We present an update of the clinical and radiological results of 62 consecutive acetabular revisions using impacted morsellised cancellous bone grafts and a cemented acetabular component in 58 patients, at a mean follow-up of 22.2 years (20 to 25). The Kaplan-Meier survivorship for the acetabular component with revision for any reason as the endpoint was 75% at 20 years (95% confidence interval (CI) 62 to 88) when 16 hips were at risk. Excluding two revisions for septic loosening at three and six years, the survivorship at 20 years was 79% (95% CI 67 to 93). With further exclusions of one revision of a well-fixed acetabular component after 12 years during a femoral revision and two after 17 years for wear of the acetabular component, the survivorship for aseptic loosening was 87% at 20 years (95% CI 76 to 97). At the final review 14 of the 16 surviving hips had radiographs available. There was one additional case of radiological loosening and four acetabular reconstructions showed progressive radiolucent lines in one or two zones. Acetabular revision using impacted large morsellised bone chips (0.5 cm to 1 cm in diameter) and a cemented acetabular component remains a reliable technique for reconstruction, even when assessed at more than 20 years after surgery

A total of 219 hips in 192 patients aged between 18 and 65 years were randomised to 28-mm metal-on-metal uncemented total hip replacements (THRs, 107 hips) or hybrid hip resurfacing (HR, 112 hips). At a mean follow-up of eight years (6.6 to 9.3) there was no significant difference between the THR and HR groups regarding rate of revision (4.0% (4 of 99) vs 5.8% (6 of 104), p = 0.569) or re-operation rates without revision (5.1% (5 of 99) vs 2.9% (3 of 104), p = 0.428). In the THR group one recurrent dislocation, two late deep infections and one peri-prosthetic fracture required revision, whereas in the HR group five patients underwent revision for femoral head loosening and one for adverse reaction to metal debris. The mean University of California, Los Angeles activity scores were significantly higher in HR (7.5 (. sd. 1.7) vs 6.9 (. sd. 1.7), p = 0.035), but similar mean Western Ontario and McMaster Universities Osteoarthritis Index scores were obtained (5.8 (. sd. 9.5) in HR vs 5.1 (. sd. 8.9) in THR, p = 0.615) at the last follow-up. Osteolysis was found in 30 of 81 THR patients (37.4%), mostly in the proximal femur, compared with two of 83 HR patients (2.4%) (p < 0.001). At five years the mean metal ion levels were < 2.5 μg/l for cobalt and chromium in both groups; only titanium was significantly higher in the HR group (p = 0.001). Although revision rates and functional scores were similar in both groups at mid-term, long-term survival analysis is necessary to determine whether one procedure is more advantageous than the other. Cite this article: Bone Joint J 2013;95-B:1464–73

The in-cement technique for revision hip arthroplasty involves retaining the original cement-bone interface. This has been proven to be a biomechanically stronger method than recementing after complete removal of the original cement mantle. This study reviewed a series of 54 consecutive revision hip arthroplasty procedures, using the in-cement technique, between November 1999 and November 2003. Clinical and radiological follow-up included functional assessment. There were 54 procedures performed in 51 patients, whose mean age at surgery was 70.3 years (45 to 85). A total of 42 were available at a mean follow-up of 29.2 months (6 to 51). There was no radiological evidence of loosening. Functional assessments were available for 40 patients who had a mean Harris hip score of 85.2 (51.9 to 98.5), a mean Oxford hip score of 19.6 (12 to 41), a mean UCLA activity profile score of 5.9 (3 to 8) and a mean SF-36 score of 78.0 (31.6 to 100). The in-cement technique provides consistent, high functional outcomes and should be considered in appropriately selected cases

The outcome of surgery for recurrent lumbar disc herniation is debatable. Some studies show results that are comparable with those of primary discectomy, whereas others report worse outcomes. The purpose of this study was to compare the outcome of revision lumbar discectomy with that of primary discectomy in the same cohort of patients who had both the primary and the recurrent herniation at the same level and side. A retrospective analysis of prospectively gathered data was undertaken in 30 patients who had undergone both primary and revision surgery for late recurrent lumbar disc herniation. The outcome measures used were visual analogue scales for lower limb (VAL) and back (VAB) pain and the Oswestry Disability Index (ODI). There was a significant improvement in the mean VAL and ODI scores (both p < 0.001) after primary discectomy. Revision surgery also resulted in improvements in the mean VAL (p < 0.001), VAB (p = 0.030) and ODI scores (p < 0.001). The changes were similar in the two groups (all p > 0.05). Revision discectomy can give results that are as good as those seen after primary surgery. Cite this article: Bone Joint J 2013;95-B:90–4

There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival using re-intervention for any reason as the endpoint was 91% (95% confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at one and five years, respectively. There were two revisions for dislocation of the humeral head, one open reduction for modular humeral component dissociation, one internal fixation for nonunion, one trimming of a prominent screw and one re-cementation for aseptic loosening complicated by infection, ultimately requiring excision arthroplasty. Two patients sustained nerve palsies. Revision TSR after a peri-prosthetic humeral fracture associated with bone loss and/or loose components is a salvage procedure that can provide a stable platform for elbow and hand function. Good rates of union can be achieved using a stem that bypasses the fracture. There is a high rate of complications and function is not as good as with the original replacement

Peri-prosthetic fracture after joint replacement in the lower limb is associated with significant morbidity. The primary aim of this study was to investigate the incidence of peri-prosthetic fracture after total hip replacement (THR) and total knee replacement (TKR) over a ten-year period using a population-based linked dataset. Between 1 April 1997 and 31 March 2008, 52 136 primary THRs, 8726 revision THRs, 44 511 primary TKRs, and 3222 revision TKRs were performed. Five years post-operatively, the rate of fracture was 0.9% after primary THR, 4.2% after revision THR, 0.6% after primary TKR and 1.7% after revision TKR. Comparison of survival analysis for all primary and revision arthroplasties showed peri-prosthetic fractures were more likely in females, patients aged > 70 and after revision arthroplasty. Female patients aged > 70 should be warned of a significantly increased risk of peri-prosthetic fracture after hip or knee replacement. The use of adjuvant medical treatment to reduce the effect of peri-prosthetic osteoporosis may be a direction of research for these patients

The practice of removing a well-fixed cementless femoral component is associated with high morbidity. Ceramic bearing couples are low wearing and their use minimises the risk of subsequent further revision due to the production of wear debris. A total of 165 revision hip replacements were performed, in which a polyethylene-lined acetabular component was revised to a new acetabular component with a ceramic liner, while retaining the well-fixed femoral component. A titanium sleeve was placed over the used femoral trunnion, to which a ceramic head was added. There were 100 alumina and 65 Delta bearing couples inserted. . The mean Harris hip score improved significantly from 71.3 (9.0 to 100.0) pre-operatively to 91.0 (41.0 to 100.0) at a mean follow up of 4.8 years (2.1 to 12.5) (p < 0.001). No patients reported squeaking of the hip. There were two fractures of the ceramic head, both in alumina bearings. No liners were seen to fracture. No fractures were observed in components made of Delta ceramic. At 8.3 years post-operatively the survival with any cause of failure as the endpoint was 96.6% (95% confidence interval (CI) 85.7 to 99.3) for the acetabular component and 94.0% (95% CI 82.1 to 98.4) for the femoral component. The technique of revising the acetabular component in the presence of a well-fixed femoral component with a ceramic head placed on a titanium sleeve over the used trunnion is a useful adjunct in revision hip practice. The use of Delta ceramic is recommended. Cite this article: Bone Joint J 2013;95-B:333–8

Squeaking arising from a ceramic-on-ceramic (CoC) total hip replacement (THR) may cause patient concern and in some cases causes patients to seek revision surgery. We performed a meta-analysis to determine the incidence of squeaking and the incidence of revision surgery for squeaking. A total of 43 studies including 16 828 CoC THR that reported squeaking, or revision for squeaking, were entered into the analysis. The incidence of squeaking was 4.2% and the incidence of revision for squeaking was 0.2%. The incidence of squeaking in patients receiving the Accolade femoral stem was 8.3%, and the incidence of revision for squeaking in these patients was 1.3%. Cite this article: Bone Joint J 2014;96-B:181–7

The need for supplementary screw fixation in acetabular revisions is still widely debated. We carried out 439 acetabular revisions over an eight-year period. In 171 hips with contained or small segmental defects, the Morscher press-fit cup was used. These revisions were followed prospectively. No screws were used for additional fixation. A total of 123 hips with a mean follow-up of 7.4 years (5 to 10.5) were available for clinical and radiological review. There was no further revision of a press-fit cup for aseptic loosening. Radiological assessment revealed osteolysis in three hips. Of the original 171 hips there was cranial and medial migration of up to 6 mm at two years in 44 (26%). No further migration was seen after the second post-operative year. Acetabular revision without screws is possible with excellent medium-term results in well selected patients

During the 11-year-period from 1970 to 1980, 799 total hip arthroplasties with metal-on-plastic prostheses were performed for primary osteoarthritis. In all cases high viscosity cement was used, but not under pressure; acetabular cartilage was removed, but the femoral canal was not plugged. The rate of revision and risk factors were evaluated by survivorship analysis. The overall cumulative revision rates were 11%, 14% and 19% after 8, 10, and 14 years respectively. When prophylactic antibiotics were not used, there was a significant risk of revision for infection. The risk of revision for mechanical loosening of both the acetabular and femoral components was significantly increased for men, younger patients, and if a snap-fit prosthesis with a 35 mm head and short wedged stem was used. The survivorship findings were validated by multivariate statistical analysis

The results of 140 total hip revision procedures for "non-septic" loosening, dislocation, and fracture of the femoral stem or shaft have been personally reviewed and rated by the Harris method. The minimum follow-up period was six months: thirty-three (24 per cent) showed excellent or good results, seventy-two (51 per cent) showed fair or poor results. Subsequent excision arthroplasty was performed in thirty-one patients. The infection rate for these revision procedures was very high, suggesting that many were already infected at the time of revision, and that every "loose" hip must be assumed to be infected until proved otherwise. The mortality rate of 3 per cent was surprisingly low after more than one major surgical procedure in these elderly patients

We undertook a study to determine the rates of infection and revision of total knee replacement (TKR) in patients with renal failure, renal transplantation and those undergoing renal dialysis in Scotland. The overall early and late infection rates were 1.10% and 2.19% compared with 1.06% and 2.01%, respectively, for non-renal patients. Patients with renal failure had a significantly increased risk of early infection (1.6%, relative risk 1.52, p = 0.002) and late infection (4.47%, relative risk 2.22, p < 0.001). Those on renal dialysis had significantly increased risks of late infection (8.03%, relative risk 3.99, p < 0.001) and early revision (3.70%, relative risk 4.40, p < 0.001). Renal transplant patients had a significantly increased risk of late infection, regardless of whether renal transplantation occurred before TKR (9.09%, relative risk 4.517, p = 0.027) or at any time (8.0%, relative risk 3.975, p = 0.047). There were significantly increased rates of comorbidities associated with infection for all the renal patient groups. Logistic regression analysis showed that renal failure and renal dialysis were independent risk factors for early infection and revision, respectively

We reviewed 19 revision hip arthroplasties in which the new femoral component had been recemented into the old, intact cement mantle. The mean time from the first operation to revision was 64 months and the average follow-up was 59 months. There were 7 excellent, 11 good, and one fair result. No femoral component had been revised for loosening and all the stems appeared radiographically stable. Complications included intraoperative perforation of the femur on two occasions and one dislocation. The use of the cement-within-cement technique requires that the old cement surface be dry and roughened to increase the surface area and that the cement be injected in the liquid phase to prevent lamination. The indications for this technique include a broken stem with an intact distal cement mantle, the removal of a femoral component for revision of a loose cup to improve exposure and/or increase offset, recurrent dislocation secondary to component malposition, and debonding of the femoral component within an intact cement mantle

Primary total hip arthroplasty (THA) is one of the most effective ways of improving quality of life (QoL). We have compared the improvement in QoL in 62 patients who had a cemented revision of a THA with that of 62 primary replacements. One year after operation the median QoL score had been significantly improved in both groups; from 0.870 to 0.990 in the primary group (p < 0.0001) and from 0.870 to 0.980 in the revised group (p < 0.0001). There was no significant difference in the improvement in scores between the groups (p = 0.29). When reviewed after four years there was no difference in the pain score for either group (p = 0.89), but that for function had deteriorated significantly. This was associated with revision surgery (p = 0.018) and a low preoperative QoL score (p = 0.004). We conclude that both primary and revision operations give a significant improvement in the QoL but function after revision may be less durable than after a primary arthroplasty

We report the use of an allograft prosthetic composite for reconstruction of the skeletal defect in complex revision total hip replacement for severe proximal femoral bone loss. Between 1986 and 1999, 72 patients (20 men, 52 women) with a mean age of 59.9 years (38 to 78) underwent reconstruction using this technique. At a mean follow-up of 12 years (8 to 20) 57 patients were alive, 14 had died and one was lost to follow-up. Further revision was performed in 19 hips at a mean of 44.5 months (11 to 153) post-operatively. Causes of failure were aseptic loosening in four, allograft resorption in three, allograft nonunion in two, allograft fracture in four, fracture of the stem in one, and deep infection in five. The survivorship of the allograft-prosthesis composite at ten years was 69.0% (95% confidence interval 67.7 to 70.3) with 26 patients remaining at risk. Survivorship was statistically significantly affected by the severity of the pre-operative bone loss (Paprosky type IV; p = 0.019), the number of previous hip revisions exceeding two (p = 0.047), and the length of the allograft used (p = 0.005)

Dislocation is a common reason for revision following total hip replacement. This study investigated the relationship between the bearing surface and the risk of revision due to dislocation. It was based on 110 239 primary total hip replacements with a diagnosis of osteoarthritis collected by the Australian Orthopaedic Association National Joint Replacement Registry between September 1999 and December 2007. A total of 862 (0.78%) were revised because of dislocation. Ceramic-on-ceramic bearing surfaces had a lower risk of requiring revision due to dislocation than did metal-on-polyethylene and ceramic-on-polyethylene surfaces, with a follow-up of up to seven years. However, ceramic-on-ceramic implants were more likely to have larger prosthetic heads and to have been implanted in younger patients. The size of the head of the femoral component and age are known to be independent predictors of dislocation. Therefore, the outcomes were stratified by the size of the head and age. There is a significantly higher rate of revision for dislocation in ceramic-on-ceramic bearing surfaces than in metal-on-polyethylene implants when smaller sizes (≤ 28 mm) of the head were used in younger patients (< 65 years) (hazard ratio = 1.53, p = 0.041) and also with larger (> 28 mm) and in older patients (≥ 65 years) (hazard ratio = 1.73, p = 0.016)

We retrospectively reviewed 11 consecutive patients with an infected reverse shoulder prosthesis. Patients were assessed clinically and radiologically, and standard laboratory tests were carried out. Peroperative samples showed Propionbacterium acnes in seven, coagulase-negative Staphylococcus in five, methicillin-resistant staphylococcus aureus in one and Escherichia coli in one. Two multibacterial and nine monobacterial infections were seen. Post-operatively, patients were treated with intravenous cefazolin for at least three days and in all antibiotic therapy was given for at least three months. Severe pain (3 of 11) or severe limitation of function (3 of 11) are not necessarily seen. A fistula was present in eight, but function was not affected. All but one patient were considered free of infection after one-stage revision at a median follow-up of 24 months, and without antibiotic treatment for a minimum of six months. One patient had a persistent infection despite a second staged revision, but is now free of infection with a spacer. Complications included posterior dislocation in one, haematoma in one and a clavicular fracture in one. At the most recent follow-up the median post-operative Constant-Murley score was 55, 6% adjusted for age, gender and dominance. A one-stage revision arthroplasty reduces the cost and duration of treatment. It is reliable in eradicating infection and good functional outcomes can be achieved

We present our experience with a double-mobility acetabular component in 155 consecutive revision total hip replacements in 149 patients undertaken between 2005 and 2009, with particular emphasis on the incidence of further dislocation. The mean age of the patients was 77 years (42 to 89) with 59 males and 90 females. In all, five patients died and seven were lost to follow-up. Indications for revision were aseptic loosening in 113 hips, recurrent instability in 29, peri-prosthetic fracture in 11 and sepsis in two. The mean follow-up was 42 months (18 to 68). Three hips (2%) in three patients dislocated within six weeks of surgery; one of these dislocated again after one year. All three were managed successfully with closed reduction. Two of the three dislocations occurred in patients who had undergone revision for recurrent dislocation. All three were found at revision to have abductor deficiency. There were no dislocations in those revised for either aseptic loosening or sepsis. These results demonstrate a good mid-term outcome for this component. In the 29 patients revised for instability, only two had a further dislocation, both of which were managed by closed reduction

Objectives. The purpose of this study was to develop an accurate, reliable and easily applicable method for determining the anatomical location of the joint line during revision knee arthroplasty. Methods. The transepicondylar width (TEW), the perpendicular distance between the medial and lateral epicondyles and the distal articular surfaces (DMAD, DLAD) and the distance between the medial and lateral epicondyles and the posterior articular surfaces (PMAD, DLAD) were measured in 40 knees from 20 formalin-fixed adult cadavers (11 male and nine female; mean age at death 56.9 years, . sd. 9.4; 34 to 69). The ratios of the DMAD, PMAD, DLAD and PLAD to TEW were calculated. Results. The mean TEW, DMAD, PMAD, DLAD and PLAD were 82.76 mm (standard deviation (. sd. ) 7.74), 28.95 mm (. sd. 3.3), 28.57 mm (. sd. 3), 23.97 mm (. sd. 3.27) and 24.42 mm (. sd. 3.14), respectively. The ratios between the TEW and the articular distances (DMAD/TEW, DLAD/TEW, PMAD/TEW and PLAD/TEW) were calculated and their means were 0.35 (. sd. 0.02), 0.34 (. sd. 0.02), 0.28 (. sd. 0.03) and 0.29 (. sd. 0.03), respectively. Conclusion. This method provides a simple, reproducible and reliable technique enabling accurate anatomical joint line restoration during revision total knee arthroplasty. Cite this article: B. Ozkurt, T. Sen, D. Cankaya, S. Kendir, K. Basarır, Y. Tabak. The medial and lateral epicondyle as a reliable landmark for intra-operative joint line determination in revision knee arthroplasty. Bone Joint Res 2016;5:280–286. DOI: 10.1302/2046-3758.57.BJR-2016-0002.R1

The purpose of this prospective study was to evaluate the long-term clinical and radiological outcomes of revision of the femoral component of a total hip replacement using impaction bone grafting. Femoral revision with an impacted allograft was performed on 29 patients (31 hips). In all, 21 hips (68%) had grade III or IV femoral defects according to the Endo-Klinik classification. A total of 11 patients (12 hips) died before the ten-year follow-up period. Of the remaining patients, 18 patients (19 hips) were followed for 10 to 15 years; three further patients died during this time. None of the 31 stems underwent further revision of their stem. However, four stems showed extensive subsidence (> 15 mm). One of these patients had a femoral fracture that required fixation. Three other patients had a femoral fracture, two of which required fixation and the other was treated conservatively. Patients with a femoral fracture and/or severe subsidence had significantly more grade IV defects (six of seven hips; p = 0.004). One patient needed a closed reduction for dislocation. Impaction allografting in revision hip surgery gives good long-term results for femora with grades I, II and III Endo-Klinik-classified defects. Extensive subsidence and femoral fractures were seen mainly in patients with grade IV damaged femora