Pathological assessment of periprosthetic tissues is important, not only for diagnosis, but also for understanding the pathobiology of implant failure. The host response to wear particle deposition in periprosthetic tissues is characterised by cell and tissue injury, and a reparative and inflammatory response in which there is an innate and adaptive immune response to the material components of implant wear. Physical and chemical characteristics of implant wear influence the nature of the response in periprosthetic tissues and account for the development of particular complications that lead to implant failure, such as osteolysis which leads to aseptic loosening, and soft-tissue necrosis/inflammation, which can result in pseudotumour formation. The innate response involves phagocytosis of implant-derived wear particles by macrophages; this is determined by pattern recognition receptors and results in expression of cytokines, chemokines and growth factors promoting inflammation and osteoclastogenesis; phagocytosed particles can also be cytotoxic and cause cell and tissue necrosis. The adaptive immune response to wear debris is characterised by the presence of lymphoid cells and most likely occurs as a result of a cell-mediated hypersensitivity reaction to cell and tissue components altered by interaction with the material components of particulate wear, particularly metal ions released from cobalt-chrome wear particles. Cite this article: Professor N. A. Athanasou. The pathobiology and pathology of aseptic implant failure. Bone Joint Res 2016;5:162–168. DOI: 10.1302/2046-3758.55.BJR-2016-0086

Introduction. Mechanical or corrosive failure of total knee arthroplasties (TKAs) is difficult to diagnose with current laboratory and radiographic analyses. As such, the goal of this study was to determine the mean blood concentration of cobalt, chromium, and titanium in a series of revision TKAs with mechanical implant failure and evaluate whether they facilitated identification of the underlying TKA failure mechanism. Methods. Serum cobalt, chromium, and titanium levels and synovial fluid characteristics were evaluated in 12 patients (13 aseptic revision TKAs) who underwent revision TKA between 2000 and 2020 at a single academic institution for mechanical implant failure or corrosion. Seventy-five percent were re-revisions of previously revised TKAs. Mean time to revision was 6 years. Modular metallic junctions were present in 100%. Twenty-five percent did not have another in situ total joint arthroplasty, and the remaining patients did not have a metal-on-metal articulation that could lead to elevation in serum metal ion levels. Mean follow-up after the revision TKA was 8 months. Results. Mean serum cobalt, chromium, and titanium concentrations were 11 ng/mL, 6 ng/mL, and 3 ng/mL, respectively. Serum metal ion levels facilitated failure mechanism identification in 75%, which included modular junction failure (6 cases), constraint locking mechanism failure (3 cases), corrosion of modular metallic interfaces (2 cases), and implant fracture (1 case). Arthrocentesis was performed in 75%. Mean synovial fluid cell count was 950 cells/mcL. Monocytes were the predominant mean cell type (41%), followed by neutrophils (35%), and lymphocytes (22%). Conclusion. Serum metal ion assessment should be considered when the etiology of painful primary or revision TKAs, particularly those with modular metallic junctions, remains elusive after routine evaluation

Aims. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common orthopaedic procedures requiring postoperative radiographs to confirm implant positioning and identify complications. Artificial intelligence (AI)-based image analysis has the potential to automate this postoperative surveillance. The aim of this study was to prepare a scoping review to investigate how AI is being used in the analysis of radiographs following THA and TKA, and how accurate these tools are. Methods. The Embase, MEDLINE, and PubMed libraries were systematically searched to identify relevant articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O’Malley framework were followed. Study quality was assessed using a modified Methodological Index for Non-Randomized Studies tool. AI performance was reported using either the area under the curve (AUC) or accuracy. Results. Of the 455 studies identified, only 12 were suitable for inclusion. Nine reported implant identification and three described predicting risk of implant failure. Of the 12, three studies compared AI performance with orthopaedic surgeons. AI-based implant identification achieved AUC 0.992 to 1, and most algorithms reported an accuracy > 90%, using 550 to 320,000 training radiographs. AI prediction of dislocation risk post-THA, determined after five-year follow-up, was satisfactory (AUC 76.67; 8,500 training radiographs). Diagnosis of hip implant loosening was good (accuracy 88.3%; 420 training radiographs) and measurement of postoperative acetabular angles was comparable to humans (mean absolute difference 1.35° to 1.39°). However, 11 of the 12 studies had several methodological limitations introducing a high risk of bias. None of the studies were externally validated. Conclusion. These studies show that AI is promising. While it already has the ability to analyze images with significant precision, there is currently insufficient high-level evidence to support its widespread clinical use. Further research to design robust studies that follow standard reporting guidelines should be encouraged to develop AI models that could be easily translated into real-world conditions. Cite this article: Bone Joint J 2022;104-B(8):929–937

To determine the outcome of subtrochanteric fractures treated by intramedullary (IM) nailing and identify causes for implant failure. We performed a retrospective analysis of all subtrochanteric fractures treated by intramedullary nailing in Belfast trauma units between February 2006 and 2009. This subgroup of patients was identified using the Fractures Outcome Research Database (FORD). Demographic data, implant type, operative details, duration of surgery and level of operator were collected and presented. Post-operative X-rays were assessed for accuracy of reduction. One hundred and twenty two (122) patients were identified as having a subtrochanteric fracture treated by IM nailing. There were 79 females and 43 males. Age range was 16 to 93 (mean 78). 95 (78%) cases were performed by training grades and 27 (22%) by consultants. Duration of surgery ranged from 73–129mins (mean 87mins). 47 patients (38.5%) were found to have a suboptimal reduction and 75 patients (61.5%) had an anatomical reduction on immediate post-operative x-ray. One year from surgery 73/122 patients were available for follow up. Of those patients with suboptimal reduction, 13/47 (27.7%) required further surgery. 8 required complete revision with bone grafting, and 5 underwent dynamisation. A further 6 patients had incomplete union. In the anatomical group, 4 patients underwent further surgery (5%). 3 required dynamisation and one had exchange nailing for an infected non-union. 3 patients had incomplete union at last follow up. 5/47 (10.6%) had open reduction in the suboptimal group compared to 25/75 (33.3%) in the anatomical group. Of the 27 cases performed by consultants, 13 (48%) were open reduction, compared to 17/93 (18%) by training grades. This study has shown that inadequate reduction of subtrochanteric fractures, leads to increased rates of non union and ultimately implant failure. We recommend a low threshold for performing open reduction to ensure anatomical reduction is achieved in all cases

Background. The management of non-unions of subtrochanteric femoral fractures with associated implant failure is challenging. This study assessed the outcome of a cohort of patients treated according to the diamond concept. Methods. Between 2005–2010 all patients with subtrochanteric aseptic non-unions presented post implant failure (Gamma Nail breakage) were eligible in the absence of severe systemic pathologies and comorbidities. Demographics, initial fracture pattern, method of stabilisation, mode of failure of metal work, time to revision of fixation, complications, time to union, and functional outcome were recorded over a minimum period of follow-up of 12 months. The revision strategy was based on the “diamond concept;” optimising the mechanical and biological environment (revision of fixation, osteoinduction/BMP-7, osteoconduction/RIA harvested graft, and osteogenicity/concentrate of bone marrow aspirate). Results. Out of 280 nailing procedures 12 (4.3%) cases met the inclusion criteria. A consistent mode of metalwork failure was recorded with initial breakage of the proximal distal locking screw followed by nail breakage at the lag screw level. Biomechanical SEM analysis of the nails revealed no structural damage besides the standard fatigue striation. Varus mal-reduction was present in all cases, with an average of 7.3 degrees (5–11). The average time to screw failure was 4.3 months (2–6) and nail failure was 5.9 months (4–10). All but one of the cases were revised to a 95 degrees blade plate and one to an Affixus nail. Time to union was 6.5 months (5–10). All but one of the cases by 12 months have returned to their preinjury level of mobilisation. Conclusion. Varus mal-reduction must be avoided in the initial stabilisation of subtrochanteric fractures. Proximal distal screw failure is predictive of future fracture non-union and subsequent nail breakage. The diamond concept for optimising mechanics and bone biology is a successful method for managing complex sub-trochanteric non-unions with failed metalwork

We examined the association between patient-related factors and the risk of initial, short- and long-term implant failure after primary total hip replacement. We used data from the Danish Hip Arthroplasty Registry between 1 January 1995 and 31 December 2002, which gave us a total of 36 984 patients. Separate analyses were carried out for three follow-up periods: 0 to 30 days, 31 days to six months (short term), and six months to 8.6 years after primary total hip replacement (long term). The outcome measure was defined as time to failure, which included re-operation with open surgery for any reason. Male gender and a high Charlson co-morbidity index score were strongly predictive for failure, irrespective of the period of follow-up. Age and diagnosis at primary total hip replacement were identified as time-dependent predictive factors of failure. During the first 30 days after primary total hip replacement, an age of 80 years or more and hip replacement undertaken as a sequela of trauma, for avascular necrosis or paediatric conditions, were associated with an increased risk of failure. However, during six months to 8.6 years after surgery, being less than 60 years old was associated with an increased risk of failure, whereas none of the diagnoses for primary total hip replacement appeared to be independent predictors

Total hip replacement procedures provide a very effective treatment modality for a wide range of diseases and injures to joints. The annual number of primary and surgeries has been increasing. In Region Emilia Romagna, 4000000 inhabitants, 4587 total hip replacements (THA) were performed in 1997 and the number raised up to 5410 in 2002 ( + 18%). Emiarthoplasties were respectively 1914 and 2215 (+ 16%). Parallely number of revision raised from 550 to 938 (+71%). In 2003 incidence of primary THAs in Emilia-Romagna is 107/100.000 inhabitants, higher than mean national value (76/100000). Data of both primary and revision surgeries are collected by RIPO (Register for Orthopaedic Prosthetic Implantology) that started its activity in Rizzoli Institute on January 1990 and in Regione Emilia-Romagna on January 2000. The recording of data is done for each joint replacement operation and it consists on the identification of the patient, information about diagnosis or reason for re-operation, surgical approach, antibiotic and antithromboembolic prophylaxis, perioperative complications. Acetabular, femoral and head components are separately registered, on the basis of stickers with catalogue numbers provided by manufacturers with the implants. Fixation of the components is recorded as well. Among the purposes of the Register there are the identification of early prosthesis failures, the information of surgeons on the outcome of their patients, the creation of a benchmarking tool for consultants and the speedy identification of relevant patients if a particular prosthesis or a particular batch gives cause for concern. As for Scandinavian registers, revision is used as an end-point in the analyses. On this basis it is possible to calculate survival curves either aggregated or stratified. By Cox multivariate analysis it has been ascertained that risk factors in total hip arthroplasties are represented by sex (females have lower risk than males), by age (younger than 40 are more at risk than 40–70s, and older than 70 are less at risk than 40–70s) and by pathology (fracture, coxites and Paget diseases have higher risk than coxarthrosis). Basing on these data, survival analysis was normalized and the influence of articular coupling and fixation of the components on prosthesis outcome have been evaluated. It resulted that failures are more likely to occur when metal on metal, or metal on polyethylene or ceramic on polyethylene devices rather than ceramic on ceramic implants are implanted. Similarly cemented and hybrid THAs fail at higher rate than uncemented ones. All data are referred to a 11 years follow-up. At present time Kaplan Meier analysis indicates a survival rate of total hip arthroplasties performed at Istituto Rizzoli of nearly 90% at ten years follow-up (9717 primary implants, 435 failures). Main reasons for revisions are aseptic loosening of the cup (33%),aseptic loosening of both components (18%), aseptic loosening of the stem (17%), deep infection (7.9%),dislocation (7.6%),prosthesis fracture (3%) etc. Aseptic loosening represent, therefore, the most frequent cause for revision. Results obtained at Istituto Rizzoli fit in the benchmarking set by the British NICE (National Institute for Clinical Excellence) that states that the revision rate should be of 10% or less at 10 years. To improve these results attention should be pointed on new models: hip prosthesis technology is continually changing, with new designs and techniques being introduced. There is a need to strike a balance between using prostheses with published long-term performance data, and the need to develop and improve hip prosthesis. A solution to this problem could be to entrust reference clinical centers the evaluation of the effectiveness of any new prosthesis for at least three years, before opening free distribution in standard orthopaedic units,as suggested by NICE. Only models that reach the ‘entry benchmark’ in adequately sized, well conducted observational studies, can be implanted with a good safety. At present time it is unlikely that clinical evaluation data on long term effectiveness is required by Notified Body for ‘CE’ marking, unless new materials are involved in the manufacture. This happens despite the fact that even small changes to existing prostheses can have a significant impact on implant performance and revision rate. Other factors than the already discussed can influence the surgery outcome, and among these the volume of operations performed in the hospital, the ability of the surgeon and its confidence with the technique, the compliance of the patient. Only an overall view of the situation will allow to reach the goal of reduction of need for revision of total hip arthroplasties

We studied 12 patients (13 elbows) who underwent total elbow replacement (TER) using the Kudo Mk IV or V prosthesis between 1989 and 1997. There were eight females and four males (mean age: 61 years, range: 38–74 years). The diagnosis was Rheumatoid arthritis in 10 patients and osteoarthritis in two patients. In each patient the initial result was classified as either excellent or good. All these patients then reported the recurrence of severe pain at a mean of four years from the time of the primary operation. Radiographic examination demonstrated fracture of the humeral stem in 10 elbows and subluxation of the joint in three elbows. The fractured humeral components were exchanged for long stem components. The three subluxated elbows were found to have undergone delamination and loosening of the ulnar components which were revised. One of these required revision to a linked prosthesis due to bone loss. In each case metallosis was found involving principally the synovial tissues which were as far as possible excised. Each patient regained a similar range of movement to that following the primary arthroplasty but continues to experience episodes of pain requiring anti-inflammatory medication. This is in contrast to our patients requiring revision procedures for implant loosening or instability who have become pain free. We conclude that the development of metallosis complicating mechanical implant failure predisposes to persisting symptoms following revision arthroplasty and recommend that this should be undertaken sooner rather than later when mechanical failure is detected

Aim: The aim of our retrospective study was to evaluate the precision of implantation of two different resurfacing systems and if incorrect positioning is a risk factor for implant failure. Method:. We started with the Birmingham Hip Resurfacing system (MMT,UK) and later introduced the Durom resurfacing system (Zimmer). We analysed the follow-up rx of all patients operated in our clinic. We measured the inclination of the cup, the CCD-angle of the head component, the alignement in respect to the neck axis, if the component had an eccentric position or if superior or inferior notching had occured. We compared the rate of failure of the two systems. Patients: In 90 patients a Mc Minn hip resurfacing system was implanted. The mean age in this group was 52 years (range 29 – 68 years). There were 64 male and 26 female patients. In 75 patients we implanted a Durom resurfacing system. The mean age in this group was 53 years (range 20 – 72 years). There were 55 male and 20 female patients. Results: In both groups the mean CCD angle was higher than before surgery, indicating that the head component was usually implanted in a slight valgus position. In 20 % of the cases component alignement was not ideal in both systems. There were four revisions of patients with the Durom system and three revision of patients with the McMinn system. The main reason for failure was weakening of the superior neck portion. Conclusion: As we were in the learning curve in hip resurfacing in a high number of cases positioning of the implant was not as it should be. This remained in most cases without clinical consequences but weakening of the superior neck portion seems to be the main reason leading to failure

Despite great progress in implant design, materials and new implantation techniques aseptic loosening is still the most frequent cause of implant failure in THA, which was found to be increased especially in patients with osteonecrosis of the femoral head (ON-FH). While a direct link between aseptic loosening and periprosthetic bone loss still remains elusive, there is plentiful evidence for a close association with early migration of implant components. Although the beneficial effect of bisphonates on periprosthetic bone mass is well established, little is known to date about their effects on implant migration. This is an important issue, because successful prevention of early implant migration would provide strong evidence of a beneficial effect on the survival rate of THA. Previously, Krismer et al. found that a total migration of the cup of ≥ 1mm and a subsidence of ≥ 1.5mm 2 years after surgery was highly predictive for aseptic implant failure of THA within 8 to 10 years. Fifty patients with end-stage ON-FH were consecutively enrolled to receive either 4mg of ZOL or saline solution (CTR) in a double-blind fashion. Radiographs standardized for EBRA-digital analysis were performed at each follow-up exam at 7 weeks, 6 months, 1 year, and yearly thereafter. The minimum follow-up period was 2 years (median follow-up: 2.8 years). Migration of the acetabular and femoral components was analyzed with the EBRA-digital software (University of Inns-bruck, Austria) independently by 3 investigators fully blinded to randomization. Within the placebo group, distal migration of the stem (subsidence) steadily increased up to −1.2mm ± 0.6 SD at 2 years after THA without reaching a plateau phase (P< 0.001, Friedman ANOVA). Less but a nearly curvilinear migration pattern was found for the acetabular components, with a transverse migration of 0.6mm ± 1.0 SD and a vertical migration of 0.6mm ± 0.8 SD at 2 years (P< 0.001, Friedman ANOVA). Treatment with ZOL effectively minimized the migration of cups in both the transverse and vertical direction (0.15 mm ± 0.6 SD and 0.06 mm ± 0.6 SD, respectively, P< 0.05, ANOVA), and a trend to a decreased subsidence was also found for stem migration (−0.91 mm ± 0.51 SD; P=0.11, ANOVA). In addition, total cup migration exceeding 1mm at 2 years was significantly reduced by ZOL in 8 patients (12 vs 4 in CTR vs ZOL, respectively) as was also found in 6 patients for subsidence (≥ 1.5mm in 9 vs 3 patients in CTR vs ZOL, respectively) (P< 0.05, Fisher’s exact). This is the first clinical trial reporting that a single infusion of ZOL suffices to improve initial implant fixation in THA. Based on best evidence available to date, this new concept shows great promise of improving the long-term outcome in THA and should be given attention in long-term trial

355 non-cemented MOM arthroplasties, of a single surgeon, with a follow up of 3–16 years (avg. 7.5 years) were retrospectively reviewed for evidence of pseudotumor and aseptic mechanical failure. There were 186 with 28 mm heads, 126 with 34 mm heads, 47 with 38 mm heads, from a single manufacturer.

There were 5 revisions of 38 mm heads for atraumatic painful “metalosis” 4–8 years after implantation (10.7%).

There were 4 revisions of 34 mm heads for post-traumatic instability (dislocation) with secondary metalosis 4–7 years after implantation (3.1%)

There were 2 revisions of 28 mm heads for post-traumatic instability (dislocation) with secondary metalosis 6–12 years after implantation (1.1%).

There were 5 patients, all with 38 mm heads, with asymptomatic “psoas bursae” with elevated serum CR and Co levels (1.0–3.0).

All of the failed THR's had acetabular components with lateral tilt <50 degrees (35–50), and anteversion angles <15 degrees (0–15). 2 of the 34 mm and both 28 mm instabilities were the consequence of injuries sustained in motor vehicle accidents. The remaining 2 instabilities with 34 mm implants were the result of mechanical falls.

Particulate debris, whether secondary to polyethylene, ceramic or metal articulations has been well documented as a cause of synovitis and damage to bony and soft tissues adjacent to a THR. This debris appears to be the result of material wear and mechanical failure with use over time. Unlike native articular cartilage, these materials are incapable of self-lubrication. Therefore THR articulations are dependent upon the penetration of ambient synovial fluid to provide lubrication of the replacement surfaces. This study suggests that increase in head diameter may reduce penetration of synovial fluid between the articulating surfaces of a THR, compromising the lubrication of bearing surfaces; thereby contributing to accelerated wear and premature failure of larger MOM arthroplasties.

Tissues from five patients who underwent revision operations for failed total hip replacements were found to contain large quantities of particulate titanium. In four cases this metal must have come from titanium alloy screws used to fix the acetabular component; in the fifth case it may also have originated from a titanium alloy femoral head. Monoclonal antibody labelling showed abundant macrophages and T-lymphocytes, in the absence of B-lymphocytes, suggesting sensitisation to titanium. Skin patch testing with dilute solutions of titanium salts gave negative results in all five patients. However, two of them had a positive skin test to a titanium-containing ointment.

The aim of this study was to establish any association between implant cut-out and a Tip Apex Distance (TAD), ≥25mm, in proximal femoral fractures, following closed reduction and stabilisation, with either a Dynamic Hip Screw (DHS) or Intramedullary Hip Screw (IMHS) device. Furthermore, we investigated whether any difference in cut-out rate was related to fracture configuration or implant type.

WE conducted a retrospective review of the full clinical records and radiographs of 65 consecutive patients, who underwent either DHS or IMHS fixation of proximal femoral fractures. The TAD was measured in the standard fashion using the combined measured AP and lateral radiograph distances. Fractures were classified according to the Muller AO classification.

35 patients underwent DHS fixation and 30 patients had IMHS fixation. 5 in each group had a TAD≥25mm. There were no cut-outs in the DHS group and 3 in the IMHS group. 2 of the cut-outs had a TAD≥25mm. The 3 cut-outs in the IMHS group had a fracture classification of 31-A2, 31-A3 and 32-A3.1 respectively. In addition, the fractures were inadequately reduced and fixed into a varus position.

A TAD<25mm would appear to be associated with a lower rate of cut-out. The cut-out rate in the IMHS group was higher than the DHS group. Contributing factors may have included an unstable fracture configuration and inadequate closed fracture reduction at the time of surgery.

Aims. Safety concerns surrounding osseointegration are a significant barrier to replacing socket prosthesis as the standard of care following limb amputation. While implanted osseointegrated prostheses traditionally occur in two stages, a one-stage approach has emerged. Currently, there is no existing comparison of the outcomes of these different approaches. To address safety concerns, this study sought to determine whether a one-stage osseointegration procedure is associated with fewer adverse events than the two-staged approach. Methods. A comprehensive electronic search and quantitative data analysis from eligible studies were performed. Inclusion criteria were adults with a limb amputation managed with a one- or two-stage osseointegration procedure with follow-up reporting of complications. Results. A total of 19 studies were included: four one-stage, 14 two-stage, and one article with both one- and two-stage groups. Superficial infection was the most common complication (one-stage: 38% vs two-stage: 52%). There was a notable difference in the incidence of osteomyelitis (one-stage: nil vs two-stage: 10%) and implant failure (one-stage: 1% vs two-stage: 9%). Fracture incidence was equivocal (one-stage: 13% vs two-stage: 12%), and comparison of soft-tissue, stoma, and mechanical related complications was not possible. Conclusion. This review suggests that the one-stage approach is favourable compared to the two-stage, because the incidence of complications was slightly lower in the one-stage cohort, with a pertinent difference in the incidence of osteomyelitis and implant failure. Cite this article: Bone Jt Open 2023;4(7):539–550

Aims. Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined. Methods. This single-centre retrospective cohort study included 116 patients (117 ankles) who underwent revision TAA for failed primary TAA between July 2000 and March 2010. Survival analysis and risk factor assessment were performed, and clinical performance and patient satisfaction were evaluated preoperatively and at last follow-up. Results. The mean duration from initial revision TAA to last follow-up was 15.0 years (SD 3.0; 11.2 to 20.5). The cumulative survival rates of the revised ankles were 81% (95% confidence interval (CI) 74% to 88%), 74% (65% to 82%), and 70% (61% to 79%) at five, ten, and 15 years, respectively. Comorbidities prior to primary TAA, aseptic loosening, instability, or grafting of cysts were found to be the most common risk factors for secondary revision. The median value for preoperative pain, as assessed using the visual analogue scale, declined from 6 (interquartile range (IQR) 5 to 8) to 2 (IQR 0 to 5) (p < 0.001) and the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from 43 (SD 17) preoperatively to 70 (SD 20) (p < 0.001) at last follow-up. Conclusion. Revision TAA offers acceptable survival rates after 15 years; it therefore offers a valuable option for treatment of implant failure in carefully selected cases. Although patient-reported outcomes improve substantially, the degree of improvement reported following primary TAA is not achieved. Cite this article: Bone Joint J 2024;106-B(1):46–52

Aims. Proximal femoral endoprosthetic replacements (PFEPRs) are the most common reconstruction option for osseous defects following primary and metastatic tumour resection. This study aimed to compare the rate of implant failure between PFEPRs with monopolar and bipolar hemiarthroplasties and acetabular arthroplasties, and determine the optimum articulation for revision PFEPRs. Methods. This is a retrospective review of 233 patients who underwent PFEPR. The mean age was 54.7 years (SD 18.2), and 99 (42.5%) were male. There were 90 patients with primary bone tumours (38.6%), 122 with metastatic bone disease (52.4%), and 21 with haematological malignancy (9.0%). A total of 128 patients had monopolar (54.9%), 74 had bipolar hemiarthroplasty heads (31.8%), and 31 underwent acetabular arthroplasty (13.3%). Results. At a mean 74.4 months follow-up, the overall revision rate was 15.0%. Primary malignancy (p < 0.001) and age < 50 years (p < 0.001) were risk factors for revision. The risks of death and implant failure were similar in patients with primary disease (p = 0.872), but the risk of death was significantly greater for patients who had metastatic bone disease (p < 0.001). Acetabular-related implant failures comprised 74.3% of revisions; however, no difference between hemiarthroplasty or arthroplasty groups (p = 0.209), or between monopolar or bipolar hemiarthroplasties (p = 0.307), was observed. There was greater radiological wear in patients with longer follow-up and primary bone malignancy. Re-revision rates following a revision PFEPR was 34.3%, with dual-mobility bearings having the lowest rate of instability and re-revision (15.4%). Conclusion. Hemiarthroplasty and arthroplasty PFEPRs carry the same risk of revision in the medium term, and is primarily due to acetabular complications. There is no difference in revision rates or erosion between monopolar and bipolar hemiarthroplasties. The main causes of failure were acetabular wear in the hemiarthroplasty group and instability in the arthroplasty group. These risks should be balanced and patient prognosis considered when contemplating the bearing choice. Dual-mobility, constrained bearings, or large diameter heads (> 32 mm) are recommended in all revision PFEPRs. Cite this article: Bone Joint J 2021;103-B(10):1633–1640

Background. Dynamic Hip Screw (DHS) is the most frequently used implant in management of intertrochanteric femoral fractures. There is a known statistical relationship between a tip-apex distance (TAD) >25mm and higher rate of implant failure. Our aim was to analyse all DHS procedures performed in our trust from seventeen months and compare their TAD values to the acceptable standard of ≤25mm. Methods. All patients undergoing DHS between April 2020-August 2021 were identified from our theatre system. Additionally, those presenting to hospital with implant failures were included. Patient demographics, date of surgery, fracture classification (AO) and date/mode of failure were recorded. Intraoperative fluoroscopy images were reviewed to calculate TAD, screw location and neck shaft angles by two independent observers. Results. 215 patients were identified, five of which were excluded due to inadequate fluoroscopy. Failure was seen in 3.3% of the cohort (n=7), of which 71.4% had an unacceptable TAD. In total, 21 patients (10%) had TAD >25mm, of whom 12 had superiorly and 15 had posteriorly placed screws. There were no failures in patients with a TAD of <20mm whereas a TAD >30mm had 50% failure rate. Conclusion. This audit reinforces the importance of aiming for a low TAD (preferably <20mm) intraoperatively. It is also desirable to avoid superiorly and significantly posteriorly placed screws. Implications. Complex hip revision surgery in the elderly bears substantial financial implications to the NHS and, more importantly, causes prolonged morbidity to the patient. Adhering to established standards will ensure reduced implant failure and best patient care

Aim. The aim of this study was to investigate the clinical relevance of an isolated positive sonication fluid culture (SFC) in patients who underwent revision surgery of a prosthetic joint. We hypothesized that cases with a positive SFC have a higher rate of infection and prosthesis failure during follow-up compared to controls with a negative SFC. Method. This retrospective multicentre observational study was performed within the European Study Group of Implant-Associated Infections (ESGIAI). All patients who underwent revision surgery of a prosthetic joint between 2013 and 2019 and had a minimum follow-up of 1 year were included. Patients with positive tissue cultures or synovial fluid cultures were excluded from the study. Results. 95 cases (positive SFC) and 201 controls (negative SFC) were included. There was no difference in infection and prosthesis failure during follow-up between both groups. When solely analysing patients that were not treated with antibiotics, 16% of the cases had an infection during follow-up versus 5% of the controls (P 0.046). Conclusions. Withholding antimicrobial treatment in patients with an isolated positive SFC is associated with a higher reinfection rate. Antimicrobial treatment should be considered in isolated positive SFC, especially in case of high virulent pathogens

Arthroplasty in patients who are intravenous drug abusers presents a complex challenge, frequently requiring intervention at a younger age. The cohort suffer increased complication rates due to significant co-morbidities and poor engagement in medical services, in comparison to other patients undergoing lower limb arthroplasty. Multiple small studies show arthroplasty in this patient cohort is associated with high complication and mortality rates. A search of electronic databases were undertaken with the assistance of the library services from the Rotherham NHS Foundation Trust, including Chocraine, SCOPUS and PubMed. Abstracts were reviewed and relevant studies extracted for full review. Full text articles were reviewed based on strict inclusion and exclusion criteria. Searches identified Two thousand and forty-four papers; twenty-seven studies were identified for full review of the paper based on the inclusion criteria above. From this, nine studies were deemed appropriate to for data extraction. These nine papers present one hundred and thirty-two cases of lower limb arthroplasty, fifty nine Total Knee Arthroplasty and seventy three Total Hip Arthroplasty. From this the authors examined incidences of implant failure due to infection, revision, mortality, dislocation, aseptic loosening, peri-prosthetic fracture, or other causes. Of these, 58% of patients (n = 77) with a history of intravenous drug abuse suffered some form of significant complication; 4% of this cohort (n = 5) were lost to follow up. Infection was reported in 32% of cases and a mortality rate of 4.7%. The rising demand of lower limb arthroplasty for intra-venous drug abusers presents a very real problem for the modern Orthopaedic surgeon. Within the studies examined, more than half report implant failure. This study synthesises the available literature regarding treatment of these patients to help facilitate decision making and informed consent

Introduction. The condition of the soft tissues surrounding an ankle fracture influences timing and treatment of injuries. Conventional treatment used an open approach to facilitate anatomical reduction and rigid internal fixation. Intramedullary devices for fibular fractures provide a safe alternative in patients in which the condition of the soft tissue envelope or the patient's co-morbidities may benefit from a less invasive approach. We compared outcomes for patients treated with open reduction internal fixation (ORIF) with those undergoing treatment with fibular nails (FN). Methods. 13 consecutive patients treated with fibular nails (FN) were compared with 13 age-matched patients that underwent open reduction and internal fixation (ORIF). All patients were followed to union. Study outcomes were time from admission to surgery, length of stay, wound failure, implant failure, revision surgery, OMAS and SF-36. Results. There was no difference in age or sex distribution between groups. There was no difference in OMAS at 1 year (83 ± 9 in FN group; 80± 21 in ORIF group) and SF-36 (94 ± 11 and 90 ± 20). There were 2 implant failures in the ORIF group and none in the FN group. There was one wound failure in the ORIF group and none in the FN group. Patients treated with FN had a shorter time to surgery (1 day ± 24 hours vs 3 days ± 24 hours) and shorter length of stay (1 day ± 24 hours vs 4 days ± 96 hours). Conclusion. FN is a safe method to treat patients with displaced distal fibular fractures that may have a poor soft tissue envelope and risk factors for wound healing. FN reduces the time to surgery and overall length of stay compared with similar patients treated with conventional ORIF