Aims

The prevalence of obesity is increasing substantially around the world. Elevated BMI increases the risk of complications following total hip arthroplasty (THA). We sought to evaluate trends in BMI and complication rates of obese patients undergoing primary THA over the last 30 years.

The relative advantages and disadvantages of two-stage versus one-stage management of infected total hip arthroplasties are the current subject of intense debate. To understand the merits of each approach detailed information on the short and, importantly, longer-term outcomes of each must be known. The purpose of this study was to assess the long-term results of two-stage exchange arthroplasty for THAs in one of the largest series to date.

We identified 331 infected THAs treated with a two-stage exchange arthroplasty between 1993 and 2021 at a single institution. Patients were excluded if they had prior treatment for infection. Mean age at reimplantation was 66 years, 38% were female, and mean BMI was 30 kg/m². PJI diagnosis was based on the 2011 MSIS criteria. A competing risk model accounting for death was utilized. Mean follow up was 8 years.

The cumulative incidence of reinfection was 7% at 1 year and 11% at 5 and 10 years. Factors predictive of reinfection included BMI>30 kg/m² (HR 2; p=0.049), and need for a spacer exchange (HR 3.2; p=0.006). The cumulative incidence of any revision was 13% at 5 and 10 years. The cumulative incidence of aseptic revision was 3% at 1 year, 7% at 5 years, and 8% at 10 years. Dislocation occurred in 33 hips (11% at 10 years; 45% required revision). Factors predictive of dislocation were female sex (HR 2; p=0.047) and BMI<30 kg/m² (HR 3; p=0.02). The mean HHS improved from 54 to 75 at 10 years.

In this series of 331 two-stage exchange arthroplasties performed for infected hips, we found a low aseptic revision rate (8%) and a low rate of reinfection (11%) at 10 years. These long-term mechanical and infection data must be kept in mind when considering a paradigm shift to one-stage exchanges.

Level of Evidence: Level III

Angular proximal femoral deformities increase the technical complexity of primary total hip arthroplasties (THAs). The goals were to determine the long-term implant survivorship, risk factors, complications, and clinical outcomes of contemporary primary THAs in this difficult cohort.

Our institutional total joint registry was used to identify 119 primary THAs performed in 109 patients with an angular proximal femoral deformity between 1997 and 2017. The deformity was related to previous femoral osteotomy in 85%, and developmental or metabolic disorders in 15%. 53% had a predominantly varus angular deformity. The mean age was 44 years, mean BMI was 29 kg/m², and 59% were female. An uncemented metaphyseal fixation stem was used in 30%, an uncemented diaphyseal fixation stem in 28%, an uncemented modular body stem with metaphyseal fixation sleeve in 24%, and a cemented stem in 18%. Simultaneous corrective femoral osteotomy was performed in 18%. Kaplan-Meier survivorships and Harris hip scores were reported. Mean follow-up was 8 years.

The 10-year survivorships free of femoral loosening, aseptic femoral revision, any revision, and any reoperation were 95%, 93%, 90% and 88%, respectively. Revisions occurred in 13 hips for: aseptic femoral component loosening (3), stem fracture (2), dislocation (2), aseptic acetabular loosening (2), polyethylene liner exchange (2), and infection (2). Preoperative varus angular deformities were associated with a higher risk of any revision (HR 10, p=0.03), and simultaneous osteotomies with a higher risk of any reoperation (HR 3.6, p=0.02). Mean Harris hip scores improved from 52 preoperatively to 82 at 10 years (p<0.001).

In the largest series to date of primary THAs in patients with angular proximal femoral deformities, we found a good 10-year survivorship free from any revision. Varus angular deformities, particularly those treated with a simultaneous osteotomy due to the magnitude or location of the deformity, had a higher reoperation rate.

Keywords: Proximal femoral deformity; dysplasia; femoral osteotomy; survivorship; revision

Level of evidence: Level III, comparative retrospective cohort

Aims

Uncemented implants are now commonly used at reimplantation of a two-stage revision total hip arthoplasty (THA) following periprosthetic joint infection (PJI). However, there is a paucity of data on the performance of the most commonly used uncemented femoral implants – modular fluted tapered (MFT) femoral components – in this setting. This study evaluated implant survival, radiological results, and clinical outcomes in a large cohort of reimplantation THAs using MFT components.

Aims

Breast cancer survivors have known risk factors that might influence the results of total hip arthroplasty (THA) or total knee arthroplasty (TKA). This study evaluated clinical outcomes of patients with breast cancer history after primary THA and TKA.

Aims

Dislocation remains a leading cause of failure following revision total hip arthroplasty (THA). While dual-mobility (DM) bearings have been shown to mitigate this risk, options are limited when retaining or implanting an uncemented shell without modular DM options. In these circumstances, a monoblock DM cup, designed for cementing, can be cemented into an uncemented acetabular shell. The goal of this study was to describe the implant survival, complications, and radiological outcomes of this construct.

Aims

Contemporary outcomes of primary total hip arthroplasties (THAs) with highly cross-linked polyethylene (HXLPE) liners in patients with inflammatory arthritis have not been well studied. This study examined the implant survivorship, complications, radiological results, and clinical outcomes of THA in patients with inflammatory arthritis.

There is a paucity of mid-term data on modular dual-mobility (MDM) constructs versus large (≥40 mm) femoral heads (LFH) in revision total hip arthroplasties (THAs). The purpose of this study was to update our prior series at 10 years, with specific emphasis on survivorships free of re-revision for dislocation, any re-revision, and dislocation.

We identified 300 revision THAs performed at a single tertiary care academic institution from 2011 to 2014. Aseptic loosening of the acetabular component (n=65), dislocation (n=59), and reimplantation as part of a two-stage exchange protocol (n=57) were the most common reasons for index revision. Dual-mobility constructs were used in 124 cases, and LFH were used in 176 cases. Mean age was 66 years, mean BMI was 31 kg/m², and 45% were female. Mean follow-up was 7 years.

The 10-year survivorship free of re-revision for dislocation was 97% in the MDM cohort and 91% in the LFH cohort with a significantly increased risk of re-revision for dislocation in the LFH cohort (HR 5.2; p=0.03). The 10-year survivorship free of any re-revision was 90% in the MDM cohort and 84% in the LFH cohort with a significantly increased risk of any re-revision in the LFH cohort (HR 2.5; p=0.04). The 10-year survivorship free of any dislocation was 92% in the MDM cohort and 87% in the LFH cohort. There was a trend towards an increased risk of any dislocation in the LFH cohort (HR 2.3; p=0.06).

In this head-to-head comparison, revision THAs using MDM constructs had a significantly lower risk of re-revision for dislocation compared to LFH at 10 years. In addition, there was a trend towards lower risk of any dislocation.

Level of Evidence: IV

Cup-cage constructs are one of several methods commonly used to treat severe acetabular bone loss during contemporary revision total hip arthroplasty. The purpose of this study was to provide a long-term results of the technique with emphasis on implant survivorship, radiographic results, and clinical outcomes for both full and half cup-cage reconstructions.

We identified 57 patients treated with a cup-cage reconstruction for major acetabular bone loss between 2002–2012. All patients had Paprosky Type 2B through 3B bone loss, with 60% having an associated pelvic discontinuity. Thirty-one patients received a full cup-cage construct, and 26 a half cup-cage. Mean age at reconstruction was 66 years, 75% were female, and the mean BMI was 27 kg/m². Mean follow-up was 10 years.

The 10-year cumulative incidences of any revision were 14% and 12% for the full and half cup-cage construct groups, respectively. Of the 9 revisions, 3 were for dislocation, 2 for aseptic loosening and construct failure (both were pelvic discontinuities), 1 for adverse local tissue reaction, and 1 for infection with persistent pelvic discontinuity. The 10-year cumulative incidences of revision for aseptic loosening were 4.5% and 5% for the full and half cup-cage constructs, respectively. Of the unrevised cases, incomplete and non-progressive zone 3 radiolucent lines were observed in 10% of patients in each group. Three patients experienced partial motor and sensory sciatic nerve palsies (2 in the full and 1 in the half cup-cage group). Both the full and half cup-cage cohorts demonstrated significantly improved Harris hip scores.

Full and half cup-cage reconstructions for major acetabular defects were successful at 10 years in regards to acetabular fixation without appreciable differences between the two techniques. However, zone 3 radiolucent lines were not uncommon in association with discontinuities, and dislocation continues to be a problem.

There is a paucity of long-term data on modular fluted tapered (MFT) stems for two-stage reimplantation following periprosthetic joint infection (PJI). The purpose of this study was to evaluate implant survivorship, radiographic results, and clinical outcomes in a large cohort of reimplantation THAs using MFT stems.

We identified 236 reimplantation THAs from a single tertiary care academic institution from 2000 to 2020. Two designs of MFT stems were used as part of an established two-stage exchange protocol for the treatment of PJI. Mean age at reimplantation was 65 years, mean BMI was 32 kg/m², and 46% were female. Median stem diameter was 19 mm, and median stem length was 195 mm. Mean follow-up was 7 years. A competing risk model accounting for death was utilized.

The 15-year cumulative incidence of any revision was 24%. There were 48 revisions, with the most common reasons being dislocation (n=25) and PJI (n=16). The 15-year cumulative incidence of any reoperation was 28%. Only 13 revisions involved the fluted tapered portion of the component (FTC), for a 15-year cumulative incidence of any FTC revision of 8%. Only 2 FTCs were revised for aseptic loosening, resulting in a 15-year cumulative incidence of FTC revision for aseptic loosening of 1%. Stem subsidence >5 mm occurred in 2% of unrevised cases, and all stems were radiographically stable at most recent follow-up. Mean HHS was 77 at most recent follow-up.

This series demonstrated that MFT stems were durable and reliable even in the setting of two-stage reimplantation for infection. While the incidence of aseptic loosening was very low, the incidence of any revision was 24% at 15 years, primarily caused by dislocation and recurrent PJI.

Level of Evidence: IV

The last two decades have seen remarkable technological advances in total hip arthroplasty (THA) implant design. Porous ingrowth surfaces and highly crosslinked polyethylene (HXLPE) have been expected to dramatically improve implant survivorship. The purpose of the present study was to evaluate survival of contemporary cementless acetabular components following primary THA.

16,421 primary THAs performed for osteoarthritis between 2000 and 2019 were identified from our institutional total joint registry. Patients received one of 12 contemporary cementless acetabular designs with HXLPE liners. Components were grouped based on ingrowth surface into 4 categories: porous titanium (n=10,952, mean follow-up 5 years), porous tantalum (n=1223, mean follow-up 5 years), metal mesh (n=2680, mean follow-up 6.5 years), and hydroxyapatite (HA) coated (n=1566, mean follow-up 2.4 years). Kaplan-Meier analyses were performed to assess the survivorship free of acetabular revision. A historical series of 182 Harris-Galante-1 (HG-1) acetabular components was used as reference.

The 15-year survivorship free of acetabular revision was >97% for all 4 contemporary cohorts. Compared to historical control, porous titanium (HR 0.06, 95% CI 0.02–0.17, p<0.001), porous tantalum (HR 0.09, 95%CI 0.03–0.29, p<0.001), metal mesh (HR 0.11, 95%CI 0.04–0.31, p<0.001), and HA-coated (HR 0.14, 95%CI 0.04–0.48, p=0.002) ingrowth surfaces had significantly lower risk of any acetabular revision. There were 16 cases (0.1%) of acetabular aseptic loosening that occurred in 8 (0.07%) porous titanium, 5 (0.2%) metal mesh, and 3 (0.2%) HA-coated acetabular components. 7 of the 8 porous titanium aseptic loosening cases occurred in one known problematic design. There were no cases of aseptic loosening in the porous tantalum group.

Modern acetabular ingrowth surfaces and HXLPE liners have improved on historical results at the mid-term. Contemporary designs have extraordinarily high revision-free survivorship, and aseptic loosening is now a rare complication.

At mid-term follow-up, survivorship of contemporary uncemented acetabular components is excellent and aseptic loosening occurs in a very small minority of patients.

Aims

Nonagenarians (aged 90 to 99 years) have experienced the fastest percent decile population growth in the USA recently, with a consequent increase in the prevalence of nonagenarians living with joint arthroplasties. As such, the number of revision total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) in nonagenarians is expected to increase. We aimed to determine the mortality rate, implant survivorship, and complications of nonagenarians undergoing aseptic revision THAs and revision TKAs.

Aims

Knowledge on total knee arthroplasties (TKAs) in patients with a history of poliomyelitis is limited. This study compared implant survivorship and clinical outcomes among affected and unaffected limbs in patients with sequelae of poliomyelitis undergoing TKAs.

Aims

The aim of this study was to determine the prevalence of depressive and anxiety disorders prior to total hip (THA) and total knee arthroplasty (TKA) and to assess their impact on the rates of any infection, revision, or reoperation.

Orthopaedic surgeons are currently faced with an overwhelming number of choices surrounding total knee arthroplasty (TKA), not only with the latest technologies and prostheses, but also fundamental decisions on alignment philosophies. From ‘mechanical’ to ‘adjusted mechanical’ to ‘restricted kinematic’ to ‘unrestricted kinematic’ — and how constitutional alignment relates to these — there is potential for ambiguity when thinking about and discussing such concepts. This annotation summarizes the various alignment strategies currently employed in TKA. It provides a clear framework and consistent language that will assist surgeons to compare confidently and contrast the concepts, while also discussing the latest opinions about alignment in TKA. Finally, it provides suggestions for applying consistent nomenclature to future research, especially as we explore the implications of 3D alignment patterns on patient outcomes.

Cite this article: Bone Joint J 2023;105-B(2):102–108.

Aims

As has been shown in larger animal models, knee immobilization can lead to arthrofibrotic phenotypes. Our study included 168 C57BL/6J female mice, with 24 serving as controls, and 144 undergoing a knee procedure to induce a contracture without osteoarthritis (OA).

Aims

Spinal anaesthesia has seen increased use in contemporary primary total knee arthroplasties (TKAs). However, controversy exists about the benefits of spinal in comparison to general anaesthesia in primary TKAs. This study aimed to investigate the pain control, length of stay (LOS), and complications associated with spinal versus general anaesthesia in primary TKAs from a single, high-volume academic centre.

Aims

We have previously reported the mid-term outcomes of revision total knee arthroplasty (TKA) for flexion instability. At a mean of four years, there were no re-revisions for instability. The aim of this study was to report the implant survivorship and clinical and radiological outcomes of the same cohort of of patients at a mean follow-up of ten years.

Aims

The aim of this study was to evaluate the incidence of liner malseating in two commonly used dual-mobility (DM) designs. Secondary aims included determining the risk of dislocation, survival, and clinical outcomes.