This study reports the results of 38 total hip arthroplasties (THAs) in 33 patients aged <  50 years, using the JRI Furlong hydroxyapatite ceramic (HAC)-coated femoral component. This represents an update of previous reports of the same cohort at ten and 16 years, which were reported in 2004 and 2009, respectively. We describe the survival, radiological and functional outcomes at a mean follow-up of 21 years (17 to 25). Of the surviving 34 THAs, one underwent femoral revision for peri-prosthetic fracture after 21 years, and one patient (one hip) was lost to follow-up. Using aseptic loosening as the end-point, 12 hips (31.5%) needed acetabular revision but none needed femoral revision, demonstrating 100% survival (95% confidence interval 89 to 100).

In young patients with high demands, the Furlong HAC–coated femoral component gives excellent long-term results.

Cite this article: Bone Joint J 2015;97-B:749–54.

Fractures around total knee arthroplasties pose a significant surgical challenge. Most can be managed with osteosynthesis and salvage of the replacement. The techniques of fixation of these fractures and revision surgery have evolved and so has the assessment of outcome. This specialty update summarises the current evidence for the classification, methods of fixation, revision surgery and outcomes of the management of periprosthetic fractures associated with total knee arthroplasty.

Cite this article: Bone Joint J 2016;98-B:1489–96.

Aims

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.

Aims

To compare the structural durability of hydroxyapatite-tricalcium phosphate (HATCP) to autologous iliac crest bone graft in calcaneal lengthening osteotomy (CLO) for pes planovalgus in childhood.

As the number of younger and more active patients treated with total knee arthroplasty (TKA) continues to increase, consideration of better fixation as a means of improving implant longevity is required. Cemented TKA remains the reference standard with the largest body of evidence and the longest follow-up to support its use. However, cementless TKA, may offer the opportunity of a more bone-sparing procedure with long lasting biological fixation to the bone. We undertook a review of the literature examining advances of cementless TKA and the reported results.

Cite this article: Bone Joint J 2016;98-B:867–73.

We hypothesised that the use of tantalum (Ta) acetabular components in revision total hip arthroplasty (THA) was protective against subsequent failure due to infection. We identified 966 patients (421 men, 545 women and 990 hips) who had undergone revision THA between 2000 and 2013. The mean follow up was 40.2 months (3 months to 13.1 years). The mean age of the men and women was 62.3 years (31 to 90) and 65.1 years (25 to 92), respectively.

Titanium (Ti) acetabular components were used in 536 hips while Ta components were used in 454 hips. In total, 73 (7.3%) hips experienced subsequent acetabular failure. The incidence of failure was lower in the Ta group at 4.4% (20/454) compared with 9.9% (53/536) in the Ti group (p < 0.001, odds ratio 2.38; 95% CI 1.37 to 4.27). Among the 144 hips (64 Ta, 80 Ti) for which revision had been performed because of infection, failure due to a subsequent infection was lower in the Ta group at 3.1% (2/64) compared with 17.5% (14/80) for the Ti group (p = 0.006).

Thus, the use of Ta acetabular components during revision THA was associated with a lower incidence of failure from all causes and Ta components were associated with a lower incidence of subsequent infection when used in patients with periprosthetic joint infection.

Cite this article: Bone Joint J 2015;97-B:45–9.

We retrospectively reviewed 44 consecutive patients (50 hips) who underwent acetabular re-revision after a failed previous revision that had been performed using structural or morcellised allograft bone, with a cage or ring for uncontained defects. Of the 50 previous revisions, 41 cages and nine rings were used with allografts for 14 minor-column and 36 major-column defects. We routinely assessed the size of the acetabular bone defect at the time of revision and re-revision surgery. This allowed us to assess whether host bone stock was restored. We also assessed the outcome of re-revision surgery in these circumstances by means of radiological characteristics, rates of failure and modes of failure. We subsequently investigated the factors that may affect the potential for the restoration of bone stock and the durability of the re-revision reconstruction using multivariate analysis.

At the time of re-revision, there were ten host acetabula with no significant defects, 14 with contained defects, nine with minor-column, seven with major-column defects and ten with pelvic discontinuity. When bone defects at re-revision were compared with those at the previous revision, there was restoration of bone stock in 31 hips, deterioration of bone stock in nine and remained unchanged in ten. This was a significant improvement (p <  0.001). Morselised allografting at the index revision was not associated with the restoration of bone stock.

In 17 hips (34%), re-revision was possible using a simple acetabular component without allograft, augments, rings or cages. There were 47 patients with a mean follow-up of 70 months (6 to 146) available for survival analysis. Within this group, the successful cases had a minimum follow-up of two years after re-revision. There were 22 clinical or radiological failures (46.7%), 18 of which were due to aseptic loosening. The five and ten year Kaplan–Meier survival rate was 75% (95% CI, 60 to 86) and 56% (95% CI, 40 to 70) respectively with aseptic loosening as the endpoint. The rate of aseptic loosening was higher for hips with pelvic discontinuity (p = 0.049) and less when the allograft had been in place for longer periods (p = 0.040).

The use of a cage or ring over structural allograft bone for massive uncontained defects in acetabular revision can restore host bone stock and facilitate subsequent re-revision surgery to a certain extent.

Cite this article: Bone Joint J 2014;96-B:319–24.

Aims

The purpose of this study was to compare the long-term results of primary total hip arthroplasty (THA) in young patients using either a conventional (CPE) or a highly cross-linked (HXLPE) polyethylene liner in terms of functional outcome, incidence of osteolysis, radiological wear and rate of revision.

Aim and Methods

The goals of this study were to define the risk factors, nature, chronology, and treatment strategies adopted for periprosthetic femoral fractures in 32 644 primary total hip arthroplasties (THAs).

The aim of this randomised controlled study was to compare functional and radiological outcomes between modern cemented and uncemented hydroxyapatite coated stems after one year in patients treated surgically for a fracture of the femoral neck. A total of 141 patients aged > 65 years were included. Patients were randomised to be treated with a cemented Exeter stem or an uncemented Bimetric stem. The patients were reviewed at four and 12 months.

The cemented group performed better than the uncemented group for the Harris hip score (78 vs 70.7, p = 0.004) at four months and for the Short Musculoskeletal Function Assesment Questionnaire dysfunction score at four (29.8 vs 39.2, p = 0.007) and 12 months (22.3 vs 34.9, p = 0.001). The mean EQ-5D index score was better in the cemented group at four (0.68 vs 0.53, p = 0.001) and 12 months (0.75 vs 0.58, p = < 0.001) follow-up. There were nine intra-operative fractures in the uncemented group and none in the cemented group.

In conclusion, our data do not support the use of an uncemented hydroxyapatite coated stem for the treatment of displaced fractures of the femoral neck in the elderly.

Cite this article: Bone Joint J 2015;97-B:1475–80.

The April 2014 Knee Roundup³⁶⁰ looks at: mobile compression as good as chemical thromboprophylaxis; patellar injury with MIS knee surgery; tibial plateau fracture results not as good as we thought; back and knee pain; metaphyseal sleeves may be the answer in revision knee replacement; oral tranexamic acid; gentamycin alone in antibiotic spacers; and whether the jury is still out on unloader braces.

Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept have raised a renewed interest in less-medialised designs and techniques. The aim of this study was to evaluate the outcome of reverse shoulder arthroplasty (RSA) with the fully-constrained, less-medialised, Bayley–Walker prosthesis performed for the treatment of rotator-cuff-deficient shoulders with glenohumeral arthritis. A total of 97 arthroplasties in 92 patients (53 women and 44 men, mean age 67 years (standard deviation (sd) 10, (49 to 85)) were retrospectively reviewed at a mean follow-up of 50 months ((sd 25) (24 to 96)). The mean Oxford shoulder score and subjective shoulder value improved from 47 (sd 9) and 24 points (sd 18) respectively before surgery to 28 (sd 11) and 61 (sd 24) points after surgery (p <  0.001). The mean pain at rest decreased from 5.3 (sd 2.8) to 1.5 (sd 2.3) (p < 0.001). The mean active forward elevation and external rotation increased from 42^°(sd 30) and 9^° (sd 15) respectively pre-operatively to 78^° (sd 39) and 24^° (sd 17) post-operatively (p < 0.001). A total of 20 patients required further surgery for complications; 13 required revision of components. No patient developed scapular notching.

The Bayley–Walker prosthesis provides reliable pain relief and reasonable functional improvement for patients with symptomatic cuff-deficient shoulders. Compared with other designs of RSA, it offers a modest improvement in forward elevation, but restores external rotation to some extent and prevents scapular notching. A longer follow-up is required to assess the survival of the prosthesis and the clinical performance over time.

Cite this article: Bone Joint J 2014;96-B:936–42.

The number of arthroplasties being undertaken is expected to grow year on year, and periprosthetic joint infections will be an increasing socioeconomic burden. The challenge to prevent and eradicate these infections has resulted in the emergence of several new strategies, which are discussed in this review.

Cite this article: Bone Joint J 2015;97-B:1162–9.

Cementless femoral stems are currently preferred for total hip replacement (THR) in the United States. Improvements in stem design, instrumentation and surgical technique have made this technology highly successful, reproducible, and applicable to the vast majority of patients requiring a THR. However, there are ongoing developments in some aspects of stem design that influence clinical results, the incidence of complications and their inherent adaptability in accommodating the needs of individual patients. Here we examine some of these design features.

Cite this article: Bone Joint J 2013;95-B, Supple A:53–6.

Large osteochondral lesions (OCLs) of the shoulder of the talus cannot always be treated by traditional osteochondral autograft techniques because of their size, articular geometry and loss of an articular buttress. We hypothesised that they could be treated by transplantation of a vascularised corticoperiosteal graft from the ipsilateral medial femoral condyle.

Between 2004 and 2011, we carried out a prospective study of a consecutive series of 14 patients (five women, nine men; mean age 34.8 years, 20 to 54) who were treated for an OCL with a vascularised bone graft. Clinical outcome was assessed using a visual analogue scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. Radiological follow-up used plain radiographs and CT scans to assess graft incorporation and joint deterioration.

At a mean follow-up of 4.1 years (2 to 7), the mean VAS for pain had decreased from 5.8 (5 to 8) to 1.8 (0 to 4) (p = 0.001) and the mean AOFAS hindfoot score had increased from 65 (41 to 70) to 81 (54 to 92) (p = 0.003). Radiologically, the talar contour had been successfully reconstructed with stable incorporation of the vascularised corticoperiosteal graft in all patients. Joint degeneration was only seen in one ankle.

Treatment of a large OCL of the shoulder of the talus with a vascularised corticoperiosteal graft taken from the medial condyle of the femur was found to be a safe, reliable method of restoring the contour of the talus in the early to mid-term.

Cite this article: Bone Joint J 2015;97-B:1242–9.

The incidence of periprosthetic fractures of the ankle is increasing. However, little is known about the outcome of treatment and their management remains controversial. The aim of this study was to assess the impact of periprosthetic fractures on the functional and radiological outcome of patients with a total ankle arthroplasty (TAA).

A total of 505 TAAs (488 patients) who underwent TAA were retrospectively evaluated for periprosthetic ankle fracture: these were then classified according to a recent classification which is orientated towards treatment. The outcome was evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) score and a visual analogue scale for pain, and radiologically.

A total of 21 patients with a periprosthetic fracture of the ankle were identified. There were 13 women and eight men. The mean age of the patients was 63 years (48 to 74). Thus, the incidence of fracture was 4.17%.

There were 11 intra-operative and ten post-operative fractures, of which eight were stress fractures and two were traumatic. The prosthesis was stable in all patients. Five stress fractures were treated conservatively and the remaining three were treated operatively.

A total of 17 patients (81%) were examined clinically and radiologically at a mean follow-up of 53.5 months (12 to 112). The mean AOFAS score at follow-up was 79.5 (21 to 100). The mean AOFAS score in those with an intra-operative fracture was 87.6 (80 to 100) and for those with a stress fracture, which were mainly because of varus malpositioning, was 67.3 (21 to 93). Periprosthetic fractures of the ankle do not necessarily adversely affect the clinical outcome, provided that a treatment algorithm is implemented with the help of a new classification system.

Cite this article: Bone Joint J 2015;97-B:950–6.

We reviewed the outcome of 69 uncemented, custom-made, distal femoral endoprosthetic replacements performed in 69 patients between 1994 and 2006. There were 31 women and 38 men with a mean age at implantation of 16.5 years (5 to 37). All procedures were performed for primary malignant bone tumours of the distal femur. At a mean follow-up of 124.2 months (4 to 212), 53 patients were alive, with one patient lost to follow-up. All nine implants (13.0%) were revised due to aseptic loosening at a mean of 52 months (8 to 91); three implants (4.3%) were revised due to fracture of the shaft of the prosthesis and three patients (4.3%) had a peri-prosthetic fracture. Bone remodelling associated with periosteal cortical thinning adjacent to the uncemented intramedullary stem was seen in 24 patients but this did not predispose to failure. All aseptically loose implants in this series were diagnosed to be loose within the first five years.

The results from this study suggest that custom-made uncemented distal femur replacements have a higher rate of aseptic loosening compared to published results for this design when used with cemented fixation. Loosening of uncemented replacements occurs early indicating that initial fixation of the implant is crucial.

Cite this article: Bone Joint J 2014;96-B:263–9.