Periprosthetic femoral fractures are increasing in incidence, and typically occur in frail elderly patients. They are similar to pathological fractures in many ways. The aims of treatment are the same, including 'getting it right first time' with a single operation, which allows immediate unrestricted weightbearing, with a low risk of complications, and one that avoids the creation of stress risers locally that may predispose to further peri-implant fracture. The surgical approach to these fractures, the associated soft-tissue handling, and exposure of the fracture are key elements in minimizing the high rate of complications. This annotation describes the approaches to the femur that can be used to facilitate the surgical management of peri- and interprosthetic fractures of the femur at all levels using either modern methods of fixation or revision arthroplasty.

Cite this article: Bone Joint J 2023;105-B(6):593–601.

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).

Aims. Femoral cement-in-cement revision is a well described technique to reduce morbidity and complications in hip revision surgery. Traditional techniques for septic revision of hip arthroplasty necessitate removal of all bone cement from the femur. In our two centres, we have been using a cement-in-cement technique, leaving the distal femoral bone cement in selected patients for septic hip revision surgery, both for single and the first of two-stage revision procedures. A prerequisite for adoption of this technique is that the surgeon considers the cement mantle to be intimately fixed to bone without an intervening membrane between cement and host bone. We aim to report our experience for this technique. Methods. We have analyzed patients undergoing this cement-in-cement technique for femoral revision in infection, and present a consecutive series of 89 patients. Follow-up was undertaken at a mean of 56.5 months (24.0 to 134.7) for the surviving cases. Results. Seven patients (7.9%) required further revision for infection. Ten patients died of causes unrelated to their infection before their two-year review (mean 5.9 months; 0.9 to 18.6). One patient was lost to follow-up at five months after surgery, and two patients died of causes unrelated to their hip shortly after their two-year review was due without attending. Of the remaining patients, 69 remained infection-free at final review. Radiological review confirms the mechanical success of the procedure as previously described in aseptic revision, and postoperative Oxford Hip Scores suggest satisfactory functional outcomes. Conclusion. In conclusion, we found that retaining a well-fixed femoral cement mantle in the presence of infection and undertaking a cement-in-cement revision was successful in 82 of the patients (92.1%) in our series of 89, both in terms of eradication of infection and component fixation. These results are comparable to other more invasive techniques and offer significant potential benefits to the patient. Cite this article: Bone Joint J 2022;104-B(2):212–220

Aims

Cement-in-cement revision of the femoral component represents a widely practised technique for a variety of indications in revision total hip arthroplasty. In this study, we compare the clinical and radiological outcomes of two polished tapered femoral components.

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We aimed to compare the implant survival, complications, readmissions, and mortality of Vancouver B2 periprosthetic femoral fractures (PFFs) treated with internal fixation with that of B1 PFFs treated with internal fixation and B2 fractures treated with revision arthroplasty.

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To establish our early clinical results of a new total knee arthroplasty (TKA) tibial component introduced in 2013 and compare it to other designs in use at our hospital during the same period.

Aims. Periprosthetic fractures (PPFs) around cemented taper-slip femoral prostheses often result in a femoral component that is loose at the prosthesis-cement interface, but where the cement-bone interface remains well-fixed and bone stock is good. We aim to understand how best to classify and manage these fractures by using a modification of the Vancouver classification. Methods. We reviewed 87 PPFs. Each was a first episode of fracture around a cemented femoral component, where surgical management consisted of revision surgery. Data regarding initial injury, intraoperative findings, and management were prospectively collected. Patient records and serial radiographs were reviewed to determine fracture classification, whether the bone cement was well fixed (B2W) or loose (B2L), and time to fracture union following treatment. Results. In total, 47 B2W fractures (54.0%) and one B3 fracture (1.1%) had cement that remained well-fixed at the cement-bone interface. These cases were treated with cement-in-cement (CinC) revision arthroplasty. Overall, 43 fractures with follow-up united, and two patients sustained further fractures secondary to nonunion and required further revision surgery. A total of 19 B2L fractures (21.8%) and 19 B3 fractures (21.8%) had cement that was loose at the cement-bone interface. These cases were managed by revision arthroplasty with either cemented or uncemented femoral components, or proximal femoral arthroplasty. One case could not be classified. Conclusion. We endorse a modification of the original Vancouver system to include a subclassification of B2 fractures around cemented femoral prostheses to include B2W (where cement is well-fixed to bone) and B2L (where the cement is loose). Fractures around taper-slip design stems are more likely to fracture in a B2W pattern compared to fractures around composite beam design stems which are more likely to fracture in a B2L pattern. B2W fractures can reliably be managed with CinC revision. Cite this article: Bone Joint J 2021;103-B(1):71–78

Aims

In the 1990s, a bioactive bone cement (BABC) containing apatite-wollastonite glass-ceramic (AW-GC) powder and bisphenol-a-glycidyl methacrylate resin was developed at our hospital. In 1996, we used BABC to fix the acetabular component in primary total hip arthroplasty (THA) in 20 patients as part of a clinical trial. The purpose of this study was to investigate the long-term results of primary THA using BABC.

Aims. The aim of this study was to evaluate the long-term inducible displacement of cemented tibial components ten years after total knee arthroplasty (TKA). Patients and Methods. A total of 15 patients from a previously reported prospective trial of fixation using radiostereometric analysis (RSA) were examined at a mean of 11 years (10 to 11) postoperatively. Longitudinal supine RSA examinations were acquired at one week, one year, and two years postoperatively and at final follow-up. Weight-bearing RSA examinations were also undertaken with the operated lower limb in neutral and in maximum internal rotation positions. Maximum total point motion (MTPM) was calculated for the longitudinal and inducible displacement examinations (supine versus standing, standing versus internal rotation, and supine versus standing with internal rotation). Results. All patients showed some inducible displacement. Two patients with radiolucent lines had greater mean standing-supine MTPM displacement (1.35; . sd. 0.38) compared with the remaining patients (0.68; . sd. 0.36). These two patients also had a greater mean longitudinal MTPM at ten years (0.64; . sd. 0.50) compared with the remaining patients (0.39; . sd. 0.13 mm). Conclusion. Small inducible displacements in well-fixed cemented tibial components were seen ten years postoperatively, of a similar magnitude to that which has been reported for well-fixed components one to two years postoperatively. Greater displacements were found in components with radiolucent lines. Cite this article: Bone Joint J 2018;100-B:170–5

Aims

In the initial development of total shoulder arthroplasty (TSA), the humeral component was usually fixed with cement. Cementless components were subsequently introduced. The aim of this study was to compare the long-term outcome of cemented and cementless humeral components in arthroplasty of the shoulder.

Aims. Compared with primary total hip arthroplasty (THA), revision surgery can be challenging. The cement-in-cement femoral revision technique involves removing a femoral component from a well-fixed femoral cement mantle and cementing a new stem into the original mantle. This technique is widely used and when carried out for the correct indications, is fast, relatively inexpensive and carries a reduced short-term risk for the patient compared with the alternative of removing well-fixed cement. We report the outcomes of this procedure when two commonly used femoral stems are used. Patients and Methods. We identified 1179 cement-in-cement stem revisions involving an Exeter or a Lubinus stem reported to the Swedish Hip Arthroplasty Register (SHAR) between January 1999 and December 2015. Kaplan-Meier survival analysis was performed. Results. Survivorship is reported up to six years and was better in the Exeter group (91% standard deviation (. sd). 2.8% versus 85% . sd. 5.0%) (p = 0.02). There was, however, no significant difference in the survival of the stem and risk of re-revision for any reason (p = 0.58) and for aseptic loosening (p = 0.97), between revisions in which the Exeter stem (94% . sd. 2.2%; 98% . sd. 1.6%) was used compared with those in which the Lubinus stem (95% . sd. 3.2%; 98% . sd.  2.2%) was used. The database did not allow identification of whether a further revision was indicated for loosening of the acetabular or femoral component or both. Conclusion. The cement-in-cement technique for revision of the femoral component gave promising results using both designs of stem, six years post-operatively. Cite this article: Bone Joint J 2017;99-B(4 Supple B):27–32

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We present the clinical and radiological results at a minimum follow-up of five years for patients who have undergone multiple cement-in-cement revisions of their femoral component at revision total hip arthroplasty (THA).

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Periprosthetic fracture (PF) after primary total hip arthroplasty (THA) is an uncommon but potentially devastating complication. This study aims to investigate the influence of cemented stem designs on the risk of needing a revision for a PF.

Revision of a cemented hemiarthroplasty of the hip may be a hazardous procedure with high rates of intra-operative complications. Removing well-fixed cement is time consuming and risks damaging already weak bone or perforating the femoral shaft. The cement-in-cement method avoids removal of intact cement and has shown good results when used for revision total hip arthroplasty (THA). The use of this technique for the revision of a hemiarthroplasty to THA has not been previously reported. A total of 28 consecutive hemiarthroplasties (in 28 patients) were revised to a THA using an Exeter stem and the cement-in-cement technique. There were four men and 24 women; their mean age was 80 years (35 to 93). Clinical and radiographic data, as well as operative notes, were collected prospectively and no patient was lost to follow-up. Four patients died within two years of surgery. The mean follow up of the remainder was 70 months (25 to 124). Intra-operatively there was one proximal perforation, one crack of the femoral calcar and one acetabular fracture. No femoral components have required subsequent revision for aseptic loosening or are radiologically loose. . Four patients with late complications (14%) have since undergone surgery (two for a peri-prosthetic fracture, and one each for deep infection and recurrent dislocation) resulting in an overall major rate of complication of 35.7%. The cement-in-cement technique provides reliable femoral fixation in this elderly population and may reduce operating time and rates of complication. Cite this article: Bone Joint J 2015;97-B:1623–7

We are currently facing an epidemic of periprosthetic fractures around the hip. They may occur either during surgery or post-operatively. Although the acetabulum may be involved, the femur is most commonly affected. We are being presented with new, difficult fracture patterns around cemented and cementless implants, and we face the challenge of an elderly population who may have grossly deficient bone and may struggle to rehabilitate after such injuries. The correct surgical management of these fractures is challenging. This article will review the current choices of implants and techniques available to deal with periprosthetic fractures of the femur.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):48–55.

In 2005, we demonstrated that the polished triple-tapered C-stem at two years had migrated distally and rotated internally. From that series, 33 patients have now been followed radiologically, clinically and by radiostereometric analysis (RSA) for up to ten years. The distal migration within the cement mantle had continued and reached a mean of 2 mm (0.5 to 4.0) at ten years. Internal rotation, also within the cement mantle, was a mean 3.8° (external 1.6° to internal 6.6°) The cement mantle did not show any sign of migration or loosening in relation to the femoral bone. There were no clinical or radiological signs indicating that the migration or rotation within the cement mantle had had any adverse effects for the patients.

Cite this article: Bone Joint J 2014;96-B:604–8.

Two-stage exchange remains the gold standard for treatment of peri-prosthetic joint infection after total hip replacement (THR). In the first stage, all components and associated cement if present are removed, an aggressive debridement is undertaken including a complete synovectomy, and an antibiotic-loaded cement spacer is put in place. Patients are then treated with six weeks of parenteral antibiotics, followed by an ‘antibiotic free period’ to help ensure the infection has been eradicated. If the clinical evaluation and serum inflammatory markers suggest the infection has resolved, then the second stage can be completed, which involves removal of the cement spacer, repeat debridement, and placement of a new THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:84–7.

The technique of femoral cement-in-cement revision is well established, but there are no previous series reporting its use on the acetabular side at the time of revision total hip replacement. We describe the technique and report the outcome of 60 consecutive acetabular cement-in-cement revisions in 59 patients at a mean follow-up of 8.5 years (5 to 12). All had a radiologically and clinically well-fixed acetabular cement mantle at the time of revision. During the follow-up 29 patients died, but no hips were lost to follow-up. The two most common indications for acetabular revision were recurrent dislocation (46, 77%) and to complement femoral revision (12, 20%).

Of the 60 hips, there were two cases of aseptic loosening of the acetabular component (3.3%) requiring re-revision. No other hip was clinically or radiologically loose (96.7%) at the latest follow-up. One hip was re-revised for infection, four for recurrent dislocation and one for disarticulation of a constrained component. At five years the Kaplan-Meier survival rate was 100% for aseptic loosening and 92.2% (95% CI 84.8 to 99.6), with revision for any cause as the endpoint.

These results support the use of cement-in-cement revision on the acetabular side in appropriate cases. Theoretical advantages include preservation of bone stock, reduced operating time, reduced risk of complications and durable fixation.

There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival using re-intervention for any reason as the endpoint was 91% (95% confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at one and five years, respectively.

There were two revisions for dislocation of the humeral head, one open reduction for modular humeral component dissociation, one internal fixation for nonunion, one trimming of a prominent screw and one re-cementation for aseptic loosening complicated by infection, ultimately requiring excision arthroplasty. Two patients sustained nerve palsies.

Revision TSR after a peri-prosthetic humeral fracture associated with bone loss and/or loose components is a salvage procedure that can provide a stable platform for elbow and hand function. Good rates of union can be achieved using a stem that bypasses the fracture. There is a high rate of complications and function is not as good as with the original replacement.

An 81-year-old woman presented with a fracture in the left femur. She had well-fixed bilateral hip replacements and had received long-term bisphosphonate treatment. Prolonged bisphosphonate use has been recently linked with atypical subtrochanteric and diaphyseal femoral fractures. While the current definition of an atypical fracture of the femur excludes peri-prosthetic fractures, this case suggests that they do occur and should be considered in patients with severe osteopenia. Union of the fracture followed cessation of bisphosphonates and treatment with teriparatide. Thus, this case calls into question whether prophylactic intramedullary nailing is sufficient alone to treat early or completed atypical femoral fractures.