Aims. The National Joint Registry for England, Wales and Northern Ireland (NJR) has extended its scope to report on hospital, surgeon and implant performance. Data linkage of the NJR to the London Implant Retrieval Centre (LIRC) has previously evaluated data quality for hip primary procedures, but did not assess revision records. . Methods. We analysed metal-on-metal hip revision procedures performed between 2003 and 2013. A total of 69 929 revision procedures from the NJR and 929 revised pairs of components from the LIRC were included. Results. We were able to link 716 (77.1%) revision procedures on the NJR to the LIRC. This meant that 213 (22.9%) revision procedures at the LIRC could not be identified on the NJR. We found that 349 (37.6%) explants at the LIRC completed the full linkage process to both NJR primary and revision databases. Data completion was excellent (> 99.9%) for revision procedures reported to the NJR. Discussion. This study has shown that only approximately one third of retrieved components at the LIRC, contributed to survival curves on the NJR. We recommend prospective registry-retrieval linkage as a tool to feedback missing and erroneous data to the NJR and improve data quality. Take home message: Prospective Registry – retrieval linkage is a simple tool to evaluate and improve data quality on the NJR. Cite this article: Bone Joint J 2016;98-B:33–9

Aim

Aim of this monocentric, prospective study was to evaluate the safety, efficacy, clinical and radiographical results at 24-month follow-up (N = 6 patients) undergoing hip revision surgery with severe acetabular bone defects (Paprosky 2C-3A-3B) using a combination of a novel phase-pure betatricalciumphosphate - collagen 3D matrix with allograft bone chips.

During hip revision removal of old cement mantle is a major problem. In cases of satisfactory bond between cement mantle and the underlying bone, cementing the revision stem into the old mantle is regarded as a highly attractive option. The aim was the analysis of the shearing strength of the interface between two layers of poly-methylmethacrylate cement in the presence of fluid. A laboratory, two-dimensional model of the interface was used. Effect of different viscosity fluids and volumes on its strength was checked. 6 variants (control monoblock, dry surface, surface stained with small or large volume of water or highly viscous fluid) containing 7 repeats were exposed to a single shearing stress to failure. Large volume of viscous fluid prevented bonding completely in two cases and significantly weakened the other samples showing mean failure stress of 5.53 MPa. This was significantly lower compared with control monoblock (19.8MPa), dry surface variant (16.9MPa) and the stain with small amount high viscosity fluid (16.01MPa). Interestingly, presence of a large volume of low viscosity fluid did not significantly reduce resistance to shear stress (17.05MPa). In all but large volume of viscous fluid variants, the failure occurred away from the interface between two cement layers. Large amount of viscous fluid weakened significantly this interface. If such a viscous fluid could be eliminated by copious water irrigation it is likely that strength of the cement-cement bond will be maintained. Our observations suggest that cement-in-cement technique seems to be biomechanically acceptable

Hip revision failures are partly due to the poor quality of femoral bone stock. Several work showed that bone reconstruction without grafts is possible around a non cemented, stable stem. It is enhanced by a transfemoral approach. We designed the Restoration TM DLS stem (anatomical, S curved, HA coating and distal locking to ensure a primary stability). Preoperative planning is necessary. The operative technique is based on a double postero-lateral femoral flaps approach. An innovating and modular instrumentation was developed. It rests on a femoral clamp that solidarises the femur and the trial stem, and allows a precise adjustment of the length and the stem anteversion. A targeting device allows a precise distal locking of the final implant. Osteosynthesis of the flaps is carried out by cerclages in order to bring the bone around the prosthesis. Forty-seven revisions cases were followed up. No major peroperative incident has occurred. We report one case of locking error. Compared to the planning, the instrumentation was considered to be precise in 94% for the adjustment of the leg length and of the ante-version. The bone adaptation around the implant was generally correct. In 21 cases, it was necessary to carry out metaphysal re-calibration or osteotomies for correction of a femoral deviation. The synthesis of the flaps is stable in 92%. For follow up greater than 3 months, the consolidation of the osteotomies is effective in 90%. This study made it possible to validate a surgical procedure by transfemoral approach that makes safe implant and cement removal. It also allowed us to validate an innovating, precise yet flexible instrumentation that allows, after preoperative planning, the anatomical reconstruction of the femur around the stem. A perfect proximal adaptation of the femur to the implant is necessary to the good tolerance of the distal locking

We investigated whether the indentation of bone cement spacers used in revision of infected joint arthroplasty with a MacDonald dissector increased the elution of antibiotic in vitro. A total of 24 cement discs containing either 0.17 g (0.88% w/w), 0.25 g (1.41% w/w), or 0.33 g (1.75% w/w) gentamicin of constant size were made. Of these, 12 were indented with the dissector. Each disc was immersed in ammonium acetate buffer in a sealed container, and fluid from each container was sampled at zero, one, three, six, 24, 48 and 72 hours and at one, and two weeks. The concentration of gentamicin in the fluid was analysed using high performance liquid chromatography mass spectrometry.

The fluid sampled at 72 hours from the indented discs containing 0.17 g gentamicin (0.88% w/w) contained a mean of 113 mcg/ml (90.12 to 143.5) compared with 44.5 mcg/ml (44.02 to 44.90) in the fluid sampled from the plain discs (p = 0.012). In discs containing 0.33 g gentamicin (1.75% w/w), the concentration eluted from the indented discs at 72 hours was a mean of 316 mcg/ml (223 to 421) compared with a mean of 118 mcg/ml (100 to 140) from the plain discs (p < 0.001).

At two weeks, these significant differences persisted. At nine weeks the indented discs eluted a greater concentration for all gentamicin doses, but the difference was only significant for the discs containing 0.17 g (0.88% w/w, p = 0.006). However if the area under the curve is taken as a measure of the total antibiotic eluted, the indented discs eluted more gentamicin than the plain discs for the 0.17 g (0.88% w/w, p = 0.031), the 0.25 g (1.41% w/w, p < 0.001) and the 0.33 g (1.75% w/w, p < 0.001) discs.

When preparing antibiotic spacers for use in staged revision arthroplasty surgery we recommend indenting the spacer with a MacDonald dissector to increase the elution of antibiotic.

Cite this article: Bone Joint J 2015;97-B:1519–24.

Introduction. Large acetabular bone defects caused by aseptic loosening are common. Reconstruction of large segmental defects can be challenging. Various implants and operative techniques have been developed to allow further acetabular revision in cases where bone stock is poor. Reconstitution of bone stock is desirable especially in younger patients. The aim of the study was to review the clinical and radiological results of hip revision with structural acetabular bone grafts using fresh frozen allograft and cemented components. Method. Between 1990 and 2014, 151 first time revisions for aseptic acetabular loosening with acetabular reconstruction with a fresh frozen structural allograft and cemented components were performed at our hospital. Graft dimensions, number of screws used and socket coverage by the graft were measured on the post-operative AP radiograph. Follow-up radiographs were analysed for socket loosening, quality of graft union, graft and graft resorption. Results. At a mean follow-up of 7 years 11 months (range 0 – 22), 5 patients had died and 24 hips revised (15.9%). One hundred and three hips had a follow-up greater than 5 years. The reasons for re-revision were infection in 1, recurrent dislocation in 4, aseptic stem loosening in 4 and aseptic cup loosening in 21 (13.9%). Survival analysis with revision for aseptic cup loosening as the endpoint was 80.2% at 10 years. Conclusion. The results using solid allograft to reconstruct the acetabulum are encouraging with a follow-up to 22 years. Structural allograft is a good option to reconstruct segmental defects of the acetabulum at revision surgery and we especially advocate its use to reconstitutes bone stock in younger patients

Introduction: today there is still no consense in reconstruction of severe acetabular defects in hip revision. Since 1988 we use size matched impacted acetabulum allografts. We evaluate how they behave in the mid- and longterm. Material and method: we present our first 44 transplants with a mean follow-up of 11,2 years (range 6 to 17). The mean age of the patients was 58,6 years (range 19 to 83). According to Gross Classification 26 cases presented an acetabular defect type III while 18 presented type IV. Evaluation included Merle D’Aubigne Score and radiological assessment of allograft and cup according to Engh Criteria (JBJS, 1994). Results: homogenization of the radiological trabecular pattern was observed in 42 from 44 cases (95,4 %). There were 3 infections and 7 cases of aseptic loosening (15,9 %), that were revised with new cup implantation. Up to now none of these 7 cases have shown further signs of loosening. According to the Kaplan-Meier’s curves the overall predictive survival rate was 76.4 % at 15 years. In cases of pelvic discontinuity (type IV) survivorship was significantly higher (85,7%, p=0,018). There was a highly marked improvement in Merle D’Aubigne Score in Gait (2,2 preoperative – 4,9 at follow-up, p=0,021) and Pain (2,5 preoperative 5,4 at follow-up, p=0,032). Conclusions: despite published reports with high incidence of failures in the midterm with structural allografts this serie shows clearly that a size matched impacted acetabulum allograft can be successfull in severe defficiencies if proper donor selection and excellent fixation technique is undertaken

Introduction. Osteolysis causing proximal femoral deficiency is a major problem in revision hip arthroplasty. Various methods including impaction bone grafting and bone allografts have been used to address this issue. We have analysed bone reformation using extended trochanteric osteotomy and distally fixed proximal hydroxyapatite-coated modular revision hip system (Stryker Restoration System) in 100 consecutive revisions by a single surgeon. Method. Consecutive patients undergoing revision of femoral stem using posterior approach, extended trochanteric osteotomy and modular hip revision system were included in the study. Exclusion criteria were infection and loss of follow up. Paprosky grading system was used to assess bone loss. Standardized pre-op radiographs and follow-up radiographs at 6 weeks, 6 months and yearly post surgery were used for analysis. Minimum follow-up of 18 months (1.5–3.5 years). Bone reformation is quantified as definite reformation, some evidence of reformation and no bone reformation. Extended trochanteric osteotomy union rates and subsidence rates were also observed. Result. Average age of patients was 71 years with 54% females and 46% males. The majority of femurs had significant bone loss (Paprosky type III 84%, Type II 16%). Bone reformation was evident in all patients and early bone reformation was observed in most patients in this study. The extended trochanteric osteotomy union rate was 100%. Subsidence was observed in 6 patients out of which 4 were non progressive (3patients 5–10mm and 1patient less than 5mm) and 2 were progressive and significant (more than 10 mm) with 1 patient requiring re-revision. Discussion. All patients in the study demonstrated reconstitution of the proximal femoral deficiency. Stability of the reconstruction, and viability of the osteotomy flap are key for a successful outcome. We believe this technique is reliable, reproducible and good option for the treatment of proximal femoral deficiency in revision total hip surgery. Await long term outcome

The Oxford hip score (OHS) at 6 months and five years of less than 27 has previously been reported as having a 5.2% chance of requiring revision of their total hip arthroplasty (THA) within 2 years. We determined whether the OHS obtained at 10 years after surgery would be a suitable screening tool in lieu of clinic visits to detect patients requiring closer monitoring.

We reviewed data from the NZ Joint Registry between January 1999 and December 2016. OHS at 10 years was available for 5,165 non-revised THA patients. Patients were separated into four categories based on their OHS: 3,483 (67%) scored 42–48, 1,023 (20%) scored 34–41, 373 (7%) scored 27–33, and 286 (5%) scored 0–26.

For patients with a 6-month OHS, revision risk within 2 years was 1.3% in the 42–48 group, 2.5% in the 34–41 group, 4.6% in the 27–33 group, and 10.2 % in the 0–27 group. If only patients with a grading of 33 or less were offered clinical follow-up, 659/5165 patients (12.7%) would require evaluation and of these, 46/659 (7%) could be expected to require revision within two years. Of those patients with an OHS > 34 not evaluated, only a small number, 72/4506 (1.6%), might require a revision.

The OHS at 10 years of patients with a THA who have a grading less than 27 is a much stronger predictor of revision than OHS at 6 months or 5 years. Use of the 10 year OHS as a screening tool for THA requires evaluation of only one in eight patients, with the chance of missing 1 in 63 patients not followed up who might require a revision.

Introduction: Osteolysis is a significant problem associated with hip replacement. In the early stages of osteolysis, when the implant is still stable, formal revision is technically demanding and may result in signififant bone loss. A recently described technique for acetabular component revision addresses osteolysis, retaining the acetabular cup and cementing a new polyethylene liner.

Materials and Methods: Between January 2000 and December 2003, 29 liner cementation revisions in 27 patients were performed. The mean age was 61 years (range 37–77), the mean time elapsed after the original surgery was 6.7 years (3–14). 23 of the hips (79%) were ABG (Howmedica). Only 20 (69%) of the patients were clinically symptomatic. At surgery the polyethylene was removed and osteolytic cysts were debrided. Then, the metal acetabular component was tested for stability. Obviously, only stable metal implants were not revised. The cysts were filled with bone graft or bone substitute and a new polyethylene liner was cemented in with methylmetacrilate augmented gentamicin. The patients were evaluated by modified Harris Hip Score (HHS) and by SF-12 score. The mean follow up was 25 months (10–45).

Results: The average HHS was 86/4 and its pain component was 38.8. The average physical component of SF-12 was 45.9 (19.5–57.2) and the average metal component was 54.6 (29–66.9). The post-operative HHS and the SF-12 scores were high (good or excellent) in all patients reflecting good clinical outcome. In patients who were asymptomatic prior to surgery, both the HHS and the pain score were significantly higher compared to the symptomatic patients (p< 0.01). One patient with extensive bone loss needed revision surgery due to early postoperative fracture of the acetabulum, and another patient had recurrent dislocations that required revision.

Summary: We conclude that revision of the polyethylene liner and cementation of a new one is a safe and useful technique in patients with stable acetabular shell. This is especially true for asymptomatic patients with osteolysis.

We present the early results of a bone conserving implant, the Thrust Plate Prosthesis (TPP) used for the revision of failed resurfacings of the hip in nine patients.

Four revisions were for fractured neck of femurs. The original implant in this fracture group was a McMinn resurfacing. The original acetabular component was retained. Five revisions were due to aseptic loosening. Four of the original implants in this group were Beuchal Pappas (BP) resurfacings and one was a Cormet2000 resurfacing.

In the fracture group the average age was 46yrs (34–70). The time from primary to revision surgery was 5.8 months (3–11). The Harris hip scores improved in all patients to their pre fracture level of 90 (83–99).

In the aseptic loosening group the average age was 62yrs (53–67). The time from primary to revision surgery was 121 months for the BP resurfacings and 19 months for the Cormet. The Harris hip scores also improved in this group to an average of 73.8 (50–100).

Hip resurfacing presents an attractive option for the younger patient. It is a bone conserving procedure with the added benefit of increased stability by using a large diameter head. Fracture of the femoral neck is a specific early complication. The usual treatment of this complication has been revision to a more traditional design, loosing the benefits of bone conservation.

The TPP is a bone preserving implant that has metaphyseal fixation of the proximal femur. It has satisfactory long term results (Huggler, 1993). The use of the TPP for revision of failed resurfacings has proved to be straight forward. Our early results are promising in the fracture group, but revision for aseptic loosening did not correlate with a high hip score. It remains to be proven that revision of a bone conserving hip replacement will maintain a high quality function. For the younger patient with a failed resurfacing, revision with a TPP can offer continued bone conservation.

Great diffusion of hip prosthetic surgery, in relatively-young patients too, generates as consequence an increase in prosthesis failures associated with limited or massive bone losses, making revision surgery mandatory, even in most advanced degrees of osteolysis.

In best surgery strategy planning are essential: - evaluation of osteolysis degree with standard x-Rays; - evaluation of periprosthetic bone turn-over with scintigraphy (both a specific as they give merely qualitative evaluations of bone remodeling); – quantitative evaluation of periprosthetic bone mineral density with periprosthetic mineralometry (D.E.X.A.). Data obtained with these methods allow more accurate decisions, during the pre-operative phase, regarding the most indicated implant for revision surgery: mid or long-stem, with or without omoplastic transplants, with or without materials promoting bone rehabitation. In any case, the surgeon must have all possible solutions in order to eventually change the operative plan during surgical act.

Following qualitative and quantitative periprosthetic bone evaluations, we use to classify stem and cup mobilizations with Italian Group for Revision (GIR) classification. According to GIR classification, our actual trends in the choice of revision prostheses, in the most advanced degrees of complex mobilizations of stem and cup, are the following: - GIR 3 (Enlargement of the femoral shaft with thinning of cortical bone and loosing of 2 or more walls; loosening and acetabular deformation with losing of one ore more columns and the bottom). In this degree we prefer a long-stem concept straight prosthesis; this prosthesis allows an immediately more stable implant, due to optimized length, in opposition to rotation forces and assuring force transfer in both proximal and distal direction. When osteolysis is wider, it was necessary a strategy change, searching a more distal locking of the implant, according to Wagner’s criteria. The SL Wagner’s prosthesis restores cohesion with the reabsorbed bone surface, generating a relative stability in the immediate post-op period; in the following 2 months, an intense bone apposition, which brings to a progressive filling of bone losses, takes place. For this purpose, it is not indicated, apart from surgical way used, cutting the muscle insertions around the thinned wall. This revision prosthesis is fixed without the use of cement due to the distal blocking, guaranteed by his conical shape; the stem is straight and it is not fit to the natural front-bending of femoral shaft. For this last explained reason, we follow these guidelines, improving our results, using a cementless anatomic modular stem: with this kind of implant design, that preserves cortical bone of femoral shaft from stress shielding, and the extremely wide (XX combination) choice of head and neck components, we are now able to regain as well as possible, the correct offset and center of rotation. For the acetabular loosening, we use to implant oval cups, that naturally fit the acetabular lesion, with or without bone grafts impaction in bone loss areas.- GIR 4 (Massive proximal bone loss all around the shaft; massive peri-acetabular loss). In the past we implanted wide-resection cemented (Muller) or non cemented (Kotz) prosthesis, originally designed for onchologic patients, to treat complete femoral osteolysis. The wide resection uncemented prosthesis, after follow up, supports the Wagner’s theory of distal support, because in spite of an almost complete bone sacrifice, there is an attempt of periprosthetic corticalization by the femoral bone. Since some years we implant even in this cases a modular distally-anatomic revision prosthesis, this type of prosthesis, thanks to his proximal component, provides a relative primary metaphyseal support, that improves global stability of implant. In massive peri-acetabular loss we prefer the use of oval components with peripheral supports and obturatory hook, with bone graft impaction. Only as “extrema ratio” we choose for the implant a McMinn stemmed cup.

From these guidelines, integrated with clinical observation at mid range follow-up, appears clerarly that cementless prosthesis in hip revision surgery, even in most advanced degrees of osteolysis, are really able to guarantee good results for the patient. These patients, previously implanted with hip prosthesis, have intrinsic limitations of hip joint ROM, sometimes associated with muscular impairments; therefore it’s rarely possible to bring back the hip to an optimal degree of function, especially if compared with a normal joint. The goodness of long-term results must be therefore evaluated in relation to patient’s conditions before the operation itself, especially according to bone conditions regarding osteointegration of prosthesis. If follow up of patient is constant, allowing to program with good timing the revision surgery, if necessary, the use of cementless prostheses is a very powerful (nevertheless conservative) instrument for good functional recovery of these patients.

Introduction: Radial Impaction Grafting (RIG) has been proposed as a method for improving durability and reliability of cementing a collared femoral component in radial compressed bonegraft. In a prospective, baseline-control, multicenter clinical study the clinical and quality of life scores, survival rate, complications and radiographic findings were evaluated. The main objective of this study is to establish and indentify factors that contribute to the fracture rate. We tried to establish a model that represents the simplest combination of factors that predict femur fracture following the RIG technique.

Patients and Methods: Eighty-eight patients enrolled the study: 59 women and 29 men with average age of 74 (38–90) years. The average follow-up was 4 years (2–7.2). The results of 81 patients were evaluated. The Endo-classification (EC) was used for the determination of the pre-operative femoral bone loss; type 1 was noticed in 25 cases, type 2 in 44, type 3 in 17 and type 4 in 1 case.

At 70 patients the femur was augmented (mesh, cerclage(s) and/or plate). A short stem (115–135mm) was used in 48% and a long stem (165–225mm) in 52% of the cases.

Results: The average total HHS increased from a pre-operative score of 44 (median 44) to 91 (median 94) at > 5 years fu and the HHS-pain score from 17 (median 20) respectively to 43 (median 44). The average VAS for pain at > 5 years fu was 2.5 (0–100 scale). Ninety-three percent of the patients were very-extremely satisfied with the result.

Postoperative the femoral stem had a varus position (6 –10°) in 4 cases. In 6 cases the stem was in posterior and 3 cases in anterior position.

Progressive subsidence was demonstrated in 1 patient increasing to 5 mm at 1 year fu. Three patients showed subsidence of 3 mm at 3 months, but were stable afterwards. Slightly increasing radiolucent lines (> 2 mm) were noticed in 2 patients in subcortical areas, but never any signs of osteolysis.

Intra- and postoperative femoral fractures occurred in 12 patients (13,6%). There were 3 dislocations and 1 loosening of a trochanteric osteotomy. Despite the fractures there was no loosening of a stem during follow-up period.

After bivariate multilevel analysis, conducted to determine a relationship between the fracture complication and all other variables, a multivariate model was developed of the most significant variables to determine the predictor factors for femoral fracture. Only the Endo-classification and age are predictors for a fracture following a RIG procedure (p-value 0.003).

Each higher EC type increases the probability of a fracture after RIG 2.01 times and each added year of life 1.07 times. So the risk of getting a femoral fracture increases exponentially with age from 1.7% at 55 years to 15.5% at 90 years in EC type 1. The fracture risk in EC type 4 increases from 4.7% at 40 years to almost 60% at 90 years.

Aims: This prospective study investigated the possibilities of substitute osteointegration in an unfavourable environment. Methods: 26 patients aged 57 to 92 years (average 80) have been followed up from 6 to 24 months with serial AP and lateral X-rays. The acetabular damages were: 2 SOFCOT grade I, 9 grade II, and 15 grade III.Granules ofTriosite¨ þlled the cavitary defects mixed with and covered by cancellous bone. One pack was used 13 times; two,6 times; three, 6 times; and four, once. An HA coated hemispherical cementless cup was pressþtted, stable without screws 8 times. Results: In other cases the acetabular cup remained stable without any lucency. Disappearance of the granules was observed only 4 times. In 14 cases osteo-integration seemed in progress, but the granular shape was still discernable. In 8 cases, even at 2 years follow-up, the granules were well visible (those were cases of grade III defects). Conclusion: In acetabular revision of a total hip replacement, the size of the defect may need a large amount of cancellous autograft. Bone substitutes seem an elegant means of sparing the patientñs bone. The rstþpapers on this topic seemed rather enthusiastic, but our experience is more contrasted. It seems that the speed of resorption of this bone substitute be volume-dependant: the bigger the defect, the slower the osteo-integration. May be growth factors should be added to speed up the process.

This study utilised NJR primary hip data from the 6^th Annual Report to determine the rate and indication for revision between cemented, uncemented, hybrid and resurfacing prosthetic groups. Regression analysis was performed to identify the influence of gender and ASA grade on these revision rates. Validity of the data was interrogated by exploring for episodes of misclassification.

Two-staged exchange arthroplasty with an antibiotic-impregnated PMMA cement spacer in-between two stages has a success rate of 85% to 95% in eradication of infection. Use of vancomycine in high doses has a high potential for complications due to nephrotoxicity.

The aim of this study was to evaluate the results of two-staged exchange arthroplasty in infected hip arthroplasty using low-dose vancomycine-impregnated PMMA cement as an interim spacer between stages.

Thirty-five (20 females, 15 males, average age: 60) patients with a confirmed infected total hip arthroplasty who were treated between 1999 and 2005 were the subjects of the study. In the first stage after removal of the prosthesis and debridement, a spacer made of 40 grams of PMMA cement impregnated with 1 gr vancomycine was placed in the infected joint space. Postoperatively, patients were treated with 6 weeks of intravenous antibiotics in consultation with an infectious disease consultant. When CRP and ESR returned to normal levels, revision surgery with cementless components was performed.

The average follow-up after the second stage was 4 years. The ESR and CRP decreased significantly before the second stage with this treatment protocol (from 81.28 to 17.54 mm/h p< 0.001 and 10.05 to 0.64 mg/dl respectively, p< 0.001). The mean interval between the two stages was 193.3 days. A second debridement was needed in 4 patients (10.8 %) because they did not respond to treatment. Two patients (5.4 %) had recurrent infections after reimplantation and underwent a resection arthroplasty. None of the patients suffered from antibiotic toxicity.

Two-stage exchange arthroplasty using a low dose vancomycine-impregnated cement spacer was an effective method in treating infected hip replacements. With using a lower dose than previously reported, we were able to avoid antibiotic toxicity while effectively treating our patients with the same success rate.

Introduction: Hip resurfacing arthroplasty is increasing in popularity, particularly in young and active patients. One unique advantage is retention of upper femoral bone stock with the hypothesis of easy revision should the resurfacing fail. The pupose of this study was to document the complexity or otherwise of our early experience with failed hip resurfacing.

Methods: We retrospectively reviewed all the patients who had revision surgery for failed hip resurfacing arthroplasty at our institution.

Results: Eleven patients with mean age of 52.8 years underwent revision of resurfacing at a mean time of 21.2 months following primary surgery. Revision was performed for deep infection in 4, cup loosening in 4 and 1 patient each for femoral neck fracture, avascular necrosis, and femoral loosening. For the 4 patients with cup loosening, the acetabular component was revised in 3 using a dysplasia Birmingham cup while 1 patient had both components revised. Of the 4 patients with deep infection, 3 had both components revised as one-stage revision with cemented components and 1 patient had a pseudarthosis. For the 3 cases with femoral loosening, neck fracture or avascular necrosis only the femoral component was revised using a cemented stem. Bone grafting was performed in 1 patient who had revision for loosening of acetabular cup with protrusio.

Conclusion: Acetabular failure appears to be equally common as femoral failure in resurfacing arthroplasty. Revision of both aseptic and septic failure appears to be relatively straightforward with primary implants used in all cases.

Aims: The purpose of this Paper is to review the preliminary results of a new tapered cementless revision stem, the T3, designed for cases of severe bone stock loss (Paprosky 2b, c and 3) usually representing a difficult challenge for the orthopaedic Surgeon. Methods: The T3 stem is made of Titanium alloy with a textured surface finish. The stem consists of a series of distal conical components to achieve a diaphyseal mechanical stability and 4 proximal bodies. The lateral offset is 42 mm and the cervicodiaphyseal angle is 138°. Between December 1998 and September 2001 we have implanted 22 T3 stems in 22 patients. Indications were severe bone loss in 13 cases, failed but stable cemented/cementless stems in 7 cases and peri-prosthetic fracture in 2. 14 patients were male and 8 female, the average age was 70 years. The average follow-up was 27 mo. In all cases a trans-femoral approach was used. The 7 cases with failed but stable stem showed pre-op a Paprosky 1 bone loss. However in these cases a trans-femoral approach was necessary to remove the stem and then a tapered stem became indispensable; 10 patients showed a Paprosky 2 bone loss (A=3 cases, B=3 cases, C=4 cases) and 5 a Paprosky 3. Post-op management was the same of a primary cementless case with full weight-bearing at 30 days. Results: The average Harris score was 40 points pre-op and 87 post-op. Good and Excellent results were 19(86%), 1 was Fair and 2 Poor (9%). Complications were 2 dislocations reduced conservatively and 1 paresis of Peroneal nerve recovered in 5 months. Bone reconstruction was excellent in 19 cases. 14 cases showed no subsidence and 8 < 5mm. Conclusion: T3 showed excellent preliminary results specially for what concerns bone reconstruction and lack of subsidence.

Revision total hip replacement may be technically challenging, with component selection being one of the challenges. Modular titanium femoral components have some advantages, and our aim was to assess the medium term outcome of the use of such a component [Revitan or PFM]

We reviewed 323 patients undergoing revision with one of these femoral stems. We applied the Oxford Hip Score, the Charnley Class, and the Devane Patient Activity Level to each patient.

The average follow up time was 6.58 years. The mean Oxford score was 35.74.39.8% of the patients were Charnley Class B. 52.4% of patients had an activity score indicating a moderate level of activity ie they could participate in gardening, swimming and other leisure pursuits.

The overall outcome was good with this prosthesis. The Oxford scores were comparable with the national mean for revision THR on the NZ National Joint Register.

Aims. The burden of revision total hip arthroplasty (rTHA) continues to grow. The surgery is complex and associated with significant costs. Regional rTHA networks have been proposed to improve outcomes and to reduce re-revisions, and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for a rTHA service, and to assess the financial impact of case complexity at a tertiary referral centre within the NHS. Methods. A retrospective analysis of all revision hip procedures was performed at this centre over two consecutive financial years (2018 to 2020). Cases were classified according to the Revision Hip Complexity Classification (RHCC) and whether they were infected or non-infected. Patients with an American Society of Anesthesiologists (ASA) grade ≥ III or BMI ≥ 40 kg/m. 2. are considered “high risk” by the RHCC. Costs were calculated using the Patient Level Information and Costing System (PLICS), and remuneration based on Healthcare Resource Groups (HRG) data. The primary outcome was the financial difference between tariff and cost per patient episode. Results. In all, 199 revision episodes were identified in 168 patients: 25 (13%) least complex revisions (H1); 110 (55%) complex revisions (H2); and 64 (32%) most complex revisions (H3). Of the 199, 76 cases (38%) were due to infection, and 78 patients (39%) were “high risk”. Median length of stay increased significantly with case complexity from four days to six to eight days (p = 0.006) and for revisions performed for infection (9 days vs 5 days; p < 0.001). Cost per episode increased significantly between complexity groups (p < 0.001) and for infected revisions (p < 0.001). All groups demonstrated a mean deficit but this significantly increased with revision complexity (£97, £1,050, and £2,887 per case; p = 0.006) and for infected failure (£2,629 vs £635; p = 0.032). The total deficit to the NHS Trust over two years was £512,202. Conclusion. Current NHS reimbursement for rTHA is inadequate and should be more closely aligned to complexity. An increase in the most complex rTHAs at major revision centres will likely place a greater financial burden on these units. Cite this article: Bone Jt Open 2023;4(8):559–566