The number of arthroplasties of the hip and knee is predicted to increase rapidly during the next 20 years. Accompanying this is the dilemma of how to follow-up these patients appropriately. Current guidelines recommend long-term follow-up to identify patients with aseptic loosening, which can occur more than a decade postoperatively. The current guidelines and practices of orthopaedic surgeons vary widely. Existing models take up much clinical time and are expensive. Pilot studies using ‘virtual’ clinics and advanced-practice physiotherapists have shown promise in decreasing the time and costs for orthopaedic surgeons and patients. This review discusses current practices and future trends in the follow-up of patients who have an arthroplasty. Cite this article: Bone Joint J 2018;100-B:6–10

Aims. A variety of surgical approaches are used for total hip arthroplasty (THA), all with reported advantages and disadvantages. A number of common complications can occur following THA regardless of the approach used. The purpose of this study was to compare five commonly used surgical approaches with respect to the incidence of surgery-related complications. Patients and Methods. The electronic medical records of all patients who underwent primary elective THA at a single large-volume arthroplasty centre, between 2011 and 2016, with at least two years of follow-up, were reviewed. After exclusion, 3574 consecutive patients were included in the study. There were 1571 men (44.0%) and 2003 women (56.0%). Their mean age and body mass index (BMI) was 63.0 years (. sd. 11.8) and 29.1 kg/m. 2. (. sd. 6.1), respectively. Data gathered included the age of the patient, BMI, the American Society of Anesthesiologists (ASA) score, estimated blood loss (EBL), length of stay (LOS), operating time, the presence of intra- or postoperative complications, type of complication, and the surgical approach. The approaches used during the study were posterior, anterior, direct lateral, anterolateral, and the northern approach. The complications that were recorded included prolonged wound drainage without infection, superficial infection, deep infection, dislocation, aseptic loosening, and periprosthetic fracture. Finally, the need for re-operation was recorded. Means were compared using analysis of variance (ANOVA) and Student’s t-tests where appropriate and proportions were compared using the chi-squared test. Results. A total of 248 patients had 263 complications related to the surgery, with an incidence of 6.94%. The anterior approach had the highest incidence of complications (8.5% (113/1329)) and the posterior approach had the lowest, at 5.85% (97/1657; p = 0.006). Most complications were due to deep infection (22.8%), periprosthetic fracture (22.4%), and prolonged wound drainage (21.3%). The rate of dislocation was 0.84% (14/1657) with the posterior approach and 1.28% (17/1329) with the anterior approach (p = 0.32). Conclusion. Overall, THA has a relatively low complication rate. However, the surgical approach plays a role in the incidence of complications. We found that the posterior approach had a significantly lower overall complication rate compared with the anterior approach, with an equal dislocation rate. Periprosthetic fracture and surgical site infection contributed most to the early complication rates. Cite this article: Bone Joint J 2019;101-B:646–651

Aims. The aim of this study was to report the outcomes of different treatment options for glenoid loosening following reverse shoulder arthroplasty (RSA) at a minimum follow-up of two years. Patients and Methods. We retrospectively studied the records of 79 patients (19 men, 60 women; 84 shoulders) aged 70.4 years (21 to 87) treated for aseptic loosening of the glenosphere following RSA. Clinical evaluation included pre- and post-treatment active anterior elevation (AAE), external rotation, and Constant score. Results. From the original cohort, 29 shoulders (35%) were treated conservatively, 27 shoulders (32%) were revised by revision of the glenosphere, and 28 shoulders (33%) were converted to hemiarthroplasty. At last follow-up, conservative treatment and glenoid revision significantly improved AAE, total Constant score, and pain, while hemiarthroplasty did not improve range of movement or clinical scores. Multivariable analysis confirmed that conservative treatment and glenoid revision achieved similar improvements in pain (glenoid revision vs conservative, beta 0.44; p = 0.834) but that outcomes were significantly worse following hemiarthroplasty (beta -5.00; p = 0.029). Conclusion. When possible, glenoid loosening after RSA should first be treated conservatively, then by glenosphere revision if necessary, and last by salvage hemiarthroplasty. Cite this article: Bone Joint J 2019;101-B:461–469

Aims. The aim of this study was to compare the incidence of aseptic loosening after the use of a cemented acetabular component and a Trabecular Metal (TM) acetabular component (Zimmer Inc., Warsaw, Indiana) at acetabular revision with bone impaction grafting. Patients and Methods. A total of 42 patients were included in the study. Patients were randomised to receive an all- polyethylene cemented acetabular component (n = 19) or a TM component (n = 23). Radiostereometric analysis and conventional radiographic examinations were performed regularly up to two years post-operatively or until further revision. Results. The proximal migration was significantly higher in the cemented group. At two years, the median proximal migration was 1.45 mm and 0.25 mm in the cemented and TM groups, respectively (p = 0.02). One cemented component was revised due to dislocation. There were no revisions in the TM group. Conclusion. Lower proximal migration in the TM group suggests that this design might be associated with a lower risk of aseptic loosening in the long term compared with an all polyethylene cemented component. Longer follow-up is required to confirm the clinical advantages of using this component at acetabular revision. Cite this article: Bone Joint J 2017;99-B:880–6

Aims. Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent. Patients and Methods. A total of 278 consecutive total ankle arthroplasties (251 patients), performed by four surgeons over a six-year period in Wrightington Hospital (Wigan, United Kingdom) were prospectively reviewed. There were 143 men and 108 women with a mean age of 64 years (41 to 86). The data were recorded on each follow-up visit. Any complications either during initial hospital stay or subsequently reported on follow-ups were recorded, investigated, monitored, and treated as warranted. Literature search included the studies reporting the outcomes and complications of TAA implants. Results. There were wound-healing problems in nine ankles (3.2%), superficial infection in 20 ankles (7.2%), and deep infection in six ankles (2.2%). Intraoperative fractures occurred in medial malleoli in 27 ankles (9.7%) and in lateral malleoli in four ankles (1.4%). Aseptic loosening and osteolysis were seen 16 ankles (5.8%). Fracture of the polyethylene component occurred in one ankle (0.4%) and edge-loading in seven ankles (2.5%). We observed medial gutter pain in 31 ankles (11.1%). The incidence of thromboembolism occurred in two ankles (0.7%). The results were found to be comparable to the previously reported complications of total ankle arthroplasty in the literature. Conclusion. Total ankle arthroplasty continues to evolve and improve the ankle function. Despite high overall complication rates with TAA surgery, most complications appear to be minor and do not affect final clinical outcome. Our results and literature review will help in the consent process and provide detailed complication rates for an informed consent. Cite this article: Bone Joint J 2018;100-B:1352–8

Aims. The aim of this study was to evaluate the prosthesis characteristics and associated conditions that may modify the survival of total femoral endoprosthetic replacements (TFEPR). Patients and Methods. In all, 81 patients treated with TFEPR from 1976 to 2017 were retrospectively evaluated and failures were categorized according to the Henderson classification. There were 38 female patients (47%) and 43 male patients (53%) with a mean age at diagnosis of 43 years (12 to 86). The mean follow-up time was 10.3 years (0 to 31.7). A survival analysis was performed followed by univariate and multivariate Cox regression to identify independent implant survival factors. Results. The revision-free survival of the implant was 71% at five years and 63.3% at ten years. Three prostheses reached 15 years without revision. The mean Musculoskeletal Tumor Society score in the group was 26 (23 to 28). The mechanisms of failure were infection in 18%, structural failures in 6%, tumour progression in 5%, aseptic loosening in 2%, and soft-tissue failures in 1%. Prostheses used for primary reconstruction after oncological resections had lower infection rates than revision implants (8% vs 25%; p = 0.001). The rates of infection in silver-coated and non-silver-coated prosthesis were similar (17.4% vs 19.%; p = 0.869). The incidence of hip dislocation was 10%. Rotating hinge prosthesis had a lower failure rate than fixed hinge prosthesis (5.3% vs 11%). After Cox regression, the independent factors associated with failures were the history of previous operations (hazard ratio (HR) 3.7; p = 0.041), and the associated arthroplasty of the proximal tibia (HR 3.8; p = 0.034). At last follow-up, 11 patients (13%) required amputation. Conclusion. TFEPR offers a reliable reconstruction option for massive bone loss of the femur, with a good survival when the prosthesis is used as a primary implant. The use of a rotating hinge at the knee and dual mobility bearing at the hip may be adequate to reduce the risk of mechanical and soft-tissue failures. Infection remains the main concern and there is insufficient evidence to support the routine use of silver-coated endoprosthesis. Cite this article: Bone Joint J 2019;101-B:522–528

We describe the clinical and radiological results of 120 consecutive revision hip replacements in 107 patients, using the JRI Furlong hydroxyapatite-ceramic-coated femoral component. The mean age of the patients at operation was 71 years (36 to 92) and the mean length of follow-up 8.0 years (5.0 to 12.4). We included patients on whom previous revision hip surgery had taken place. The patients were independently reviewed and scored using the Harris hip score, the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and the Charnley modification of the Merle d’Aubigné and Postel score. Radiographs were assessed by three reviewers for the formation of new bone, osteolysis, osseointegration and radiolucent lines in each Gruen zone. The mean Harris hip score was 85.8 (42 to 100) at the latest post-operative review. The mean WOMAC and Merle d’Aubigné and Postel scores were 34.5 and 14.8, respectively. The mean visual analogue score for pain (possible range 0 to 10) was 1.2 overall, but 0.5 specifically for mid-thigh pain. There were no revisions of the femoral component for aseptic loosening. There were four re-revisions, three for infection and one for recurrent dislocation. Radiological review of all the femoral components, including the four re-revisions showed stable bony ingrowth and no new radiolucent lines in any zone. Using revision or impending revision for aseptic loosening as an end-point, the cumulative survival of the femoral component at ten years was 100% (95% confidence interval 94 to 100). We present excellent medium- to long-term clinical, radiological and survivorship results with the fully hydroxyapatite-ceramic-coated femoral component in revision hip surgery

Aims. Current guidelines consider analyses of joint aspirates, including leucocyte cell count (LC) and polymorphonuclear percentage (PMN%) as a diagnostic mainstay of periprosthetic joint infection (PJI). It is unclear if these parameters are subject to a certain degree of variability over time. Therefore, the aim of this study was to evaluate the variation of LC and PMN% in patients with aseptic revision total knee arthroplasty (TKA). Methods. We conducted a prospective, double-centre study of 40 patients with 40 knee joints. Patients underwent joint aspiration at two different time points with a maximum period of 120 days in between these interventions and without any events such as other joint aspirations or surgeries. The main indications for TKA revision surgery were aseptic implant loosening (n = 24) and joint instability (n = 11). Results. Overall, 80 synovial fluid samples of 40 patients were analyzed. The average time period between the joint aspirations was 50 days (SD 32). There was a significantly higher percentage change in LC when compared to PMN% (44.1% (SD 28.6%) vs 27.3% (SD 23.7%); p = 0.003). When applying standard definition criteria, LC counts were found to skip back and forth between the two time points with exceeding the thresholds in up to 20% of cases, which was significantly more compared to PMN% for the European Bone and Joint Infection Society (EBJIS) criteria (p = 0.001), as well as for Musculoskeletal Infection Society (MSIS) (p = 0.029). Conclusion. LC and PMN% are subject to considerable variation. According to its higher interindividual variance, LC evaluation might contribute to false-positive or false-negative results in PJI assessment. Single LC testing prior to TKA revision surgery seems to be insufficient to exclude PJI. On the basis of the obtained results, PMN% analyses overrule LC measurements with regard to a conclusive diagnostic algorithm. Cite this article: Bone Jt Open 2021;2(8):566–572

Aims. Dual mobility (DM) implants have been shown to reduce the dislocation rate after total hip arthroplasty (THA), but there remain concerns about the use of cobalt chrome liners inserted into titanium shells. The aim of this study was to assess the clinical outcomes, metal ion levels, and periprosthetic femoral bone mineral density (BMD) at mid-term follow-up in young, active patients receiving a modular DM THA. Methods. This was a prospective study involving patients aged < 65 years, with a BMI of < 35 kg/m. 2. , and University of California, Los Angeles activity score of > 6 who underwent primary THA with a modular cobalt chrome acetabular liner, highly cross-linked polyethylene mobile bearing, and a cementless titanium femoral stem. Patient-reported outcome measures, whole blood metal ion levels (μg/l), and periprosthetic femoral BMD were measured at baseline and at one, two, and five years postoperatively. The results two years postoperatively for this cohort have been previously reported. Results. A total of 43 patients were enrolled. At minimum follow-up of five years, 23 (53.4%) returned for clinical and radiological review, 25 (58.1%) had metal ion analysis performed, 19 (44.2%) underwent dual energy x-ray absorptiometry scans, and 25 (58%) completed a pain-drawing questionnaire. The mean modified Harris Hip Scores improved significantly from 54.8 (SD 19) preoperatively to 93.08 (SD 10.5) five years postoperatively (p < 0.001). One patient was revised for aseptic acetabular loosening. The mean cobalt levels increased from 0.065 μg/l (SD 0.03) to 0.08 (SD 0.05) and the mean titanium levels increased from 0.35 (SD 0.13) to 0.78 (SD 0.29). The femoral BMD ratio decreased in Gruen Zone 1 (91.9%) at five years postoperatively compared with the baseline scores at six weeks potoperatively. The femoral BMD ratio was maintained in Gruen zones 2 to 7. Conclusion. The use of a modular DM component and a cementless, tapered femoral stem shows excellent mid-term survivorship with minimal concerns for corrosion and metal ion release in a cohort of young, active patients undergoing primary THA. Cite this article: Bone Joint J 2021;103-B(7 Supple B):73–77

We compared the results of 146 patients who received an anatomic modular knee fixed-bearing total knee replacement (TKR) in one knee and a low contact stress rotating platform mobile-bearing TKR in the other. There were 138 women and eight men with a mean age of 69.8 years (42 to 80). The mean follow-up was 13.2 years (11.0 to 14.5). The patients were assessed clinically and radiologically using the rating systems of the Hospital for Special Surgery and the Knee Society at three months, six months, one year, and annually thereafter. The assessment scores of both rating systems pre-operatively and at the final review did not show any statistically significant differences between the two designs of implant. In the anatomic modular knee group, one knee was revised because of aseptic loosening of the tibial component and one because of infection. In addition, three knees were revised because of wear of the polyethylene tibial bearing. In the low contact stress group, two knees were revised because of instability requiring exchange of the polyethylene insert and one because of infection. The radiological analysis found no statistical difference in the incidence of radiolucent lines at the final review (Student’s t-test, p = 0.08), most of which occurred at tibial zone 1. The Kaplan-Meier survivorship for aseptic loosening of the anatomic modular knee and the low contact stress implants at 14.5 years was 99% and 100%, respectively, with a 95% confidence interval of 94% to 100% for both designs. We found no evidence of the superiority of one design over the other at long-term follow-up

Aims. The primary aim of this study was to compare the wear properties of vitamin E-diffused, highly crosslinked polyethylene (VEPE) and one formulation of moderately crosslinked and mechanically annealed ultra-high molecular weight polyethylene (ModXLPE) in patients five years after primary total hip arthroplasty (THA). The secondary aim was to assess the clinical results of patients treated with VEPE by evaluating patient-reported outcome measures (PROMs), radiological evidence of fixation, and the incidence of mechanical failure. Patients and Methods. A total of 208 patients (221 THAs) from four international centres were recruited into a prospective study involving radiostereometric analysis (RSA) and the assessment of clinical outcomes. A total of 193 hips (87%) were reviewed at the five-year follow-up. Of these, 136 (70%) received VEPE (vs ModXLPE) liners and 68 (35%) received ceramic (vs metal) femoral heads. PROMs and radiographs were collected preoperatively and at one, two, and five years postoperatively. In addition, RSA images were collected to measure PE wear postoperatively and at one, two, and five years after surgery. Results. We observed similar bedding in one year postoperatively and wear two years postoperatively between the two types of liner. However, there was significantly more penetration of the femoral head in the ModXLPE cohort compared with the VEPE cohort five years postoperatively (p < 0.001). The only variables independently predictive of increased wear were ModXLPE (vs VEPE) liner type (β = 0.22, p = 0.010) and metal (vs ceramic) femoral head (β = 0.21, p = 0.013). There was no association between increased wear and the development of radiolucency (p = 0.866) or PROMs. No patient had evidence of osteolysis. Conclusion. Five years postoperatively, patients with VEPE (vs ModXLPE) and ceramic (vs metal) femoral heads had decreased wear. The rates of wear for both liners were very low and have not led to any osteolysis or implant failure due to aseptic loosening

We have examined the results obtained with 72 NexGen legacy posterior stabilised-flex fixed total knee replacements in 47 patients implanted by a single surgeon between March 2003 and September 2004. Aseptic loosening of the femoral component was found in 27 (38%) of the replacements at a mean follow-up of 32 months (30 to 48) and 15 knees (21%) required revision at a mean of 23 months (11 to 45). We compared the radiologically-loose and revised knees with those which had remained well-fixed to identify the factors which had contributed to this high rate of aseptic loosening. Post-operatively, the mean maximum flexion was 136° (110° to 140°) in the loosened group and 125° (95° to 140°) in the well-fixed group (independent t-test, p = 0.022). Squatting, kneeling, or sitting cross-legged could be achieved by 23 (85%) of the loosened knees, but only 22 (49%) of the well-fixed knees (chi-squared test, p = 0.001). The loosened femoral components were found to migrate into a more flexed position, but no migration was detected in the well-fixed group. These implants allowed a high degree of flexion, but showed a marked rate of early loosening of the femoral component, which was associated with weight-bearing in maximum flexion

We reviewed 264 consecutive primary total hip replacements in 244 patients in which the Harris-Galante I porous-coated acetabular component had been used. The mean follow-up was 95 months (69 to 132). In 221 arthroplasties a 32 mm ceramic head had been used, and in the other 43 one of cobalt-chrome alloy. There were 124 women and 120 men with a mean age at operation of 56.8 years (21 to 83). Survival analysis of the acetabular components was performed using the following definitions of failure: 1) infection; 2) removal because of aseptic loosening; 3) removal for any cause; and 4) a worst-case analysis including removal of the cup or infection or loss to follow-up. Two well-fixed cups had been removed because of deep infection and three, similarly sound cups had been exchanged at the time of femoral revision. None of the acetabular components had required revision for aseptic loosening. After 11 years survival was 97.7% using the worst-case criterion. Radiological analysis of 187 acetabular components at a mean of 82 months (41 to 132) revealed no case of aseptic loosening. Pelvic osteolysis was seen in only one patient, but was not progressive and showed signs of regression. The results using these acetabular components are encouraging but the need for regular follow-up remains since complications such as significant wear of the liner, massive osteolysis of the pelvis, aseptic loosening and late infection may increase in the second decade

Aims. We carried out a further study of the long-term results of the cemented Exeter femoral component in patients under the age of 40 with a mean follow-up of 13.6 years (10 to 20). Patients and Methods. We reviewed our original cohort of 104 cemented Exeter stems in 78 consecutive patients with a mean age of 31 years (16 to 39). Only one patient was lost to radiological follow-up. Results. A total of six patients (eight hips) had died for reasons unrelated to their surgery. There had been one further periprosthetic fracture from a fall and one fractured femoral stem. No revisions for aseptic loosening were undertaken during the whole study period. Overall, 11 hips had progressive radiolucent lines in one or more zones. The Kaplan Meier survival percentages at ten and 17 years were 97.1% (95% confidence interval (CI) 91.3 to 99.1) and 92.1% (95% CI 74.1 to 97.8) with revision for any reason as the endpoint, and 100% at both ten and 17 years with aseptic loosening (95% CI 83.8 to 100) as the endpoint. No additional hips were classified as radiologically loose. Conclusion. The Exeter femoral component continues to function satisfactorily in young patients for up to 17 years after surgery. Cite this article: Bone Joint J 2017;99-B:192–8

Aims. The number of revision total knee arthroplasties (TKA) that are performed is expected to increase. However, previous reports of the causes of failure after TKA are limited in that they report the causes at specific institutions, which are often dependent on referral patterns. Our aim was to report the most common indications for re-operations and revisions in a large series of posterior-stabilised TKAs undertaken at a single institution, excluding referrals from elsewhere, which may bias the causes of failure. Patients and Methods. A total of 5098 TKAs which were undertaken between 2000 and 2012 were included in the study. Re-operations, revisions with modular component exchange, and revisions with non-modular component replacement or removal were identified from the medical records. The mean follow-up was five years (two to 12). Results. The Kaplan-Meier ten-year survival without a re-operation, modular component revision and non-modular component revision was 95.7%, 99.3% and 95.3%, respectively. The most common indications for a re-operation were: post-operative stiffness (58%), delayed wound healing (21%), and patellar clunk (11%). The indications for isolated modular component revision were acute periprosthetic joint infection (PJI) (64%) and instability (36%). The most common indications for non-modular component revision were chronic PJI (52%), aseptic loosening (17%), periprosthetic fracture (10%), and instability (10%). Conclusion. Post-operative stiffness remains the most common indication for re-operation after TKA. Infection is the most common indication for modular and non-modular component revision. Aseptic loosening was not an uncommon cause of failure, however, it was much less common than in national registry and non-registry data. Focusing on posterior-stabilised TKAs initially performed at our institution allowed for an accurate assessment of the causes of failure in a contemporary specialty practice. Cite this article: Bone Joint J 2017;99-B:647–52

Aims. Our aim was to report survivorship data and lessons learned with the Corail/Pinnacle cementless total hip arthroplasty (THA) system. Patients and Methods. Between August 2005 and March 2015, a total of 4802 primary cementless Corail/Pinnacle THAs were performed in 4309 patients. In March 2016, we reviewed these hips from a prospectively maintained database. Results . A total of 80 hips (1.67%) have been revised which is equivalent to a cumulative risk of revision of 2.5% at ten years. The rate of revision was not significantly higher in patients aged ≥ 70 years (p = 0.93). The leading indications for revision were instability (n = 22, 0.46%), infection (n = 20, 0.42%), aseptic femoral loosening (n = 15, 0.31%) and femoral fracture (n = 6, 0.12%). There were changes in the surgical technique with respect to the Corail femoral component during the ten-year period involving a change to collared components and a trend towards larger size. These resulted in a decrease in the rate of iatrogenic femoral fracture and a decrease in the rate of aseptic loosening. Conclusion. The rate of revision in this series is comparable with the best performing THAs in registry data. Most revisions were not directly related to the implants. Despite extensive previous experience with cemented femoral components, the senior author noted a learning curve requiring increased focus on primary stability. The number of revisions related to the femoral component is reducing. Any new technology has a learning curve that may be independent of surgical experience. Cite this article: Bone Joint J 2016;98-B:1589–96

Aims. Total ankle arthroplasty (TAA) has become the most reliable surgical solution for patients with end-stage arthritis of the ankle. Aseptic loosening of the talar component is the most common complication. A custom-made artificial talus can be used as the talar component in a combined TAA for patients with poor bone stock of the talus. The purpose of this study was to investigate the functional and clinical outcomes of combined TAA. Patients and Methods. Ten patients (two men, eight women; ten ankles) treated using a combined TAA between 2009 and 2013 were matched for age, gender, and length of follow-up with 12 patients (one man, 11 women; 12 ankles) who underwent a standard TAA. All had end-stage arthritis of the ankle. The combined TAA features a tibial component of the TNK ankle (Kyocera, Kyoto, Japan) and an alumina ceramic artificial talus (Kyocera), designed using individualized CT data. The mean age at the time of surgery in the combined TAA and standard TAA groups was 71 years (. 61. to 82) and 75 years (62 to 82), respectively. The mean follow-up was 58 months (43 to 81) and 64 months (48 to 88), respectively. The outcome was assessed using the Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale, the Ankle Osteoarthritis Scale (AOS), and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q). Results. The mean preoperative JSSF score of the combined TAA and standard TAA groups was 44 (. sd. 11) and 49 (. sd. 10), respectively. The mean postoperative JSSF scores were 89 (. sd. 6.1) and 72 (. sd. 15), respectively. The mean postoperative JSSF score of the combined TAA group was significantly higher (p = 0.0034). The mean preoperative AOS scores for pain and function in the combined TAA and standard TAA groups were 5.8 (. sd. 3.3) and 5.5 (. sd. 3.1), and 8.6 (. sd. 1.3), and 7.1 (. sd. 2.9), respectively. The mean postoperative AOS scores of pain and function were 2.5 (. sd. 2.5) and 2.2 (. sd. 1.9), and 2.5 (. sd. 3.3) and 3.4 (. sd. 2.9), respectively. There were no significant differences between the two groups in terms of postoperative AOS scores. The mean postoperative SAFE-Q scores were: for pain, 76 (. sd. 23) and 70 (. sd. 23); for physical function, 66 (. sd. 25) and 55 (. sd. 27); for social function, 73 (. sd. 35) and 62 (. sd. 34); for shoe-related, 73 (. sd. 19) and 65 (. sd. 26); and for general health, 78 (. sd. 28) and 67 (. sd. 29), respectively. There were no significant differences between the two groups in terms of postoperative SAFE-Q scores. Conclusion. Combined TAA resulted in better clinical results than standard TAA. Cite this article: Bone Joint J 2019;101-B:443–446

Aims. Loss or absence of proximal femoral bone in revision total hip arthroplasty (THA) remains a significant challenge. While the main indication for the use of proximal femoral replacements (PFRs) is in the treatment of malignant disease, they have a valuable role in revision THA for loosening, fracture and infection in patients with bone loss. Our aim was to determine the clinical outcomes, implant survivorship, and complications of PFRs used in revision THA for indications other than malignancy. Patients and Methods. A retrospective review of 44 patients who underwent revision THA using a PFR between 2000 and 2013 was undertaken. Their mean age was 79 years (53 to 97); 31 (70%) were women. The bone loss was classified as Paprosky IIIB or IV in all patients. The mean follow-up was six years (2 to 12), at which time 22 patients had died and five were lost to follow-up. Results. The mean Harris Hip Score improved from 42.8 (25.9 to 82.9) pre-operatively to 68.5 (21.0 to 87.7) post-operatively (p = 0.0009). A total of two PFRs had been revised, one for periprosthetic infection eight years post-operatively and one for aseptic loosening six years post-operatively. The Kaplan-Meier survivorship free of any revision or removal of an implant was 86% at five years and 66% years at ten years. A total of 12 patients (27%) had a complication including six with a dislocation. Conclusion. PFRs provide a useful salvage option for patients, particularly the elderly with massive proximal femoral bone loss who require revision THA, with significant clinical improvement. While the survivorship of the implant is good at five years, dislocation continues to be the most common complication. The judicious use of larger femoral heads, dual-mobility constructs, or constrained liners may help to minimise the risk of dislocation. Cite this article: Bone Joint J 2017;99-B:325–9

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

Aims. The optimal method of tibial component fixation remains uncertain in total knee arthroplasty (TKA). Hydroxyapatite coatings have been applied to improve bone ingrowth in uncemented designs, but may only coat the directly accessible surface. As peri-apatite (PA) is solution deposited, this may increase the coverage of the implant surface and thereby fixation. We assessed the tibial component fixation of uncemented PA-coated TKAs versus cemented TKAs. Patients and Methods. Patients were randomised to PA-coated or cemented TKAs. In 60 patients (30 in each group), radiostereometric analysis of tibial component migration was evaluated as the primary outcome at baseline, three months post-operatively and at one, two and five years. A linear mixed-effects model was used to analyse the repeated measurements. Results. After five years of follow-up, one (cemented) component was revised due to ligament instability. Overall, uncemented PA-coated tibial components migrated significantly more (p = 0.003), with the mean maximum total point motion (MTPM) at five years being 0.62 mm (95% confidence intervals (CI) 0.49 to 0.76) for cemented tibial components and 0.97 mm (95% CI 0.81 to 1.15) for PA-coated tibial components in TKA. However, between three months and five years the cemented TKAs migrated significantly more (p = 0.02), displaying a MTPM of 0.27 mm (95% CI, 0.19 to 0.36) versus 0.13 mm (95% CI, 0.01 to 0.25) for PA-coated tibial components. One implant in each group was considered at risk for aseptic loosening due to continuous migration after five years of follow-up, albeit with different migration patterns for each group (i.e. higher initial migration but diminishing over time for the PA-coated component versus gradually increasing migration for the cemented component). Conclusion. The tibial components of PA-coated TKAs showed more overall migration compared with the tibial components of cemented TKAs. However, post hoc analysis showed that this difference was caused by higher migration of PA-coated components in the first three months, after which a stable migration pattern was observed. Clinically, there was no significant difference in outcome between the groups. Cite this article: Bone Joint J 2017;99-B:1467–76