We report on 397 consecutive revision total hip replacements in 371 patients with a mean clinical and radiological follow-up of 12.9 years (10 to 17.7). The mean age at surgery was 69 years (37 to 93). A total of 28 patients (8%) underwent further revision, including 16 (4%) femoral components. In all 223 patients (56%, 233 hips) died without further revision and 20 patients (5%, 20 hips) were lost to follow-up. Of the remaining patients, 209 (221 hips) were available for clinical assessment and 194 (205 hips) for radiological review at mean follow-up of 12.9 years (10 to 17.7). The mean Harris Hip Score improved from 58.7 (11 to 92) points to 80.7 (21 to 100) (p <  0.001) and the mean Merle d’Aubigné and Postel hip scores at final follow-up were 4.9 (2 to 6), 4.5 (2 to 6) and 4.3 (2 to 6), respectively for pain, mobility and function. Radiographs showed no lucencies around 186 (90.7%) femoral stems with stable bony ingrowth seen in 199 stems (97%). The survival of the S-ROM femoral stem at 15 years with revision for any reason as the endpoint was 90.5% (95% confidence interval (CI) 85.7 to 93.8) and with revision for aseptic loosening as the endpoint 99.3% (95% CI 97.2 to 99.8). We have shown excellent long-term survivorship and good clinical outcome of a cementless hydroxyapatite proximally-coated modular femoral stem in revision hip surgery. Cite this article: Bone Joint J 2014;96-B:730–6

Little is known about the efficacy of graduated compression stockings in preventing venous thromboembolism after hip surgery. We conducted a prospective, randomised single-blind study to determine whether the addition of compression stockings to fondaparinux conferred any additional benefit. The study included 874 patients, of whom 795 could be evaluated (400 in the fondaparinux group and 395 in the fondaparinux plus compression stocking group). Fondaparinux was given post-operatively for five to nine days, either alone or combined with wearing stockings, which were worn for a mean 42 days (35 to 49). The study outcomes were venous thromboembolism, or sudden death before day 42. Duplex ultrasonography was scheduled within a week of day 42. Safety outcomes were bleeding and death from venous thromboembolism. The prevalence of deep-vein thrombosis was similar in the two groups 5.5% (22 of 400) in the fondaparinux group and 4.8 (19 of 395) in the fondaparinux plus stocking group (odds ratio 0.88, 95% confidence interval 0.46 to 1.65, p = 0.69). Major bleeding occurred in only one patient. The addition of graduated compression stockings to fondaparinux appears to offer no additional benefit over the use of fondaparinux alone

Over a 13-year period we studied all patients who underwent major hip and knee surgery and were diagnosed with objectively confirmed symptomatic venous thromboembolism, either deep venous thrombosis or non-fatal pulmonary embolism, within six months after surgery. Low-molecular-weight heparin had been given while the patients were in hospital. There were 5607 patients. The cumulative incidence of symptomatic venous thromboembolism was 2.7% (150 of 5607), of which 1.1% had developed pulmonary embolism, 1.5% had deep venous thrombosis and 0.6% had both. Patients presented with deep venous thrombosis at a median of 24 days and pulmonary embolism at 17 days after surgery for hip fracture. After total hip replacement, deep venous thrombosis and pulmonary embolism occurred at a median of 21 and 34 days respectively. After total knee replacement, the median time to the presentation of deep venous thrombosis and pulmonary embolism was 20 and 12 days respectively. The cumulative risk of venous thromboembolism lasted for up to three months after hip surgery and for one month after total knee replacement. Venous thromboembolism was diagnosed after discharge from hospital in 70% of patients who developed this complication. Despite hospital-based thromboprophylaxis, most cases of clinical venous thromboembolism occur after discharge and at different times according to the operation performed

Revision after failed femoral components may be technically demanding due to loss of peri-prosthetic bone. This retrospective study evaluated the long-term results of femoral revision using the cementless Wagner Self-Locking stem. Between 1992 and 1998, 68 consecutive hips in 66 patients underwent femoral revision using this implant. A total of 25 patients died from unrelated causes without further revision; the remaining 41 hips in 41 patients (12 men and 29 women) with a mean age of 61 years (29 to 80) were reviewed at a mean follow-up of 13.9 years (10.4 to 15.8). A transfemoral approach was used in 32 hips. A total of five stems required further revision because of infection in two, progressive subsidence in two and recurrent dislocation in one. Four hips had dislocated and eight stems had subsided ≥ 10 mm. The mean Harris hip score improved from 33 points pre-operatively to 75 points at final follow-up (p < 0.001). In all, 33 stems (91.7%) showed radiological signs of stable bone fixation. The cumulative survival rates at 15.8 years with femoral revision for any reason and for stem failure as the endpoints were 92.0% (95% confidence interval (CI) 86.0% to 98.4%) and 96.6% (95% CI 92.2% to 100%), respectively. The survivorship with revision and ≥ 10 mm migration of the stem as the endpoint was 83.6% (95% CI 76.6% to 91.4%). This study shows quite good survival and moderate clinical outcome when using a monoblock tapered titanium stem for supporting the regeneration of bone in complex revision hip surgery.

The results of hip and knee replacement surgery are generally regarded as positive for patients. Nonetheless, they are both major operations and have recognised complications. We present a review of relevant claims made to the National Health Service Litigation Authority. Between 1995 and 2010 there were 1004 claims to a value of £41.5 million following hip replacement surgery and 523 claims to a value of £21 million for knee replacement. The most common complaint after hip surgery was related to residual neurological deficit, whereas after knee replacement it was related to infection. Vascular complications resulted in the highest costs per case in each group. Although there has been a large increase in the number of operations performed, there has not been a corresponding relative increase in litigation. The reasons for litigation have remained largely unchanged over time after hip replacement. In the case of knee replacement, although there has been a reduction in claims for infection, there has been an increase in claims for technical errors. There has also been a rise in claims for non-specified dissatisfaction. This information is of value to surgeons and can be used to minimise the potential mismatch between patient expectation, informed consent and outcome. Cite this article: Bone Joint J 2013;95-B:122–6

Aims

Patients may present with concurrent symptomatic osteoarthritis (OA) of the hip and degenerative disorders of the lumbar spine, with surgical treatment being indicated for both. Whether arthroplasty of the hip or spinal surgery should be performed first remains uncertain.

Over an eight-month period we prospectively enrolled 122 patients who underwent arthroscopic surgery of the hip for femoroacetabular impingement and met the inclusion criteria for this study. Patients with bilateral hip arthroscopy, avascular necrosis and previous hip surgery were excluded. Ten patients refused to participate leaving 112 in the study. There were 62 women and 50 men. The mean age of the patients was 40.6 yrs (95% confidence interval (CI) 37.7 to 43.5). At arthroscopy, 23 patients underwent osteoplasty only for cam impingement, three underwent rim trimming only for pincer impingement, and 86 underwent both procedures for mixed-type impingement. The mean follow-up was 2.3 years (2.0 to 2.9). The mean modified Harris hip score (HHS) improved from 58 to 84 (mean difference = 24 (95% CI 19 to 28)) and the median patient satisfaction was 9 (1 to 10). Ten patients underwent total hip replacement at a mean of 16 months (8 to 26) after arthroscopy. The predictors of a better outcome were the pre-operative modified HHS (p = 0.018), joint space narrowing ≥ 2 mm (p = 0.005), and repair of labral pathology instead of debridement (p = 0.032). Hip arthroscopy for femoroacetabular impingement, accompanied by suitable rehabilitation, gives a good short-term outcome and high patient satisfaction

Objectives

Prosthetic joint infection (PJI) is the most common cause of arthroplasty failure. However, infection is often difficult to detect by conventional bacterial cultures, for which false-negative rates are 23% to 35%. In contrast, 16S rRNA metagenomics has been shown to quantitatively detect unculturable, unsuspected, and unviable pathogens. In this study, we investigated the use of 16S rRNA metagenomics for detection of bacterial pathogens in synovial fluid (SF) from patients with hip or knee PJI.

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

Objectives

Previous studies have evidenced cement-in-cement techniques as reliable in revision arthroplasty. Commonly, the original cement mantle is reshaped, aiding accurate placement of the new stem. Ultrasonic devices selectively remove cement, preserve host bone, and have lower cortical perforation rates than other techniques. As far as the authors are aware, the impact of ultrasonic devices on final cement-in-cement bonds has not been investigated. This study assessed the impact of cement removal using the Orthosonics System for Cemented Arthroplasty Revision (OSCAR; Orthosonics) on final cement-in-cement bonds.

The April 2014 Trauma Roundup. 360 . looks at: is it safe to primarily close dog bite wounds?; conservative transfusion evidence based in hip fracture surgery; tibial nonunion is devastating to quality of life; sexual dysfunction after traumatic pelvic fracture; hemiarthroplasty versus fixation in displaced femoral neck fractures; silver VAC dressings “Gold Standard” in massive wounds; dual plating for talar neck fracture; syndesmosis and fibular length easiest errors in ankle fracture surgery; and dual mobility: stable as a rock in fracture

This study investigates the use of porous biphasic ceramics as graft extenders in impaction grafting of the femur during revision hip surgery. Impaction grafting of the femur was performed in four groups of sheep. Group one received pure allograft, group two 50% allograft and 50% BoneSave, group three 50% allograft and 50% BoneSave type 2 and group four 10% allograft and 90% BoneSave as the graft material. Function was assessed using an index of pre- and post-operative peak vertical ground reaction force ratios. Changes in bone mineral density were measured by dual energy X ray absorptiometry (DEXA) scanning. Loosening and subsidence were assessed radiographically and by histological examination of the explanted specimens. There was no statistically significant difference between the four groups after 18 months of unrestricted functional loading for all outcome measures

We carried out a morphometric analysis of acetabular dysplasia in patients with cerebral palsy requiring hip surgery using three-dimensional CT. We evaluated 54 hips in 27 patients. The contralateral normal hips of ten patients with unilateral Perthes’ disease were used as a control group. The acetabular defects were assessed qualitatively as anterior, posterior or global. Quantitative assessments were made using three-directional acetabular indices (anterosuperior, superolateral and posterosuperior) and measured by multiplanar reformation, from which we calculated the acetabular volume. In the qualitative study, posterior defects were most common in the subluxation group whereas global defects predominated in the dislocation group. In the quantitative study, all acetabular indices in both the subluxation and dislocation groups were higher than those in the control group and the superolateral indices showed a tendency to elevation in the dislocation group. The acetabular volume was largest in the control group, smallest in the dislocation group, and intermediate between the two in the subluxation group

Aims

Cardiac magnetic resonance (CMR) was used to assess whether cardiac function or tissue composition was affected in patients with well-functioning metal-on-metal hip resurfacing arthroplasties (MoMHRA) when compared with a group of controls, and to assess if metal ion levels correlated with any of the functional or structural parameters studied.