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 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
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
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
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
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,
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
INTRODUCTION. The increasing incidence of
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
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
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
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
The most common classification of
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
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
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
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
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
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
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