The recruitment drive, investment and collaboration within Betsi Cadwaladr University Health Board (BCUHB) sites providing specialist lower limb arthroplasty and trauma service has evolved over last few years with aims to improve patient care and reduce reliance on tertiary referral centres. Through our service-evaluation project, we reviewed the results of treatment provided for periprosthetic femur fractures (PPFFs) presenting to BCUHB sites over last 4 years. We retrospectively reviewed consecutive PPFFs admitted at three BCUHB sites from January’20 to June’23 with mean follow-up of 20.8 ± 13.2 (8–49) months [n=161; Mean age: 82.2 ± 8.5 (59–101) years, Females:107]. Over the review period we noted a 23% increase in service demand for care of PPFFs. Majority were managed surgically [132/161] [38 revision arthroplasties; 94 ORIFs] at BCUHB sites and two patients were referred to tertiary centre. Average time to surgery was 3.5 days. 90% of the PPFFs were managed successfully with 10% (16/159) having orthopaedic complications needing further intervention. 6.3 (10/159) had medical complications and did not need orthopaedic re-intervention. In our series, 12-month re-operation rate was 6.1% (8/132) and 1-month, 3-month and 1-year mortality rate was 6.3%, 11.3% and 21.4% respectively. These results are comparable to the published results of PPFF management at tertiary centres. Potential cost savings compared to transfer to tertiary centre for PPFF management was £2.31 million. Thus, it is possible to successfully provide adequate care for PPFFs at DGHs and efforts should be made to appropriately equip and adequately staff DGHs, to provide service for local PPFF care

Periprosthetic femoral shaft fractures are a significant complication of total hip arthroplasty. Plate osteosynthesis with or without onlay strut allograft has been the mainstay of treatment around well-fixed stems. Nonunions are a rare, challenging complication of this fixation method. The number of published treatment strategies for periprosthetic femoral nonunions are limited. In this series, we report the outcomes of a novel orthogonal plating surgical technique for addressing nonunions in the setting of Vancouver B1 and C-type periprosthetic fractures that previously failed open reduction internal fixation (ORIF). A retrospective chart review of all patients from 2010 to 2014 with Vancouver B1/C total hip arthroplasty periprosthetic femoral nonunions was performed. All patients were treated primarily with ORIF. Nonunion was defined as no radiographic signs of fracture healing nine months post-operatively, with or without hardware failure. Exclusion criteria included open fractures and periprosthetic infections. The technique utilised a mechanobiologic strategy of atraumatic exposure, resection of necrotic tissue, bone grafting with adjuvant recombinant growth factor and revision open reduction internal fixation. Initially, compression was achieved using an articulated tensioning device and application of an anterior plate. This was followed by locked lateral plating. Patients remained non-weight bearing for eight weeks. Six Vancouver B1/C periprosthetic femoral nonunions were treated. Five patients were female with an average age of 80.3 years (range 72–91). The fractures occurred at a mean of 5.8 years (range 1–10) from their initial arthroplasty procedure. No patients underwent further revision surgery; there were no wound dehiscence, hardware failures, infections, or surgical complications. All patients had a minimum of nine months follow up (mean 16.6, range 9–36). All fractures achieved osseous union, defined as solid bridging callus over at least two cortices and pain free, independent ambulation, at an average of 24.4 weeks (range 6.1–39.7 weeks). To our knowledge, this is the first case series describing 90–90 locked compression plating using modern implants for periprosthetic femoral nonunions. This is a rare but challenging complication of total hip arthroplasty and we present a novel solution with satisfactory preliminary outcomes. Orthogonal locked compression plating utilising an articulated tensioning device and autograft with adjuvant osteoinductive allograft should be considered in periprosthetic femur fractures around a well-fixed stem. Further biomechanical and clinical research is needed to improve our treatment strategies in this population

Purpose. The purpose of this study was to evaluate the results of modular revision stems, uncemented fluted, tapered to treat periprosthetic femoral (PFF) fracture; we specifically evaluated fracture union, implant stability, patient outcomes, and complications to compare the differences between cemented and cementless primary stem. Materials and Methods. We retrospectively reviewed 56 cases of unstable periporsthetic femoral fracture (forty B2 and sixteen B3) treated with the uncemented fluted and tapered modular distal fixation stem with or with or without autogenous bone graft. Clinical outcomes were assessed with Harris Hip Score and WOMAC score. Radiologic evaluations were conducted using Beals and Tower's criteria. Any complication during the follow-up period was recorded. Results. The average follow-up period was 52.1±32.7 months. The average Harris Hip Score was 72.4±19.1. All fractures were united, and a good consolidation was achieved in 47 cases. There was femoral stem subsidence in 3 cases less than 10 mm without an evidence of loosening both radiologically and clinically. The radiologic results using Beals and Towers’ criteria were excellent in 36 hips, good in 10 hips and poor in 10 hips. Radiologic bone union took longer time and statistically significant stem subsidence was observed in cemented primary stem compared to cementless primary stem (Fig1,2). At each follow-up examination the clinical score was significantly higher in patients with cementless primary stem. Conclusion. Our results support the view that cement primary stem has less favorable result in terms of revision arthroplasty for periprosthetic femoral fractures

Background. Obesity has been linked with increased rates of knee osteoarthritis. Limited information is available on the survival and functional outcome results of rTKR in the obese patients. This registry-based study aimed to identify whether BMI is an independent risk factor for poorer functional outcomes and /or implant survival in rTKA. Methods. New Zealand Joint Registry (NZJR) data of patients who underwent rTKA from 1st January 2010 to January 2023 was performed. Demographics, American Society of Anesthesiologists (ASA), BMI, Operative time, indications for revision and components revised of the patients undergoing rTKA was collected. Oxford knee score (OKS) at 6 months and rates of second revision (re- revision) were stratified based on standardised BMI categories. Results. Of the 2687 revisions, functional outcome scores were available for 1261 patients. Oxford knee scores following rTKA are significantly inferior in higher BMI patients (36.5 vs 31.5 p<0.001). This held true when adjusted for age (35.7 vs 30.9 p<0.001). Tibial component loosening was a more common indication for revision in patients with BMI >40 (31.1% vs 21% for BMI <25), whereas periprosthetic femoral fracture was significantly more commonly seen in patients with BMI <25. Re-revision rates displayed no significant differences between any pairs of BMI groups (2.18/100 component years) and adjusting for age and sex did not alter this (p= 0.462). Indications for re-revision were also not different between BMI categories. Over 50% of the rTKA patients were obese. Significantly more obese patients were ASA grade 3,4 and more were <75 years. Operative time was longer in the obese patients (p<0.001). Conclusions. Although overall re-revision rates are similar between all BMI categories, the functional outcomes favour those with lower BMI. Patients with higher BMI are younger, more comorbid and carry potentially higher perioperative risks. The registry data provides valuable information when providing counsel to patients undergoing rTKA and lends further support to optimising patients prior to pTKA

The management of periprosthetic distal femur fractures is an issue of increasing importance for orthopaedic surgeons. Because of the expanding indications for total knee arthroplasty (TKA) and an aging population with increasingly active lifestyles there has been a corresponding increase in the prevalence of these injuries. The management of these fractures is often complex because of issues with obtaining fixation around implants and dealing with osteopenic bone or compromised bone stock. In addition, these injuries frequently occur in frail, elderly patients, and the early restoration of function and ambulation is critical in these patients. There remains substantial controversy with respect to the optimal treatment of periprosthetic distal femur fractures, with some advocating for Locked Plating (LP), others Retrograde Intramedullary Nailing (RIMN) and finally those who advocate for Distal Femoral Replacement (DFR). The literature comparing these treatments, has been infrequent, and commonly restricted to single-center studies. The purpose of this study was to retrospectively evaluate a large series of operatively treated periprosthetic distal femur fractures from multiple centers and compare treatment strategies. Patients who were treated operatively for a periprosthetic distal femur fracture at 8 centers across North America between 2003 and 2018 were retrospectively identified. Baseline characteristics, surgical details and post-operative clinical outcomes were collected from patients meeting inclusion criteria. Inclusion criteria were patients aged 18 and older, any displaced operatively treated periprosthetic femur fracture and documented 1 year follow-up. Patients with other major lower extremity trauma or ipsilateral total hip replacement were excluded. Patients were divided into 3 groups depending on the type of fixation received: Locked Plating, Retrograde Intramedullary Nailing and Distal Femoral Replacement. Documented clinical follow-up was reviewed at 2 weeks, 3 months, 6 months and 1 year following surgery. Outcome and covariate measures were assessed using basic descriptive statistics. Categorical variables, including the rate of re-operation, were compared across the three treatment groups using Fisher Exact Test. In total, 121 patients (male: 21% / female: 79%) from 8 centers were included in our analysis. Sixty-seven patients were treated with Locked Plating, 15 with Retrograde Intramedullary Nailing, and 39 were treated with Distal Femoral Replacement. At 1 year, 64% of LP patients showed radiographic union compared to 77% in the RIMN group (p=0.747). Between the 3 groups, we did not find any significant differences in ambulation, return to work and complication rates at 6 months and 1 year (Table 1). Reoperation rates at 1 year were 27% in the LP group (17 reoperations), 16% in the DFR group (6 reoperations) and 0% in the RIMN group. These differences were not statistically significant (p=0.058). We evaluated a large multicenter series of operatively treated periprosthetic distal femur fractures in this study. We did not find any statistically significant differences at 1 year between treatment groups in this study. There was a trend towards a lower rate of reoperation in the Retrograde Intramedullary Nailing group that should be evaluated further with prospective studies. For any figures or tables, please contact the authors directly

Introduction. Cementless grit-blasted tapered-wedge titanium femoral stems are being used with increasing frequency in hip arthroplasty because of excellent long-term outcomes. However, periprosthetic femur fracture is a potentially worrisome phenomenon in these types of femoral stems. The aim of this study is to report the incidence of stem loosening in association with periprosthetic femur fractures following hip arthroplasty using cementless grit-blasted tapered-wedge stems. Materials & Methods. A total of 36 Vancouver Type B1 and B2 periprosthetic femur fractures following either hemiarthroplasty or total hip arthroplasty using cementless grit-blasted tapered-wedge titanium femoral stems (GB group) were identified from a retrospective review of the medical records at three participating academic institutions. The control group consisted of 21 Vancouver Type B1 and B2 periprosthetic femur fractures following either hemiarthroplasty or total hip arthroplasty using cementless proximal porous-coated femoral stems (PC group) at the same institutions during the same period of the study. All femoral stems included in this study had been a well-fixed state before the occurrence of periprosthetic femur fractures. All patients in both groups were treated surgically with either open reduction and internal fixation or femoral stem revision. Femoral stem stability was assessed by preoperative radiographs and was confirmed by intraoperative scrutinization. The incidence of stem loosening was compared between the groups. Results. There was no significant difference between the groups with respect to demographic data including age, gender, body mass index, primary diagnosis, Dorr types of proximal femur, and time to fracture. All fractures occurred from low-energy mechanisms. Mean age at the time of hip arthroplasty was 54.5 years in the GB group and 57.0 years in the PC group. Mean time interval between hip arthroplasty and periprosthetic fracture was 49.6 months in the GB group and 44.4 months in the PC group. At the time of the last follow-up, 29 (80.6%) of 36 fractures was Vancouver B2 in the GB group, whereas only 3 (14.3%) of 21 fractures was Vancouver B2 in the PC group (P <0.001). Conclusions. High incidence of stem loosening was developed in association with periprosthetic femur fractures in previously well-fixed cementless grit-blasted tapered-wedge femoral stems in our population. We believe that this is an underreported phenomenon of these types of stem design

Introduction. In recent years, there has been an increase in hip joint replacement surgery using short bone-preserving femoral stem. However, there are very limited data on postoperative periprosthetic fractures after cementless fixation of these stem although the periprosthetic fracture is becoming a major concern following hip replacement surgery. The purpose of this study is to determine incidence of postoperative periprosthetic femoral fractures following hip arthroplasty using bone preserving short stem in a large multi-center series. Materials & Methods. We retrospectively reviewed 897 patients (1089 hips) who underwent primary total hip arthroplasty (THA) or bipolar hemiarthroplasty (BHA) during the same interval (2011–2016) in which any other cementless, short bone-preserving femoral stem was used at 7 institutions. During the study, 1008 THAs were performed and 81 BHAs were performed using 4 different short femoral prostheses. Average age was 57.4 years (range, 18 – 97 years) with male ratio of 49.7% (541/1089). Postoperative mean follow-up period was 1.9 years (range, 0.2 – 7.9 years). Results. Overall incidence of postoperative periprosthetic femoral fractures was 1.1% (12/1089). The mean age of these 12 patients were 71.2 year (range, 43 – 86 years). Seven patients were female and other 5 were male. Time interval between primary arthroplasty and fracture were mean 1.1 years (range, 0.1 – 4.8 years). Injury mechanism is a slip in 10 fractures and fall from 1m or less in 2. Three fractures occurred after BHA while 9 occurred after THA. Four fractures were in type AG and other 8 were in type B1 according to Vancouver classification. Of the 4 with AG type, 2 underwent open reduction and internal fixation and 2 took conservative management. Of the 8 with B1 type, 6 underwent open reduction and internal fixation and 2 took conservative management. Conclusion. The prevalence of postoperative periprosthetic femoral fractures was 1.1% in a multicenter retrospective analysis of 1089 hips. Our findings suggest that postoperative periprosthetic fracture can occur after hip replacement surgery using short bone-preserving stem although the incidence is relatively low

INTRODUCTION. The increasing incidence of periprosthetic femoral fractures (PFF) after total hip arthroplasty presents growing concerns due to challenges in treatment and increased mortality. PFF are often observed when the prosthesis is implanted in varus, especially with blade-type stems. To help elucidate its impact on the PFF risk, the specific research question is: What is the effect of misalignment of a blade-type stem (resulting in down-sized prosthesis) on 1)the distribution and magnitude of cortical stresses and 2)implant-bone micromotion. METHOD. We developed two finite element models consisting of an average female femur implanted within a generic blade-type stem prosthesis, (i)in neutral alignment, and (ii)oriented in 5° of varus, coupled with corresponding down-sizing of the prosthesis. Each model consisted of 1.1million elements, while the average mesh length at the implant-bone interface was 0.4mm. Elastic moduli of 15GPa(cortex), 150MPa(trabecular bone), and 121GPa(implant), and Poisson's ratio of 0.3 were assumed. The distal end was fixed and the interface was defined as a surface-to-surface contact with friction coefficients (dynamic 0.3; static 0.4). Walking and stair-climbing were simulated by loading the joint contact and muscle forces after scaling to the subjects’ body weight. The peak von Mises stress and the average stress within the surface having 1cm diameter and the center at where the peak stress occurred at each contacting area, the interfacial micromotion along medial, lateral side were analyzed. For statistical analysis, two-tailed t-test was performed between the neutral and varus cases over four loading cycles with significance level of p<0.05. RESULTS. Neutral alignment led to three areas of cortical/implant contact with focal load transfer via those areas, whereas varus placement limited to two areas (Figure 1). In both simulations, the greatest stress was observed at the proximal medial contact. With varus, average and peak stresses increased by 39% and 65% during walking and 28% and 35% during stair-climbing, respectively (Table 1). Micromotion was greatest over the proximal third of the interface, especially along lateral side (Figure 2). The 90. th. percentile values with the varus exceeded the neutral by 35% with walking and 28% with stair-climbing over the lateral interface. DISCUSSION. The proximal medial location of the greatest stress correlates well with clinical observations in PFF involving a posteromedial calcar fragment. Based on current lesser stress than the reported yield stress, loading during daily living activities may result in microdamage rather than an immediate PFF. However, impact loading such as hammering for stem insertion may introduce PFF at the location, especially with in varus. The increase in interfacial micromotion is expected to lead to increase in the risk for implant loosening, also leading to PFF. Further study is needed to confirm the validity and generalizability of these findings. SIGNIFICANCE/CLINICAL RELEVANCE. This study demonstrates the importance of proper alignment of femoral stems of a blade-type design. The misalignment (resulting in down-sizing) increased stress up to 65% and micromotion up to 35% around prosthesis, even during daily activities, thus increased attention to proper implant alignment and sizing is suggested when using components of this design. For any figures or tables, please contact the authors directly

Fully constrained liners are used to treat recurrent dislocations or patients at high risk after total hip replacements. However, they can cause significant morbidities including recurrent dislocations, infections, aseptic loosening and fractures. We examine long term results of 111 patients with tripolar constrained components to assess their redislocation and failure rate. The purpose of this study was to assess survivorship, complications and functional outcomes at a minimum 10 years after the constrained tripolar liners used in our institute. We retrospectively identified 111 patients who had 113 revision tripolar constrained liners between 1998 and 2008. Eighty-nine were revised due to recurrent dislocations, 11 for pseudotumor with dysfunctional abductors, and 13 for periprosthetic infection with loss of soft tissue stabilizers. All patients had revision hip arthroplasty before the constrained liner was used: 13 after the first revision, 17 after the second, 38 after the third, and 45 had more than 3 revisions. We extracted demographics, implant data, rate of dislocations and incidence of other complications. Kaplan Meier curves were used to assess dislocation and failure for any reason. WOMAC was used to assess quality of life. At 10 years, the survival free of dislocation was 95.6% (95%CI 90- 98), and at 20 years to 90.6% (95% CI 81- 95.5). Eight patients (7.1%) had dislocations of their constrained liners: 1 patient had simultaneous periprosthetic infection identified at the time of open reduction, and 1 patient sustained stem fracture 3 months prior to the liner dislocation. At 10 years, the survival to any further surgery was 89.4% (95% CI 82–93.8), and at 20 years, this was 82.5 (95% CI 71.9–89.3). Five patients (4.4%) had deep infection: 4 of these had excision arthroplasty due to failure to control infection, while 1 patient was treated successfully with debridement, exchange of mobile components and intravenous antibiotics. Two patients (1.8%) had dissociated rings that required change of liner, ring and head. Two patients (1.8%) had periprosthetic femoral fractures that were treated by revision stems and exchange of constrained liners. The mean WOMAC functional and pain scores were 66.2 and 75.9 of 100, respectively. Constrained tripolar liners in our institute provided favourable results in the long term for recurrent dislocation hip arthroplasty with dysfunctional hip stabilizers. Infection in these patients can prove to be difficult to treat due to their poor soft tissue conditions from repeated surgeries. Comparing long terms results from other types of constrained liners is essential to evaluate these salvage liners

The benefit of using a long intramedullary device for the treatment of geriatric intertrochanteric hip fractures is unknown. The InterTAN device (Smith and Nephew, Memphis TN) is offered in either Short (180–200 mm) or Long (260–460 mm) constructs and was designed to provide stable compression across primary intertrochanteric fracture fragments. The objective of our study was to determine whether Short InterTANs are equivalent to Long InterTANs in terms of functional and adverse outcomes for the treatment of geriatric intertrochanteric hip fractures. 108 patients with OTA classification 31A–1 and 31A–2 intertrochanteric hip fractures were included in our study and prospectively followed at one of four Canadian Level-1 Trauma Centres. Our primary outcomes included two validated primary outcome measures: the Functional Independence Measure (FIM), to measure function, and the Timed Up and Go (TUG), to measure motor performance. Secondary outcome measures included blood loss, length of procedure, length of stay and adverse events. A pre-injury FIM was measured by retrospective recall and all postoperative outcomes were assessed on postoperative day 3, at discharge, at 6 weeks, 3 months, 6 months and 12 months postoperatively. Unpaired t-tests and Chi-square tests were used for the comparison of continuous and categorical variables respectively between the Short and Long InterTAN groups. A statistically significant difference was defined as p<0.05. Our study included 71 Short InterTAN and 37 Long InterTAN patients with 31A–1 and 31A–2 intertrochanteric hip fractures. Age, sex, BMI, side, living status and comorbidities were similar between the two groups. The mean operative time was significantly lower in the Short InterTAN group (61 mins) as compared to the Long InterTAN group (71 mins)(p0.05). There were 5 periprosthetic femur fractures in the short InterTAN group versus 1 in the long InterTAN group. Non-mechanical adverse outcomes such as myocardial infarction, pulmonary embolism, urinary tract infections, pneumonia and death all had similar incidence rates between the two InterTAN groups. Both the Short and Long InterTAN patient cohorts displayed similar improvements in performance and overall function over the course of a year following intertrochanteric hip fracture fixation. The recorded operative times for Short InterTAN fixation were significantly shorter than those recorded for the Long InterTAN patients. Alternatively, a significantly higher proportion of Short InterTAN patients sustained periprosthetic femur fractures within a year of implantation as compared to the Long InterTAN group

Introduction & aims. Apparently well-orientated total hip replacements (THR) can still fail due to functional component malalignment. Previously defined “safe zones” are not appropriate for all patients as they do not consider an individual's spinopelvic mobility. The Optimized Positioning System, OPS. TM. (Corin, UK), comprises preoperative planning based on a patient-specific dynamic analysis, and patient-specific instrumentation for delivery of the target component alignment. The aim of this study was to determine the early revision rate from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) for THRs implanted using OPS. TM. . Method. Between January 4. th. 2016 and December 20. st. 2017, a consecutive series of 841 OPS. TM. cementless total hip replacements were implanted using a Trinity acetabular cup (Corin, UK) with either a TriFit TS stem (98%) or a non-collared MetaFix stem (2%). 502 (59%) procedures were performed through a posterior approach, and 355 (41%) using the direct superior approach. Mean age was 64 (range; 27 to 92) and 51% were female. At a mean follow-up of 15 months (range; 3 to 27), the complete list of 857 patients was sent to the AOANJRR for analysis. Results. There were 5 revisions: . a periprosthetic femoral fracture at 1-month post-op in a 70F. a ceramic head fracture at 12-months post-op in a 59M. a femoral stem loosening at 7-months post-op in a 58M. a femoral stem loosening at 16-months post-op in a 64M. an anterior dislocation in a 53M, that was revised 9 days after the primary procedure. CT analysis, prior to revision surgery, revealed acetabular cup orientation of 46°/31° (inclination/anteversion) and femoral stem anteversion of 38°. Conclusions. These preliminary findings suggest the OPS. TM. dynamic planning and delivery system provides good early results, with a low rate of revision for dislocation. Limitations of the study will be discussed

Background. The clinical results of total hip arthroplasty (THA) with a cementless prosthesis have been constantly improving due to progress in the area of stem design and surface finish. However, majority of stems are well-fixed with canal filling or diaphyseal fit, and cortical hypertrophy or metaphyseal bone atrophy has been often observed. Cementless Spotorno stem (CLS stem; Zimmer, Warsaw, USA) is a double-tapered rectangular straight stem. The purpose of this study is to investigate the mean 13 years' results of CLS stem and to evaluate the press-fit stability of CLS stem. Methods. Between 1999 and 2004, we treated 134 patients (142 hips) with CLS stem. Of those patients, 86 females (92 hips) and 13 males (14 hips), in total 99 patients (106 hips) were available at minimum of 11 years after surgery. At the time of follow-up, six females and five males were dead. The follow-up rate was 82% and the mean follow-up period was 13 years (SD; 20, range; 11–16). The mean age at the time of surgery was 65 years (SD; 10, range; 38–86). The mean body mass index was 24 (SD; 1.8, range; 19 to 28). Preoperative diagnoses were osteoarthritis in 92 patients, osteonecrosis in five patients, and rheumatoid arthritis in two patients. Majority of the patients were female because 84 patients of osteoarthritis suffered from hip dysplasia. For cementless acetabular reconstruction, APR cups (Zimmer, Warsaw, USA) were implanted in 10 hips, IOP cups (Zimmer, Warsaw, USA) in 22 hips, and Converge cups (Zimmer, Warsaw, USA) in 74 hips. As the liner of acetabular component, conventional UHMWPE (Sulene: Zimmer, Warsaw, USA) was used in APR cup and highly crosslinked UHMWPE (Durasul: Zimmer, Warsaw, USA) in IOP and Converge cups. The lipped liner was chosen in all cases, and lipped lesion was placed posteriorly. The radiographic stability of the femoral stem was determined by Engh's criteria. The ascertained period of spot welds was noted by Gruen zones on the femoral side. The presence of stress shielding, and subsidence was also evaluated. Results. A stable stem with bony on-growth was identified in all cases. The mean period of expression of spot welds was 11 months in zone 2, 10 months in zone 3, 9 months in zone 5, and 9 months in zone 6. Stress shielding of more than grade 2 was observed in only 8 hips, which was non-progressive at 1 year after surgery. Subsidence of more than 2mm was not observed in any of the hips. The cortical hypertrophy at the tip of stem was not observed. The postoperative dislocation occurred in six hips (6%) and periprosthetic femoral fracture occurred in two hips (2%). Revised surgery was performed in three hips for a recurrent dislocation and two periprosthetic femoral fracture. Conclusions. Excellent stability of CLS stem has been maintained without abnormal bone reaction at proximal femur. CLS stem is considered to achieve not only press-fit stability at trochanteric and subtrochanteric level, but bony fixation by osseointegration within 1 year after THA

The most common classification of periprosthetic femoral fractures is the Vancouver classification. The classification has been validated by multiple centers. Fractures are distinguished by location, stability of the femoral component, and bone quality. Although postoperative and intraoperative fractures are classified using the same three regions, the treatment algorithm is slightly different. Type A fractures involve the greater and lesser trochanter. Fractures around the stem or just distal to the stem are Type B and subcategorised depending on stem stability and bone quality. Type C fractures are well distal to the stem and are treated independent of the stem with standard fixation techniques. The majority of fractures are either B1 (stable stem) or B2 (unstable stem). The stem is retained and ORIF of the fracture performed for B1 fractures. B2 and B3 fractures require stem revision with primary stem fixation distal to the fracture. Intraoperative fractures use the same A, B, C regions but are subtyped 1–3 as cortical perforations, nondisplaced, and displaced unstable fractures, respectively. With the exception of A1 intraoperative fractures all other intraoperative fractures require surgical treatment. A recent publication utilizing a New York state registry highlighted the patient risk of mortality associated with periprosthetic hip fractures. One month, 6 month and 1 year mortality was 3.2%, 3.8% and 9.7%, respectively. The mortality risk was lower for periprosthetic fractures treated with ORIF at 1 and 6 months compared to fractures requiring revision total hip

Simultaneous bilateral total hip arthroplasties (THAs) present unique and unwarranted dangers to the patient and surgeon alike. These include a significantly increased risk of blood transfusion (up to 50% in contemporary series even with the use of tranexamic acid), longer operative times, longer length of stays, and higher mortality rates in patients with minimal risk factors (age > 75 years, rheumatoid arthritis, higher ASA class, and/or male sex). This is even in light of the fact that the vast majority of literature has a substantial selection bias in which only the healthiest, youngest, non-obese, and most motivated patients are included. Traditionally, simultaneous bilateral THAs were completed in the lateral decubitus position. This required the surgeon and surgical team to reposition the patient onto a fresh wound, as well as additional prepping and draping. To mitigate these additional limitations of simultaneous bilateral THAs, there has been a recent trend towards utilizing the direct anterior approach. However, this particular approach presents its own unique set of complications such as an increased risk of periprosthetic femoral fracture and early femoral failure, an increased risk of impaired wound healing (particularly in obese patients), potential injury to the lateral femoral cutaneous nerve with subsequent neurogenic pain, and traction-related neurologic injuries. When compounded with the risks of simultaneous bilateral THAs, the complication profile becomes prohibitive for an elective procedure with an otherwise very low morbidity

Introduction. Revision total hip arthroplasty is a complex procedure and becoming more common. Acetabular implant loosening or fracture has previously been treated with a cup and cage construct. Recent studies have shown significant failure rates with Cup Cage constructs in more complex 3B and 3C Acetabular revisions. As a result the use of 3D printed custom made acetabular components has become more common. Method. We present 5 cases with severe acetabular bone loss that were treated with 3D printed acetabular components. The components were manufactured by OSSIS medical in New Zealand. The patient's original femoral stem was retained in all cases. Pre operatively the implant design was approved by the arthroplasty team prior to final manufacture. Implants were provided with a sterilisable model used intraoperatively for reference. Results. Five cases of 3D printed acetabular implants have been used locally for complex revision total hip arthroplasty with no immediate intraoperative or postoperative complications. Follow up of 1 – 5 years. One patient fell, five years post operatively. Sustaining a periprosthetic femur fracture requiring plate fixation, however, the acetabular component remained stable. No patient has undergone surgery for any failure of the acetabular component. Conclusions. This study shows 3D printed custom acetabular implants are efficient and effective in our hands. Early results from the design team suggest improved results compared to TM cup / cage systems. None of the implants have failed for any reason to date

Anterior supine intermuscular total hip arthroplasty (ASI-THA) has emerged as a muscle sparing, less-invasive procedure. The anterior interval is both intermuscular and internervous, providing the advantages of little or no muscle dissection, and a true minimally invasive alternative. It is versatile, with reported use expanding beyond the primary realm to revision and resurfacing THA as well as treatment of acute fracture in elderly patients, who due to their diminished regenerative capacity may benefit more from the muscle-sparing nature of the anterior approach. The ASI approach involves the use of a standard radiolucent operative table with the table extender at the foot of the bed and the patient supine. Fluoroscopy is used in every case. A table-mounted femur elevator is utilised to facilitate femoral preparation. A retrospective review identified 824 patients undergoing 934 consecutive primary ASI-THA performed between January 2007 and December 2010. Age averaged 63.2 years (27‐92), BMI averaged 29.9 kg/m2 (16.9–59.2). Gender was 49% males and 51% females. Stem types were short in 82% and standard length in 18%. Follow-up averaged 23.1 months (1‐73). Operative time averaged 63.1 minutes (29‐143). Blood loss averaged 145.3 mL (25‐1000). Transfusion rate was 3.3% (30 of 914) in single procedures and 80% (8 of 10) in simultaneous bilateral procedures. Length of stay averaged 1.7 days (1‐12). Intraoperatively there were 3 calcar cracks and 1 canal perforation treated with cerclage cables. There were 6 wound complications requiring debridement. Four hips had significant lateral femoral cutaneous nerve parathesias not resolved at 12 months. One femoral nerve palsy occurred. At up to 73 months follow-up there have been 21 revisions (2.2%): 2 infection, 1 malpositioned cup corrected same day, 5 metal complications, 2 dislocations, 2 loose cups with one requiring concomitant stem revision secondary to inability to disarticulate trunnion, 1 femoral subsidence and 8 periprosthetic femoral fractures. Primary THA can be safely performed utilising this muscle-sparing approach. We did not see an alarmingly high rate of complications. Instead, rapid recovery and quick return to function were observed. ASI-THA appears to be safe. The recovery advantage utilising this surgical approach is irrefutable. There are complications, most notably periprosthetic femur fracture. The rate, however, appears to be low and decreases with increased experience. There is no need for a special operative or fracture table to perform the procedure. Whether the complication rate is higher with the use of these expensive devices is unknown, but our results demonstrate a 2.2% reoperation rate with the use of the ASI approach performed on a standard OR table. Continued refinement of the technical aspects of ASI-THA may lessen the complication rate

Anterior supine intermuscular total hip arthroplasty (ASI-THA) has emerged as a muscle sparing, less-invasive procedure. The anterior interval is both intermuscular and internervous, providing the advantages of little or no muscle dissection, and a true minimally invasive alternative. It is versatile, with reported use expanding beyond the primary realm to revision and resurfacing THA as well as treatment of acute fracture in elderly patients, who due to their diminished regenerative capacity may benefit more from the muscle-sparing nature of the anterior approach. The ASI approach involves the use of a standard radiolucent operative table with the table extender at the foot of the bed and the patient supine. Fluoroscopy is used in every case. A table-mounted femur elevator is utilised to facilitate femoral preparation. A retrospective review identified 824 patients undergoing 934 consecutive primary ASI-THA performed between January 2007 and December 2010. Age averaged 63.2 years (27–92), BMI averaged 29.9 kg/m2 (16.9–59.2). Gender was 49% males and 51% females. Stem types were short in 82% and standard length in 18%. Follow-up averaged 23.1 months (1–73). Operative time averaged 63.1 minutes (29–143). Blood loss averaged 145.3 minutes (25–1000). Transfusion rate was 3.3% (30 of 914) in single procedures and 80% (8 of 10) in simultaneous bilateral procedures. Length of stay averaged 1.7 days (1–12). Intraoperatively there were 3 calcar cracks and 1 canal perforation treated with cerclage cables. There were 6 wound complications requiring debridement. Four hips had significant lateral femoral cutaneous nerve parathesias not resolved at 12 months. One femoral nerve palsy occurred. At up to 73 months follow-up there have been 21 revisions (2.2%): 2 infection, 1 malpositioned cup corrected same day, 5 metal complications, 2 dislocations, 2 loose cups with one requiring concomitant stem revision secondary to inability to disarticulate trunnion, 1 femoral subsidence and 8 periprosthetic femoral fractures. Primary THA can be safely performed utilising this muscle-sparing approach. We did not see an alarmingly high rate of complications. Instead, rapid recovery and quick return to function were observed. ASI-THA appears to be safe. The recovery advantage utilising this surgical approach is irrefutable. There are complications, most notably periprosthetic femur fracture. The rate, however, appears to be low and decreases with increased experience. There is no need for a special operative or fracture table to perform the procedure. Whether the complication rate is higher with the use of these expensive devices is unknown, but our results demonstrate a 2.2% reoperation rate with the use of the ASI approach performed on a standard OR table. Continued refinement of the technical aspects of ASI-THA may lessen the complication rate

Although the introduction of ultraporous metals in the forms of acetabular components and augments has substantially improved the orthopaedic surgeon's ability to reconstruct severely compromised acetabuli, there remain some revision THAs that are beyond the scope of cups, augments, and cages. In situations involving catastrophic bone loss, allograft-prosthetic composites or custom acetabular components may be considered. Custom components offer the potential advantages of immediate, rigid fixation with a superior fit individualised to each patient. These custom triflange components require a preoperative CT scan with three-dimensional (3-D) reconstruction using rapid prototyping technology, which has evolved substantially during the past decade. The surgeon can fine-tune exact component positioning, determine location and length of screws, modify the fixation surface with, for example, the addition of hydroxyapatite, and dictate which screws will be locked to enhance fixation. The general indications for using custom triflange components include: (1) failed prior salvage reconstruction with cage or porous metal construct augments, (2) large contained defects with possible discontinuity, (3) known pelvic discontinuity, and (4) complex multiply surgically treated hips with insufficient bone stock to reconstruct using other means. We previously reported on our center's experience with 23 patients (24 hips) treated with custom triflange components with minimum 2-year follow-up. This method of reconstruction was used in a cohort of patients with Paprosky Type 3B acetabular defects, which represented 3% (30 of 955) of the acetabular revisions we performed during the study period of 2003 to 2012. At a mean follow-up of 4.8 years (range, 2.3 – 9 years) there were four subsequent surgical interventions: two failures secondary to sepsis, and one stem revision and one open reduction internal fixation for periprosthetic femoral fracture. There were two minor complications managed nonoperatively, but all of the components were noted to be well-fixed with no obvious migration or loosening observed on the most recent radiographs. Harris hip scores improved from a mean of 42 (SD ±16) before surgery to 65 (SD ±18) at latest follow-up (p < 0.001). More recently, we participated in a multi-center study of 95 patients treated with reconstruction using custom triflange components who had a mean follow-up of 3.5 years. Pelvic defects included Paprosky Type 2C, 3A, 3B and pelvic discontinuity. Concomitant femoral revision was performed in 21 hips. Implants used a mean of 12 screws with 3 locking screws. Twenty of 95 patients (21%) experienced at least one complication, including 6% dislocation, 6% infection, and 2% femoral-related issues. Implants were ultimately removed in 11% of hips. One hip was revised for possible component loosening. Survivorship with aseptic loosening as the endpoint was 99%. Custom acetabular triflange components represent yet another tool in the reconstructive surgeon's armamentarium. These devices can be helpful in situations of catastrophic bone loss, achieving reliable fixation. Clinical results are inferior to both primary THA and more routine revision THA. Patients and surgeons should be aware of the increased complications associated with these complex hip revisions

Background. Total hip replacement is a highly successful procedure, yet access to arthroplasty is limited in many developing nations. In response, organizations in the United States have conducted service trips to provide international arthroplasty care to underserved populations. Little outcomes data are currently available related to these trips. We aimed to assess patient outcomes following total hip arthroplasty performed on a surgical mission trip. Methods. We completed an arthroplasty service trip to Brazil during which we performed 46 total hip arthroplasties (THA) on 38 patients. Patient demographic data, comorbidity profile, complication data, and pre- and postoperative Modified Harris Hip Score (mHHS), PROMIS Short Form Pain (SF-Pain), PROMIS Short Form Physical Function (SF-Function), and HOOS Jr scores were collected. Baseline and final follow-up scores were compared. In addition, we utilized a novel questionnaire that was designed to determine outcomes most relevant to patients receiving joint replacements in developing countries. A multivariate regression analysis was performed to identify associations between patient factors and outcomes. Results and Discussion. The mean patient age was 48.8 years, and 47% were female. 30 patients had a unilateral THA and 8 had bilateral simultaneous THA. 61% of patients had a preoperative diagnosis of osteoarthritis (OA), 13% avascular necrosis, 13% post-traumatic OA, 8% developmental hip dysplasia, and 5% rheumatoid arthritis. Mean pain duration was 1–5 years for 45% of patients and >5 years for 55% of patients. The mean mHHS, HOOS, PROMIS SF-Pain and PROMIS SF-Function all improved significantly compared to baseline at 2 and 6 weeks post-operatively. Multivariate regression analysis did not reveal any associations between patient reported outcomes and age, gender, pain duration, preoperative diagnosis or unilateral versus bilateral surgery. Subjective questionnaires at 12 weeks postoperatively revealed that surgery met expectations for 94% of patients; 97% of patients had as much pain relief as they expected; 45% of patients had no physical limitations; 82% of patients were not taking any medications for their hip (18% used occasional NSAIDs); 82% of patients gained new independence at home; and 97% felt their overall quality of life improved significantly. Two patients had postoperative periprosthetic femur fractures requiring an ORIF. One patient had a DVT requiring 6 months of anticoagulation. Conclusion. We found that patients in a developing country benefitted significantly from total hip arthroplasty when performed by a visiting surgical team, with acceptable complication profiles. Validated legacy outcome measures show improvements in pain and function after THA similar to those observed in patients in the United States. Additionally, the results of our questionnaire help to identify outcomes of specific interest to developing countries with relatively limited resources, particularly regaining functional independence after THA

Although the introduction of ultraporous metals in the forms of acetabular components and augments has substantially improved the orthopaedic surgeon's ability to reconstruct severely compromised acetabuli, there remain some revision THAs that are beyond the scope of cups, augments, and cages. In situations involving catastrophic bone loss, allograft-prosthetic composites or custom acetabular components may be considered. Custom components offer the potential advantages of immediate, rigid fixation with a superior fit individualised to each patient. These custom triflange components require a pre-operative CT scan with 3-D reconstruction using rapid prototyping technology. The surgeon can fine-tune exact component positioning, determine location and length of screws, modify the fixation surface with, for example, the addition of hydroxyapatite, and dictate which screws will be locked to enhance fixation. The general indications for using custom triflange components include: (1) failed prior salvage reconstruction with cage or porous metal construct augments, (2) large contained defects with possible discontinuity, (3) known pelvic discontinuity, and (4) complex multiply surgically treated hips with insufficient bone stock to reconstruct using other means. The general indications for using custom triflange components include: (1) failed prior salvage reconstruction with cage or porous metal construct augments, (2) large contained defects with possible discontinuity, (3) known pelvic discontinuity, and (4) complex multiply surgically treated hips with insufficient bone stock to reconstruct using other means. We previously reported on our center's experience with 23 patients (24 hips) treated with custom triflange components with minimum 2-year follow-up. This method of reconstruction was used in a cohort of patients with Paprosky Type 3B acetabular defects, which represented 3% (30 of 955) of the acetabular revisions we performed during the study period of 2003 to 2012. At a mean follow-up of 4.8 years (range, 2.3–9 years) there were 4 subsequent surgical interventions: 2 failures secondary to sepsis, and 1 stem revision and 1 open reduction internal fixation for periprosthetic femoral fracture. There were two minor complications managed non-operatively, but all of the components were noted to be well-fixed with no obvious migration or loosening observed on the most recent radiographs. Harris Hip Scores improved from a mean of 42 (SD ±16) before surgery to 65 (SD ±18) at latest follow-up (p<0.001). More recently, we participated in a multi-center study of 95 patients treated with reconstruction using custom triflange components w a mean follow-up of 3.5 years. Pelvic defects included Paprosky Type 2C, 3A, 3B and pelvic discontinuity. Concomitant femoral revision was performed in 21 hips. Implants used a mean of 12 screws with 3 locking screws. Twenty of 95 patients (21%) experienced at least one complication, including 6% dislocation, 6% infection, and 2% femoral-related issues. Implants were ultimately removed in 11% of hips. One hip was revised for possible component loosening. Survivorship with aseptic loosening as the endpoint was 99%. Custom acetabular triflange components represent yet another tool in the reconstructive surgeon's armamentarium. These devices can be helpful in situations of catastrophic bone loss, achieving reliable fixation. Clinical results are inferior to both primary THA and more routine revision THA. Patients and surgeons should be aware of the increased complications associated with these complex hip revisions