Aims. Congenital pseudarthrosis of the tibia (CPT) has traditionally been a difficult condition to treat, with high complication rates, including nonunion, refractures, malalignment, and leg length discrepancy. Surgical approaches to treatment of
The purpose of this study was to determine the association between prior sleeve gastrectomy in patients undergoing primary total hip and knee arthroplasty, and 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up. This is a retrospective, single-centre analysis. Patients undergoing primary hip or knee arthroplasty with a prior sleeve gastrectomy were eligible for inclusion (n = 80 patients). A morbidly obese control group was established from the same institutional registry using a 1:2 match, for cases:controls with arthroplasty based on propensity score using age, sex, pre-sleeve gastrectomy BMI, Current Procedural Terminology code to identify anatomical location, and presurgical haemoglobin A1C. Outcomes included 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up. Multivariable logistic regressions evaluated associations of underlying preoperative demographic and treatment characteristics with outcomes.Aims
Methods
The aims of this study were to evaluate the incidence of reoperation (all cause and specifically for periprosthetic femoral fracture (PFF)) and mortality, and associated risk factors, following a hemiarthroplasty incorporating a cemented collarless polished taper slip stem (PTS) for management of an intracapsular hip fracture. This retrospective study included hip fracture patients aged 50 years and older treated with Exeter (PTS) bipolar hemiarthroplasty between 2019 and 2022. Patient demographics, place of domicile, fracture type, delirium status, American Society of Anesthesiologists (ASA) grade, length of stay, and mortality were collected. Reoperation and mortality were recorded up to a median follow-up of 29.5 months (interquartile range 12 to 51.4). Cox regression was performed to evaluate independent risk factors associated with reoperation and mortality.Aims
Methods
Pigment epithelium-derived factor (PEDF) is known to induce several types of tissue regeneration by activating tissue-specific stem cells. Here, we investigated the therapeutic potential of PEDF 29-mer peptide in the damaged articular cartilage (AC) in rat osteoarthritis (OA). Mesenchymal stem/stromal cells (MSCs) were isolated from rat bone marrow (BM) and used to evaluate the impact of 29-mer on chondrogenic differentiation of BM-MSCs in culture. Knee OA was induced in rats by a single intra-articular injection of monosodium iodoacetate (MIA) in the right knees (set to day 0). The 29-mer dissolved in 5% hyaluronic acid (HA) was intra-articularly injected into right knees at day 8 and 12 after MIA injection. Subsequently, the therapeutic effect of the 29-mer/HA on OA was evaluated by the Osteoarthritis Research Society International (OARSI) histopathological scoring system and changes in hind paw weight distribution, respectively. The regeneration of chondrocytes in damaged AC was detected by dual-immunostaining of 5-bromo-2'-deoxyuridine (BrdU) and chondrogenic markers.Aims
Methods
In recent years, the use of a collared cementless femoral prosthesis has risen in popularity. The design intention of collared components is to transfer some load to the resected femoral calcar and prevent implant subsidence within the cancellous bone of the metaphysis. Conversely, the load transfer for a cemented femoral prosthesis depends on the cement-component and cement-bone interface interaction. The aim of our study was to compare the three most commonly used collared cementless components and the three most commonly used tapered polished cemented components in patients aged ≥ 75 years who have undergone a primary total hip arthroplasty (THA) for osteoarthritis (OA). Data from the Australian Orthopaedic Association National Joint Replacement Registry from 1 September 1999 to 31 December 2022 were analyzed. Collared cementless femoral components and cemented components were identified, and the three most commonly used components in each group were analyzed. We identified a total of 11,278 collared cementless components and 47,835 cemented components. Hazard ratios (HRs) from Cox proportional hazards models, adjusting for age and sex, were obtained to compare the revision rates between the groups.Aims
Methods
Modular dual-mobility (DM) articulations are increasingly used during total hip arthroplasty (THA). However, concerns remain regarding the metal liner modularity. This study aims to correlate metal artifact reduction sequence (MARS)-MRI abnormalities with serum metal ion levels in patients with DM articulations. A total of 45 patients (50 hips) with a modular DM articulation were included with mean follow-up of 3.7 years (SD 1.2). Enrolled patients with an asymptomatic, primary THA and DM articulation with over two years’ follow-up underwent MARS-MRI. Each patient had serum cobalt, chromium, and titanium levels drawn. Patient satisfaction, Oxford Hip Score, and Forgotten Joint Score-12 (FJS-12) were collected. Each MARS-MRI was independently reviewed by fellowship-trained musculoskeletal radiologists blinded to serum ion levels.Aims
Methods
The aim of this retrospective study was to assess the incidence of early periprosthetic femoral fracture (PFF) associated with Charnley-Kerboull (CK) femoral components cemented according to the ‘French paradox’ principles through the Hueter anterior approach (HAA) in patients older than 70 years. From a prospectively collected database, all short CK femoral components implanted consecutively from January 2018 to May 2022 through the HAA in patients older than 70 years were included. Exclusion criteria were age below 70 years, use of cementless femoral component, and approaches other than the HAA. A total of 416 short CK prostheses used by 25 surgeons with various levels of experience were included. All patients had a minimum of one-year follow-up, with a mean of 2.6 years (SD 1.1). The mean age was 77.4 years (70 to 95) and the mean BMI was 25.3 kg/m2 (18.4 to 43). Femoral anatomy was classified according to Dorr. The measured parameters included canal flare index, morphological cortical index, canal-calcar ratio, ilium-ischial ratio, and anterior superior iliac spine to greater trochanter (GT) distance.Aims
Methods
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:
The aim of this study was to report the three-year follow-up for a series of 400 patients with a displaced intracapsular fracture of the hip, who were randomized to be treated with either a cemented polished tapered hemiarthroplasty or an uncemented hydroxyapatite-coated hemiarthroplasty. The mean age of the patients was 85 years (58 to 102) and 273 (68%) were female. Follow-up was undertaken by a nurse who was blinded to the hemiarthroplasty that was used, at intervals for up to three years from surgery. The short-term follow-up of these patients at a mean of one year has previously been reported.Aims
Methods
This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures. Using the National Surgical Quality Improvement Programme (NSQIP) database, patients who underwent common orthopaedic surgery procedures from 1 January to 31 December 2021 were extracted. Patient preoperative COVID-19 status, demographics, comorbidities, type of surgery, and postoperative complications were analyzed. Propensity score matching was conducted between COVID-19-positive and -negative patients. Multivariable regression was then performed to identify both patient and provider risk factors independently associated with the occurrence of 30-day postoperative adverse events.Aims
Methods
The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing joint arthroplasty have a higher incidence of adverse outcomes than those without IBD. A comprehensive literature search was conducted to identify eligible studies reporting postoperative outcomes in IBD patients undergoing joint arthroplasty. The primary outcomes included postoperative complications, while the secondary outcomes included unplanned readmission, length of stay (LOS), joint reoperation/implant revision, and cost of care. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model when heterogeneity was substantial.Aims
Methods
The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate? PHFs occurring between 1 January 2009 and 31 December 2019 were identified from the Medicare physician service records. Incidence rates were determined, mortality rates were calculated, and semiparametric Cox regression was applied, incorporating 23 demographic, clinical, and socioeconomic covariates, to compare the mortality risk between treatments.Aims
Methods
In the last decade, perioperative advancements have expanded the use of outpatient primary total knee arthroplasty (TKA). Despite this, there remains limited data on expedited discharge after revision TKA. This study compared 30-day readmissions and reoperations in patients undergoing revision TKA with a hospital stay greater or less than 24 hours. The authors hypothesized that expedited discharge in select patients would not be associated with increased 30-day readmissions and reoperations. Aseptic revision TKAs in the National Surgical Quality Improvement Program database were reviewed from 2013 to 2020. TKAs were stratified by length of hospital stay (greater or less than 24 hours). Patient demographic details, medical comorbidities, American Society of Anesthesiologists (ASA) grade, operating time, components revised, 30-day readmissions, and reoperations were compared. Multivariate analysis evaluated predictors of discharge prior to 24 hours, 30-day readmission, and reoperation.Aims
Methods
Aims. Periprosthetic hip fractures (PPFs) after total hip arthroplasty are difficult to treat. Therefore, it is important to identify modifiable risk factors such as stem selection to reduce the occurrence of PPFs. This study aimed to clarify differences in fracture torque, surface strain, and fracture type analysis between three different types of cemented stems. Methods. We conducted biomechanical testing of bone analogues using six cemented stems of three different types: collarless polished tapered (CPT) stem, Versys Advocate (Versys) stem, and Charnley-Marcel-Kerboull (CMK) stem. Experienced surgeons implanted each of these types of stems into six bone analogues, and the analogues were compressed and internally rotated until failure. Torque to fracture and fracture type were recorded. We also measured surface strain distribution using triaxial rosettes. Results. There was a significant difference in fracture torque between the three stem types (p = 0.036). Particularly, the median fracture torque for the
Corticosteroid injections are often used to manage glenohumeral arthritis in patients who may be candidates for future total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (rTSA). In the conservative management of these patients, corticosteroid injections are often provided for symptomatic relief. The purpose of this study was to determine if the timing of corticosteroid injections prior to TSA or rTSA is associated with changes in rates of revision and periprosthetic joint infection (PJI) following these procedures. Data were collected from a national insurance database from January 2006 to December 2017. Patients who underwent shoulder corticosteroid injection within one year prior to ipsilateral TSA or rTSA were identified and stratified into the following cohorts: < three months, three to six months, six to nine months, and nine to 12 months from time of corticosteroid injection to TSA or rTSA. A control cohort with no corticosteroid injection within one year prior to TSA or rTSA was used for comparison. Univariate and multivariate analyses were conducted to determine the association between specific time intervals and outcomes.Aims
Methods
The purpose of this study was to assess the prevalence of depression and anxiety symptoms in patients undergoing shoulder surgery using the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Depression and Anxiety computer adaptive tests, and to determine the factors associated with more severe symptoms. Additionally, we sought to determine whether PROMIS Depression and Anxiety were associated with functional outcomes after shoulder surgery. This was a retrospective analysis of 293 patients from an urban population who underwent elective shoulder surgery from 2015 to 2018. Survey questionnaires included preoperative and two-year postoperative data. Bivariate analysis was used to identify associations and multivariable analysis was used to control for confounding variables.Aims
Methods
There is conflicting evidence on the safety of intra-articular injections of hyaluronic acid (HA) or corticosteroids (CSs) before total knee arthroplasty (TKA). We performed a meta-analysis of the relationship between intra-articular injections and subsequent infection rates after TKA. We searched PubMed, EMBASE, and the Cochrane Library for cohort studies that assessed the effect of preoperative injection of drugs into the joint cavity on the infection rate after TKA. The outcomes analyzed included the total infection rate, as well as those for different preoperative injection time periods and different drugs.Aims
Methods
This study used an artificial neural network (ANN) model to determine the most important pre- and perioperative variables to predict same-day discharge in patients undergoing total knee arthroplasty (TKA). Data for this study were collected from the National Surgery Quality Improvement Program (NSQIP) database from the year 2018. Patients who received a primary, elective, unilateral TKA with a diagnosis of primary osteoarthritis were included. Demographic, preoperative, and intraoperative variables were analyzed. The ANN model was compared to a logistic regression model, which is a conventional machine-learning algorithm. Variables collected from 28,742 patients were analyzed based on their contribution to hospital length of stay.Aims
Methods
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. Radiographs of 71 patients with a PFF admitted consecutively at two centres between 25 February 2012 and 19 May 2020 were collated by an independent investigator. Six observers (three hip consultants and three trainees) were familiarized with the UCS. Each PFF was classified on two separate occasions, with a mean time between assessments of 22.7 days (16 to 29). Interobserver reliability for more than two observers was assessed using percentage agreement and Fleiss’ kappa statistic. Intraobserver reliability between two observers was calculated with Cohen kappa statistic. Validity was tested on surgically managed UCS type B PFFs where stem stability was documented in operation notes (n = 50). Validity was assessed using percentage agreement and Cohen kappa statistic between radiological assessment and intraoperative findings. Kappa statistics were interpreted using Landis and Koch criteria. All six observers were blinded to operation notes and postoperative radiographs.Aims
Methods
This study evaluates risk factors influencing fracture characteristics for postoperative periprosthetic femoral fractures (PFFs) around cemented stems in total hip arthroplasty. Data were collected for PFF patients admitted to eight UK centres between 25 May 2006 and 1 March 2020. Radiographs were assessed for Unified Classification System (UCS) grade and AO/OTA type. Statistical comparisons investigated relationships by age, gender, and stem fixation philosophy (polished taper-slip (PTS) vs composite beam (CB)). The effect of multiple variables was estimated using multinomial logistic regression to estimate odds ratios (ORs) with 95% confidence intervals (CIs). Surgical treatment (revision vs fixation) was compared by UCS grade and AO/OTA type.Aims
Methods
Hip arthroplasty does not always restore normal anatomy. This is due to inaccurate surgery or lack of stem sizes. We evaluated the aptitude of four total hip arthroplasty systems to restore an anatomical and medialized hip rotation centre. Using 3D templating software in 49 CT scans of non-deformed femora, we virtually implanted: 1) small uncemented calcar-guided stems with two offset options (Optimys, Mathys), 2) uncemented straight stems with two offset options (Summit, DePuy Synthes), 3) cemented undersized stems (Exeter philosophy) with three offset options (CPT, ZimmerBiomet), and 4) cemented line-to-line stems (Kerboul philosophy) with proportional offsets (Centris, Mathys). We measured the distance between the templated and the anatomical and 5 mm medialized hip rotation centre.Aims
Methods
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. 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.Aims
Methods
Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method. We retrospectively reviewed all patients undergoing THA via the DAA between 2011 and 2017 at our institution. Primary outcome was dislocation at minimum two-year follow-up. Patients were stratified by demographic details and risk factors for dislocation, and an in-depth analysis of dislocations was performed.Aims
Methods
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. 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.Aims
Methods
The Exeter V40 cemented polished tapered stem system has demonstrated excellent long-term outcomes. This paper presents a systematic review of the existing literature and reports on a large case series comparing implant fractures between the Exeter V40 series; 125 mm and conventional length stem systems. A systematic literature search was performed adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. In parallel, we performed a retrospective single centre study of Exeter V40 femoral stem prosthetic fractures between April 2003 and June 2020.Aims
Methods
It has been suggested that the direct anterior approach (DAA) should be used for total hip arthroplasty (THA) instead of the posterior approach (PA) for better early functional outcomes. We conducted a value-based analysis of the functional outcome and associated perioperative costs, to determine which surgical approach gives the better short-term outcomes and lower costs. This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and the Cochrane Handbook. Several online databases were searched. Non-stratified and stratified meta-analyses were conducted to test the confounding biases in the studies which were included. The mean cost and probability were used to determine the added costs of perioperative services.Aims
Methods
The purpose of this study was to assess total knee arthroplasty (TKA) volume and rates of early complications in morbidly obese patients over the last decade, where the introduction of quality models influencing perioperative care pathways occurred. Patients undergoing TKA between 2011 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI < 40 kg/m2 and ≥ 40 kg/m2 and evaluated by the number of cases per year. The 30-day rates of any complication, wound complications, readmissions, and reoperation were assessed. Trends in these endpoints over the study period were compared between groups using odds ratios (ORs) and multivariate analyses.Aims
Methods
The aim of this study was to compare ten-year longitudinal healthcare costs and revision rates for patients undergoing unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). The Humana database was used to compare 2,383 patients undergoing UKA between 2007 and 2009, who were matched 1:1 from a cohort of 63,036 patients undergoing primary TKA based on age, sex, and Elixhauser Comorbidity Index. Medical and surgical complications were tracked longitudinally for one year following surgery. Rates of revision surgery and cumulative mean healthcare costs were recorded for this period of time and compared between the cohorts.Aims
Methods
The aim of this study was to identify the risk factors for adverse events following the surgical correction of cervical spinal deformities in adults. We identified adult patients who underwent corrective cervical spinal surgery between 1 January 2007 and 31 December 2015 from the MarketScan database. The baseline comorbidities and characteristics of the operation were recorded. Adverse events were defined as the development of a complication, an unanticipated deleterious postoperative event, or further surgery. Patients aged < 18 years and those with a previous history of tumour or trauma were excluded from the study.Aims
Methods
Advances in surgical technique and implant design may influence the incidence and mechanism of failure resulting in revision total hip arthroplasty (rTHA). The purpose of the current study was to characterize aetiologies requiring rTHA, and to determine whether temporal changes existed in these aetiologies over a ten-year period. All rTHAs performed at a single institution from 2009 to 2019 were identified. Demographic information and mode of implant failure was obtained for all patients. Data for rTHA were stratified into two time periods to assess for temporal changes: 2009 to 2013, and 2014 to 2019. Operative reports, radiological imaging, and current procedural terminology (CPT) codes were cross-checked to ensure the accurate classification of revision aetiology for each patient.Aims
Methods
We conducted a systematic review and meta-analysis to compare the mortality, morbidity, and functional outcomes of cemented versus uncemented hemiarthroplasty in the treatment of intracapsular hip fractures, analyzing contemporary and non-contemporary implants separately. PubMed, Medline, EMBASE, CINAHL, and Cochrane Library were searched to 2 February 2020 for randomized controlled trials (RCTs) comparing the primary outcome, mortality, and secondary outcomes of function, quality of life, reoperation, postoperative complications, perioperative outcomes, pain, and length of hospital stay. Relative risks (RRs) and mean differences (with 95% confidence intervals (CIs)) were used as summary association measures.Aims
Methods
Natural Language Processing (NLP) offers an automated method to extract data from unstructured free text fields for arthroplasty registry participation. Our objective was to investigate how accurately NLP can be used to extract structured clinical data from unstructured clinical notes when compared with manual data extraction. A group of 1,000 randomly selected clinical and hospital notes from eight different surgeons were collected for patients undergoing primary arthroplasty between 2012 and 2018. In all, 19 preoperative, 17 operative, and two postoperative variables of interest were manually extracted from these notes. A NLP algorithm was created to automatically extract these variables from a training sample of these notes, and the algorithm was tested on a random test sample of notes. Performance of the NLP algorithm was measured in Statistical Analysis System (SAS) by calculating the accuracy of the variables collected, the ability of the algorithm to collect the correct information when it was indeed in the note (sensitivity), and the ability of the algorithm to not collect a certain data element when it was not in the note (specificity).Aims
Methods
The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database. All patients who underwent primary TKA or THA between January 2012 and December 2017 were identified and stratified based upon hematocrit level. In this analysis, we defined anaemia as packed cell volume (Hct) < 36% for women and < 39% for men, and further stratified anaemia as mild anaemia (Hct 33% to 36% for women, Hct 33% to 39% for men), and moderate to severe (Hct < 33% for both men and women). Univariate and multivariate analyses were used to evaluate the incidence of multiple adverse events within 30 days of arthroplasty.Aims
Methods
Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF. A total of 97 consecutive PPFs (49 males and 48 females) were included with a mean age of 66 years (standard deviation (SD) 14.9). Of these, 86 patients were treated with surgery and 11 were treated conservatively. All living patients had a minimum two-year follow-up. Patient demographics details, fracture healing, functional scores, and complications were assessed. Clinical outcomes between internal fixation and revisions in patients with or without a stable femoral component were compared. Conservatively treated PPFs were evaluated in terms of mortality and healing status. A logistic regression analysis was performed to identify risk factors for complications.Aims
Methods
Debate continues about whether it is better to use a cemented or uncemented hemiarthroplasty to treat a displaced intracapsular fracture of the hip. The aim of this study was to attempt to resolve this issue for contemporary prostheses. A total of 400 patients with a displaced intracapsular fracture of the hip were randomized to receive either a cemented polished tapered stem hemiarthroplasty or an uncemented Furlong hydroxyapatite-coated hemiarthroplasty. Follow-up was conducted by a nurse blinded to the implant at set intervals for up to one year from surgery.Aims
Methods
The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures Pre- and postoperative opioid use were studied among patients from a national insurance database undergoing seven common orthopaedic procedures using univariate log-rank tests and multivariate Cox proportional hazards analyses.Aims
Patients and Methods
We investigated patient characteristics and outcomes of Vancouver type B periprosthetic fractures treated with femoral component revision and/or osteosynthesis. The study utilized data from the Swedish Hip Arthroplasty Register (SHAR) and information from patient records. We included all primary total hip arthroplasties (THAs) performed in Sweden since 1979, and undergoing further surgery due to Vancouver type B periprosthetic femoral fracture between 2001 and 2011. The primary outcome measure was any further reoperation between 2001 and 2013. Cross-referencing with the National Patient Register was performed in two stages, in order to identify all surgical procedures not recorded on the SHAR.Aims
Patients and Methods
Currently, periprosthetic fractures are excluded from the American Society for Bone and Mineral Research (ASBMR) definition of atypical femoral fracture (AFFs). This study aims to report on a series of periprosthetic femoral fractures (PFFs) that otherwise meet the criteria for AFFs. Secondary aims were to identify predictors of periprosthetic atypical femoral fractures (PAFFs) and quantify the complications of treatment. This was a retrospective case control study of consecutive patients with periprosthetic femoral fractures between 2007 and 2017. Two observers identified 16 PAFF cases (mean age 73.9 years (44 to 88), 14 female patients) and 17 typical periprosthetic fractures in patients on bisphosphonate therapy as controls (mean age 80.7 years (60 to 86, 13 female patients). Univariate and multivariate analysis was performed to identify predictors of PAFF. Management and complications were recorded.Aims
Patients and Methods
The aim of this study was to give estimates of the incidence of component incompatibility in hip and knee arthroplasty and to test the effect of an online, real-time compatibility check. Intraoperative barcode registration of arthroplasty implants was introduced in Denmark in 2013. We developed a compatibility database and, from May 2017, real-time compatibility checking was implemented and became part of the registration. We defined four classes of component incompatibility: A-I, A-II, B-I, and B-II, depending on an assessment of the level of risk to the patient (A/B), and on whether incompatibility was knowingly accepted (I/II).Aims
Materials and Methods
Cephalomedullary nails (CMNs) are commonly used for the treatment of intertrochanteric hip fractures. Total hip arthroplasty (THA) may be used as a salvage procedure when fixation fails in these patients. The aim of this study was to analyze the complications of THA following failed intertrochanteric hip fracture fixation using a CMN. Patients who underwent THA were identified from the 5% subset of Medicare Parts A/B between 2002 and 2015. A subgroup involving those with an intertrochanteric fracture that was treated using a CMN during the previous five years was identified and compared with the remaining patients who underwent THA. The length of stay (LOS) was compared using both univariate and multivariate analysis. The incidence of infection, dislocation, revision, and re-admission was compared between the two groups, using multivariate analysis adjusted for demographic, hospital, and clinical factors.Aims
Patients and Methods
The purpose of this exploratory study was to investigate if the 24-hour activity profile (i.e. waking activities and sleep) objectively measured using wrist-worn accelerometry of patients scheduled for total hip arthroplasty (THA) improves postoperatively. A total of 51 THA patients with a mean age of 64 years (24 to 87) were recruited from a single public hospital. All patients underwent THA using the same surgical approach with the same prosthesis type. The 24-hour activity profiles were captured using wrist-worn accelerometers preoperatively and at 2, 6, 12, and 26 weeks postoperatively. Patient-reported outcomes (Hip Disability and Osteoarthritis Outcome Score (HOOS)) were collected at all timepoints except two weeks postoperatively. Accelerometry data were used to quantify the intensity (sedentary, light, moderate, and vigorous activities) and frequency (bouts) of activity during the day and sleep efficiency. The analysis investigated changes with time and differences between Charnley class.Aims
Patients and Methods
The aim of this study was to characterize the factors leading to transfemoral amputation after total knee arthroplasty (TKA), as well as the rates of mortality and functional independence after this procedure in these patients. This was a multicentre retrospective review with a prospective telephone survey for the assessment of function. All patients with a TKA who subsequently required transfemoral amputation between January 2001 and December 2015 were included. Demographic information, medical comorbidities, and postoperative mortality data were collected. A 19-item survey was used for the assessment of function in surviving patients.Aims
Patients and Methods
Aims
Patients and Methods
This study describes and compares the operative management and outcomes in a consecutive case series of patients with dislocated hemiarthroplasties of the hip, and compares outcomes with those of patients not sustaining a dislocation. Of 3326 consecutive patients treated with hemiarthroplasty for fractured neck of femur, 46 (1.4%) sustained dislocations. Of the 46 dislocations, there were 37 female patients (80.4%) and nine male patients (19.6%) with a mean age of 83.8 years (66 to 100). Operative intervention for each, and subsequent dislocations, were recorded. The following outcome measures were recorded: dislocation; mortality up to one-year post-injury; additional surgery; residential status; mobility; and pain score at one year.Aims
Patients and Methods
For this retrospective cohort study, patients aged ≤ 30 years
(very young) who underwent total hip arthroplasty (THA) were compared
with patients aged ≥ 60 years (elderly) to evaluate the rate of
revision arthroplasty, implant survival, the indications for revision,
the complications, and the patient-reported outcomes. We retrospectively reviewed all patients who underwent primary
THA between January 2000 and May 2015 from our institutional database.
A total of 145 very young and 1359 elderly patients were reviewed.
The mean follow-up was 5.3 years (1 to 18). Logistic generalized
estimating equations were used to compare characteristics and the revision
rate. Survival was evaluated using Kaplan–Meier curves and hazard
rates were created using Cox regression.Aims
Patients and Methods
Cement thickness of at least 2 mm is generally associated with more favorable results for the femoral component in cemented hip arthroplasty. However, French-designed stems have shown favorable outcomes even with thin cement mantle. The biomechanical behaviors of a French stem, Charnley-Marcel-Kerboull (CMK) and cement were researched in this study. Six polished CMK stems were implanted into a composite femur, and one million times dynamic loading tests were performed. Stem subsidence and the compressive force at the bone-cement interface were measured. Tantalum ball (ball) migration in the cement was analyzed by micro CTObjective
Methods
The factors that predispose to recurrent instability and revision
stabilization procedures after arthroscopic Bankart repair for anterior
glenohumeral instability remain unclear. We sought to determine
the rate and risk factors associated with ongoing instability in
patients undergoing arthroscopic Bankart repair for instability
of the shoulder. We used the Statewide Planning and Research Cooperative System
(SPARCS) database to identify patients with a diagnosis of anterior
instability of the shoulder undergoing arthroscopic Bankart repair
between 2003 and 2011. Patients were followed for a minimum of three
years. Baseline demographics and subsequent further surgery to the ipsilateral
shoulder were analyzed. Multivariate analysis was used to identify
independent risk factors for recurrent instability.Aims
Materials and Methods
The aim of this study was to test the null hypothesis that there
is no difference, from the payer perspective, in the cost of treatment
of a distal radial fracture in an elderly patient, aged >
65 years,
between open reduction and internal fixation (ORIF) and closed reduction (CR). Data relating to the treatment of these injuries in the elderly
between January 2007 and December 2015 were extracted using the
Humana and Medicare Advantage Databases. The primary outcome of
interest was the cost associated with treatment. Secondary analysis included
the cost of common complications. Statistical analysis was performed
using a non-parametric Aims
Materials and Methods
The purpose of this study was to evaluate trends in opioid use
after unicompartmental knee arthroplasty (UKA), to identify predictors
of prolonged use and to compare the rates of opioid use after UKA,
total knee arthroplasty (TKA) and total hip arthroplasty (THA). We identified 4205 patients who had undergone UKA between 2007
and 2015 from the Humana Inc. administrative claims database. Post-operative
opioid use for one year post-operatively was assessed using the
rates of monthly repeat prescription. These were then compared between
patients with and without a specific variable of interest and with
those of patients who had undergone TKA and THA.Aims
Materials and Methods
We sought to determine whether cobalt-chromium alloy (CoCr) femoral
stem tapers (trunnions) wear more than titanium (Ti) alloy stem
tapers (trunnions) when used in a large diameter (LD) metal-on-metal
(MoM) hip arthroplasty system. We performed explant analysis using validated methodology to
determine the volumetric material loss at the taper surfaces of
explanted LD CoCr MoM hip arthroplasties used with either a Ti alloy
(n = 28) or CoCr femoral stem (n = 21). Only 12/14 taper constructs
with a rough male taper surface and a nominal included angle close
to 5.666° were included. Multiple regression modelling was undertaken
using taper angle, taper roughness, bearing diameter (horizontal
lever arm) as independent variables. Material loss was mapped using
a coordinate measuring machine, profilometry and scanning electron
microscopy.Aims
Patients and Methods
Patellofemoral arthroplasty (PFA) has experienced significant
improvements in implant survivorship with second generation designs.
This has renewed interest in PFA as an alternative to total knee
arthroplasty (TKA) for younger active patients with isolated patellofemoral
osteoarthritis (PF OA). We analysed the cost-effectiveness of PFA We used a Markov transition state model to compare cost-effectiveness
between PFA and TKA. Simulated patients were aged 60 (base case)
and 50 years. Lifetime costs (2015 United States dollars), quality-adjusted
life year (QALY) gains and incremental cost-effectiveness ratio
(ICER) were calculated from a healthcare payer perspective. Annual rates
of revision were derived from the National Joint Registry for England,
Wales, Northern Ireland and the Isle of Man. Deterministic and probabilistic
sensitivity analysis was performed for all parameters against a
$50 000/QALY willingness to pay. Aims
Patients and Methods
Lumbar fusion is known to reduce the variation in pelvic tilt
between standing and sitting. A flexible lumbo-pelvic unit increases
the stability of total hip arthroplasty (THA) when seated by increasing
anterior clearance and acetabular anteversion, thereby preventing
impingement of the prosthesis. Lumbar fusion may eliminate this protective
pelvic movement. The effect of lumbar fusion on the stability of
total hip arthroplasty has not previously been investigated. The Medicare database was searched for patients who had undergone
THA and spinal fusion between 2005 and 2012. PearlDiver software
was used to query the database by the International Classification
of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedural
code for primary THA and lumbar spinal fusion. Patients who had
undergone both lumbar fusion and THA were then divided into three
groups: 1 to 2 levels, 3 to 7 levels and 8+ levels of fusion. The
rate of dislocation in each group was established using ICD-9-CM codes.
Patients who underwent THA without spinal fusion were used as a
control group. Statistical significant difference between groups
was tested using the chi-squared test, and significance set at p
<
0.05.Aims
Patients and Methods
Objectives. Favourable results for collarless polished tapered stems have been reported, and cement creep due to taper slip may be a contributing factor. However, the ideal cement thickness around polished stems remains unknown. We investigated the influence of cement thickness on stem subsidence and cement creep. Methods. We cemented six collarless polished tapered (CPT) stems (two stems each of small, medium and large sizes) into composite femurs that had been reamed with a large
Advances in arthroscopic techniques for rotator cuff repair have
made the mini-open approach less popular. However, the mini-open
approach remains an important technique for repair for many surgeons.
The aims of this study were to compare the integrity of the repair,
the function of the shoulder and satisfaction post-operatively using
these two techniques in patients aged >
50 years. We identified 22 patients treated with mini-open and 128 patients
treated with arthroscopic rotator cuff repair of July 2007 and June
2011. The mean follow-up was two years (1 to 5). Outcome was assessed
using the American Shoulder and Elbow Surgeons (ASES) and Simple
Shoulder Test (SST) scores, and satisfaction. The integrity of the repair
was assessed using ultrasonography. A power analysis ensured sufficient
enrolment.Aims
Patients and Methods
Periprosthetic femoral fractures (PFF) following total hip arthroplasty
(THA) are devastating complications that are associated with functional
limitations and increased overall mortality. Although cementless
implants have been associated with an increased risk of PFF, the
precise contribution of implant geometry and design on the risk
of both intra-operative and post-operative PFF remains poorly investigated.
A systematic review was performed to aggregate all of the PFF literature
with specific attention to the femoral implant used. A systematic search strategy of several journal databases and
recent proceedings from the American Academy of Orthopaedic Surgeons
was performed. Clinical articles were included for analysis if sufficient
implant description was provided. All articles were reviewed by
two reviewers. A review of fundamental investigations of implant
load-to-failure was performed, with the intent of identifying similar
conclusions from the clinical and fundamental literature.Aims
Patients and Methods
Aims. 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. Patients and Methods. We analysed data on 257 202 primary THAs with cemented stems
and 390 linked first revisions for PF recorded in the National Joint
Registry (NJR) of England, Wales and Northern Ireland to determine
if a cemented femoral stem brand was associated with the risk of
having revision for a PF after primary THA. All cemented femoral
stem brands with more than 10 000 primary operations recorded in
the NJR were identified. The four most commonly used cemented femoral
stems were the Exeter V40 (n = 146 409),
Surgeons have commonly used modular femoral heads and stems from
different manufacturers, although this is not recommended by orthopaedic
companies due to the different manufacturing processes. We compared the rate of corrosion and rate of wear at the trunnion/head
taper junction in two groups of retrieved hips; those with mixed
manufacturers (MM) and those from the same manufacturer (SM). We identified 151 retrieved hips with large-diameter cobalt-chromium
heads; 51 of two designs that had been paired with stems from different
manufacturers (MM) and 100 of seven designs paired with stems from
the same manufacturer (SM). We determined the severity of corrosion
with the Goldberg corrosion score and the volume of material loss
at the head/stem junction. We used multivariable statistical analysis
to determine if there was a significant difference between the two
groups. Aims
Materials and Methods
We assessed the difference in hospital based and early clinical
outcomes between the direct anterior approach and the posterior
approach in patients who undergo total hip arthroplasty (THA). The outcome was assessed in 448 (203 males, 245 females) consecutive
patients undergoing unilateral primary THA after the implementation
of an ‘Enhanced Recovery’ pathway. In all, 265 patients (mean age:
71 years (49 to 89); 117 males and 148 females) had surgery using
the direct anterior approach (DAA) and 183 patients (mean age: 70
years (26 to 100); 86 males and 97 females) using a posterior approach.
The groups were compared for age, gender, American Society of Anesthesiologists
grade, body mass index, the side of the operation, pre-operative
Oxford Hip Score (OHS) and attendance at ‘Joint school’. Mean follow-up
was 18.1 months (one to 50).Aims
Patients and Methods
Hemiarthroplasty of the hip is usually carried out through either
a direct lateral or posterior approach. The aim of this prospective
observational study was to determine any differences in patient-reported
outcomes between the two surgical approaches. From the Swedish Hip Arthroplasty Register we identified patients
of 70 years and above who were recorded as having had a hemiarthroplasty
during 2009. Only patients who had been treated with modern prostheses
were included. A questionnaire was posted to those who remained
alive one year after surgery. A total of 2118 patients (78% of those
available) with a mean age of 85 years (70 to 102) returned the
questionnaire. Aims
Patients and Methods
The long-term functional outcome of total hip arthroplasty (THA)
performed by trainees is not known. A multicentre retrospective
study of 879 THAs was undertaken to investigate any differences
in outcome between those performed by trainee surgeons and consultants. A total of 879 patients with a mean age of 69.5 years (37 to
94) were included in the study; 584 THAs (66.4%) were undertaken
by consultants, 138 (15.7%) by junior trainees and 148 (16.8%) by
senior trainees. Patients were scored using the Harris Hip Score
(HHS) pre-operatively and at one, three, five, seven and ten years
post-operatively. Surgical outcome, complications and survival were
compared between groups. The effect of supervision was determined
by comparing supervised and unsupervised trainees. A primary univariate
analysis was used to select variables for inclusion in multivariate
analysis. Aims
Patients and Methods
The outcome of 219 revision total hip arthroplasties
(THAs) in 98 male and 121 female patients, using 137 long length
and 82 standard length cemented collarless double-taper femoral
stems in 211 patients, with a mean age of 72 years (30 to 90) and
mean follow-up of six years (two to 18) have been described previously.
We have extended the follow-up to a mean of 13 years (8 to 20) in
this cohort of patients in which the pre-operative bone deficiency Paprosky
grading was IIIA or worse in 79% and 73% of femurs with long and
standard stems, respectively. For the long stem revision group, survival to re-revision for
aseptic loosening at 14 years was 97% (95% confidence interval (CI)
91 to 100) and in patients aged >
70 years, survival was 100%. Two
patients (two revisions) were lost to follow-up and 86 patients
with 88 revisions had died. Worst-case analysis for survival to
re-revision for aseptic loosening at 14 years was 95% (95% CI 89
to 100) and 99% (95% CI 96 to 100) for patients aged >
70 years. One
additional long stem was classified as loose radiographically but
not revised. For the standard stem revision group, survival to re-revision
for aseptic loosening at 14 years was 91% (95% CI 83 to 99). No
patients were lost to follow-up and 49 patients with 51 hips had
died. No additional stems were classified as loose radiographically. Femoral revision using a cemented collarless double-taper stem,
particularly with a long length stem, and in patients aged >
70
years, continues to yield excellent results up to 20 years post-operatively,
including in hips with considerable femoral metaphyseal bone loss. Cite this article:
There is little evidence on the cost effectiveness
of different brands of hip prostheses. We compared lifetime cost effectiveness
of frequently used brands within types of prosthesis including cemented
(Exeter V40 Contemporary, Exeter V40 Duration and Exeter V40 Elite
Plus Ogee), cementless (Corail Pinnacle, Accolade Trident, and Taperloc Exceed)
and hybrid (Exeter V40 Trilogy, Exeter V40 Trident, and
The aim of this study was to assess the effect
of frictional torque and bending moment on fretting corrosion at
the taper interface of a modular femoral component and to investigate
whether different combinations of material also had an effect. The
combinations we examined were 1) cobalt–chromium (CoCr) heads on
CoCr stems 2) CoCr heads on titanium alloy (Ti) stems and 3) ceramic
heads on CoCr stems. In test 1 increasing torque was imposed by offsetting the stem
in the anteroposterior plane in increments of 0 mm, 4 mm, 6 mm and
8 mm when the torque generated was equivalent to 0 Nm, 9 Nm, 14
Nm and 18 Nm. In test 2 we investigated the effect of increasing the bending
moment by offsetting the application of axial load from the midline
in the mediolateral plane. Increments of offset equivalent to head
+ 0 mm, head + 7 mm and head + 14 mm were used. Significantly higher currents and amplitudes were seen with increasing
torque for all combinations of material. However, Ti stems showed
the highest corrosion currents. Increased bending moments associated
with using larger offset heads produced more corrosion: Ti stems
generally performed worse than CoCr stems. Using ceramic heads did
not prevent corrosion, but reduced it significantly in all loading
configurations. Cite this article:
The clinical utility of routine cross sectional imaging of the
abdomen and pelvis in the screening and surveillance of patients
with primary soft-tissue sarcoma of the extremities for metastatic
disease is controversial, based on its questionable yield paired
with concerns regarding the risks of radiation exposure, cost, and
morbidity resulting from false positive findings. Through retrospective review of 140 patients of all ages (mean
53 years; 2 to 88) diagnosed with soft-tissue sarcoma of the extremity
with a mean follow-up of 33 months (0 to 291), we sought to determine
the overall incidence of isolated abdominopelvic metastases, their
temporal relationship to chest involvement, the rate of false positives, and
to identify disparate rates of metastases based on sarcoma subtype.Objectives
Methods
The December 2014 Knee Roundup360 looks at: national guidance on arthroplasty thromboprophylaxis is effective; unicompartmental knee replacement has the edge in terms of short-term complications; stiff knees, timing and manipulation; neuropathic pain and total knee replacement; synovial fluid α-defensin and CRP: a new gold standard in joint infection diagnosis?; how to assess anterior knee pain?; where is the evidence? Five new implants under the spotlight; and a fresh look at ACL reconstruction
The August 2014 Trauma Roundup360 looks at: On-table CT for calcaneal fractures; timing of femoral fracture surgery and outcomes; salvage arthroplasty for failed internal fixation of the femoral neck; screw insertion in osteoporotic bone; fibular intramedullary nailing on the ascendant; posterior wall acetabular fractures not all that innocent; bugs, plating and resistance and improving outcomes in olecranon tension band wiring.
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:
We report a multicentre prospective consecutive
study assessing the long-term outcome of the proximally hydroxyapatite
(HA)-coated ABG II monobloc femoral component in a series of 1148
hips in 1053 patients with a mean age at surgery of 64.77 years
(22 to 80) at a mean follow-up of 10.84 years (10 to 15.25). At
latest follow-up, the mean total Harris hip score was 94.7 points
( Cite this article:
Congenital pseudarthrosis of the tibia (CPT)
is a rare but well recognised condition. Obtaining union of the pseudarthrosis
in these children is often difficult and may require several surgical
procedures. The treatment has changed significantly since the review
by Hardinge in 1972, but controversies continue as to the best form
of surgical treatment. This paper reviews these controversies. Cite this article:
We prospectively followed 191 consecutive collarless
polished tapered (CPT) femoral stems, implanted in 175 patients
who had a mean age at operation of 64.5 years (21 to 85). At a mean
follow-up of 15.9 years (14 to 17.5), 86 patients (95 hips) were
still alive. The fate of all original stems is known. The 16-year
survivorship with re-operation for any reason was 80.7% (95% confidence
interval 72 to 89.4). There was no loss to follow-up, with clinical
data available on all 95 hips and radiological assessment performed
on 90 hips (95%). At latest follow-up, the mean Harris hip score
was 78 (28 to 100) and the mean Oxford hip score was 36 (15 to 48).
Stems subsided within the cement mantle, with a mean subsidence
of 2.1 mm (0.4 to 19.2). Among the original cohort, only one stem
(0.5%) has been revised due to aseptic loosening. In total seven
stems were revised for any cause, of which four revisions were required
for infection following revision of the acetabular component. A
total of 21 patients (11%) required some sort of revision procedure;
all except three of these resulted from failure of the acetabular
component. Cemented acetabular components had a significantly lower
revision burden (three hips, 2.7%) than Harris Galante uncemented
components (17 hips, 21.8%) (p <
0.001). The
The removal of all prosthetic material and a
two-stage revision procedure is the established standard management of
an infected total hip replacement (THR). However, the removal of
well-fixed femoral cement is time-consuming and can result in significant
loss of bone stock and femoral shaft perforation or fracture. We
report our results of two-stage revision THR for treating infection,
with retention of the original well-fixed femoral cement mantle
in 15 patients, who were treated between 1989 and 2002. Following
partial excision arthroplasty, patients received local and systemic
antibiotics and underwent reconstruction and re-implantation at
a second-stage procedure, when the infection had resolved. The mean follow-up of these 15 patients was 82 months (60 to
192). Two patients had positive microbiology at the second stage
and were treated with six weeks of appropriate antibiotics; one
of these developed recurrent infection requiring further revision.
Successful eradication of infection was achieved in the remaining
14 patients. We conclude that when two-stage revision is used for the treatment
of peri-prosthetic infection involving a THR, a well-fixed femoral
cement mantle can be safely left
Congenital pseudarthrosis of the tibia is an uncommon manifestation of neurofibromatosis type 1 (NF1), but one that remains difficult to treat due to anabolic deficiency and catabolic excess. Bone grafting and more recently recombinant human bone morphogenetic proteins (rhBMPs) have been identified as pro-anabolic stimuli with the potential to improve the outcome after surgery. As an additional pharmaceutical intervention, we describe the combined use of rhBMP-2 and the bisphosphonate zoledronic acid in a mouse model of NF1-deficient fracture repair. Fractures were generated in the distal tibiae of neurofibromatosis type 1-deficient ( When only rhBMP but no zoledronic acid was used to promote repair, 75% of fractures in These data support the concept that preventing bone loss in combination with anabolic stimulation may improve the outcome following surgical treatment for children with congenital pseudarthoris of the tibia and NF1.
This study reports the mid-term results of a large-bearing hybrid metal-on-metal total hip replacement in 199 hips (185 patients) with a mean follow-up of 62 months (32 to 83). Two patients died of unrelated causes and 13 were lost to follow-up. In all, 17 hips (8.5%) have undergone revision, and a further 14 are awaiting surgery. All revisions were symptomatic. Of the revision cases, 14 hips showed evidence of adverse reactions to metal debris. The patients revised or awaiting revision had significantly higher whole blood cobalt ion levels (p = 0.001), but no significant difference in acetabular component size or position compared with the unrevised patients. Wear analysis (n = 5) showed increased wear at the trunnion-head interface, normal levels of wear at the articulating surfaces and evidence of corrosion on the surface of the stem. The cumulative survival rate, with revision for any reason, was 92.4% (95% confidence interval 87.4 to 95.4) at five years. Including those awaiting surgery, the revision rate would be 15.1% with a cumulative survival at five years of 89.6% (95% confidence interval 83.9 to 93.4). This hybrid metal-on-metal total hip replacement series has shown an unacceptably high rate of failure, with evidence of high wear at the trunnion-head interface and passive corrosion of the stem surface. This raises concerns about the use of large heads on conventional 12/14 tapers.
The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) for the treatment of congenital pseudarthrosis of the tibia has been investigated in only one previous study, with promising results. The aim of this study was to determine whether rhBMP-2 might improve the outcome of this disorder. We reviewed the medical records of five patients with a mean age of 7.4 years (2.3 to 21) with congenital pseudarthrosis of the tibia who had been treated with rhBMP-2 and intramedullary rodding. Ilizarov external fixation was also used in four of these patients. Radiological union of the pseudarthrosis was evident in all of them at a mean of 3.5 months (3.2 to 4) post-operatively. The Ilizarov device was removed after a mean of 4.2 months (3.0 to 5.3). These results indicate that treatment of congenital pseudarthrosis of the tibia using rhBMP-2 in combination with intramedullary stabilisation and Ilizarov external fixation may improve the initial rate of union and reduce the time to union. Further studies with more patients and longer follow-up are necessary to determine whether this surgial procedure may significantly enhance the outcome of congenital pseudarthrosis of the tibia, considering the refracture rate (two of five patients) in this small case series.
We compared the medium-term clinical and radiological results of hybrid total hip replacement (THR) with metal-on-metal Birmingham hip resurfacing (BHR) in two groups of 54 young patients matched for age, gender, body mass index and pre-operative levels of activity. The clinical outcome was assessed by the University of California, Los Angeles (UCLA) activity score, the Oxford Hip Score (OHS) and the EuroQol scores. Radiologically, all hips were assessed for migration and osteolysis, the hybrid THRs for polyethylene wear and the BHRs for a pedestal sign. The mean follow-up of the patients with a hybrid THR was ten years and for those with a BHR, nine years. Four patients with a hybrid THR and one with a BHR had died. In each group five were lost to follow-up. The revision rate of the hybrid THRs was 16.7% (9 of 54) and of the BHRs 9.3% (5 of 54) (p = 0.195). Radiographs of a further eight hybrid THRs demonstrated wear and osteolysis, and they await revision (p = 0.008). Of the unrevised BHRs 90% had radiological changes, of which approximately 50% had progressed over the previous four years. All hybrid THRs demonstrated linear polyethylene wear with a mean of 1.24 mm (0.06 to 3.03). The BHRs recorded superior OHS (p = 0.013), UCLA (p = 0.008), and EuroQol visual analogue scores (p = 0.009). After nine years, patients with BHRs remained more active and had a lower rate of revision than those with hybrid THRs. Both groups demonstrated progressive radiological changes at medium-term follow-up.
This study evaluated the feasibility of using published data from more than one register to define the performance of different hip implants. In order to obtain estimates of performance for specific types of hip system from different register, we analysed data from the annual reports of five national and one Italian regional register. We extracted the number of implants and rates of implant survival at different periods of follow-up. Our aim was to assess whether estimates of cumulative survival rate were comparable with data from registers from different countries, and our conclusion was that such a comparison could only be performed incompletely.
The purpose of this study was to compare the clinical and radiological outcome of patients with intact, broken and removed syndesmosis screws after Weber B or C ankle fracture with an associated injury to the syndesmosis. We hypothesised that there would be no difference. Of a possible 142 patients who fulfilled our inclusion criteria, 52 returned for clinical and radiological assessment at least one year after surgery. Of these, 27 had intact syndesmosis screws, ten had broken screws, and 15 had undergone elective removal of the screw. The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot score was 83.07 ( There was no difference in clinical outcome of patients with intact or removed syndesmotic screws. Paradoxically, patients with a broken syndesmosis screw had the best clinical outcome. Our data do not support the removal of intact or broken syndesmosis screws, and we caution against attributing post-operative ankle pain to breakage of the syndesmosis screw.
Between 1999 and 2005, 10 264 patients who had undergone total hip replacement (THR) for subcapital fracture of the hip were compared with 76 520 in whom THR had been performed for other reasons. All the cases were identified through the Swedish Hip Arthroplasty Register. The THRs performed as primary treatment for fracture were also compared with those done after failure of internal fixation. After seven years the rate of revision was higher in THR after fracture (4.4% vs 2.9%). Dislocation and periprosthetic fracture were the most common causes of revision. The risk was higher in men than in women. The type of femoral component and the surgical approach influenced the risk. After correction for gender, type of component and the surgical approach the revision rates were similar in the primary and secondary fracture THR groups. Total hip replacement is therefore a safe method for both the primary and secondary management of fracture of the hip.
Muscle atrophy has been demonstrated in patients suffering from osteoarthritis of the hip, but little is known about muscular recovery after total hip replacement (THR). A total of 20 patients with unilateral osteoarthritis of the hip were assessed before, six months and two years after THR. The cross-sectional area and radiological density of the muscles of the hip, thigh, calf and back were measured using CT. We hypothesised that the muscles would not recover fully after operation. After two years comparison of the limb with the THR with the healthy limb showed that there was such a reduction in the cross-sectional area in iliopsoas (7.0%; p = 0.006) and the hip adductors (8.4%, p = 0.003) and in the radiological density in gluteus maximus (10.1 Hounsfield units; p <
0.001), gluteus medius/minimus (5.6 Hounsfield units; p = 0.011), iliopsoas (3.9 Hounsfield units; p <
0.001) and the adductors (2.4 Hounsfield units; p = 0.022). Thus, there was persistent muscle atrophy in muscles acting about the hip two years after THR. We suggest that an earlier operation or a more intensive rehabilitation may reverse these changes.
The creep and wear behaviour of highly cross-linked polyethylene and standard polyethylene liners were examined in a prospective, double-blind randomised, controlled trial using radiostereometric analysis. We randomised 54 patients to receive hip replacements with either highly cross-linked polyethylene or standard liners and determined the three-dimensional penetration of the liners over three years. After three years the mean total penetration was 0.35 mm (SD 0.14) for the highly cross-linked polyethylene group and 0.45 mm (SD 0.19) for the standard group. The difference was statistically significant (p = 0.0184). From the pattern of penetration it was possible to discriminate creep from wear. Most (95%) of the creep occurred within six months of implantation and nearly all within the first year. There was no difference in the mean degree of creep between the two types of polyethylene (highly cross-linked polyethylene 0.26 mm, SD 0.17; standard 0.27 mm, SD 0.2; p = 0.83). There was, however, a significant difference (p = 0.012) in the mean wear rate (highly cross-linked polyethylene 0.03 mm/yr, SD 0.06; standard 0.07 mm/yr, SD 0.05). Creep and wear occurred in significantly different directions (p = 0.01); creep was predominantly proximal whereas wear was anterior, proximal and medial. We conclude that penetration in the first six months is creep-dominated, but after one year virtually all penetration is due to wear. Highly cross-linked polyethylene has a 60% lower rate of wear than standard polyethylene and therefore will probably perform better in the long term.
We determined the ten-year life expectancy of 5831 patients who had undergone 6653 elective primary total hip replacements at a regional orthopaedic centre between April 1993 and October 2004. Using hospital, general practitioner and the local health authority records, we recorded the dates of death for those who died following surgery. The mean age at operation was 67 years (13 to 96) with a male:female ratio of 2:3. Of 1154 patients with a ten-year follow-up 340 (29.5%) had died a mean of 5.6 years (0 to 10) after surgery. Using Kaplan-Meier curves, the ten-year survival was 89% in patients under 65 years at surgery, 75% in patients aged between 65 and 74 years, and 51% in patients over 75. The standardised mortality rates were considerably higher for patients under 45 years, 20% higher for those between 45 and 64 years, and steadily reduced in patients aged 65 and over. The survival of cemented hip replacement derived from the Swedish Hip Arthroplasty Register Annual Report 2004 exceeds the life expectancy of patients over the age of 60 in our area, suggesting that cemented hip replacement is the procedure of choice in this population.
This study explored the relationship between the initial stability of the femoral component and penetration of cement into the graft bed following impaction allografting. Impaction allografting was carried out in human cadaveric femurs. In one group the cement was pressurised conventionally but in the other it was not pressurised. Migration and micromotion of the implant were measured under simulated walking loads. The specimens were then cross-sectioned and penetration of the cement measured. Around the distal half of the implant we found approximately 70% and 40% of contact of the cement with the endosteum in the pressure and no-pressure groups, respectively. The distal migration/micromotion, and valgus/varus migration were significantly higher in the no-pressure group than in that subjected to pressure. These motion components correlated negatively with the mean area of cement and its contact with the endosteum. The presence of cement at the endosteum appears to play an important role in the initial stability of the implant following impaction allografting.
We investigated 219 revisions of total hip replacement (THR) in 211 patients using a collarless double-taper cemented femoral component. The mean age of the patients was 72 years (30 to 90). The 137 long and 82 standard length stems were analysed separately. The mean follow-up was six years (2 to 18), and no patient was lost to follow-up. Survival of the long stems to re-revision for aseptic loosening at nine years was 98% (95% confidence interval (CI) 94 to 100), and for the standard stems was 93% (95% CI 85 to 100). At five years, one long stem was definitely loose radiologically and one standard stem was probably loose. Pre-operative femoral bone deficiency did not influence the results for the long stems, and corrective femoral osteotomy was avoided, as were significant subsidence, major stress shielding and persistent thigh pain. Because of these reliable results, cemented long collarless double-taper femoral components are recommended for routine revision THR in older patients.
We undertook a review of the literature relating to the two basic stem designs in use in cemented hip replacement, namely loaded tapers or force-closed femoral stems, and the composite beam or shape-closed designs. The associated stem fixation theory as understood from It is clear that both design principles are capable of producing successful long-term results, providing that their specific requirements of stem metallurgy, shape and surface finish, preparation of the bone and handling of the cement are observed.
We compared the five- to seven-year clinical and radiological results of the metal-on-metal Birmingham hip resurfacing with a hybrid total hip arthroplasty in two groups of 54 hips, matched for gender, age, body mass index and activity level. Function was excellent in both groups, as measured by the Oxford hip score, but the Birmingham hip resurfacings had higher University of California at Los Angeles activity scores and better EuroQol quality of life scores. The total hip arthroplasties had a revision or intention-to-revise rate of 8%, and the Birmingham hip resurfacings of 6%. Both groups demonstrated impending failure on surrogate end-points. Of the total hip arthroplasties, 12% had polyethylene wear and osteolysis under observation, and 8% of Birmingham hip resurfacings showed migration of the femoral component. Polyethylene wear was present in 48% of the hybrid hips without osteolysis. Of the femoral components in the Birmingham hip resurfacing group which had not migrated, 66% had radiological changes of unknown significance.
We compared the safety and outcome of one-stage bilateral total hip arthroplasty with those of a two-stage procedure during different admissions in a prospective, randomised controlled trial in an Asian population. Of 168 patients included in the study, 83 had a single- and 85 a two-stage procedure. Most of the patients (59.9%) suffered from inflammatory arthritis. The intra-operative complications, early systemic complications, the operating time, positioning of the components, the functional score, restoration of limb length and survival rates at 96 months were similar in the two groups. The total estimated blood loss was significantly lower in patients undergoing a one-stage procedure than in patients who had a two-stage procedure, but the transfusion requirements were significantly higher in the former group (p = 0.001). The hospital stay was significantly shorter in the one-stage group, 7.25 days (
We describe a technique of ‘cross-hip distraction’ to reduce a dislocated hip with subsequent reconstruction of the joint for septic arthritis with extensive femoral osteomyelitis. A 27-year-old woman presented with a dislocated, collapsed femoral head and chronic osteomyelitis of the femur. Examination revealed a leg-length discrepancy of 7 cm and an irritable hip. A staged technique was used with primary clearance of osteomyelitis and secondary reconstruction of the hip. A cross-hip monolateral external fixator was used to establish normal anatomy followed by an arthroplasty. A good functional outcome was achieved. The use of cross-hip distraction avoids soft-tissue and nerve damage and achieved improved abductor function before arthroplasty.
We assessed leg length discrepancy and hip function in 90 patients undergoing primary total hip arthroplasty before surgery and at three and 12 months after. Function was measured using the Oxford hip score (OHS). After surgery the mean OHS improved by 26 points after three months and by 30 points after 12. After operation 56 (62%) limbs were long by a mean of 9 mm and this was perceived by 24 (43%) patients after three months and by 18 (33%) after 12. The mean OHS in patients who perceived true lengthening was 27% worse than the rest of the population after three months and 18% worse after 12. In 55 (98%) patients, lengthening occurred in the femoral component. Appropriate placement of the femoral component could significantly reduce a patient’s perception of discrepancy of length.
An analysis of the cement mantle obtained with the Exeter impaction allografting system at one centre showed that it was either deficient or absent in almost 47% of Gruen zones. We therefore examined the mantle obtained using this system at another hospital and compared the results with those from the
