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. 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 CPT rasp to achieve various thicknesses of the cement mantle. Two or three tantalum balls were implanted in the proximal cement in each femur. A cyclic loading test was then performed for each stem. The migration of the balls was measured three-dimensionally, using a micro-computed tomography (CT) scanner, before and after loading. A digital displacement gauge was positioned at the stem shoulder, and stem subsidence was measured continuously by the gauge. Final stem subsidence was measured at the balls at the end of each stem.Objectives
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:
Multimodal infiltration of local anaesthetic provides effective
control of pain in patients undergoing total knee arthroplasty (TKA).
There is little information about the added benefits of posterior
capsular infiltration (PCI) using different combinations of local
anaesthetic agents. Our aim was to investigate the effectiveness
of the control of pain using multimodal infiltration with and without
infiltration of the posterior capsule of the knee. In a double-blind, randomised controlled trial of patients scheduled
for unilateral primary TKA, 86 were assigned to be treated with
multimodal infiltration with (Group I) or without (Group II) PCI.
Routine associated analgesia included the use of bupivacaine, morphine,
ketorolac and epinephrine. All patients had spinal anaesthesia and patient-controlled
analgesia (PCA) post-operatively. A visual analogue scale (VAS)
for pain and the use of morphine were recorded 24 hours post-operatively.
Side effects of the infiltration, blood loss, and length of stay
in hospital were recorded.Aims
Patients and Methods
The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery. A total of 17 DBM products were used as search terms in two available databases: Embase and PubMed according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses statement. All articles that reported the clinical use of a DBM-product in trauma and orthopaedic related surgery were included.Objectives
Methods
The objective of this five-year prospective, blinded, randomised
controlled trial (RCT) was to compare femoral head penetration into
a vitamin E diffused highly cross-linked polyethylene (HXLPE) liner
with penetration into a medium cross-linked polyethylene control
liner using radiostereometric analysis. Patients scheduled for total hip arthroplasty (THA) were randomised
to receive either the study E1 (32 patients) or the control ArComXL
polyethylene (35 patients). The median age (range) of the overall
cohort was 66 years (40 to 76).Aims
Patients and Methods
We investigated changes in the axial alignment of the ipsilateral
hip and knee after total hip arthroplasty (THA). We reviewed 152 patients undergoing primary THA (163 hips; 22
hips in men, 141 hips in women) without a pre-operative flexion
contracture. The mean age was 64 years (30 to 88). The diagnosis
was osteoarthritis (OA) in 151 hips (primary in 18 hips, and secondary
to dysplasia in 133) and non-OA in 12 hips. A posterolateral approach
with repair of the external rotators was used in 134 hips and an
anterior approach in 29 hips. We measured changes in leg length
and offset on radiographs, and femoral anteversion, internal rotation
of the hip and lateral patellar tilt on CT scans, pre- and post-operatively. Aims
Patients and Methods
Little biomechanical information is available about kinematically aligned (KA) total knee arthroplasty (TKA). The purpose of this study was to simulate the kinematics and kinetics after KA TKA and mechanically aligned (MA) TKA with four different limb alignments. Bone models were constructed from one volunteer (normal) and three patients with three different knee deformities (slight, moderate and severe varus). A dynamic musculoskeletal modelling system was used to analyse the kinematics and the tibiofemoral contact force. The contact stress on the tibial insert, and the stress to the resection surface and medial tibial cortex were examined by using finite element analysis.Objectives
Materials and Methods
To date, there is insufficient evidence available to compare
the outcome of cemented and uncemented fixation of the humeral stem
in reverse shoulder arthroplasty (RSA). A systemic review comprising 41 clinical studies was performed
to compare the functional outcome and rate of complications of cemented
and uncemented stems in RSA. These included 1455 cemented and 329
uncemented shoulders. The clinical characteristics of the two groups
were similar. Variables were compared using pooled frequency-weighted means
and relative risk ratios (RR).Aims
Methods
A retrospective review was performed of patients
undergoing primary cementless total knee replacement (TKR) using
porous tantalum performed by a group of surgical trainees. Clinical
and radiological follow-up involved 79 females and 26 males encompassing
115 knees. The mean age was 66.9 years (36 to 85). Mean follow-up
was 7 years (2 to 11). Tibial and patellar components were porous
tantalum monoblock implants, and femoral components were posterior
stabilised (PS) in design with cobalt–chromium fibre mesh. Radiological
assessments were made for implant positioning, alignment, radiolucencies,
lysis, and loosening. There was 95.7% survival of implants. There
was no radiological evidence of loosening and no osteolysis found.
No revisions were performed for aseptic loosening. Average tibial
component alignment was 1.4° of varus (4°of valgus to 9° varus),
and 6.2° (3° anterior to 15° posterior) of posterior slope. Mean
femoral component alignment was 6.6° (1° to 11°) of valgus. Mean tibiofemoral
alignment was 5.6° of valgus (7° varus to 16° valgus). Patellar
tilt was a mean of 2.4° lateral (5° medial to 28° lateral). Patient
satisfaction with improvement in pain was 91%. Cementless TKR incorporating
porous tantalum yielded good clinical and radiological outcomes
at a mean of follow-up of seven-years. Cite this article:
Intact abductors of the hip play a crucial role
in preventing limping and are known to be damaged through the direct lateral
approach. The extent of trauma to the abductors after revision total
hip replacement (THR) is unknown. The aim of this prospective study
was to compare the pre- and post-operative status of the gluteus
medius muscle after revision THR. We prospectively compared changes
in the muscle and limping in 30 patients who were awaiting aseptic
revision THR and 15 patients undergoing primary THR. The direct
lateral approach as described by Hardinge was used for all patients.
MRI scans of the gluteus medius and functional analyses were recorded
pre-operatively and six months post-operatively. The overall mean
fatty degeneration of the gluteus medius increased from 35.8% (1.1
to 98.8) pre-operatively to 41% (1.5 to 99.8) after multiple revision
THRs (p = 0.03). There was a similar pattern after primary THR,
but with considerably less muscle damage (p = 0.001), indicating
progressive muscle damage. Despite an increased incidence of a positive
Trendelenburg sign following revision surgery (p = 0.03) there was
no relationship between the cumulative fatty degeneration in the
gluteus medius and a positive Trendelenburg sign (p = 0.26). The
changes associated with other surgical approaches to the hip warrant
investigation. Cite this article:
We report on the outcome of the Synergy cementless femoral stem
with a minimum follow-up of 15 years (15 to 17). A retrospective review was undertaken of a consecutive series
of 112 routine primary cementless total hip arthroplasties (THAs)
in 102 patients (112 hips). There were 60 female and 42 male patients
with a mean age of 61 years (18 to 82) at the time of surgery. A
total of 78 hips in the 69 patients remain Aims
Patients and Methods
We evaluated the short-term functional outcome and prevalence
of bearing-specific generation of audible noise in 301 patients
(336 hips) operated on with fourth generation (Delta) medium diameter
head, ceramic-on-ceramic (CoC) total hip arthroplasties (THAs). There were 191 female (63%) and 110 male patients (37%) with
a mean age of 61 years (29 to 78) and mean follow-up of 2.1 years
(1.3 to 3.4). Patients completed three questionnaires: Oxford Hip
Score (OHS), Research and Development 36-item health survey (RAND-36)
and a noise-specific symptom questionnaire. Plain radiographs were also
analysed. A total of three hips (0.9%) were revised. Aims
Patients and Methods
The strain on clinic and surgeon resources resulting
from a rise in demand for total knee replacement (TKR) requires reconsideration
of when and how often patients need to be seen for follow-up. Surgeons
will otherwise require increased paramedical staff or need to limit
the number of TKRs they undertake. We reviewed the outcome data
of 16 414 primary TKRs undertaken at our centre to determine the
time to re-operation for any reason and for specific failure mechanisms.
Peak risk years for failure were determined by comparing the conditional
probability of failure, the number of failures divided by the total
number of TKRs cases, for each year. The median times to failure
for the most common failure mechanisms were 4.9 years (interquartile
range (IQR) 1.7 to 10.7) for femoral and tibial loosening, 1.9 years
(IQR 0.8 to 3.9) for infection, 3.1 years (IQR 1.6 to 5.5) for tibial
collapse and 5.6 years (IQR 3.4 to 9.3) for instability. The median
time to failure for all revisions was 3.3 years (IQR 1.2 to 8.5),
with an overall revision rate of 1.7% (n = 282). Results from our
patient population suggest that patients be seen for follow-up at
six months, one year, three years, eight years, 12 years, and every
five years thereafter. Patients with higher pain in the early post-operative
period or high body mass index (≥ 41 kg/m2) should be
monitored more closely. Cite this article:
Patients from a randomised trial on resurfacing
hip arthroplasty (RHA) (n = 36, 19 males; median age 57 years, 24
to 65) comparing a conventional 28 mm metal-on-metal total hip arthroplasty
(MoM THA) (n = 28, 17 males; median age 59 years, 37 to 65) and
a matched control group of asymptomatic patients with a 32 mm ceramic-on-polyethylene
(CoP) THA (n = 33, 18 males; median age 63 years, 38 to 71) were
cross-sectionally screened with metal artefact reducing sequence-MRI
(MARS-MRI) for pseudotumour formation at a median of 55 months (23
to 72) post-operatively. MRIs were scored by consensus according
to three different classification systems for pseudotumour formation. Clinical scores were available for all patients and metal ion
levels for MoM bearing patients. Periprosthetic lesions with a median volume of 16 mL (1.5 to
35.9) were diagnosed in six patients in the RHA group (17%), one
in the MoM THA group (4%) and six in the CoP group (18%). The classification
systems revealed no clear differences between the groups. Solid
lesions (n = 3) were exclusively encountered in the RHA group. Two patients
in the RHA group and one in the MoM THA group underwent a revision
for pseudotumour formation. There was no statistically significant
relationship between clinical scoring, metal ion levels and periprosthetic
lesions in any of the groups. Periprosthetic fluid collections are seen on MARS-MRI after conventional
CoP THA and RHA and may reflect a soft-tissue collection or effusion. Currently available MRI classification systems seem to score
these collections as pseudotumours, causing an-overestimatation
of the incidence of pseudotumours. Cite this article:
There is no single standardised method of measuring
the orientation of the acetabular component on plain radiographs
after total hip arthroplasty. We assessed the reliability and accuracy
of three methods of assessing anteversion of the acetabular component
for 551 THAs using the PolyWare software and the methods of Liaw
et al, and of Woo and Morrey. All measurements of the three methods
had excellent intra- and inter-observer reliability. The values
of the PolyWare software, which determines version of the acetabular
component by edge detection were regarded as the reference standard.
Although the PolyWare software and the method of Liaw et al were similarly
precise, the method of Woo and Morrey was significantly less accurate
(p <
0.001). The method of Liaw et al seemed to be more accurate
than that of Woo and Morrey when compared with the measurements
using the PolyWare software. If the qualified lateral radiograph
was selected, anteversion measured using the method of Woo and Morrey
was considered to be relatively reliable. Cite this article:
Posterior tilt of the pelvis with sitting provides biological
acetabular opening. Our goal was to study the post-operative interaction
of skeletal mobility and sagittal acetabular component position. This was a radiographic study of 160 hips (151 patients) who
prospectively had lateral spinopelvic hip radiographs for skeletal
and implant measurements. Intra-operative acetabular component position
was determined according to the pre-operative spinal mobility. Sagittal
implant measurements of ante-inclination and sacral acetabular angle were
used as surrogate measurements for the risk of impingement, and
intra-operative acetabular component angles were compared with these.Aims
Materials and Methods
We report our experience of revision total hip
replacement (THR) using the Revitan curved modular titanium fluted revision
stem in patients with a full spectrum of proximal femoral defects.
A total of 112 patients (116 revisions) with a mean age of 73.4
years (39 to 90) were included in the study. The mean follow-up
was 7.5 years (5.3 to 9.1). A total of 12 patients (12 hips) died
but their data were included in the survival analysis, and four
patients (4 hips) were lost to follow-up. The clinical outcome,
proximal bone regeneration and subsidence were assessed for 101
hips. The mean Harris Hip Score was 88.2 (45.8 to 100) after five years
and there was an increase of the mean Barnett and Nordin-Score,
a measure of the proximal bone regeneration, of 20.8 (-3.1 to 52.7).
Five stems had to be revised (4.3%), three (2.9%) showed subsidence,
five (4.3%) a dislocation and two of 85 aseptic revisions (2.3%)
a periprosthetic infection. At the latest follow-up, the survival with revision of the stem
as the endpoint was 95.7% (95% confidence interval 91.9% to 99.4%)
and with aseptic loosening as the endpoint, was 100%. Peri-prosthetic
fractures were not observed. We report excellent results with respect to subsidence, the risk
of fracture, and loosening after femoral revision using a modular
curved revision stem with distal cone-in-cone fixation. A successful
outcome depends on careful pre-operative planning and the use of
a transfemoral approach when the anatomy is distorted or a fracture
is imminent, or residual cement or a partially-secured existing
stem cannot be removed. The shortest appropriate stem should, in
our opinion, be used and secured with >
3 cm fixation at the femoral
isthmus, and distal interlocking screws should be used for additional
stability when this goal cannot be realised. Cite this article:
Reconstruction of the acetabulum after failed total hip arthroplasty
(THA) can be a surgical challenge in the presence of severe bone
loss. We report the long-term survival of a porous tantalum revision
acetabular component, its radiological appearance and quality of
life outcomes. We reviewed the results of 46 patients who had undergone revision
of a failed acetabular component with a Paprosky II or III bone
defect and reconstruction with a hemispherical, tantalum acetabular
component, supplementary screws and a cemented polyethylene liner.Aims
Patients 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
