Purpose: Infection after TJA is a rare but devastating complication. Horizontal laminar airflow has been advocated to reduce infection rate.

Methods: 896 consecutive primary and revision total joint arthroplasties of the hip and knee were retrospectively reviewed. The first 751 were performed before February 2004 in a horizontal laminar air flow room; the final 146 were performed without laminar flow from February 2004 through May 2005. All patients received the same perioperative antibiotics, wound management, and rehabilitation program. Body exhaust systems were worn in all cases.

Results: There were a total of 10 infections (1.1%) requiring surgical treatment, including 6 deep knee infections (0.67%), and four (0.45%) wounds (3 knees and 1 hip) with delayed healing or superficial infections. 9 of the infections occurred in the laminar flow group (1.2%), including all 6 deep knee infections (6/456=1.3%), 2 knee and 1 hip wound infection. Only 1 infection (0.68%), in a knee wound, occurred in the non-laminar flow group. There were no deep hip infections. Statistically, more knees became infected than hips overall (9/550=1.64% vs 1/346=0.29%)(p< 0.01) and more knees developed deep infection with laminar flow than without (6/456=1.2% vs 0/94=0.00%)(p< 0.1).

Conclusions: Laminar air flow did not alter the infection rate in THA, but may have increased infection rate in TKA. Infection is multifactorial, and longer follow up of the non-laminar flow group may reduce the differences seen. Nevertheless, this data agrees with other published data and is of significant concern for the TKA surgeon and patient alike.

Purpose: Patellar Clunk is associated with posterior stabilized (PS) femoral components in which a scarred synovial suprapatellar nodule catches on the femoral box with active extension of the flexed knee. We investigated whether a rotating platform tibial component increases the incidence of patellar clunk.

Methods: From December 1998 to June 2006, a single surgeon performed 659 primary TKAs. 329 fixed-bearing tibial components and 330 rotating platforms were implanted. The same PS femoral component was used in all cases. All components were from the PFC Sigma Total Knee System (DePuy, Warsaw, IN, USA). The incidence of patellar clunk requiring reoperation was evaluated prospectively.

Results: There were 17 arthroscopies performed on 16 knees in 15 patients. One patient required bilateral arthroscopies, and one a repeat arthroscopy. 6 (1.8%) arthroscopies were required in the fixed bearing group, and 10 (3%) in the rotating platform group (p< 0.10 NS). The repeat arthroscopy was in the rotating platform group. Time to arthroscopy from the index surgery was 13.6 months (Range 5–40) for the entire group, 15.2 months (Range 8–40) for the fixed-bearing group, and 12.6 months (Range 5–20) for the rotating platform group (p< 0.10 NS).

Conclusions: The incidence of patellar clunk is not increased by the use of a rotating platform tibial component in TKA. While the mobile bearing may improve patellar tracking, causing the extensor mechanism to seat deeper in the trochlear groove, it does not seem to represent a risk factor for the development of the suprapatellar scarring that predisposes to patellar clunk.

Purpose: The original C-STEM (DePuy, Warsaw, IN, USA), a triple tapered polished collarless cemented stem, has an established clinical record. The new C-stem-AMT retains the identical intramedullary design, but enhances the extramedullary portion of the stem with a high offset option, and a mini-taper which is fully covered by the head, and accommodates a broad range of head diameters and neck lengths. This is an early report of clinical experience with the C-STEM AMT.

Methods: From March 2005 to June 2006, 34 C-STEMAMTs were implanted in 32 patients (21 females, 13 males) with mean age of 69 years (R 52–89). Diagnoses were Osteoarthritis in 30, AVN in 2, DDH in 1, and loose femoral implant in 1. Average follow-up was 9.7 months (R 3–18).

Preoperative and postoperative Harris Hip Scores, radiographs, and postoperative complications were recorded prospectively and compared to an early cohort of 66

C-Stems previously implanted between May 1999 and July 2001.

Results: Harris Hip Scores improved from 38 to 99 at one year. There has been no loosening, significant subsidence or reoperations. No dislocations have occurred, in contrast to 6 (9%) dislocations in the original C-Stem group.

Conclusions: As expected, the behaviour of the intramedullary portion of the C-Stem AMT is mirroring the experience with the C-Stem. The enhanced extramedullary design which accommodates additional neck lengths and head sizes, improves range of motion and provides additional offset has substantially reduced dislocation by facilitating accurate reconstruction of appropriate hip biomechanics.

Purpose: Double-tapered polished cemented femoral stems have demonstrated excellent long-term clinical results, but subsidence with cement mantle fracture, distal stress transfer and proximal stress shielding persist as problems. Adding a third taper from broad lateral to narrow medial purportedly reduces subsidence and improves proximal bone loading and preservation. We report our independent experience with a triple-tapered collarless polished cemented stem.

Methods: Between May 1999 and July 2001, 66 C-Stems (DePuy, Warsaw, IN, USA) were implanted in 45 females and 15 males, with a mean age of 67 years (R 35–86) and mean weight of 77 Kg (R 42–117). Diagnoses were OA in 62, RA in 1, AVN in 2 and fracture in 1. Average follow-up was 58 months (R 45–71).

Results: Harris hip scores improved from a mean of 43 (R17–100) to 84 (R 10–100). SF36 and WOMAC scores improved similarly. Six hips dislocated, but there were no reoperations. Subsidence was less than 1 mm in all cases. There was no radiographic stress shielding. Bone quality was maintained, especially in the critical medial calcar region, with positive bone remodeling along radial stress lines and improvement over time of some bone-cement interfaces.

Conclusions: The C-Stem, a triple-tapered collarless polished cemented stem, engages the surrounding cement mantle in an axially stable manner, minimizing subsidence to within the creep tolerances of cement. The radial stresses so generated favorably load the proximal bone, stimulating positive bone remodeling and eliminating stress-shielding. The clinical results at short to mid-term follow-up in this non-designer series are outstanding.

Purpose: Proximal femur fracture occurring at the time of femoral canal preparation or insertion of the femoral component is a recognized complication of primary total hip arthroplasty.

Methods: Two hundred seventy three consecutive primary THAs were reviewed retrospectively for occurrence of intraoperative fracture. 146 cemented femoral components and 127 cementless femoral components were implanted. Intraoperative management of non- or minimally-displaced proximal femur fractures involved placement of either one or two cerclage cables, with postoperative weightbearing to tolerance using an assistive device for approximately six weeks.

Results: Eight (2.9%) hips sustained an intraoperative non- or minimally-displaced fracture of the proximal femur: six (75%) occurred using cementless stems and two (25%) occurred using cemented stems. At an average follow-up of 57 months (R 26–90 months), all patients in the fractured cohort have remained radiographically stable, with well-fixed femoral components showing no evidence of subsidence. All of the patients in this fractured group have achieved good or excellent functional results.

Conclusions: Midterm follow-up results suggest that non- or minimally-displaced proximal femur fractures occurring at the time of primary THA can safely and effectively be managed by placement of single or multiple cerclage cables, and without significant modification of standard postoperative rehabilitation protocols. No compromise in functional outcome has been observed with this treatment method.