Aims. This study aimed to identify the tibial component and femoral component coronal angles (TCCAs and FCCAs), which concomitantly are associated with the best outcomes and survivorship in a cohort of fixed-bearing, cemented, medial unicompartmental knee arthroplasties (UKAs). We also investigated the potential two-way interactions between the TCCA and FCCA. Methods. Prospectively collected registry data involving 264 UKAs from a single institution were analyzed. The TCCAs and FCCAs were measured on postoperative radiographs and absolute angles were analyzed. Clinical assessment at six months, two years, and ten years was undertaken using the Knee Society Knee score (KSKS) and Knee Society Function score (KSFS), the Oxford Knee Score (OKS), the 36-Item Short-Form Health Survey questionnaire (SF-36), and range of motion (ROM). Fulfilment of expectations and satisfaction was also recorded. Implant survivorship was reviewed at a mean follow-up of 14 years (12 to 16). Multivariate regression models included covariates, TCCA, FCCA, and two-way interactions between them. Partial residual graphs were generated to identify angles associated with the best outcomes. Kaplan-Meier analysis was used to compare implant survivorship between groups. Results. Significant two-way interaction effects between TCCA and FCCA were identified. Adjusted for each other and their interaction, a TCCA of between 2° and 4° and a FCCA of between 0° and 2° were found to be associated with the greatest improvements in knee scores and the probability of fulfilling expectations and satisfaction at ten years. Patients in the optimal group whose TCCA and FCCA were between 2° and 4°, and 0° and 2°, respectively, had a significant survival benefit at 15 years compared with the non-optimal group (optimal: survival = 100% vs non-optimal: survival = 92%, 95% confidence interval (CI) 88% to 96%). Conclusion. Significant two-way interactions between the TCCA and FCCA demonstrate the importance of evaluating the alignment of the components concomitantly in future studies. By doing so, we found that patients who concomitantly had both a TCCA of between 2° and 4° and a FCCA of between 0° and 2° had the best patient-reported outcome measures at ten years and better survivorship at 15 years. Cite this article: Bone Joint J 2021;103-B(2):338–346

In posterior stabilised total knee replacement (TKR) a larger femoral component is sometimes selected to manage the increased flexion gap caused by resection of the posterior cruciate ligament. However, concerns remain regarding the adverse effect of the increased anteroposterior dimensions of the femoral component on the patellofemoral (PF) joint. Meanwhile, the gender-specific femoral component has a narrower and thinner anterior flange and is expected to reduce the PF contact force. PF contact forces were measured at 90°, 120°, 130° and 140° of flexion using the NexGen Legacy Posterior Stabilized (LPS)-Flex Fixed Bearing Knee system using Standard, Upsized and Gender femoral components during TKR. Increasing the size of the femoral component significantly increased mean PF forces at 120°, 130° and 140° of flexion (p = 0.005, p < 0.001 and p < 0.001, respectively). No difference was found in contact force between the Gender and the Standard components. Among the patients who had overhang of the Standard component, mean contact forces with the Gender component were slightly lower than those of the Standard component, but no statistical difference was found at 90°, 120°, 130° or 140° of flexion (p = 0.689, 0.615, 0.253 and 0.248, respectively). Upsized femoral components would increase PF forces in deep knee flexion. Gender-specific implants would not reduce PF forces

Radiostereometric analysis (RSA) can detect early micromovement in unstable implant designs which are likely subsequently to have a high failure rate. In 2010, the Articular Surface Replacement (ASR) was withdrawn because of a high failure rate. In 19 ASR femoral components, the mean micromovement over the first two years after implantation was 0.107 mm (. sd. 0.513) laterally, 0.055 mm (. sd. 0.204) distally and 0.150 mm (. sd. 0.413) anteriorly. The mean backward tilt around the x-axis was -0.08° (. sd. 1.088), mean internal rotation was 0.165° (. sd. 0.924) and mean varus tilt 0.238° (. sd. 0.420). The baseline to two-year varus tilt was statistically significant from zero movement, but there was no significant movement from one year onwards. We conclude that the ASR femoral component achieves initial stability and that early migration is not the mode of failure for this resurfacing arthroplasty

Aims. Femoral component anteversion is an important factor in the success of total hip arthroplasty (THA). This retrospective study aimed to investigate the accuracy of femoral component anteversion with the Mako THA system and software using the Exeter cemented femoral component, compared to the Accolade II cementless femoral component. Methods. We reviewed the data of 30 hips from 24 patients who underwent THA using the posterior approach with Exeter femoral components, and 30 hips from 24 patients with Accolade II components. Both groups did not differ significantly in age, sex, BMI, bone quality, or disease. Two weeks postoperatively, CT images were obtained to measure acetabular and femoral component anteversion. Results. The mean difference in femoral component anteversion between intraoperative and postoperative CT measurements (system accuracy of component anteversion) was 0.8° (SD 1.8°) in the Exeter group and 2.1° (SD 2.3°) in the Accolade II group, respectively (p = 0.020). The mean difference in anteversion between the plan and the postoperative CT measurements (clinical accuracy of femoral component anteversion) was 1.2° (SD 3.6°) in the Exeter group, and 4.2° (SD 3.9°) in the Accolade II group (p = 0.003). No significant differences were found in acetabular component inclination and anteversion; however, the clinical accuracy of combined anteversion was significantly better in the Exeter group (0.6° (SD 3.9°)) than the Accolade II group (3.6° (SD 4.1°)). Conclusion. The Mako THA system and software helps surgeons control the femoral component anteversion to achieve the target angle of insertion. The Exeter femoral component, inserted using Mako THA system, showed greater precision for femoral component and combined component anteversion than the Accolade II component. Cite this article: Bone Joint J 2024;106-B(3 Supple A):104–109

Aims. The aim of this study was to report the long-term follow-up of cemented short Exeter femoral components when used in primary total hip arthroplasty (THA). Methods. We included all primary 394 THAs with a cemented short Exeter femoral component (≤ 125 mm) used in our tertiary referral centre between October 1993 and December 2021. A total of 83 patients (21%) were male. The median age of the patients at the time of surgery was 42 years (interquartile range (IQR) 30 to 55). The main indication for THA was a childhood hip disease (202; 51%). The median follow-up was 6.7 years (IQR 3.1 to 11.0). Kaplan-Meier survival analyses were performed to determine the rates of survival with femoral revision for any indication, for septic loosening, for fracture of the femoral component and for aseptic loosening as endpoints. The indications for revision were evaluated. Fractures of the femoral component were described in detail. Results. The 20-year rate of survival was 85.4% (95% confidence interval (CI) 73.9 to 92.0) with revision for any indication, 96.2% (95% CI 90.5 to 98.5) with revision for septic loosening and 92.7% (95% CI 78.5 to 97.6) with revision for fracture of the femoral component. No femoral components were revised for aseptic loosening. There were 21 revisions of the femoral component; most (seven) as part of a two-stage management of infection. Fracture of the femoral component occurred in four THAs (1.0%) at 6.6, 11.6, 16.5, and 18.2 years of follow-up, respectively. Three of these were transverse fractures and occurred at the level of the lesser trochanter. In one THA, there was a fracture of the neck of the component. Conclusion. THAs using cemented short Exeter femoral components showed acceptable rates of survival of the femoral component at long-term follow-up, in this young cohort of patients. Although fracture is a rare complication of these components, surgeons should be aware of their incidence and possible risk factors. Cite this article: Bone Joint J 2024;106-B(3 Supple A):137–142

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. Methods. From our prospectively collated database, we identified all patients undergoing cement-in-cement revision from January 2005 to January 2013 who had a minimum of two years' follow-up. All cases were performed by the senior author using either an Exeter short revision stem or the C-Stem AMT high offset No. 1 prosthesis. Patients were followed-up annually with clinical and radiological assessment. Results. A total of 97 patients matched the inclusion criteria (50 Exeter and 47 C-Stem AMT components). There were no significant differences between the patient demographic data in either group. Mean follow-up was 9.7 years. A significant improvement in Oxford Hip Score (OHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 12-item Short-Form Survey (SF-12) scores was observed in both cohorts. Leg lengths were significantly shorter in the Exeter group, with a mean of -4 mm in this cohort compared with 0 mm in the C-Stem AMT group. One patient in the Exeter group had early evidence of radiological loosening. In total, 16 patients (15%) underwent further revision of the femoral component (seven in the C-Stem AMT group and nine in the Exeter group). No femoral components were revised for aseptic loosening. There were two cases of femoral component fracture in the Exeter group. Conclusion. Our series shows promising mid-term outcomes for the cement-in-cement revision technique using either the Exeter or C-Stem AMT components. These results demonstrate that cement-in-cement revision using a double or triple taper-slip design is a safe and reliable technique when used for the correct indications. Cite this article: Bone Joint J 2021;103-B(7):1215–1221

Aims. The primary aim of this trial was to compare the subsidence of two similar hydroxyapatite-coated titanium femoral components from different manufacturers. Secondary aims were to compare rotational migration (anteversion/retroversion and varus/valgus tilt) and patient-reported outcome measures between both femoral components. Methods. Patients were randomized to receive one of the two femoral components (Avenir or Corail) during their primary total hip arthroplasty between August 2018 and September 2020. Radiostereometric analysis examinations at six, 12, and 24 months were used to assess the migration of each implanted femoral component compared to a baseline assessment. Patient-reported outcome measures were also recorded for these same timepoints. Overall, 50 patients were enrolled (62% male (n = 31), with a mean age of 65.7 years (SD 7.3), and mean BMI of 30.2 kg/m. 2. (SD 5.2)). Results. The two-year subsidence was similar for Avenir (-0.018 mm (95% confidence interval (CI) -0.053 to 0.018) and Corail (0.000 mm (95% CI -0.027 to 0.026; p = 0.428). Both anteversion/retroversion (Avenir 0.139° (95% CI -0.204 to 0.481°); Corail -0.196° (95% CI -0.445 to 0.053°; p = 0.110) and varus/valgus tilt (Avenir -0.024° (95% CI -0.077 to 0.028); Corail -0.049° (95% CI -0.098 to 0.000°; p = 0.473) were not statistically significantly different. After two years, patients reported similar improvements in EuroQol five-dimension five-level health questionnaire (Avenir 0.22 (SD 0.2); Corail 0.22 (SD 0.18); p = 0.965) and other outcomes scores. Patient satisfaction on a five-point Likert scale was also similar between both groups after two years (Avenir 1.38 (SD 0.88); Corail 1.33 (SD 0.57); p = 0.846). Conclusion. The performance of both femoral components was similar in terms of stability and patient outcomes. Cite this article: Bone Joint J 2023;105-B(10):1045–1051

Aims. We present the results, in terms of survival, clinical outcome, and radiological appearance at 20 years, in a cohort of 225 cemented Exeter Universal femoral components (Stryker, Newbury, UK) implanted in 207 patients, at a district general hospital. Methods. All patients in this study had a total hip arthroplasty (THA) using an Exeter Universal femoral component with a cemented (n = 215) or cementless (n = 10) acetabular component. Clinical and radiological data were collected prospectively at one year, five years, and every five years thereafter. Patients lost to radiological and clinical follow-up (five) were cross-referenced with National Joint Registry (NJR) data and general practitioner (GP) records to assess whether they had undergone revision for any reason. Results. During this period of study 144 patients (157 hips) died (69.78%). Two patients were lost to follow-up, leaving 61 patients (66 hips) available for review (29.33%). Of the 225 hips, three underwent revision for femoral failure with osteolysis. One underwent femoral component revision for treatment of a periprosthetic fracture. Eight underwent revision of the acetabular component only for loosening. Two hips had both components revised, when components were found to be loose at time of revision for acetabular loosening, though no radiological femoral osteolysis. Two patients underwent revision for infection. Using femoral loosening as an endpoint, the survival of the Exeter Universal femoral component was 98.7% (n = 220, 95% confidence interval (CI) 96.1% to 100%) at 20 to 22 years. Survival with an endpoint of revision for any reason was 92.6% (n = 209, 95% CI 89.4 to 95.55), with a ‘worst-case scenario’ (considering two patients lost to follow-up to have failed), the overall survival rate was 91.7% (n = 207, 95% CI 87.8 to 95.9) at 20 to 22 years. Conclusion. Our results confirm excellent long-term results for the cemented Exeter Universal femoral componentimplanted outside of the originating centre. Cite this article: Bone Joint J 2020;102-B(10):1319–1323

Aims. Periprosthetic femoral fracture (PPF) is a major complication following total hip arthroplasty (THA). Uncemented femoral components are widely preferred in primary THA, but are associated with higher PPF risk than cemented components. Collared components have reduced PPF rates following uncemented primary THA compared to collarless components, while maintaining similar prosthetic designs. The purpose of this study was to analyze PPF rate between collarless and collared component designs in a consecutive cohort of posterior approach THAs performed by two high-volume surgeons. Methods. This retrospective series included 1,888 uncemented primary THAs using the posterior approach performed by two surgeons (PKS, JMV) from January 2016 to December 2022. Both surgeons switched from collarless to collared components in mid-2020, which was the only change in surgical practice. Data related to component design, PPF rate, and requirement for revision surgery were collected. A total of 1,123 patients (59.5%) received a collarless femoral component and 765 (40.5%) received a collared component. PPFs were identified using medical records and radiological imaging. Fracture rates between collared and collarless components were analyzed. Power analysis confirmed 80% power of the sample to detect a significant difference in PPF rates, and a Fisher’s exact test was performed to determine an association between collared and collarless component use on PPF rates. Results. Overall, 17 PPFs occurred (0.9%). There were 16 fractures out of 1,123 collarless femoral components (1.42%) and one fracture out of 765 collared components (0.13%; p = 0.002). The majority of fractures (n = 14; 82.4%) occurred within 90 days of primary THA. There were ten reoperations for PPF with collarless components (0.89%) and one reoperation with a collared component (0.13%; p = 0.034). Conclusion. Collared femoral components were associated with significant decreases in PPF rate and reoperation rate for PPF compared to collarless components in uncemented primary THA. Future studies should investigate whether new-generation collared components reduce PPF rates with longer-term follow-up. Cite this article: Bone Joint J 2024;106-B(3 Supple A):115–120

Aims. Revision total hip arthroplasty in patients with Vancouver type B3 fractures with Paprosky type IIIA, IIIB, and IV femoral defects are difficult to treat. One option for Paprovsky type IIIB and IV defects involves modular cementless, tapered, revision femoral components in conjunction with distal interlocking screws. The aim of this study was to analyze the rate of reoperations and complications and union of the fracture, subsidence of the stem, mortality, and the clinical outcomes in these patients. Methods. A total of 46 femoral components in patients with Vancouver B3 fractures (23 with Paprosky type IIIA, 19 with type IIIB, and four with type IV defects) in 46 patients were revised with a transfemoral approach using a modular, tapered, cementless revision Revitan curved femoral component with distal cone-in-cone fixation and prospectively followed for a mean of 48.8 months (SD 23.9; 24 to 112). The mean age of the patients was 80.4 years (66 to 100). Additional distal interlocking was also used in 23 fractures in which distal cone-in-cone fixation in the isthmus was < 3 cm. Results. One patient (2.2%) died during the first postoperative year. After six months, 43 patients (93.5%) had osseous, and three had fibrous consolidation of the fracture and the bony flap, 42 (91.3%) had bony ingrowth and four had stable fibrous fixation of the stem. No patient had radiolucency around the interlocking screws and no screw broke. One patient had non-progressive subsidence and two had a dislocation. The mean Harris Hip Score increased from of 57.8 points (SD 7.9) three months postoperatively to 76.1 points (SD 10.7) 24 months postoperatively. Conclusion. The 2° tapered, fluted revision femoral component with distal cone-in-cone-fixation, combined with additional distal interlocking in patients with bony deficiency at the isthmus, led to reproducibly good results in patients with a Vancouver B3 fracture and Paprosky type IIIA, IIIB, and IV defects with regard to union of the fracture, subsidence or loosening of the stem, and clinical outcomes. Cite this article: Bone Joint J 2024;106-B(4):344–351

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). Methods. Data were collected for patients admitted to five UK centres. The primary outcome measure was the two-year reoperation rate. Secondary outcomes were time to surgery, transfusion requirements, critical care requirements, length of stay, two-year local complication rates, six-month systemic complication rates, and mortality rates. Comparisons were made by the form of treatment (ORIF vs revision) and UCS type (B1 vs B2/B3). Kaplan-Meier survival analysis was performed with two-year reoperation for any reason as the endpoint. Results. A total of 317 periprosthetic fractures (in 317 patients) with a median follow-up of 3.6 years (interquartile range (IQR) 2.0 to 5.4) were included. The fractures were type B1 in 133 (42.0%), B2 in 170 (53.6%), and B3 in 14 patients (4.4%). ORIF was performed in 167 (52.7%) and revision in 150 patients (47.3%). The two-year reoperation rate (15.3% vs 7.2%; p = 0.021), time to surgery (4.0 days (IQR 2.0 to 7.0) vs 2.0 days (IQR 1.0 to 4.0); p < 0.001), transfusion requirements (55 patients (36.7%) vs 42 patients (25.1%); p = 0.026), critical care requirements (36 patients (24.0%) vs seven patients (4.2%); p < 0.001) and two-year local complication rates (26.7% vs 9.0%; p < 0.001) were significantly higher in the revision group. The two-year rate of survival was significantly higher for ORIF (91.9% (standard error (SE) 0.023%) vs 83.9% (SE 0.031%); p = 0.032) compared with revision. For B1 fractures, the two-year reoperation rate was significantly higher for revision compared with ORIF (29.4% vs 6.0%; p = 0.002) but this was similar for B2 and B3 fractures (9.8% vs 13.5%; p = 0.341). The most common indication for reoperation after revision was dislocation (12 patients; 8.0%). Conclusion. Revision surgery has higher reoperation rates, longer surgical waiting times, higher transfusion requirements, and higher critical care requirements than ORIF in the management of periprosthetic fractures around polished taper-slip femoral components after THA. ORIF is a safe option providing anatomical reconstruction is achievable. Cite this article: Bone Joint J 2023;105-B(2):124–134

Aims. The aims of this study were to evaluate wear on the surface of cobalt-chromium (CoCr) femoral components used in total knee arthroplasty (TKA) and compare the wear of these components with that of ceramic femoral components. Methods. Optical profilometry was used to evaluate surface roughness and to examine the features created by the wear process in a knee wear simulator. We developed a method of measuring surface changes on five CoCr femoral components and quantifying the loss of material from the articular surface during the wear process. We also examined the articular surface of three ceramic femoral components from a previous test for evidence of surface damage, and compared it with that of CoCr components. Results. We found that the surface roughness of CoCr components rapidly increased during the first 1,000 wear cycles, then reached a steady state, but material loss from the surface continued at a rate of 1,778,000 μm. 3. per million cycles as carbides were removed from its matrix. These carbides formed third-body wear particles, leading to the formation of new scratches even as older scratches were worn away. In contrast, no scratching, loss of material, or other surface damage, when evaluated with one nanometer resolution, was found on the surface of the ceramic components after a 15 M wear cycle test. Conclusion. This study showed wear and loss of CoCr material from scratching and microabrasive wear in TKA. The material loss from the surface continued in a linear relationship with increasing cycles. We also found the absence of scratching and roughening of ceramic femoral components in simulated wear, suggesting an advantage in wear rate and avoiding metal sensitivity. This may have implications in the management of persistent pain after TKA. Cite this article: Bone Joint J 2021;103-B(6 Supple A):94–101

Aims. We evaluated a large database with mechanical failure of a single uncemented modular femoral component, used in revision hip arthroplasty, as the end point and compared them to a control group treated with the same implant. Patient- and implant-specific risk factors for implant failure were analyzed. . Methods. All cases of a fractured uncemented modular revision femoral component from one manufacturer until April 2017 were identified and the total number of implants sold until April 2017 was used to calculate the fracture rate. The manufacturer provided data on patient demographics, time to failure, and implant details for all notified fractured devices. Patient- and implant-specific risk factors were evaluated using a logistic regression model with multiple imputations and compared to data from a previously published reference group, where no fractures had been observed. The results of a retrieval analysis of the fractured implants, performed by the manufacturer, were available for evaluation. Results. There were 113 recorded cases with fracture at the modular junction, resulting in a calculated fracture rate of 0.30% (113/37,600). The fracture rate of the implant without signs of improper use was 0.11% (41/37,600). In 79% (89/113) of cases with a failed implant, either a lateralized (high offset) neck segment, an extralong head, or the combination of both were used. Logistic regression analysis revealed male sex, high body mass index (BMI), straight component design, and small neck segments were significant risk factors for failure. Investigation of the implants (76/113) showed at least one sign of improper use in 72 cases. Conclusion. Implant failure at the modular junction is associated with patient- and implant-specific risk factors as well as technical errors during implantation. Whenever possible, the use of short and lateralized neck segments should be avoided with this revision system. Implantation instructions and contraindications need to be adhered to and respected. Cite this article: Bone Joint J 2020;102-B(5):573–579

Aims. The aim of this study was to compare the migration of the femoral component, five years postoperatively, between patients with a highly cross-linked polyethylene (HXLPE) insert and those with a conventional polyethylene (PE) insert in an uncemented Triathlon fixed insert cruciate-retaining total knee arthroplasty (TKA). Secondary aims included clinical outcomes and patient-reported outcome measures (PROMs). We have previously reported the migration and outcome of the tibial components in these patients. Methods. A double-blinded randomized controlled trial was conducted including 96 TKAs. The migration of the femoral component was measured with radiostereometry (RSA) at three and six months and one, two, and five years postoperatively. PROMs were collected preoperatively and at all periods of follow-up. Results. There was no clinically relevant difference in terms of migration of the femoral component or PROMs between the HXLPE and PE groups. The mean difference in migration (maximum total point motion), five years postopeatively, was 0.04 mm (95% CI -0.06 to 0.16) in favour of the PE group. Conclusion. There was no clinically relevant difference in migration of the femoral component, for up to five years between the two groups. These findings will help to establish a benchmark for future studies on migration of femoral components in TKA. Cite this article: Bone Joint J 2024;106-B(8):826–833

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. This study aimed to evaluate the association between the sagittal alignment of the femoral component in total knee arthroplasty (TKA) and new Knee Society Score (2011KSS), under the hypothesis that outliers such as the excessive extended or flexed femoral component were related to worse clinical outcomes. Methods. A group of 156 knees (134 F:22 M) in 133 patients with a mean age 75.8 years (SD 6.4) who underwent TKA with the cruciate-substituting Bi-Surface Knee prosthesis were retrospectively enrolled. On lateral radiographs, γ angle (the angle between the distal femoral axis and the line perpendicular to the distal rear surface of the femoral component) was measured, and the patients were divided into four groups according to the γ angle. The 2011KSSs among groups were compared using the Kruskal-Wallis test. A secondary regression analysis was used to investigate the association between the 2011KSS and γ angle. Results. According to the mean and SD of γ angle (γ, 4.0 SD 3.0°), four groups (Extended or minor flexed group, −0.5° ≤ γ < 2.5° (n = 54)), Mild flexed group (2.5° ≤ γ < 5.5° (n = 63)), Moderate flexed group (5.5° ≤ γ < 8.5° (n = 26)), and Excessive flexed group (8.5° ≤ γ (n = 13)) were defined. The Excessive flexed group showed worse 2011KSSs in all subdomains (Symptoms, Satisfaction, Expectations, and Functional activities) than the Mild flexed group. Secondary regression showed a convex upward function, and the scores were highest at γ = 3.0°, 4.0°, and 3.0° in Satisfaction, Expectations, and Functional activities, respectively. Conclusion. The groups with a sagittal alignment of the femoral component > 8.5° showed inferior clinical outcomes in 2011KSSs. Secondary regression analyses showed that mild flexion of the femoral component was associated with the highest score. When implanting the Bi-Surface Knee prosthesis surgeons should pay careful attention to avoiding flexing the femoral component extensively during TKA. Our findings may be applicable to other implant designs. Cite this article: Bone Joint J 2020;102-B(6 Supple A):36–42

Aims. 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. Methods. We retrospectively reviewed the data of 112 PFFs, of which 47 (42%) B1 and 27 (24%) B2 PFFs were treated with internal fixation, whereas 38 (34%) B2 fractures underwent revision arthroplasty. Decision to perform internal fixation for B2 PFFs was based on specific radiological (polished femoral components, intact bone-cement interface) and clinical criteria (low-demand patient). Median follow-up was 36.4 months (24 to 60). Implant survival and mortality over time were estimated with the Kaplan-Meier method. Adverse events (measured with a modified Dindo-Clavien classification) and 90-day readmissions were additionally compared between groups. Results. In all, nine (8.01%) surgical failures were detected. All failures occurred within the first 24 months following surgery. The 24-month implant survival was 95.4% (95% confidence interval (CI) 89.13 to 100) for B1 fractures treated with internal fixation, 90% (95% CI 76.86 to 100) for B2 PFFs treated with osteosynthesis-only, and 85.8% (95% CI 74.24 to 97.36) for B2 fractures treated with revision THA, without significant differences between groups (p = 0.296). Readmissions and major adverse events including mortality were overall high, but similar between groups (p > 0.05). The two-year patient survival rate was 87.1% (95% CI 77.49 to 95.76), 66.7% (95% CI 48.86 to 84.53), and 84.2% (95% CI 72.63 to 95.76), for the B1 group, B2 osteosynthesis group, and B2 revision group, respectively (p = 0.102). Conclusion. Implant survival in Vancouver B2 PFFs treated with internal fixation was similar to that of B1 fractures treated with the same method and to B2 PFFs treated with revision arthroplasty. Low-demand, elderly patients with B2 fractures around well-cemented polished femoral components with an intact bone-cement interface can be safely treated with internal fixation. Cite this article: Bone Joint J 2021;103-B(7):1222–1230

We describe three cases of fracture of the titanium JRI-Furlong hydroxyapatite-ceramic (HAC)-coated femoral component. We have examined previous case reports of failure of this stem and conclude that fracture may occur in two places, namely at the neck-shoulder junction and at the conical-distal cylindrical junction. These breakages are the result of fatigue in a metallurgically-proven normal femoral component. All the cases of failure of the femoral component have occurred in patients with a body mass index of more than 25 in whom a small component, either size 9 or 10, had been used. In patients with a body mass index above normal size 9 components should be avoided and the femoral canal should be reamed sufficiently to accept a large femoral component to ensure that there is adequate metaphyseal fixation

Aims. 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). Patients and Methods. We reviewed the outcome on a consecutive series of 24 patients (10 men, 14 women) (51 procedures) who underwent more than one cement-in-cement revision of the same femoral component. The mean age of the patients was 67.5 years (36 to 92) at final follow-up. Function was assessed using the original Harris hip score (HHS), Oxford Hip Score (OHS) and the Merle D’Aubigné Postel score (MDP). Results. The mean length of follow-up was 81.7 months (64 to 240). A total of 41 isolated acetabular revisions were performed in which stem removal facilitated access to the acetabulum, six revisions were conducted for loosening of both components and two were isolated stem revisions (each of these patients had undergone at least two revisions). There was significant improvement in the OHS (p = 0.041), HHS (p = 0.019) and MDP (p = 0.042) scores at final follow-up There were no stem revisions for aseptic loosening. Survival of the femoral component was 91.9% (95% confidence intervals (CI) 71.5 to 97.9) at five years and 91.7% (95% CI 70 to 97) at ten years (number at risk 13), with stem revision for all causes as the endpoint. Conclusion. Cement-in-cement revision is a viable technique for performing multiple revisions of the well cemented femoral component during revision total hip arthroplasty at a minimum of five years follow-up. Cite this article: Bone Joint J 2017;99-B:199–203

Between 1986 and 1991 we implanted 331 consecutive Furlong hydroxyapatite-coated femoral components of a total hip replacement in 291 patients. A cemented acetabular prosthesis was used in 217 hips and a hydroxyapatite-coated component in 114. We describe the long-term clinical and radiological survival of the femoral component at a mean follow-up of 17.5 years (15 to 21). Only two patients (0.68%) were lost to follow-up. With revision of the femoral component for any reason as the endpoint, the survival at a mean of 17 years was 97.4% (95% confidence interval 94.1 to 99.5), and with revision for aseptic loosening as the endpoint it was 100%. The survival at a maximum of 21 years with revision of the femoral component for any reason as the endpoint was 97.4% (95% confidence interval 81.0 or 99.5). These results compare favourably with the best long-term results of cemented or uncemented femoral components used in total hip replacement