This large UK multicentre study evaluates clinical outcomes and identifies factors associated with local complication following PFR for non-oncological conditions.

132 patients across four UK centres underwent PFR from 01/08/2004-28/03/2023 with median follow-up of 1.9 (Q10.5-Q34.2) years. 75 (56.8%) patients were female and the mean age was 74.0 (SD 11.7) years. 103 (78%) patients had Charleston Comorbidity Index ≥3. ASA class was III or IV in 66.6%. Indications were infected revision (39, 29.5%), periprosthetic fracture (36, 27.3%), acute trauma (30, 22.7%), aseptic revision (17, 12.9%), failed trauma (nine, 6.8%) and complex primary arthroplasty (one, 0.8%). The primary outcome was the local complication rate. Secondary outcomes were systemic complications, reoperation and mortality rates. Comparisons were made with t-tests and Chi2 tests to investigate patient and surgical factors associated with local complication. Statistical significance was p<0.05.

There were 37(28.0%) local complications. These were 18 (13.6%) dislocations, eight (6.1%) prosthetic joint infections, four (3.0%) haematomas, three (2.3%) superficial infections, one (0.8%) wound dehiscence, one (0.8%) sciatic nerve palsy and one (0.8%) femoral perforation. Dislocation mostly occurred in conventional articulations (12, 9.1%) followed by dual-mobility cups (three, 2.3%), constrained cups (two, 1.5%) and hemiarthroplasty (one, 0.8%). Median time to local complication was 30 (Q14-Q3 133) days. Seven (5.3%) patients developed a systemic complication. Thirty-three (25.0%) patients underwent reoperation. Thirty-day and one-year mortality rates were 3.8% and 12.1%, respectively. Longer surgical waiting times (7.9 \[SD 16.9) versus 2.6 \[SD 4.4\] days, p<0.001) and longer operating times (212.5 \[SD 71.8\] versus 189.4 \[SD 59.3\] mins, p=0.0450) were associated with local complication.

Due to its high complication rate, PFR should be a salvage option when performed for non-oncological indications. Conventional articulations should be avoided. PFR should be delivered in a timely manner and ideally as dual-consultant cases to reduce operating time.

Polished taper-slip (PTS) cemented stems have an excellent clinical track record and are the most common stem type used in primary total hip arthroplasty (THA) in the UK. Due to low rates of aseptic loosening, they have largely replaced more traditional composite beam (CB) cemented stems. However, there is now emerging evidence from multiple joint registries that PTS stems are associated with higher rates of postoperative periprosthetic femoral fracture (PFF) compared to their CB stem counterparts. The risk of both intraoperative and postoperative PFF remains greater with uncemented stems compared to either of these cemented stem subtypes. PFF continues to be a devastating complication following primary THA and is associated with high complication and mortality rates. Recent efforts have focused on identifying implant-related risk factors for PFF in order to guide preventative strategies, and therefore the purpose of this article is to present the current evidence on the effect of cemented femoral stem design on the risk of PFF.

Cite this article: Bone Joint J 2024;106-B(1):11–15.

The Unified Classification System (UCS), or Vancouver system, is a validated and widely used classification system to guide the management of periprosthetic femoral fractures. It suggests that well-fixed stems (type B1) can be treated with fixation but that loose stems (types B2 and B3) should be revised. Determining whether a stem is loose can be difficult and some authors have questioned how to apply this classification system to polished taper slip stems which are, by definition, loose within their cement mantle. Recent evidence has challenged the common perception that revision surgery is preferable to fixation surgery for UCS-B periprosthetic fractures around cemented polished taper slip stems. Indications for fixation include an anatomically reducible fracture and cement mantle, a well-fixed femoral bone-cement interface, and a well-functioning acetabular component. However, not all type B fractures can or should be managed with fixation due to the risk of early failure. This annotation details specific fracture patterns that should not be managed with fixation alone.

Cite this article: Bone Joint J 2023;105-B(5):481–486.

Aims

The aim of this study was to compare open reduction and internal fixation (ORIF) with revision surgery for the surgical management of Unified Classification System (UCS) type B periprosthetic femoral fractures around cemented polished taper-slip femoral components following primary total hip arthroplasty (THA).

Literature surrounding artificial intelligence (AI)-related applications for hip and knee arthroplasty has proliferated. However, meaningful advances that fundamentally transform the practice and delivery of joint arthroplasty are yet to be realized, despite the broad range of applications as we continue to search for meaningful and appropriate use of AI. AI literature in hip and knee arthroplasty between 2018 and 2021 regarding image-based analyses, value-based care, remote patient monitoring, and augmented reality was reviewed. Concerns surrounding meaningful use and appropriate methodological approaches of AI in joint arthroplasty research are summarized. Of the 233 AI-related orthopaedics articles published, 178 (76%) constituted original research, while the rest consisted of editorials or reviews. A total of 52% of original AI-related research concerns hip and knee arthroplasty (n = 92), and a narrative review is described. Three studies were externally validated. Pitfalls surrounding present-day research include conflating vernacular (“AI/machine learning”), repackaging limited registry data, prematurely releasing internally validated prediction models, appraising model architecture instead of inputted data, withholding code, and evaluating studies using antiquated regression-based guidelines. While AI has been applied to a variety of hip and knee arthroplasty applications with limited clinical impact, the future remains promising if the question is meaningful, the methodology is rigorous and transparent, the data are rich, and the model is externally validated. Simple checkpoints for meaningful AI adoption include ensuring applications focus on: administrative support over clinical evaluation and management; necessity of the advanced model; and the novelty of the question being answered.

Cite this article: Bone Joint J 2022;104-B(12):1292–1303.

Periprosthetic femoral fracture (PFF) incidence following hip replacement surgery continues to rise. There is a national drive to centralise PFF treatment within specialist centres to improve clinical outcomes and cost-effectiveness. The financial implications of treating PFFs must be analysed to guide allocation of funding.

Data were collected for 129 PFFs admitted from 02/04/2014–19/05/2020. Financial data were provided by the Patient Level Information and Costing Systems (PLICS) team. Primary outcomes were cost, revenue and margin for each PFF. Additional data were collected on length of stay (LOS), critical care requirements and clinical outcomes. Statistical comparisons were made between treatment type (fixation vs revision). Significance was set to p<0.05.

Across the entire cohort, total cost was £2,389,901, total revenue was £1,695,435 and total loss was £694,481. Highest costs were ward stay (£714,591), theatre utilisation (£382,625), and overheads (£249,110). Median cost was £15,863 (IQR, £11,092-£22,221), median revenue was £11,305 (IQR, £7,147-£15,222) and median loss was £3,795 (IQR, £605-£8687). Median LOS was 21 days (IQR 13–34) and 28.7% patients required critical care admission.

Ninety-six patients were treated operatively with either fixation (n=53) or revision (n=43). Median operating time was lower for fixation versus revision (132 [IQR, 115–185] vs 201 [IQR, 159–229] minutes, p=0.001). Median cost (£17,455 [IQR, £13,095-£22,824] vs £17,399 [£13,394-£23,404]) and median loss (£5,774 [IQR, £2,092-£10,472] vs £3,860 [IQR, £96-£7,601]) were similar for fixation and revision (p=0.99 and p=0.18, respectively). Median revenue was greater for revision versus fixation (£13,925 [IQR, £11,294-£17,037] vs £12,160 [IQR, £8,486-£14,390], p=0.02). There was no difference in LOS (21 [13–34] vs 21 [14–30] days, p=0.94), critical care requirements (20 [37.7%] vs 11 [25.6%], p=0.30), reoperations (3 [5.7%] vs 6 [14.0%], p=0.29], local complications (8 [15.1%) vs 12 [27.9%], p=0.20) or systemic complications (11 [20.8%] vs 11 [25.6%], p=0.75) between fixation and revision.

PFF treatment costs are high with inadequate reimbursement through tariff. Work is needed to address this disparity and reduce costs associated with LOS, theatre utilisation and implants. Treatment cost should not be used when deciding between fixation and revision surgery.

Cemented total hip replacement (THR) provides excellent outcomes and is cost-effective. Polished taper-slip (PTS) stems demonstrate successful results and have overtaken traditional composite-beam (CB) stems. Recent reports indicate they are associated with a higher risk of postoperative periprosthetic femoral fracture (PFF) compared to CB stems. This study evaluates risk factors influencing fracture characteristics around PTS and CB cemented stems.

Data were collected for 584 PFF patients admitted to eight UK centres from 25/05/2006-01/03/2020. Radiographs were assessed for Unified Classification System (UCS) grade and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type. Statistical comparisons investigated relationships by age, gender, and stem fixation philosophy (PTS versus CB). The effect of multiple variables was estimated using multinomial logistic regression to estimate odds ratios (OR) with 95% confidence intervals (CI).

Median (IQR) age was 79.1 (72.0–86.0) years, 312 (53.6%) patients were female, and 495 (85.1%) stems were PTS. The commonest UCS grade was type B1 (278, 47.6%). The commonest AO/OTA type was spiral (352, 60.3%). Metaphyseal-split fractures occurred only with PTS stems with an incidence of 10.1%. Male gender was associated with a five-fold reduction in odds of a type C fracture (OR 0.22, 95% CI 0.12 to 0.41, p<0.001) compared to a type B fracture. CB stems were associated with significantly increased odds of transverse fracture (OR 9.51, 95% CI 3.72 to 24.34, p <0.001) and wedge fracture (OR 3.72, 95% CI 1.16 to 11.95, p <0.05) compared to PTS stems.

This is the largest study investigating PFF characteristics around cemented stems. The commonest fracture types are B1 and spiral fractures. PTS stems are exclusively associated with metaphyseal-split fractures, but their incidence is low. Males have lower odds of UCS grade C fractures compared to females. CB stems had higher odds of bending type fractures (transverse and wedge) compared to PTS stems. Biomechanical testing is needed for validation and investigation of modifiable factors which may reduce the risk of unstable fracture patterns requiring complex revision surgery over internal fixation.

Aims

This aim of this study was to assess the reliability and validity of the Unified Classification System (UCS) for postoperative periprosthetic femoral fractures (PFFs) around cemented polished taper-slip (PTS) stems.

Aims

This study evaluates risk factors influencing fracture characteristics for postoperative periprosthetic femoral fractures (PFFs) around cemented stems in total hip arthroplasty.

Aims

This study aimed to evaluate implant survival of reverse hybrid total hip arthroplasty (THA) at medium-term follow-up.

Introduction

Reverse hybrid total hip replacement (THR) offers significant theoretical benefits but is uncommonly used. Our primary objective was to evaluate implant survival with all cause revision and revision for aseptic loosening of either component as endpoints.

Introduction

The MHRA guidelines for metal on metal (MOM) suggest cobalt and chromium levels of more than 7ppb as potential for soft tissue reaction. However, in some patients soft tissue reaction is seen even in the presence of normal serum metal ions levels.

Background

Revision surgery for a failed metal on metal (MoM) hip arthroplasty is often unpredictable and challenging due to associated massive soft tissue and bony lesions. We present the analysis and early outcomes of revision surgery in failed MoM hip arthroplasties at our institution.

A prospective study was done to assess the outcome of MPFL reconstruction for patellar instability using quadriceps graft. MPFL reconstruction was done using superficial strip of quadriceps by an anteromedial incision and attached close to medial epicondyle of femur. There were 15 knees in thirteen patients with a mean age of 23.4 years. All patients had MPFL reconstruction and 5 had tibial tuberosity transfers. With a mean follow-up of 39.4 (12–57) months, the mean pre-op Kujala scores improved from 47.8 to 87.2. The mean Lysholm scores improved from 54.2 to 86.8. None of the patients had patella re-dislocations. MPFL reconstruction with quadriceps graft appears to be effective producing good results in patients with patellar instability.

To analyse the intra-operative variation in mechanical axes of the lower limb at various stages during navigated total knee replacement.

A prospective study was performed to analyse the intra-operative variation in the mechanical axes of the lower limb during navigated total knee replacement. All consecutive patients who underwent navigated total knee replacement were included and patients with inadequate data were excluded from the study. The intra-operative initial, trial and the final mechanical hip-knee-ankle axes were recorded from the navigation system. The differences between these axes were calculated and analysed. There were forty patients, of which 24 were females and 16 males with the age ranging from 37-89 (average 68.4) years. The right knee was replaced in 27 and the left knee in 13 patients. The average initial mechanical axes alignment was 0.03° valgus (3° varus to 3° valgus), trial alignment 0.64° varus (3° varus to 1.5° valgus) and final alignment 0.25° varus (4° varus to 4° valgus). Average deviation from initial to trial axes was 0.97°, trial to final axes was 0.74° and initial to final axes was 1.08°. The correlation co-efficient between the initial and the trial axes was 0.25, trial and final axes was 0.43 & initial and final axes was 0.09.

This study highlights a significant variation in mechanical axes between the different stages of navigated total knee replacement. The potential sources of intra-operative errors causing these changes could be soft tissue imbalance, variations in implant placement and possible tracker micro motion. Execution of bony cuts in near normal neutral alignment does not guarantee achievement of near normal final alignment. We advocate surgeons to be vigilant to avoid potential malalignment during navigated total knee replacement.

Background

A retrospective review of all patients transferred by helicopter ambulance to the Great Western Hospital over a 20-month period between January 2003 and September 2004 was undertaken to establish the case-mix of patients (trauma and non-trauma) transferred and the outcome of their admission and length of hospital stay.

Introduction: Glenohumeral arthritis secondary to chronic cuff deficiency not only leads to serious compromise in shoulder function but also poses a surgical challenge. There is no consensus regarding management of this problem although different arthroplasty options have been tried with variable results. We present our experience with managing this difficult problem using a shoulder resurfacing and subscapularis Z-plasty in order to improve shoulder movements, pain and function.

Patient and Methods: This study was conducted on 30-patients with rotator cuff arthropathy operated by a single surgeon at a district general hospital. There were 21 female and 9 male patients with mean age 73 years (range 62–85 years). The average duration of symptoms prior to treatment was 5.45 years (range 2–15 years). Twenty patients had uncemented shoulder resurfacing while remaining ten patients had cemented resurfacing procedure. The mean follow-up was 21 months (range 36–18 months). The patients were assessed at 3 months, 6 months, 12 months and 24 months postoperatively with European Society for shoulder and Elbow Surgery Score (ESSES) and radiograph at each visit.

Results: The ESSES score significantly improved from a mean of 47.5 preoperatively to 77.5 postoperatively, with most improvement being in subjective scoring (pain and ADL) followed by improvement in external rotation and forward flexion movement due to lengthening of subscapularis by Z-plasty. The VAS score for pain improved from average 7.4 preoperatively to 0.9 at 6 months postoperatively. On subjective scoring most patients reported good to excellent result at 6 months following surgery. There was no difference in outcome scores between cemented and uncemented resurfacing groups. No intraoperative or postoperative complications were encountered.

Our early results with shoulder resurfacing in management of rotator cuff arthropathy are encouraging. This bone conserving surgery may serve as an alternative to major procedures like reverse shoulder arthroplasty in selected group of patients.

Introduction: Clavicle fractures represent 5% of fractures in adults and almost 44% of shoulder injuries and are usually treated none operatively with good results. However significantly displaced fractures can be associated with high non-union rate and there is a lack of consensus on when surgical treatment is indicated for such fractures. The aim of this study was to identify guidelines for surgical intervention, safer surgical approach and outcome of surgical intervention.

Method: A retrospective audit of all clavicle fractures managed surgically over past 5 years (March 2004 to 2009) in a district general hospital. Case notes were reviewed to study the surgical indication, surgical approach, patient satisfaction and oxford should score and need for metal work removal.

In all 35 patients (29 male) underwent surgery for significant fracture displacement with shortening, manual workers and keen sportsmen at the time of injury. The infraclavicular approach was used in 21 patients and 14 patients had direct incision approach. Radiological union was achieved in all patients after an average of 13.26(8–24) weeks. Six patients required plate removal at 6 months following surgery, infraclavicular (2 patients) & direct approach (4 patients). All patients returned to their original occupation at average 2.55 months. The Oxford Shoulder Score at 3 months after surgery was average 15 (range12–20) and all patients, except one, scored excellent on subjective scoring.

Conclusion: Our study showed excellent surgical outcome for displaced clavicle fractures in young and active patients and is supported by the high union rate, good oxford shoulder score, early return to work and high patient satisfaction scores. The infraclaviculr approach is a betterthan direct approach based on the low complication rate and less need for metal work removal.

Purpose: To evaluate retrospectively the functional and radiographic outcome of patients who had a thumb trapeziometacarpal (TM) joint arthrodesis using a T-plate, chevron bone cuts and autologous punch graft harvested from ipsilateral distal radius.

Material and Methods: Between 2001 and 2006, 32 trapeziometacarpal (TM) joint fusions were performed in 24 patients using the above technique. The study group comprised of 16 females and 8 males with average age 52 years (range 42–62 years). Average follow-up was 14.8 months (range 14–60 months). Indications for surgery were: failure of conservative treatment; severe pain; and diminished thumb function hampering everyday life. All patients had radiological evidence of advanced TM joint arthritis (Eaton and Littler grade II to III).

In all cases, chevron bone cuts have been used. The fixation has progressed from K-wires, through single and double lag screws, tension-band wire, to an AO mini T-plate which is the present technique. With the K-wire, or simple screw methods, the failure rates were up to 50%, leading to many revision operations. Bone graft is used; in first 15 cases this was ‘Allomatrix’ but we now use local bone from the distal radius, taken with an AO tap guide used as a trephine.

Functional outcomes were assessed using Quick DASH score, and Gartland and Werley score. There was also a radiographic review. The grip and pinch strength were compared with the contralateral side. We also looked at the progression of disease at scaphotrapezial joint after the fusion of TM joint.

Results: Patient-rated outcome scores indicated very good pain relief with preservation of grip and pinch strength. There were 2 cases (7%) of non-union which required revision surgery and were probably due to poor screw placement in the trapezium. In 8 patients (25%), pain related to prominent metalwork required plate removal. In no case was there x-ray or symptomatic progression of the disease at scaphotrapezial joint. Clinically, 75% rated good, 15% fair, and 10% poor results.

Conclusion: The present form of trapeziometacarpal arthrodesis is reproducible and offers an excellent alternative to trapeziectomy especially in younger patients.

Type of study/level of evidence: Therapeutic IV.

Purpose: To evaluate retrospectively the functional and radiographic outcome of patients who had a thumb trapeziometacarpal (TM) joint arthrodesis using a T-plate, chevron bone cuts and autologous punch graft harvested from ipsilateral distal radius.

Material and Methods: Between 2001 and 2006, 32 trapeziometacarpal (TM) joint fusions were performed in 24 patients using the above technique. The study group comprised of 16 females and 8 males with average age 52 years (range 42–62 years). Average follow-up was 14.8 months (range 14–60 months). Indications for surgery were: failure of conservative treatment; severe pain; and diminished thumb function hampering everyday life. All patients had radiological evidence of advanced TM joint arthritis (Eaton and Littler grade II to III).

In all cases, chevron bone cuts have been used. The fixation has progressed from K-wires, through single and double lag screws, tension-band wire, to an AO mini T-plate which is the present technique. With the K-wire, or simple screw methods, the failure rates were up to 50%, leading to many revision operations. Bone graft is used; in first 15 cases this was ‘Allomatrix’ but we now use local bone from the distal radius, taken with an AO tap guide used as a trephine.

Functional outcomes were assessed using Quick DASH score, and Gartland and Werley score. There was also a radiographic review. The grip and pinch strength were compared with the contralateral side. We also looked at the progression of disease at scaphotrapezial joint after the fusion of TM joint.

Results: Patient-rated outcome scores indicated very good pain relief with preservation of grip and pinch strength. There were 2 cases (7%) of non-union which required revision surgery and were probably due to poor screw placement in the trapezium. In 8 patients (25%), pain related to prominent metalwork required plate removal. In no case was there x-ray or symptomatic progression of the disease at scaphotrapezial joint. Clinically, 75% rated good, 15% fair, and 10% poor results.

Conclusion: The present form of trapeziometacarpal arthrodesis is reproducible and offers an excellent alternative to trapeziectomy especially in younger patients.

Type of study/level of evidence: Therapeutic IV.