Introduction: Revision hip arthroplasty for aseptic loosening of femoral component is successfully treated with impaction bone grafting technique. Owing to easier technique and shorter operative time, distally fixed non-cemented long stems have gained popularity in the present era. However, use of long stems could make subsequent re-revision difficult due to further bone loss. The standard length stem has been often critiqued due to apprehension of peri-prosthetic fracture.

This study aims to determine the long-term outcomes of the impaction bone grafting of the femur for aseptic loosening in revision hip arthroplasty using standard length C-stems. 168 total hip revisions of 162 patients with impaction bone grafting and cemented standard C-stem (done with standardized technique) between 1995 and 2008 at a tertiary referral centre were included. Revisions for infection and segmental bone defects were excluded.

Mean follow-up of the 168 revision hips was 10.5 years (range 5 – 19.1 years). 14 patients (8.3%) were re-revised, reasons being, persistent deep infection (1.8%), repeated dislocations (1.2%), cup loosening (4.8%) and stem loosening (1.2%). Only 1 patient (0.6%) was re-revised due to stem loosening alone. No peri-prosthetic fractures (intra-operative or post-operative) or stem breakage were identified.

Use of standard stem length in hip revisions with impaction bone grafting does not increase the risk of peri-prosthetic fractures, instead, reconstitutes the bone stock. This questions the conventional principle of bypassing the distal cavitation of femur by 2 cortical diameters with the use of long stem. In our experience, a good proximal femur support is key to performance of standard length cemented stems in revision for aseptic loosening irrespective of grade of distal cavitation for cavitatory defects of femur when treated with impaction bone grafting.

The choice of stem length in total hip revision with impaction bone grafting of femur is essentially based upon the grade of cavitation of femur and surgeon's preference. The standard length stem has been often critiqued for the apprehension of peri-prosthetic fracture. Our study highlights the importance of proximal bone stock rather than distal cavitation in determining the length of femoral stem.

168 total hip revisions of 162 patients with impaction bone grafting and cemented standard C-stem (done with standardized technique) between 1995 and 2008 at a tertiary referral centre were included. Revisions for infection and segmental bone defects were excluded. Serial radiographs were retrospectively analysed by two people independently, using Endoklinik classification, Gruen zones and more and outcomes were analysed.

Mean follow-up of the 168 revision hips was 10.5 years (range 5 – 19.1 years). 14 patients (8.3%) were re-revised, reasons being, persistent deep infection (1.8%), repeated dislocations (1.2%), cup loosening (4.8%) and stem loosening (1.2%). Only 1 patient (0.6%) was re-revised due to stem loosening alone. No peri-prosthetic fractures or stem breakage were identified.

Use of standard stem length in hip revisions with impaction bone grafting doesn't increase the risk of peri-prosthetic fractures even during long term follow up period. This questions the principle of bypassing the distal cavitation of femur by 2 cortical diameters with the use of long stem. In our experience, a good proximal femur support aids in the performance of standard length cemented stems in revision for aseptic loosening irrespective of grade of distal cavitation for cavitory defects of femur treated with impaction bone grafting.

Introduction

Severe osteolysis of the femur secondary to aseptic loosening in hip arthroplasty, remains a difficult revision scenario. Multiple techniques have been developed to aid the surgeon, including restoration of bone stock with impaction bone grafting or strut allografts, various distal fixation prostheses and mega-prostheses. Cemented femoral components, with integration of the cement into the cavitations, has largely fallen out of favour. We examined the long-term outcomes with this technique.

Financial impact and patient satisfaction with four different anticoagulants for hip and knee arthroplasty in patients with a previous history of VTE- A prospective randomised trial

Introduction

Total knee replacement has been well-established form of treatment both for osteoarthritis and inflammatory arthritis. Both cemented and uncemented TKR have been used successfully. Since 1977 low contact stress (LCS) mobile bearing knee replacement has been in extensive use. Most of the intermediate and long term results reported are in osteoarthritis1–7. Though there are several studies reporting short term performance of TKR in rheumatoid arthritis8–19 there have been rare reports31 of intermediate to long-term performance of LCS uncemented TKR in rheumatoid arthritis.

To assess the incidence of infection in cases of Primary Total Knee Arthroplasty with prior steroid injection into the knee joint.

Steroid injection into the arthritic joint is a well-known modality of treatment of arthritic joints. Its efficacy is well-documented. Increased incidence of infection secondary to steroid injection as compared to uninjected joints is reported in recent literature.

A retrospective study was conducted. Four hundred and forty patients underwent Total Knee Replacement by the senior author during 1997–2005 at Wrightington hospital. Ninety patients had intraarticular steroid injection prior to surgery of which 35 patients had injection within 1 year prior to surgery. All patients had at least one year follow-up. Infection rate was assessed by case note, x-rays and microbiology review till last follow-up. One hundred and eighty patients of matched cohort who had Total Knee Replacement without steroid injection were compared for infection rate.

Two cases of superficial infection were noted in the infection group and 5 cases of superficial infection in the non-injection group. No case of deep infection was noted in either group. Statistical analysis showed no significant difference in incidence of infection in either group.

Steroids are useful adjuncts in the management of patients with arthritic joints. This study shows no increased incidence of infection in patients who were given steroid injection prior to arthroplasty.

Aim: PFC Sigma total knee was introduced in 1997 incorporating a number of design changes. We report our medium-term results of a consecutive series of PFC sigma knees performed between Nov 1997 and Dec 1998.

Method: Between November 1997 and December 1998 a consecutive series of 166 TKAs (156 patients)were carried out using the PFC Sigma total knee replacement system at Wrightington Hospital. Out of the 156 patients 9 were lost to follow-up. This left 147 patients (156 knees) with a mean follow-up of 90 months (range 84 – 96 months). 137 patients (88%) had primary osteoarthritis, 14(9%) had R.A and 5(3%) had post-traumatic arthritis. The mean age was 70 yrs (53 – 88 yrs).85 were female and 62 male. All patients were followed at 3 months, 6 months,1 year and then yearly. Clinical evaluation was done by American Knee Society and Oxford knee scores. Knee society score was used to assess the postoperative radiographs.

Results: The mean Knee society score improved from the preoperative mean of 45 (range 30 – 65) to postoperative mean of 84 points(range 45 – 92). The mean preoperative functional score was 38(range 25 –5) and mean postoperative functional score was 73 points(range 50–95). According to the final scoring 90 % of the knees were rated excellent, 4% good, 4 % fair and 2 % poor. The mean preoperative Oxford knee score was 43 (range 33–52) and mean postoperative score was 17 (14–29). Range of motion improved from a mean of 90(range 50–125) to 105(range 65–130). There was no significant difference (p = 0.03) in the American Knee Society score and Oxford knee score when comparing patients with and without resurfacing of the patella and PCL-retaining with PCL-substituting implants.1 knee (0.6%) was revised within 18 months due to aseptic loosening.1 knee(0.6%) had superficial wound infection which cleared with oral antibiotics.2 patients(2 knees) developed deep infection out of which one resolved following early debridement, the other developed chronic infection requiring long term suppressive antibiotics. 3 patients had proven below knee deep venous thrombosis; one of them developed a non-fatal pulmonary embolism. Radiological review using radiological knee society scoring showed radiolucent lines under 35 % of the tibial components(56 knees)and 11 % of Femoral components(18 knees). For survivorship analysis, the actuarial life- table method was used with calculation of the numbers at risk and the survival rates at annual intervals. The 95% confidence limits were calculated by the method of Rothman. The survivorship at the end of eight year follow-up was 99.40. None of the patellar components failed.

Conclusion: Our study shows excellent clinical results of PFC Sigma Total knee replacement after almost eight years follow-up. We plan to continue monitoring this cohort of patients for long-term results.

Introduction: Steroid Infiltration into arthritic joints are a common means of treating pain. They are also sometimes done to differentiate pain in the hip from the low back or knee. There are recent reports which suggest that the rate of infection in hip arthroplasty after injection is higher than in previously uninjected joints.

Methods: We performed a retrospective review of the notes of all patients who underwent hip replacements in Wrightington Hospital under the care of the senior author from 1997 to 2004. We identified all patients who had at least one year follow up after the procedure. The infection rates in the patients who had an injection of steroid into the joint prior to hip replacement were compared to those who had no such intervention.

Results: There were 589 patients who had a hip replacement in this period. Of these, 72 had a prior injection of steroid into the joint. In the injected group, there was no incidence of infection during the period of follow up. There was one case of infection in a patient who did not have an injection prior to the arthroplasty.

Discussion: Steroid injections are a valuable adjunct in the management of patients with arthritic joints. This review clearly identifies no increased risk of infection in patients who had the injection prior to the operation.

Introduction. Preoperative bone stock and cement-bone interface in revision total hip replacement (THR) for deep infection have never been investigated while they are both well known to be important for mechanical outcome after revision THR for aseptic loosening.

Purpose. The purpose of this study was to assess pre-operative bone stock and immediate postoperative cement-bone interface as factors affecting infection control after one stage revision THR for deep infection.

Material and methods. This study included 115 cases which satisfied following conditions; a) One stage revision THRs for deep infection were carried out by a single surgeon. b) Follow-up of more than five years was done. Preoperative bone stock was classified into four grades (Grade 0: No bone loss, Grade 1: Demarcation, Grade 2: Localized cavitation, Grade 3: Extensive bone loss). Immediate postoperative cement-bone interface was also graded into four categories (Grade A: White-out, obscure interface, Grade B: Clear line, no measurable gap, Grade C: Gap within 1mm, Grade D: Gap more than 1mm). These two factors were analyzed in view of infection control after surgery.

Results. Preoperative bone stock did not show significant influence on infection control. Immediate postoperative cement-bone interface was an affecting factor for cure of infection.

Conclusion. There was a good chance of cure of infection even in cases with significant bone loss. Good cement fixation appeared to be important in view of infection control. The results suggested the importance of shielding of medullary space with antibiotic-loaded cement from infected joint space in revision THR for infection.

A reduced femoral offset in total hip replacement has been thought to be disadvantageous. We reviewed the results of 54 consecutive primary total hip replacements in 49 patients (mean age of 68 years) performed between August 1990 and December 1994, with a mean follow-up of 8.8 years (sd 2.1). The mean pre-operative femoral offset for these hips was 41 mm (sd 7.4). All patients received a low-offset Charnley stem and a polyethylene cup inserted by a single surgeon.

At their latest follow-up, surviving patients had a significant improvement in the performance of their hip. Three had undergone revision, one each for deep infection, recurrent dislocation and late pain with subluxation. No hips had been revised, or were at risk of revision, for aseptic loosening. The mean annual linear rate of wear was 0.2 mm (sd 0.08) for the whole group. There was no correlation between the pre-operative femoral offset and the post-operative rate of wear. Our survivorship estimate was 91% when revision for any reason was taken as an end-point, but 100% if aseptic loosening was considered as the end-point. Our study demonstrates that a low-offset femoral stem can produce good, medium-term results.

Hip prostheses that do not reproduce the patients’ preoperative femoral offset have been correlated with increased wear rate, instability, abductor weakness and reduced range of motion. We have reviewed the results of 54 primary low friction arthroplasties with low offset stem commonly called “¾ neck Charnley” in 49 patients (47 females and 2 males). There has been no publication in literature on the results of this stem. Mean age was 68 years (range 30 to 83). The operations were performed by one of us, (VR) as an orthopaedic trainee, with a mean follow up of 8.7 ± 2 years. The preoperative diagnosis was 40 OA, 8 protrusio, 2 DDH, 2 post-traumatic, 1 SUFE and 1 RA. The preoperative offset was 41.9 ± 7.1 mm (mean ± STD), weight 65 ± 8.4 kg, height 156.4 ± 8 cm.

At their latest review 3 cases had been revised for infection or recurrent instability with a survivorship of 93.5% using Kaplan Meyer’s analysis. None of the femoral or acetabular components were loose or at risk of loosening. 16 cups showed demarcation in 1 zone of ≤ 1mm, and 2 cups had a 2 mm demarcation in 2 zones that was not progressive. 7 stems had ≤ 1mm demarcation in 1 zone, and 5 stems at 2 zones. Condensation at the tip of the stem was noted in 2 hips. The linear wear rate was 0.2 ± 0.08mm/year. Using Pearson’s correlation coefficient with P< 0.05, no statistically significant correlation was found between the preoperative offset and the linear wear rate.

We believe that the surgeon should try to reproduce the patient’s femoral offset aiming for the best intra-operative soft tissue balance. The linear wear rate in this series is higher than previously reported in cases that survived for over 20 years from this unit. However, at this stage of analysis low offset Charnley stems produce good medium term results.

We reviewed prospectively cemented stem revision in 106 patients with severe femoral endosteal bone lysis without infection. Bone grafts were not used in any of the patients. The minimum follow-up was three years (mean 6 years 4 months). At the last review 76.4% of the patients were free of pain and 17.9% had only mild or occasional discomfort; radiographs showed well-fixed stable stems in 101 (95.3%). An intramedullary cement plug was used at revision to improve stability in 97.7%. There was new endosteal osteolysis after revision in 17 patients; only two had severe changes. Seven hips (6.6%) required a second revision; only four of these (3.8%) were for stem loosening. Survivorship of the revised stem, using radiological evidence of stem loosening as the end point, was 95.8% at seven years. The results of stem revision arthroplasty using cement in the presence of massive endosteal cavitation are satisfactory.

We reviewed the records and radiographs of 387 cemented revisions of aseptic loose sockets after total hip replacement at a mean follow-up of 5.5 years. The clinical results were satisfactory, but at the last radiological assessment 38 sockets (9.8%) had a continuous zone of demarcation greater than 1 mm thick and another 35 (9%) showed migration. Poor acetabular bone stock had a profound influence on the outcome of revision surgery, but the results of cemented revision were comparable to those reported for cementless revision at similar mean follow-up.

We reviewed 54 patients at a mean follow-up of 4 years 4 months after rerevisions for failure of Charnley low-friction arthroplasty. Rerevision for aseptic loosening in 26 hips was satisfactory; there were no clinical failures and at the latest radiological assessment only one stem and three sockets showed signs of loosening. By contrast, nine of 20 multiple revisions for recurrent dislocation failed, as did five of eight multiple revisions for deep infection. There was radiological evidence of loosening in one stem and nine sockets in the former group and in three stems and five sockets in the latter.

We reviewed 351 cemented revisions of femoral stems performed for aseptic loosening. At a mean of six years after the revision operation 72.1% of the patients were pain-free and 21.4% had only mild or occasional discomfort. The latest radiographs showed definite stem loosening in 10 (2.8%) and 20 hips (5.7%) had required rerevision, only nine (2.6%) of which were for mechanical failure of the stem. Survivorship analysis, taking the end point as rerevision of the stem, gave 97.0% survival at eight years and 91.6% at 11 years. Excellent results both clinically and radiologically can be achieved by cemented revision of the femoral stem for aseptic loosening.

We assessed 41 patients with rheumatoid arthritis (47 hips) who had had revision hip arthroplasty, at an average follow-up of 7 years 4 months (2 to 19). The clinical results were excellent or satisfactory in 43 hips. Radiologically, 45 stems were secure. Fifteen sockets (36.6%) were radiologically loose. Three hips required rerevision. Socket failure is the predominant problem in rheumatoid patients after cemented revision arthroplasty.

We report a prospective study of 57 one-stage cemented revisions of total hip replacement for deep infection with an actively discharging sinus. The average follow-up was 7 years 4 months. Seven patients had required rerevisions, but at latest follow-up, infection was under control in 49 (86%). A discharging sinus is not, in itself, a contraindication to one-stage revision of a hip replacement.