional interaction between the gut microbiome and the immune system. This cross-talk is highly influential in shaping the host immune system and ultimately clinical infections. The hypothesis of the current study was that a change in microbiome and/or breach in GI epithelial barrier could be partially responsible for development of periprosthetic joint infections (PJI). Multiple biomarkers of gut barrier disruption were tested in parallel in plasma samples collected as part of a prospective cohort study of patients undergoing revision arthroplasty for aseptic failures or PJI (As defined by the 2018 ICM criteria). All blood samples were collected before any antibiotic was administered. Samples were tested for Zonulin, soluble CD14 (sCD14), and lipopolysaccharide (LPS) using commercially available enzyme-linked immunosorbent assays. Statistical analysis consisted of descriptive statistics, Mann-Whitney t-test, and Kruskal-Wallis test. A total of 134 patients were consented and included in the study. 44 were classified as PJI (30 chronic and 14 acute), and 90 as aseptic failures (26 primaries and 64 aseptic revisions). Both Zonulin and sCD14, but not LPS, were found to be significantly increased in the PJI group compared to non-infected cases (p<0.001; p=0.003). Higher levels of Zonulin were found in acute infections compared to chronic PJI (p=0.005. This prospective ongoing study reveals a possible link between gut permeability and the ‘gut-immune-joint axis’ in PJI. If this association continues to be born out with larger cohort recruitment and more in-depth analysis, it would have an immense implication in managing patients with PJI. In addition to administering antimicrobials, patients with PJI and other orthopedic infections may require gastrointestinal modulators such as pro and prebiotics

Aims. In previous studies, we identified multiple factors influencing the survivorship of hip resurfacing arthroplasties (HRAs), such as initial anatomical conditions and surgical technique. In addition, the University of California, Los Angeles (UCLA) activity score presents a ceiling effect, so a better quantification of activity is important to determine which activities may be advisable or detrimental to the recovered patient. We aimed to determine the effect of specific groups of sporting activities on the survivorship free of aseptic failure of a large series of HRA. Patients and Methods. A total of 661 patients (806 hips) representing 77% of a consecutive series of patients treated with metal-on-metal hybrid HRA answered a survey to determine the types and amounts of sporting activities they regularly participated in. There were 462 male patients (70%) and 199 female patients (30%). Their mean age at the time of surgery was 51.9 years (14 to 78). Their mean body mass index (BMI) was 26.5 kg/m. 2. (16.7 to 46.5). Activities were regrouped into 17 categories based on general analogies between these activities. Scores for typical frequency and duration of the sessions were used to quantify the patients’ overall time spent engaging in sporting activities. Impact and cycle scores were computed. Multivariable models were used. Results. We found no association between any category of activity and a decrease in survivorship. Impact and hip cycle scores also failed to show any association with revision for aseptic failure or wear. Conclusion. Return to sporting activities after surgery is safe for patients treated with well-designed and well-implanted HRA. Cite this article: Bone Joint J 2019;101-B:1186–1191

Previous studies have reported excellent results with tapered, titanium alloy, porous plasma-sprayed components in patients undergoing uncemented primary total hip arthroplasty (THA). The purpose of this study was to examine survival and clinical results at minimum 25-year follow-up. We reviewed all patients who underwent primary THA at our center through 1995 with a specific femoral component, the Mallory-Head Porous (MHP; Zimmer Biomet, Warsaw, IN). This device, marketed in the U.S. until December 2021, was essentially unchanged since its 1984 introduction, except the porous coating was continued circumferentially along the lateral aspect in 1987, a hydroxyapatite-coated option was offered in 1988, and an offset option was added in 1999 after the study period. Three hundred thirty-two patients (396 THA) had a minimum of 25-year follow-up. Mean age at surgery was 47.6 years (range, 21–70 years). Mean follow-up in non-failed patients was 28.7 years (range, 25 to 37 years). There were 31 femoral revisions (7.8%): 9 infection, 3 failure of ingrowth, 5 aseptic loosening, 8 osteolysis revised well-fixed, 2 periprosthetic fracture, 2 polyethylene wear with trochanteric avulsion, 1 component breakage, and 1 malalignment well-fixed. Kaplan-Meier survival with endpoint of stem revision for all causes was 94.8% (95% CI: ±0.9%) at 36.7 years, and survival with endpoint of aseptic loosening/failure of ingrowth was 98.7% (95% CI: ±0.5) at 36.7 years. Harris hip scores improved significantly from 43 preoperatively to 76 most recently. This tapered, titanium, porous plasma spray-coated femoral component continues to demonstrate high long-term survival with a low rate of femoral component revision for any reason or aseptic loosening/failure of ingrowth

For over a decade, modular titanium fluted tapered (TFT) stems have demonstrated excellent clinical success for femoral revision total hip arthroplasty (THA) surgery. The aim of this study was to report the short-term outcomes of a novel modern monoblock TFT stem used for revision and complex primary THA with a minimum of 2 years follow-up. We identified 126 patients who received a single monoblock TFT stem - 26 patients for complex THA (failed fracture fixation) and 100 patients for revision THA. The reasons for revision THA included 40 for previous prosthetic joint infection (PJI), 42 for aseptic loosening, 9 for trunnionosis, 9 for periprosthetic fractures. The Paprosky grading for femoral bone loss at the time of surgery and the measured subsidence of femoral stems at 3 months follow-up were determined. We evaluated the number and indications for re-operations. The mean time from surgery was 3.9 years (range 2.0 to 6.9 years). A paired t-test analysis showed significant improvement from pre-operative versus post-operative clinical outcome scores (p<0.001) for HHS (38.76 +/- 15.24vs. 83.42 +/- 15.38), WOMAC (45.6 ± 19.0 vs. 69.9 ± 21.3) and SF-12 Physical component (31.7 ± 8.1 vs. 37.8 ± 11.3) and SF-12 Mental component (48.2 ± 12.2 vs. 51.6 ± 12.5). The Paprosky grading for femoral bone loss was Grade 1 (3.9%), Grade 2 (35.7%), Grade 3A (47.6%), Grade 3B (11.1%) and Grade 4 (1.6%) cases. There were 18 re-operations (14.7%) with 13 for PJI (7 treated with implant retention, 6 treated with a two-staged revision), 4 for instability and one for acetabular aseptic loosening. There were no aseptic failures of the stem. This novel modern monoblock TFT stem provided reliable femoral fixation and has increasingly supplanted the use of modular TFT stems for complex primary and revision surgery in our institution

Aims. There is a paucity of long-term studies analyzing risk factors for failure after single-stage revision for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). We report the mid- to long-term septic and non-septic failure rate of single-stage revision for PJI after THA. Methods. We retrospectively reviewed 88 cases which met the Musculoskeletal Infection Society (MSIS) criteria for PJI. Mean follow-up was seven years (1 to 14). Septic failure was diagnosed with a Delphi-based consensus definition. Any reoperation for mechanical causes in the absence of evidence of infection was considered as non-septic failure. A competing risk regression model was used to evaluate factors associated with septic and non-septic failures. A Kaplan-Meier estimate was used to analyze mortality. Results. The cumulative incidence of septic failure was 8% (95% confidence interval (CI) 3.5 to 15) at one year, 13.8% (95% CI 7.6 to 22) at two years, and 19.7% (95% CI 12 to 28.6) at five and ten years of follow-up. A femoral bone defect worse than Paprosky IIIA (hazard ratio (HR) 13.58 (95% CI 4.86 to 37.93); p < 0.001) and obesity (BMI ≥ 30 kg/m. 2. ; HR 3.88 (95% CI 1.49 to 10.09); p = 0.005) were significantly associated with septic failure. Instability and periprosthetic fracture were the most common reasons for mechanical failure (5.7% and 4.5%, respectively). The cumulative incidence of aseptic failure was 2% (95% CI 0.4 to 7) at two years, 9% (95% CI 4 to 17) at five years, and 12% (95% CI 5 to 22) at ten years. A previous revision to treat PJI was significantly associated with non-septic failure (HR 9.93 (95% CI 1.77 to 55.46); p = 0.009). At the five-year timepoint, 93% of the patients were alive (95% CI 84% to 96%), which fell to 86% (95% CI 75% to 92%) at ten-year follow-up. Conclusion. Massive femoral bone loss was associated with greater chances of developing a further septic failure. All septic failures occurred within the first five years following the one-stage exchange. Surgeons should be aware of instability and periprosthetic fracture being potential causes of further aseptic revision surgery. Cite this article: Bone Joint J 2021;103-B(7):1247–1253

Aims. As our population ages, the number of octogenarians who will require a total hip arthroplasty (THA) rises. In a value-based system where operative outcomes are linked to hospital payments, it is necessary to assess the outcomes in this population. The purpose of this study was to compare outcomes of elective, primary THA in patients ≥ 80 years old to those aged < 80. Methods. A retrospective review of 10,251 consecutive THA cases from 2011 to 2019 was conducted. Patient-reported outcome (PRO) scores (Hip disability and Osteoarthritis Outcome Score (HOOS)), as well as demographic, readmission, and complication data, were collected. Results. On average, the younger cohort (YC, n = 10,251) was a mean 61.60 years old (SD 10.71), while the older cohort (OC, n = 609) was 84.25 years old (SD 3.02) (p < 0.001). The OC had greater surgical risk based on their higher mean American Society of Anesthesiologists (ASA) scores (2.74 (SD 0.63) vs 2.30 (SD 0.63); p < 0.001) and Charlson Comorbidity Index (CCI) scores (6.26 (SD 1.71) vs 3.87 (SD 1.98); p < 0.001). While the OC stayed in the hospital longer than the YC (mean 3.5 vs 2.5 days; p < 0.001), there were no differences in 90-day emergency visits (p = 0.083), myocardial infarctions (p = 0.993), periprosthetic joint infections (p = 0.214), dislocations (p = 0.993), or aseptic failure (p = 0.993). The YC was more likely to be readmitted within 90 days (3.88% vs 2.18%, Β = 0.57; p = 0.048). There were no observed differences in 12-week (p = 0.518) or one-year (p = 0.511) HOOS scores. Conclusion. Although patients ≥ 80 years old have a greater number of comorbidities than younger patients, they had equivalent perioperative complication rates and PRO scores. This study demonstrates the safety and success of elective THA in octogenarians. Cite this article: Bone Jt Open 2021;2(7):535–539

The goal of the study was to describe the features of the aseptic loosening of the cup in CoC THR and to determine factors that affect the time to revision. It is a retrospective study including all patients who had a revision of CoC THR for aseptic failure fixation of the cup, between 2007 and 2017. 55 patients (27 women, 28 men) (56 hips) were included in the study. Eight hips (13 %) had also a stem exchange. At the primary T HR, the mean age of the patients was 47.9 years (17–72), 28 press fit cups had screws, the mean diameter of the cup was 51.2 mm (46–62) and the mean inclination was 52° (37–67). Clinical and radiological data were retrospectively recorded by an observer different to the initial operators. The mean age of the patients at the revision was 55.4 years (26–84). The mean time to revision was 90.1 months (14–240), and was significantly greater in patients aged less than 52 years, in cups without screws and with a 28mm head. The trend curve of the time to cup revision showed a bimodal distribution at three and ten years. 20 cups had migrated (33%). Bone loss was rated type 1 in 41 hips (73.0%), type 2 in 12 hips and type 3 in three hips). The mean diameter of the new cup was 52.3 mm (46–64). It was inferior to that of the initial cup in 26 hips (46.4%). 31 cups were impacted (55.5%) and 25 needed to be cemented (45.5%). No macroscopic wear was detected on the ceramic implant. Aseptic loosening of the cup in CoC THA does not appear to increase over time, supporting the fact that the failure is unrelated to wear and is not due to a biological mechanism. The occurrence of two peaks of frequency over time may suggest that different mechanisms occur

Aims. This study presents the long-term survivorship, risk factors for prosthesis survival, and an assessment of the long-term effects of changes in surgical technique in a large series of patients treated by metal-on-metal (MoM) hip resurfacing arthroplasty (HRA). Patients and Methods. Between November 1996 and January 2012, 1074 patients (1321 hips) underwent HRA using the Conserve Plus Hip Resurfacing System. There were 787 men (73%) and 287 women (27%) with a mean age of 51 years (14 to 83). The underlying pathology was osteoarthritis (OA) in 1003 (75.9%), developmental dysplasia of the hip (DDH) in 136 (10.3%), avascular necrosis in 98 (7.4%), and other conditions, including inflammatory arthritis, in 84 (6.4%). Results. The mean follow-up time was 10.5 years (1 to 20). Using revision for any reason as the endpoint, the overall survivorship at 15 years was 89.4% (95% confidence interval (CI) 86.8 to 91.4). There was a substantial increase between the first and second generation of surgical technique (86.6% vs 90.1%; p = 0.05). Men with idiopathic OA had a 15-year survivorship of 94.5% and women, 82.2% (p = 0.001); gender was not a risk factor after stratification by component size and aetiology. Using revision for excessive wear (ion levels > 7 µg/l associated with symptoms or adverse local tissue reactions) as the endpoint, the 15-year survivorship was 98.5%. Risk factors for revision for all modes of failure were an underlying pathology of hip dysplasia, a contact patch to rim (CPR) distance of 7 mm or less, an age at surgery of 55 years or less, and a femoral component size of 46 mm or less. Specific risk factors for aseptic failure of the femoral component were early surgical technique, a cementless metaphyseal stem, and a body mass index of 24 kg/m. 2. or less. Conclusion. HRA is a viable concept; metal-on-metal bearings are well suited for this procedure when a well-designed device is properly implanted. The best results were obtained in men with OA, but survivorship was better for other underlying pathologies and for women after changes were made to the technique of implantation. Lifetime durability is a possible outcome for many patients despite a high level of activity. Cite this article: Bone Joint J 2018;100-B:1424–33

Aims

United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures.

Uncemented component retention with polyethylene (PE) liner and femoral head exchange is commonly used to treat periprosthetic osteolysis. The purpose was to determine long-term implant survivorship, risk factors for aseptic failures, clinical outcomes, and complications following PE liner and head exchange. We identified 116 hips in 110 patients treated with PE liner and head exchange for osteolysis from 1993 to 2004. The mean age was 58, 64 were women, and mean follow-up was 11 years. Implant survivorship free from all-cause revisions was 91% at 5-years, 81% at 10-years, and 69% at 15-years. Reasons for re-revision included subsequent conventional PE wear and osteolysis in 7 (6%), aseptic acetabular loosening in 5 (4%), and instability in 5 hips (4%). Mean time to revision for aseptic acetabular loosening was 4 years (range 1 – 7 years). Risk factors for aseptic acetabular loosening included acetabular zones of pre-revision osteolysis, percentage of cup involvement, and size of osteolytic defects. Absolute risk of acetabular loosening was 23% for three zones of osteolysis (Relative Risk (RR) 12, p<0.01), 40% if osteolysis involved more than half the cup circumference (RR 14, p<0.01), and 21% for defects greater than 600 mm. 2. (RR 11, p<0.01). Harris hip scores improved from 77 to 87 (p<0.01). The most common complication was dislocation (16%). These data quantify risk of subsequent component loosening when well fixed, uncemented implants are retained during operations for osteolysis, and may inform operative decisions regarding shell retention versus revision

Aims. This study aimed to evaluate implant survival of reverse hybrid total hip arthroplasty (THA) at medium-term follow-up. Patients and Methods. A consecutive series of 1082 THAs in 982 patients with mean follow-up of 7.9 years (5 to 11.3) is presented. Mean age was 69.2 years (21 to 94). Of these, 194 (17.9%) were in patients under 60 years, 663 (61.3%) in female patients and 348 (32.2%) performed by a trainee. Head size was 28 mm in 953 hips (88.1%) or 32 mm in 129 hips (11.9%). Survival analysis was performed and subgroups compared using log rank tests. Results. Ten-year survival (122 hips at risk) was 97.2% (95% confidence interval (CI) 95.77 to 98.11) for all-cause revision. There was no difference in survival by age (p = 0.50), gender (p = 0.78), head size (p = 0.63) or surgeon grade (p = 0.36). No acetabular components underwent revision for aseptic loosening in the entire series. Four (0.4%) aseptic stem failures occurred early at a mean of 2.5 years (0.6 to 4.8) and were associated with age under 60 years (p = 0.015). There was no difference in survival by gender (p = 0.12), head size (p = 0.43) or surgeon grade (p = 0.77) for stem revision. Conclusion. This is the largest reported study into reverse hybrid THA and it confirms successful outcomes, irrespective of age, gender, head size and surgeon grade. Cite this article: Bone Joint J 2018;100-B:1010–17

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.

We present a retrospective series of 170 cemented titanium straight-stem femoral components combined with two types of femoral head: cobalt-chromium (CoCr) alloy (114 heads) and alumina ceramic (50 heads). Of the study group, 55 patients (55 stems) had died and six (six stems) were lost to follow-up. At a mean of 13.1 years (3 to 15.3) 26 stems had been revised for aseptic loosening. The mean follow-up time for stable stems was 15.1 years (12.1 to 16.6). Survival of the stem at 15 years was 75.4% (95% confidence interval (CI) 67.3 to 83.5) with aseptic failure (including radiological failure) as the end-point, irrespective of the nature of the head and the quality of the cement mantle. Survival of the stem at 15 years was 79.1% (95% CI 69.8 to 88.4) and 67.1% (95% CI 51.3 to 82.9) with the CoCr alloy and ceramic heads, respectively. The quality of the cement mantle was graded as a function of stem coverage: stems with complete tip coverage (type 1) had an 84.9% (95% CI 77.6 to 92.2) survival at 15 years, compared with those with a poor tip coverage (type 2) which had a survival of only 22.4% (95% CI 2.4 to 42.4). The poor quality of the cement mantle and the implantation of an alumina head substantially lowered the survival of the stem. In our opinion, further use of the cemented titanium alloy straight-stem femoral components used in our series is undesirable

We report the results of cancellous femoral impaction grafting with cement in revision hip arthroplasty in all patients from one centre who had undergone surgery more than five years previously. A total of 32 surgeons undertook femoral impaction grafting in 207 patients (226 hips). There were no deaths attributable to the revision surgery; 33 patients with 35 functioning hips died with less than five years’ follow-up. One patient was lost to follow-up. Two hips (1%) developed early postoperative infection. Of the 12 stems which underwent a further surgical procedure for aseptic failure, ten were for femoral fracture and two for loosening. Survivorship with any further femoral operation as the endpoint was 90.5% (confidence intervals, 82 to 98) and using femoral reoperation for symptomatic aseptic loosening as the endpoint, the survivorship was 99.1% (confidence intervals, 96 to 100) at 10 to 11 years. As a consequence of the experience in this series, we have modified our technique with an increased use of longer stems with impacted allograft. Long stems are indicated when the host bone around the tip of a short stem is compromised, in patients with major loss of bone stock, or when a femoral fracture occurs

Aims

The purpose of this study was to evaluate unexpected positive cultures in total hip arthroplasty (THA) revisions for presumed aseptic loosening, to assess the prevalence of low-grade infection using two definition criteria, and to analyze its impact on implant survival after revision.

Aims

We present the results, in terms of survival, clinical outcome, and radiological appearance at 20 years, in a cohort of 225 cemented Exeter Universal femoral components (Stryker, Newbury, UK) implanted in 207 patients, at a district general hospital.

Aims

Hip resurfacing arthroplasty (HRA) is typically indicated for young and active patients. Due to the longevity of arthroplasty, these patients are likely to undergo revision surgery during their lifetime. There is a paucity of information on the long-term outcome of revision surgeries performed after failed HRA. The aim of our study was to provide survivorship data as well as clinical scores after HRA revisions.

Aims

Of growing concern in arthroplasty is the emergence of atypical infections, particularly Cutibacterium (formerly Propionibacterium) sp. infections. Currently, the dermal colonization rate of Cutibacterium about the hip is unknown. Therefore, the aim of this study was to investigate colonization rates of Cutibacterium sp. at locations approximating anterior and posterolateral approaches to the hip joint.

Aims

Leucocyte esterase (LE) has been shown to be an accurate marker of prosthetic joint infection (PJI), and has been proposed as an alternative to frozen section (FS) histology for intraoperative diagnosis. In this study, the intraoperative assessment of LE was compared with FS histology for the diagnosis of prosthetic hip infection.