Introduction. The biological pathways responsible for adverse reactions to metal debris (ARMD) are unknown. Necrotic and inflammatory changes in response to Co-Cr nanoparticles in periprosthetic tissues may involve both a cytotoxic response and a type IV delayed hypersensitivity response. Our aim was to establish whether differences in biological cascade activation exists in tissues of patients with end-stage OA compared to those with aseptic loosening of a metal on polyethylene (MoP) THR and those with ARMD from metal-on-metal (MoM) THR. Patients & Methods. A microarray experiment (Illumina HT12-v4) was performed to identify the range of differential gene expression between 24 patients across 3 phenotypes: Primary OA (n=8), revision for aseptic loosening of MoP THR (n=8) and ARMD associated with MoM THR (n=8). Results were validated using Taqman Low Density Array (TLDA) selecting the top 36 genes in terms of fold-change (FC)>2 and a significant difference (p<0.05) on ANOVA. Pathways of cellular interaction were explored using Ingenuity IPA software. Results. There is a similar pattern of gene expression between MoP and MoM phenotypes versus primary OA across 33,777 genes. One hundred and thirty significantly differentially expressed genes across 3 phenotypes were identified. Fifteen pathways were associated with differentially expressed genes between MoP and MoM phenotypes. TLDA demonstrated qualitative mirroring of the expression pattern observed in the microarray and consistency in the direction of change for individual genes. Discussion. There were no signature pathways in which multiple genes are differentially expressed such that inferences between the contributions of innate macrophage and adaptive T-cell responses can be made. TIMP3 & MMP12 were consistently identified in 15 pathways that were associated with differential gene expression between MoP and MoM phenotypes. Conclusion. Analyses of the expression of individual genes such as PRG4 (lubricin) have demonstrated patterns that may provide avenues for further research into biomarkers for periprosthetic osteolysis and ARMD

Using a femoral head from one manufacturer on the stem of another manufacturer poses the risk that the taper interface between the components do not contact correctly and the performance of the joint will be impaired. The cohorts in this study are a combination of modular Birmingham Hip Resurfacing (BHR) and Adept femoral heads on CPT stems. The study reviews the geometry of the taper interfaces to establish if the taper clearance angles was outside of the normal range for other taper interfaces. In addition the rates of material loss from the bearings and taper and a ranking of the stem damage were reviewed to determine if the levels of loss were above that seen for other similar joints.

The material loss analysis demonstrated that the rates or levels of loss from the bearings, taper and stem are no different to levels published for manufacturer matched joints and in many cases are lower. The results demonstrate that the taper clearance angles for the mixed manufacturer joints (BHR-CPT: 0.067 to −0.116, Adept-CPT: 0.101 to −0.056) were within the range of other studies and manufacturer matched clearances (0.134 to −0.149).

Using components from different manufacturers has not in this instance increased the level of material loss from the joints, when compared to other similar manufacturer matched joints.

Metal-on-metal resurfacing of the hip (MoMHR) has enjoyed a resurgence in the last decade, but is now again in question as a routine option for osteoarthritis of the hip. Proponents of hip resurfacing suggest that its survival is superior to that of conventional hip replacement (THR), and that hip resurfacing is less invasive, is easier to revise than THR, and provides superior functional outcomes. Our argument serves to illustrate that none of these proposed advantages have been realised and new and unanticipated serious complications, such as pseudotumors, have been associated with the procedure. As such, we feel that the routine use of MoMHR is not justified.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):17–21.

Cobalt chrome alloy is commonly used in joint replacement surgery. However, it is recognised that some patients develop lymphocyte mediated delayed type hypersensitivity (DTH) responses to this material, which may result in extensive bone and soft tissue destruction. Phase 1. United Kingdom: From an existing database, we identified extreme phenotype patient groups following metal on metal (MoM) hip resurfacing or THR: ALVAL with low wearing prostheses; ALVAL with high wear; no ALVAL with high wear; and asymptomatic patients with implants in situ for longer than ten years. Class I and II HLA genotype frequency distributions were compared between these patients’ groups, and in silico peptide binding studies were carried out using validated methodology. Phase 2. United Kingdom: We expanded the study to include more patients, including those with intermediary phenotypes to test whether an algorithm could be developed incorporating “risk genotypes”, patient age, sex and metal exposure. This model was trained in phase 3. Phase 3. United Kingdom, Australia, United States. Patients from other centres were invited to give DNA samples. The data set was split in two. 70% was used to develop machine learning models to predict failure secondary to DTH. The predictions were tested using the remaining blinded 30% of data, using time-dependent AUROCs, and integrated calibration index performance statistics. A total of 606 DNA samples, from 397 males and 209 female patients, were typed. This included 176 from patients with failed prostheses, and 430 from asymptomatic patients at a mean of >10 years follow up. C-index and ROC(t) scores suggested a high degree of discrimination, whilst the IBS indicated good calibration and further backed up the indication of high discriminatory ability. At ten years, the weighted mean survival probability error was < 4%. At present, there are no tests in widespread clinical use which use a patient's genetic profile to guide implant selection or inform post-operative management. The algorithm described herein may address this issue and we suggest that the application may not be restricted to the field of MoM hip arthroplasty

Introduction. The rise of the anterior approach (AA) in primary surgery has led to enthusiasm for using this approach in revision surgery, especially because head and liner exchanges have been accompanied by a high dislocation rate when the posterior approach (PA) is used. The aim of this study was to compare the institutional dislocation rate comparing the PA and AA in isolated head and liner exchange. Methods. A retrospective institutional database query was done to identify all aseptic head and liner exchanges between the years 2010- June, 2020. 186 hips were identified with an average age of 64.8+/−10.8 yrs (27.9–87.6) and average BMI of 28.7+/−6.3 kg/m2 (16.2–52). The reason for revision was polyethylene wear and osteolysis in 105 hips (56.5%), adverse tissue reaction to metal on metal (MOM) in 43 hips (23.1%), and recurrent instability in 38 hips (20.4%). The approach used for the revision surgery was PA in 128 hips (68.8%) and AA in 58 hips (31.2%). The mean follow-up for this cohort is 1.9±2 yrs (0.0–8.6). Results. The overall dislocation rate for the entire cohort was 28/186 (15%). There was no difference in the dislocation rate whether the revision surgery was performed by the PA 19/128 (15%) or the AA 9/58 (16%) (p=0.9). With the numbers available, there was no difference in dislocation rates when comparing reason for revision: poly wear/osteolysis 12/105 (11%), MOM 8/43 (19%) or recurrent instability 8/38 (21%) (p=0.28). The head size used in the exchange did not influence the dislocation rate; 28 mm-2/11 (18%), 32 mm-6/56 (11%), 36 mm-16/91 (18%), 40 mm-4/26 (15%) (p=0.89). Conclusion. The use of either the PA or AA did not alter the dislocation rate in our cohort. While there was a trend towards a higher dislocation rate when liner exchange was performed for MOM or recurrent instability, no statistical difference was shown with the numbers available. The head size used in the revision did not influence the rate of dislocation

Introduction. Mix and Match (M&M) describes the use of components from more than one manufacturer in a total hip replacement (THR) The NJR has records of over 90,000 instances where this practice, which is contrary to the advice of most manufacturers and regulators, has been followed. Patients, Materials and Method. The NJR database 2003–13 was interrogated and the types of M&M were grouped using head size, bearing characteristics and use of cement. Results. Total Cohort. M&M. HARD ON SOFT. Metal head on poly socket. 345,618. 79,110. Ceramic Head on a poly socket. 42,176. 7,886. HARD ON HARD. Metal on Metal (all types). 31,609. 2,131. Ceramic on Ceramic. 87,156. 3,861. In a large number of cases, the M&M metal on plastic groups outshone their non-mix and matched controls. M&M “Head on Stem” has been shown to give inferior results. In the Ceramic on poly there is no significant difference in the performance between groups. In the Hard on Hard Metal on Metal groups the results are generally poor with some M&M doing better and some worse. In the case of ceramic on ceramic there is no significant difference so far. There have been outlier reports to MHRA for both M&M and non M&M groups. Discussion. This is the first time such a study, with such large numbers has ever been undertaken. The weakness of the study is the heavy reliance on “Revision” being the sole discriminator for failure, particularly in view of the sensitivity and potential incidence of under reporting of revision in NJR. Conclusion. It is suggested that BHS endorses the use of M&M where the results show it to be advantageous to patients and in revisions when it is appropriate. Surgeons should be aware of the results in the groups where there has not been any advantage of M&M

We aimed to demonstrate the clinical safety of a novel anatomic cementless ceramic hip resurfacing device. Concerns around the safety of metal on metal arthroplasty have made resurfacing less attractive, while long term function continues to make the concept appealing. Biolox Delta ceramic is now used in more than 50% of all hip arthroplasties, suggesting that it's safety profile is acceptable. We wondered if a combination of these concepts might work?. The preclinical testing of anatomic hip resurfacing device developed by our group was presented last year. A twenty patient safety study was designed. Patients had to be between the ages of 18 and 70. The initial size range was restricted to femoral heads between 46 and 54, representing the common sizes of hip resurfacing. The primary outcomes were clinical safety, PROMs and radiological control. Secondary outcomes include CTRSA and metal ion levels. 20 patients were recruited, aged 30–69. 7 were women and 13 were men. There were no operative adverse events in their operations undertaken between September 2017 and February 2018. One patient had a short episode of atrial fibrillation on the second postoperative day, and no other complications. At three months the median oxford hip score had risen from 27 (range 14–38) to 46 (31–48). Cobalt and chromium levels were almost undetectable at 3 months. Fixation appeared satisfactory in all patients, with no migration detected in either component. CTRSA is in process. The initial safety of a novel cementless ceramic resurfacing device is demonstrated by this data. The 10 year, 250 case efficacy study will continue in 5 other European centres

Trunnionosis is an important failure mechanism of total hip arthroplasties as has recently been reported by the England and Wales national joint registry. Adverse local tissue reaction has also recently been associated with total hip arthroplasty (THA) with metal on polyethylene and ceramic on polyethylene articulations. The contributing factors in the mechanism of this failure pattern have not been elucidated, however they are likely multifactorial to include corrosion, fretting, taper design, implantation time, metal particulate debris, and wear at the metal on metal interface. Furthermore, dissimilar metallic combinations have been shown to exacerbate tribocorrosion. Authors have also reported on the use of ceramic heads to reduce trunniononis, however, tribocorrosion is still present. The majority of the literature regarding modular head neck taper fretting and corrosion involves cobalt chrome (CoCr) alloy. Little is known about head neck fretting corrosion with Oxinium femoral heads. To measure fretting, corrosion, and wear on the female tapers of retrieved Oxinium femoral heads and to determine how demographic and device factors affect these measurements. Ninety-two (92) retrieved 12/14 Oxinium heads were graded using the modified Goldberg score for subjectively grading corrosion and fretting on the taper surface. A novel silicone molding technique was validated, then applied to the female tapers of the retrievals and of two pristine Oxinium femoral heads, sizes 32+0 and 32+4. The molds were scanned using a Konica Minolta 3D laser scanner for reconstruction of the topography, dimensions, and surface features of the tapers. Geomagic software was used to align the retrieved to the pristine 3D models, allowing measurement of surface deviations (from wear) that had occurred while the heads were implanted. Patient demographic and implant data were correlated with Goldberg scores and wear deviations. The mean Goldberg score was 1.6. Goldberg scores of 1 (minimal), 2 (mild), and 3 (moderate) were present in 41 of the 92 heads (45%), 43 heads (47%), and 8 heads (8%) respectively. No implants received a score of 4 (severe). A positive significant correlation was found between length of implantation and increased female taper fretting (R = 0.436, p < 0.01). Wear deviations were significantly greater with 36mm heads compared to 32mm heads (p < 0.01) and with +4 offsets compared to 0 offsets (p = 0.013). Similar to previous work analyzing ceramic heads, Oxinium heads demonstrated predominately mild tribocorrosion grades, however do not eliminate tribocorrosion. Tribocorrosion was increased with large heads and increased offsets. This finding is consistent perhaps with greater mechanical burden that larger implants with increased offsets experience. Further investigation is needed to elucidate if Oxinium femoral heads reduce fretting and corrosion when compared to CoCr femoral heads

The bearing surface is the critical element in determining the longevity of a total hip arthroplasty. Over the past decade problems associated with bearing surfaces and modular femoral tapers have had an impact on surgeon selection of both acetabular liners and modular femoral heads. The purpose of this study was to analyse THA bearing surface trends from 2007 through 2014 using a large national database. A retrospective review of the Nationwide Inpatient Sample (NIS) database was conducted from 2007 to 2014. All patients who underwent a primary THA were identified using International Classification of Diseases, 9th edition (ICD-9) procedure codes. Bearing surface data was extracted by identifying patients with ICD-9 procedure modifier codes. Patient and hospital characteristics were recorded for each patient. Descriptive statistics were employed to characterise bearing surface trends for the following bearing surfaces: metal on polyethylene (MoP); ceramic on polyethylene (CoP); ceramic on ceramic (CoC) and metal on metal (MoM). Univariate analysis was performed to identify differences between the bearing surface groups. During the study period, 2,460,640 primary THA discharges were identified, of which 1,059,825 (43.1%) had bearing surface data available for further analysis. The breakdown of the bearing surfaces used for these THAs were as follows: MoP − 49.1% (496,713); CoP − 29.1% (307,907); CoC − 4.2% (44,823); and MoM − 19.9% (210,381). MoM utilization peaked in 2008 with 51,033 cases representing 40.1% of THAs implanted that year. The usage steadily declined and by 2014 there were only 6,600 MoM cases representing only 4.0% of the THAs. From 2007 to 2014, the use of CoP bearing surfaces increased from 11,482 discharges (11.1% of cases) in 2007, to 83,300 discharges (50.8% of cases) in 2014. CoP utilization surpassed MoP in 2014. MoP accounted for 54.7% of discharges in 2011 and just 42.1% in 2014. During the study period, MoM bearing surface usage declined precipitously, while CoP surpassed MoP as the most prevalent bearing surface used in total hip arthroplasty patients. These changes in bearing surface usage over time were clearly influenced by concerns regarding high failure rates associated with MoM articulations and reports of taper corrosion associated with modular metal femoral heads

This study utilized data from the NJR dataset on all Corail/Pinnacle total hip replacements (THR) to determine (a) the level of unit variation of the Corail/Pinnacle 36mm Metal On Metal THR within England and Wales; (b) patient, implant and surgeon factors that may be associated with higher revision rates; (c) Account for the influence of the MHRA announcement in 2010. The national Revision Rate (RR) for the Corail / Pinnacle MOM THR was 10.77% (OR:1.46; CI:1.17–1.81). This was significantly greater than other articulation combinations (MOP 1.72%, COP 1.36%, COC 2.19%). The 2010 MHRA announcement did not increase rate of revision (X. 2. =1649.63, df=13, p<.001). Patient factors associated with significantly increased revision rates included, female gender (OR 1.38 (CI 1.17–1.63, p<.001) and younger age OR 0.99 (CI 0.98–0.99), p<.001). Implant factor analysis demonstrated an inverse relationship between cup size and revision. As head length increased RR increased – highest risk of revision +12.5 (OR 1.69 (CI 1.12–2.55), p=0.13). Coxa vara, high offset stems had a higher risk of revision compared to standard offset stems (OR:1.41 (CI 1.15–1.74; p<.001). As stem size increased risk of revision decreased (OR 0.89 (CI 0.85–0.93); p<.001). Surgeon grade did not influence RR. There was significant variation in RR between hospitals with 7 units (7/61 excluding low volume centres, <50 implants) identified as having significant higher rates of revision. However, for each of these units there was a greater proportion of higher risk patients (female, cup size 50–54, stem type). This study has provided insight into unit variation, risk factors and the long term outcome of the Corail/Pinnacle 36mm MOMTHR. Future aims are to use these results to develop a risk stratified algorithm for the long term follow of these patients to minimize patient inconvenience and excess use of limited NHS resources

Introduction. Failure of metal on metal (MOM) total hip arthroplasty (THA) and resurfacing arthroplasty (HRA) due to development of adverse local tissue reaction (ALTRs) is a significant problem. The prevalence of ALTRs in asymptomatic MOM arthroplasty patients is highly variable. The purpose of this prospective, longitudinal study was to: 1) determine MRI ALTR prevalence in patients with HRA; 2) determine if patients with HRA have a greater rate of MRI ALTRs compared to control patients with ceramic on poly (COP) THA; and 3) evaluate changes in patient reported outcomes between these implant designs. Methods. Following IRB approval with informed consent, self-reported asymptomatic primary COP and HRA patients greater than one year post arthroplasty were evaluated with 4 annual (TP1–4) MRIs using a standardized protocol and serum ion level testing. Morphologic and susceptibility reduced images were acquired for each hip and evaluated for synovial thickness, volume, capsule dehiscence and the presence of ALTR. Patient reported outcomes were evaluated by Hip Disability and Osteoarthritis Outcome Scores (HOOS). Analyses were performed to detect differences of synovial thickness and volume, and HOOS subgroups between and within bearing surfaces at each time point and over time, and to compare the time to and the risk of developing MRI ALTR. Analyses were adjusted for age, gender, and length of implantation. Results. 86 hips were evaluated at the initial time point (TP1): HRA, n=41, age=58±8 y.o., 34/7 (M/F); COP, n=45, age=65±9 y.o., 22/23 (M/F). The mean synovial volume of the subjects was similar at TP1, and the synovial volume in HRA subjects increased significantly from TP1 to TP4 (mean volume difference=9 cm3, p=0.031) while COP subjects displayed a minimal increase from TP1 to TP4 (mean volume difference =0.3 cm3, p=0.9). The synovial volume in HRA subjects tended to be larger and with greater variability than COP subjects at TP4 (HRA=15±58 cm3; COP=6 ±10 cm3, p=0.3). By TP4, MRI ALTRs developed in 13/41 HRA subjects (mean time to ALTR=1.5 yr) compared to 2/25 COP subjects (mean time to ALTR=2.0 yr), p=0.001. While risk of MRI ALTRs in HRA subjects was 9.9 times the risk in COP subjects (p=0.07), 68% of HRA subjects did not have an MRI ALTR present. Significant differences of [Co] and [Cr] in HRA subjects with MRI ALTR present were not detected at 2/4 time points and 1/4 time points, respectively, and there were no significant differences in ion levels in the COP group. The HOOS sub-scores of Pain and Activity of Daily Living scores of HRA subjects were similar to COP subjects, and HRA subjects had better Sporting Ability than COP subjects at all time points. HRA subjects had higher Symptoms at TP1 (p=0.016) but both cohorts had high scores (HRA=92.3/100; COP=87.7/100). Initially dehiscent posterior capsules of HRA subjects (9%) tended not to resolve (10/11, 91%), while dehiscent COP subjects (15%) had greater resolution (6/22, 27%). The presence of osteolysis was limited (HRA: 6/41; COP: 3/45; p=0.101). Conclusion. A greater synovial volume and higher rate of MRI ALTRs was found in HRA subjects, while the patient symptomatology via HOOS remained slightly better in HRA subjects than COP subjects, suggesting a poor association between MRI ALTRs and symptoms. The presence of posterior decompression of the posterior capsule into the bursa alone was not necessarily indicative of an ALTR, and is likely a normal postoperative finding. The inconsistent findings of the serum ion level testing further supports MRI as a non-invasive imaging modality capable of assessing peri-prosthetic soft tissue complications, and should be considered as part of the routine patient follow up to allow early detection and monitoring of ALTRs

As adverse events related to metal on metal hip arthroplasty have been better understood, there has been increased interest in toxicity related to the high circulating levels of cobalt ions. However, distinguishing true toxicity from benign elevations in cobalt levels can be challenging. The purpose of this review is to examine the use of cobalt alloys in total hip arthroplasty, to review the methods of measuring circulating cobalt levels, to define a level of cobalt which is considered pathological and to review the pathophysiology, risk factors and treatment of cobalt toxicity. To the best of our knowledge, there are 18 published cases where cobalt metal ion toxicity has been attributed to the use of cobalt-chromium alloys in hip arthroplasty. Of these cases, the great majority reported systemic toxic reactions at serum cobalt levels more than 100 μg/L. This review highlights some of the clinical features of cobalt toxicity, with the goal that early awareness may decrease the risk factors for the development of cobalt toxicity and/or reduce its severity. Take home message: Severe adverse events can arise from the release of cobalt from metal-on-metal arthroplasties, and as such, orthopaedic surgeons should not only be aware of the presenting problems, but also have the knowledge to treat appropriately. Cite this article: Bone Joint J 2016;98-B:14–20

Introduction. The prevalence of adverse reactions to metal debris (ARMD) associated with metal on metal (MoM) hip arthroplasty has been reported to be as high as 69%. Such findings promoted the development of metal-artefact reducing sequence (MARS)-magnetic resonance imaging (MRI) classifications, with the aim of stratifying soft lesions by severity of disease. The Modified Oxford Classification is a straightforward system that has been shown to correlate with disease progression. Methods. The aim of this study was to test the reliability of this classification between observers. Seven observers were recruited, all with a musculoskeletal background. Using the PACS image analysis system, 20 MARS-MRI scans were provided for interpretation. Observers reviewed these scans in random order at two separate intervals over the course of five weeks. They classified them according to the Modified Oxford Classification as: ‘normal’, ‘trochanteric fluid, ‘effusion’, ‘ARMD type 1’, ‘ARMD type 2’ and ‘ARMD type 3’. Results. Statistical tests using kappa co-efficients were performed to get intra and inter observer reliabilities. Our results were compared against the grading system proposed by Landis and Koch. Our inter-rater agreement was 0.61. This is considered substantial agreement. Our intra observer scores ranged for 0.57 to 1.00 indicating consistency between the observers as individuals and as a group. Conclusion. The modified oxford classification is simple and easy to remember and has substantial reliability. It is proving to be effective in communicating, classifying and providing an understanding of disease progression

Aims

The aims of the study were to report for a cohort aged younger than 40 years: 1) indications for HRA; 2) patient-reported outcomes in terms of the modified Harris Hip Score (HHS); 3) dislocation rate; and 4) revision rate.

Aims

The main advantage of 3D-printed, off-the-shelf acetabular implants is the potential to promote enhanced bony fixation due to their controllable porous structure. In this study we investigated the extent of osseointegration in retrieved 3D-printed acetabular implants.

Aims

Large-diameter metal-on-metal (MoM) total hip arthroplasty (THA) has demonstrated unexpected high failure rates and pseudotumour formation. The purpose of this prospective cohort study is to report ten-year results in order to establish revision rate, prevalence of pseudotumour formation, and relation with whole blood cobalt levels.

Total Hip Arthroplasty (THA) is a successful operation for the management of end stage hip osteoarthritis (OA) but long term success is limited by wear of the polyethylene bearing surface. The aim of this study was to compare the rate of revision at 15 years in patients <55 who had a THA for OA, and received either cross-linked (XLPE) or conventional non cross-linked polyethylene (non-XLPE). The study population was all patients with primary THAs undertaken for OA from 1999 to 31 December 2016. Outcomes were determined for all procedures, comparing THA performed with non-XLPE and XLPE and including the effect of age, sex, and reason for revision. The principal outcome measure was time to first revision using Kaplan-Meier estimates of survivorship. There were 17,869 procedures recorded for younger patients <55 years of age undergoing THA for OA and using either non XLPE or XLPE. There was a fivefold increase in the rate of revision for procedures using non-XLPE after seven years. The 15 year cumulative percent revision of primary THA performed for OA in patients <55 with non XLPE was 17.4% (95% CI 15.5,19.5) and for XLPE was 6.6% (95%CI 5.5,7.8) HR >7 years =5.3, p<0.001. Non-XLPE and XLPE were combined with three different femoral head bearing surfaces: ceramic, metal and ceramicised metal. Within each bearing surface, XLPE had a lower rate of revision than non-XLPE. For the most common head size of 28mm XLPE had a lower rate of revision. The use of XLPE has resulted in a significant reduction in the rate of revision for younger patients undergoing THA for OA at 15 years. This evidence suggests that longevity of THA is likely to be improved and may enable younger patients to undergo surgery, confident of a reduced need for revision in the long term

Aims. This study aimed to determine if macrophages can attach and directly affect the oxide layers of 316L stainless steel, titanium alloy (Ti6Al4V), and cobalt-chromium-molybdenum alloy (CoCrMo) by releasing components of these alloys. Methods. Murine peritoneal macrophages were cultured and placed on stainless steel, CoCrMo, and Ti6Al4V discs into a 96-well plate. Cells were activated with interferon gamma and lipopolysaccharide. Macrophages on stainless steel discs produced significantly more nitric oxide (NO) compared to their control counterparts after eight to ten days and remained elevated for the duration of the experiment. Results. On stainless steel, both nonactivated and activated cell groups were shown to have a significant increase in metal ion release for Cr, Fe, and Ni (p < 0.001, p = 0.002, and p = 0.020 respectively) compared with medium only and showed macrophage-sized corrosive pits on the stainless steel surface. On titanium alloy discs there was a significant increase in aluminum (p < 0.001) among all groups compared with medium only. Conclusion. These results indicated that macrophages were able to attach to and affect the oxide surface of stainless steel and titanium alloy discs. Cite this article: Bone Joint J 2020;102-B(7 Supple B):116–121

Aims

Studying the indications for revision total hip arthroplasty (THA) may enable surgeons to change their practice during the initial procedure, thereby reducing the need for revision surgery. The aim of this study was to identify and describe the potentially avoidable indications for revision THA within five years of the initial procedure.

Aims

Femoral stems with exchangeable (modular) necks were introduced to offer surgeons an increased choice when determining the version, offset and length of the femoral neck during total hip arthroplasty (THA). It was hoped that this would improve outcomes and reduce complications, particularly dislocation. In 2010, the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) first reported an increased rate of revision after primary THA using femoral stems with an exchangeable neck. The aim of this study was to provide a more comprehensive up-to-date analysis of primary THA using femoral stems with exchangeable and fixed necks.