Aims. Cementing in arthroplasty for hip fracture is associated with improved postoperative function, but may have an increased risk of early mortality compared to uncemented fixation. Quantifying this mortality risk is important in providing safe patient care. This study investigated the association between cement use in arthroplasty and mortality at 30 days and one year in patients aged 50 years and over with hip fracture. Methods. This retrospective cohort study used linked data from the Australian Hip Fracture Registry and the National Death Index. Descriptive analysis and Kaplan-Meier survival curves tested the unadjusted association of mortality between cemented and uncemented procedures. Multilevel logistic regression, adjusted for covariates, tested the association between cement use and 30-day mortality following arthroplasty. Given the known institutional variation in preference for cemented fixation, an instrumental variable analysis was also performed to minimize the effect of unknown confounders. Adjusted Cox modelling analyzed the association between cement use and mortality at 30 days and one year following surgery. Results. The 30-day mortality was 6.9% for cemented and 4.9% for uncemented groups (p = 0.003). Cement use was significantly associated with 30-day mortality in the Kaplan-Meier survival curve (p = 0.003). After adjusting for covariates, no significant association between cement use and 30-day mortality was shown in the adjusted multilevel logistic regression (odd rati0 (OR) 1.1, 95% confidence interval (CI) 0.9 to 1.5; p = 0.366), or in the instrumental variable analysis (OR 1.0, 95% CI 0.9 to 1.0, p=0.524). There was no significant between-group difference in mortality within 30days (hazard ratio (HR) 0.9, 95% CI 0.7to 1.1; p = 0.355) or one year (HR 0.9 95% CI 0.8 to 1.1; p = 0.328) in the Cox modelling. Conclusion. No statistically significant difference in patient mortality with cement use in arthroplasty was demonstrated in this population, once adjusted for covariates. This study concludes that cementing in arthroplasty for hip fracture is a safe means of surgical fixation. Cite this article: Bone Jt Open 2023;4(3):198–204

The debate whether to use cemented or uncemented components in primary total hip replacement (THR) has not yet been considered with reference to the cost implications to the National Health Service.

We obtained the number of cemented and uncemented components implanted in 2009 from the National Joint Registry for England and Wales. The cost of each component was established. The initial financial saving if all were cemented was then calculated. Subsequently the five-year rates of revision for each type of component were reviewed and the predicted number of revisions at five years for the actual components used was compared with the predicted number of revisions for a cemented THR. This was then multiplied by the mean cost of revision surgery to provide an indication of the savings over the first five years if all primary THRs were cemented.

The saving at primary THR was calculated to be £10 million with an additional saving during the first five years of between £5 million and £8.5 million. The use of cemented components in routine primary THR in the NHS as a whole can be justified on a financial level but we recognise individual patient factors must be considered when deciding which components to use.

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).

We report the ten-year survival of a cemented total knee replacement (TKR) in patients aged < 55 years at the time of surgery, and compare the functional outcome with that of patients aged > 55 years. The data were collected prospectively and analysed using Kaplan-Meier survival statistics, with revision for any reason, or death, as the endpoint. A total of 203 patients aged < 55 years were identified. Four had moved out of the area and were excluded, leaving a total of 221 TKRs in 199 patients for analysis (101 men and 98 women, mean age 50.6 years (28 to 55)); 171 patients had osteoarthritis and 28 had inflammatory arthritis. Four patients required revision and four died. The ten-year survival using revision as the endpoint was 98.2% (95% confidence interval 94.6 to 99.4). Based on the Oxford knee scores at five and ten years, the rate of dissatisfaction was 18% and 21%, respectively. This was no worse in the patients aged < 55 years than in patients aged > 55 years.

These results demonstrate that the cemented PFC Sigma knee has an excellent survival rate in patients aged < 55 ten years post-operatively, with clinical outcomes similar to those of an older group. We conclude that TKR should not be withheld from patients on the basis of age.

Aims. To our knowledge, no study has compared the long-term results of cemented and hybrid total hip arthroplasty (THA) in patients with osteoarthritis (OA) secondary to congenital hip disease (CHD). This is a demanding procedure that may require special techniques and implants. Our aim was to compare the long-term outcome of cemented low-friction arthroplasty (LFA) and hybrid THA performed by one surgeon. Patients and Methods. Between January 1989 and December 1997, 58 hips (44 patients; one man, 43 woman; mean age 56.6 years (25 to 77)) with OA secondary to CHD were treated with a cemented Charnley LFA (group A), and 55 hips (39 patients; two men, 37 women; mean age 49.1 years (27 to 70)) were treated with a hybrid THA (group B), by the senior author (GH). The clinical outcome and survivorship were compared. Results. At all timepoints, group A hips had slightly better survivorship than those in group B without a statistically significant difference, except for the 24-year survival of acetabular components with revision for aseptic loosening as the endpoint, which was slightly worse. The survivorship was only significantly better in group A compared with group B when considering reoperation for any indication as the endpoint, 15 years postoperatively (74% vs 52%, p = 0.018). Conclusion. We concluded that there was not a substantial difference at almost any time in the outcome of cemented Charnley LFAs compared with hybrid THAs when treating patients with OA of the hip secondary to CHD. We believe, however, that after improvements in the design of components used in hybrid THA, this could be the method of choice, as it is technically easier with a shorter operating time. Cite this article: Bone Joint J 2019;101-B:1050–1057

An episode of hypotension is common during cemented joint replacement, and has been associated with circulatory collapse and sudden death. We studied the mechanism of hypotension in two groups of six dogs after simulated bilateral cemented arthroplasty. In one group, with no lavage, the insertion of cement and prosthesis was followed by severe hypotension, elevated pulmonary artery pressure, decreased systemic vascular resistance and a 21% reduction in cardiac output. In the other group, pulsatile intramedullary lavage was performed before the simulated arthroplasties. Hypotension was less, and although systemic vascular resistance decreased, the cardiac output did not change. The severity of the hypotension, the decrease in cardiac output and an increase in prostaglandin metabolites were related to the magnitude of pulmonary fat embolism. Pulsatile lavage prevents much of this fat embolism, and hence the decrease in cardiac output. The relatively mild hypotension after lavage was secondary to transient vasodilation, which may accentuate the hypotension caused by the decreased cardiac output due to a large embolic fat load. We make recommendations for the prevention and management of hypotension during cemented arthroplasty

Bleeding from cancellous bone causes lamination within bone cement and at its prosthetic interfaces, and weakens the fixation of joint replacements. We examined the effects of anaesthesia and blood pressure on bleeding in human cancellous bone, and investigated the local response to freezing saline, 1:200,000 adrenaline and hydrogen peroxide. Spinal anaesthesia reduced cancellous bleeding by an average of 44%, local freezing saline by 24%. Saline at room temperature, adrenaline solution and hydrogen peroxide each reduced it by 14%. The effects of spinal anaesthesia and of freezing saline were additive: used together they reduced bleeding by 56%. The reduction of blood contamination of cement and its interfaces should contribute to better prosthetic fixation.

We studied the effects of nine techniques of bone surface preparation on cement penetration and shear strength at the cement-bone interface in a standard model of bovine cancellous bone. In unprepared bone the mean penetration was 0.2 mm and the mean shear strength of the interface was 1.9 MPa, less than that of the underlying bone. Brushing with surface irrigation gave mean penetrations of 0.6 to 1.4 mm and mean shear strengths of 1.5 to 9.9 MPa. In 50% of specimens the interface was weaker than the underlying bone. The use of pressurised lavage resulted in mean penetrations of 4.8 to 7.9 mm and mean shear strengths of 26.5 to 36.1 MPa, which were greater than those of the cancellous bone in all specimens. Pressurised lavage was equally effective alone or in combination with brushing, and its efficacy was not altered by using pulsed or continuous jets, or by changing the temperature of the solution from 21 degrees C to 37 degrees C.

Aim: Prosthetic loosening has emerged as a most serious long-term complication after Joint Arthroplasty and the most common cause for revision. Arthroplasty is performed either under a general anaesthesia or a spinal/ epidural or a combination of the two. During general anaesthesia Sevoßurane is used for induction and maintenance. We investigated the effect of Sevoßurane on bone cement in an in vitro setting. Materials & Methods:. 40 beads of roughly the same size were prepared from 2 mixes in a sterile condition in vacuum. 20 of these beads were scanned initially under an electron microscope at 2 levels of magniþcation. The surface images of all the cement beads were analysed. Equal numbers of scanned and unscanned beads were separated into 2 groups of 20 each. They were immersed into 2 jars of normal saline. One was connected to the anaesthetic apparatus and exposed to Sevoßurane at a concentration of 2.5%. The other group (control) was exposed to oxygen. This was performed for 2 hours in an orthopaedic theatre. All the beads were then scanned. Results & Conclusions: The post Sevoßurane exposure images revealed a large number of pits of irregular dimensions on the surface. There were no changes on the surface of control beads. This suggests that in clinical concentrations Sevoßurane can affect the surface of bone cement and its mechanical properties. This can in turn affect the bone cement interface and be a potential cause of prosthetic loosening.

We reviewed 29 consecutive patients after cemented femoral revision of cemented hip arthroplasties for osteolysis. After an average follow-up of 8.5 years, osteolysis had recurred in only two cases (6.9%) and 25 femoral components (86%) remained well fixed.

Periprosthetic joint infection (PJI) in geriatric and/or multimorbid patients is an enormous challenge for orthopaedic surgeons. Revision procedures have also been demonstrated to expose patients to higher infection risks. Prior patient stratification according to presumed infection risks, followed by a more potent local antibiotic prophylaxis protocol with selective use of DALBC, is an interesting strategy to decrease the burden of PJI in high risk patients. The PubMed & EMBASE databases were screened for publications pertaining to the utilization of DALBC in cement for infection prophylaxis & prosthesis fixation. 6 preclinical & 7 clinical studies were identified which met the inclusion criteria and were stratified by level of clinical evidence. Only those studies were considered which compared the PJI outcome in the DALBC vs the SALBC group. (1). DALBC have been shown to exert a much stronger and longer lasting inhibition of biofilm formation on many PJI relevant bacteria (gram-positive and gram-negative pathogens) than single gentamicin-only containing cements. (2). DALBC use (COPAL G+C) in the intervention arm of 7 clinical studies has led to a significant reduction of PJI cases in a) cemented hemiarthroplasty procedures (3 studies, evidence level I and III), in b) cemented septic revision surgeries (2 studies, evidence level III), in c) cemented aseptic knee revisions (1 study, evidence level III) and in d) cemented primary arthroplasties in multi-morbid patients (1 study, evidence level III-IV). These benefits were not associated with more systemic side effects or a higher prevalence of broad antimicrobial resistancies. Use of DALBC is likely to be more effective in preventing PJI in high risk patients. The preliminar findings so far may encourage clinicians to consolidate this hypothesis on a wider clinical range

Abstract. Introduction. Secondary osteonecrosis of the knee affects young population and causes bilateral extensive lesions. Arthroplasty is the last resort in younger population and joint preserving options questionable in pathological bone. Conservative measures have shown failure in multiple studies and hence no gold standard treatment advocated. We aimed at identifying and analysing various treatment options for secondary osteonecrosis with respect to the outcomes and studying features of symptomatic secondary osteonecrosis with regards to demographic pattern, radiological features and causative factors. Methods. A systematic review of literature was performed in accordance with the Cochrane handbook for systematic reviews and reported according to the PRISMA guidelines. Results. Six studies which included a total of 192 patients with data on 240 knee joints were included in the final review. Follow up period ranged from 1 year to 16 years. The mean age of the patients was 34.7. 3 studies were on arthroplasty and 3 on joint preserving interventions. Majority of patients were in Stage 2 or Stage 4 of osteonecrosis. Steroid induced osteonecrosis was the majority followed by SLE and sickle cell disease. The pooled analysis showed an improvement of pre-operative knee score from 50.47 to 89.21 post-operatively. The pooled effect size for failure rate was 8.7% in joint preserving interventions and 9.2% in joint replacement group. Conclusion. Joint preserving techniques with bone marrow aspirate infiltration showed promising functional outcome and to a certain extent reversal of the pathological process. For advanced stages with subchondral collapse cemented arthroplasty showed satisfactory functional outcomes

Background. In recent years, ‘Get It Right First Time (GIRFT)’ have advocated cemented replacements in femoral part of Total hip arthroplasty (THA) especially in older patients. However, many studies were unable to show any difference in outcomes and although cemented prostheses may be associated with better short-term pain outcomes there is no clear advantage in the longer term. It is not clear when and why to do cemented instead of cementless. Aim. To assess differences in patient reported outcomes in uncemented THAs based on patient demographics in order to decide when cementless THA can be done safely. Method. Prospective data collection of consecutive 1079 uncemented THAs performed for 954 patients in single trust between 2010 and 2020. Oxford Hip Score (OHS) and complications were analysed against demographic variables (age, sex, BMI, ASA) and prosthesis features (femoral and acetabular size, offset and acetabular screws). Results. The mean pre-operative OHS was 14.6 which improved to 39.0 at 1 year follow up (P Value=0.000). There was no statistically significant difference between OHS outcome in patients aged over 70 versus younger groups. With a small number of revisable complications increase with age from 50s upwards. Male patients’ OHS score was on average 2.4 points higher than women. Men, however were 2.9 times more likely to experience fractures and high offset hips were 2.5 times more likely to experience dislocations. DAIR, intraoperative calcar fractures, post-operative fractures and dislocations were not associated with worse OHS. Patients with increased BMI had worse pre and post-operative hip functions yet, there was a significant multivariate association between increased BMI and increased improvement in OHS from pre-op to 1 year in women aged 55–80 and men under the age of 60. Femoral stem size increases with age but decreases in male patients over 80. There was no difference found in OHS between bilateral hip replacements and unilateral, nor was there any change found with laterality side of the replacement. Conclusions. This study suggests that ageing >70 is not associated with poorer outcomes despite small number of revisable complication rates that increase with age from 50 upwards. Men had marginally higher average OHS than women At 1 year. Higher BMI or ASA scores are associated with worse pre-operative hips and worse final outcome score. Despite this, the Delta OHS increases with increased BMI shown in the 55–80 year old female patients and male patients under 60. Key Words: THR, Uncemented, Oxford hip score, outcome

Abstract. Introduction. COMPOSE describes the demographics, fracture characteristics, management and associated outcomes of knee femoral periprosthetic fractures (KFPPF). Methods. Multicentre retrospective cohort study conducted 01/01/2018-31/12/2018. Data collected included: patient demographics, social and mobility characteristics, fracture characteristics, management strategy and post-treatment outcomes (length of stay, reoperation, readmission, 30-day and 12-month mortality). Results. 785 PPFs from 27 NHS sites were included in the COMPOSE cohort. Of these 162 (21%) were related to an isolated knee prosthesis (151 femur, 10 tibia and 1 patella). The KFPPF group had a mean age of 81.1 years, 127 (84%) female, 114 (76%) living in their own home, with 99 (63%) reliant on walking aids/bedbound. Most fractures were B (58%) or C (35%) type and occurred around a primary cemented replacement (141,94%) at a mean of 8.2 years after surgery. 116 (76.8%) KFPPFs were treated operatively. Mean time to surgery was 5 days and the commonest surgical strategy was fixation alone (64%) vs revision+/-fixation (36%). Mean operative time was 126 minutes and 11 (10%) patients required ITU/HDU admission after surgery. Mean LOS was 22 days and 47 patients (31%) experienced a complication prior to discharge. Overall, 5 patients (3%) had a further operation within 12 months, 7 (5%) were readmitted within 30 days and the 30-day and 12-month mortality were 6.6% and 23.2% respectively. Conclusions. KFPPF patients are elderly and frail and have mortality, re-operation and readmission rates comparable to hip fracture patients. However, they wait longer for surgery and surgical treatment is more complex

Aims. Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited. Methods. Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year. Results. A total of 3,966 patients were identified. The overall rate of SSI was 1.7% (51 patients (1.3%) with deep SSI, and 18 (0.45%) with superficial SSI). In all, 50 patients underwent revision surgery for infection (43 with DAIR, and seven with excision arthroplasty). After adjustment for other variables, only concurrent urinary tract infection (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.57 to 4.92; p < 0.001) and increasing delay to theatre for treatment of the fracture (OR 1.31 per day, 95% CI 1.12 to 1.52; p < 0.001) were predictors of developing a SSI, while a cemented arthroplasty was protective (OR 0.54, 95% CI 0.31 to 0.96; p = 0.031). In all, nine patients (20.9%) were alive at one year with a functioning hemiarthroplasty following DAIR, 20 (46.5%) required multiple surgical debridements after an initial DAIR, and 18 were converted to an excision arthroplasty due to persistent infection, with six were alive at one year. The culture of any gram-negative organism reduced success rates to 12.5% (no cases were successful with methicillin-resistant Staphylococcus aureus or Pseudomonas infection). Favourable organisms included Citrobacter and Proteus (100% cure rate). The all-cause mortality at one year after deep SSI was 55.87% versus 24.9% without deep infection. Conclusion. Deep infection remains a devastating complication regardless of the treatment strategy employed. Success rates of DAIR are poor compared to total hip arthroplasty, and should be reserved for favourable organisms in patients able to tolerate multiple surgical procedures. Cite this article: Bone Jt Open 2021;2(11):958–965

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. Methods. In this single-blind, randomized controlled, clinical radiostereometric analysis (RSA) study, the migration pattern of the cemented Corail hip stem was compared between line-to-line and standard cementing in 48 arthroplasties. The primary outcome measure was femoral stem migration in terms of rotation and translation around and along with the X-, Y-, and Z- axes measured using model-based RSA at three, 12, and 24 months. A linear mixed-effects model was used for statistical analysis. Results. Results from mixed model analyses revealed a lower mean retroversion for line-to-line (0.72° (95% confidence interval (CI) 0.38° to 1.07°; p < 0.001), but no significant differences in subsidence between the techniques (-0.15 mm (95% CI -0.53 to 0.227; p = 0.429) at 24 months. Radiolucent lines measuring < 2 mm wide were found in three and five arthroplasties cemented by the standard and line-to-line method, respectively. Conclusion. The cemented Corail stem with a force-closed design seems to settle earlier and better with the line-to-line cementing method, although for subsidence the difference was not significant. However, the lower rate of migration into retroversion may reduce the wear and cement deformation, contributing to good long-term fixation and implant survival. Cite this article: Bone Joint J 2022;104-B(1):19–26

Aims. To achieve the functional benefits of the direct anterior (DA) approach and the fixation benefits of cemented replacement, this study combined the two techniques posing the following questions: does the limited access of the DA approach adversely affect the cement technique?; and does such a cementing technique reduce the incidence of cementless complications?. Methods. A consecutive series of 341 patients (360 hips) receiving the DA approach between 2016 and 2018 were reviewed. There were 203 cementless stems and 157 cemented stems. Mean age was 75 years (70 to 86) in the cementless group and 76 years (52 to 94) in the cemented group, with 239 (70%) females in the whole series. Femoral complications were compared between the two groups. Mean follow-up was 1.5 years (0.1 to 4.4) for patients in the cementless group and 1.3 years (0.0 to 3.9) for patients in the cemented group. Results. The cementless group had a higher rate of femoral complications (8 vs 0; p = 0.011). There were two loose stems and six fractures, all requiring revision. Fractures occurred a mean 14.5 days (2 to 31) postoperatively and loosening at 189 days and 422 days postoperatively. Femoral cementing can be done using the DA approach safely and reduces the number of complications compared with a contemporary cementless series. Conclusion. A higher rate of early fractures and loosening occurred with cementless stems. This was not observed in our cemented stem cohort and cementing was safely accomplished through the DA approach. The modern femoral cementing process with the DA approach does not add to surgical complexity or time, has fewer early complications, and is a safer option for older patients compared to cementless femoral arthroplasties. Cite this article: Bone Joint J 2021;103-B(7 Supple B):33–37

Aims

Endoprosthetic reconstruction following distal femur tumour resection has been widely advocated. In this paper, we present the design of an uncemented endoprosthesis system featuring a short, curved stem, with the goal of enhancing long-term survivorship and functional outcomes.