The October 2013 Knee Roundup³⁶⁰ looks at: Make it easy, release the MCL; Do patients remember clinical information in day surgery?; Osteoarthritis and arthroscopy?; How best to double your bundles; When to operate for infection; Cementless unicompartment knee replacement?; Tibial tubercle-trochlear groove confusion; Tarts, cherries and osteoarthritis

The August 2013 Hip & Pelvis Roundup³⁶⁰ looks at: are we getting it right first time?; tantalum augments in revision hip surgery; lower wear in dual mobility?; changing faces changes outcomes; synovial fluid aspiration in MOM hips; taper disease: the new epidemic of hip surgery; the super-obese and THR; and whether well fixed stems can remain in infected hips

The outcome after total hip replacement has improved with the development of surgical techniques, better pain management and the introduction of enhanced recovery pathways. These pathways require a multidisciplinary team to manage pre-operative education, multimodal pain control and accelerated rehabilitation. The current economic climate and restricted budgets favour brief hospitalisation while minimising costs. This has put considerable pressure on hospitals to combine excellent results, early functional recovery and shorter admissions.

In this review we present an evidence-based summary of some common interventions and methods, including pre-operative patient education, pre-emptive analgesia, local infiltration analgesia, pre-operative nutrition, the use of pulsed electromagnetic fields, peri-operative rehabilitation, wound dressings, different surgical techniques, minimally invasive surgery and fast-track joint replacement units.

Cite this article: Bone Joint J 2013;95-B:1587–94.

Despite the increasing interest and subsequent published literature on hip resurfacing arthroplasty, little is known about the prevalence of its complications and in particular the less common modes of failure. The aim of this study was to identify the prevalence of failure of hip resurfacing arthroplasty and to analyse the reasons for it.

From a multi-surgeon series (141 surgeons) of 5000 Birmingham hip resurfacings we have analysed the modes, prevalence, gender differences and times to failure of any hip requiring revision. To date 182 hips have been revised (3.6%). The most common cause for revision was a fracture of the neck of the femur (54 hips, prevalence 1.1%), followed by loosening of the acetabular component (32 hips, 0.6%), collapse of the femoral head/avascular necrosis (30 hips, 0.6%), loosening of the femoral component (19 hips, 0.4%), infection (17 hips, 0.3%), pain with aseptic lymphocytic vascular and associated lesions (ALVAL)/metallosis (15 hips, 0.3%), loosening of both components (five hips, 0.1%), dislocation (five hips, 0.1%) and malposition of the acetabular component (three hips, 0.1%). In two cases the cause of failure was unknown.

Comparing men with women, we found the prevalence of revision to be significantly higher in women (women = 5.7%; men = 2.6%, p < 0.001). When analysing the individual modes of failure women had significantly more revisions for loosening of the acetabular component, dislocation, infection and pain/ALVAL/metallosis (p < 0.001, p = 0.004, p = 0.008, p = 0.01 respectively).

The mean time to failure was 2.9 years (0.003 to 11.0) for all causes, with revision for fracture of the neck of the femur occurring earlier than other causes (mean 1.5 years, 0.02 to 11.0). There was a significantly shorter time to failure in men (mean 2.1 years, 0.4 to 8.7) compared with women (mean 3.6 years, 0.003 to 11.0) (p < 0.001).

Despite the worldwide usage of the cemented Contemporary acetabular component (Stryker), no published data are available regarding its use in patients aged < 50 years. We undertook a mid- to long-term follow-up study, including all consecutive patients aged < 50 years who underwent a primary total hip replacement using the Contemporary acetabular component with the Exeter cemented stem between January 1999 and January 2006. There were 152 hips in 126 patients, 61 men and 65 women, mean age at surgery 37.6 years (16 to 49 yrs). One patient was lost to follow-up.

Mean clinical follow-up of all implants was 7.6 years (0.9 to 12.0). All clinical questionnaire scores, including Harris hip score, Oxford hip score and several visual analogue scales, were found to have improved. The eight year survivorship of all acetabular components for the endpoints revision for any reason or revision for aseptic loosening was 94.4% (95% confidence interval (CI) 89.2 to 97.2) and 96.4% (95% CI 91.6 to 98.5), respectively. Radiological follow-up was complete for 146 implants. The eight year survival for the endpoint radiological loosening was 93.1% (95% CI 86.2 to 96.6). Three surviving implants were considered radiologically loose but were asymptomatic. The presence of acetabular osteolysis (n = 17, 11.8%) and radiolucent lines (n = 20, 13.9%) in the 144 surviving cups indicates a need for continued observation in the second decade of follow-up in order to observe their influence on long-term survival.

The clinical and radiological data resulting in a ten-year survival rate > 90% in young patients support the use of the Contemporary acetabular component in this specific patient group.

Cite this article: Bone Joint J 2013;95-B:1617–25.

This study compared the demographic, clinical and patient-reported outcomes after total hip replacement (THR) and Birmingham Hip Resurfacing (BHR) carried out by a single surgeon. Patients completed a questionnaire that included the WOMAC, SF-36 scores and comorbid medical conditions. Data were collected before operation and one year after. The outcome scores were adjusted for age, gender, comorbid conditions and, at one year, for the pre-operative scores. There were 214 patients with a THR and 132 with a BHR. Patients with a BHR were significantly younger (49 vs 67 years, p < 0.0001), more likely to be male (68% vs 42% of THR, p < 0.0001) and had fewer comorbid conditions (1.3 vs 2.0, p < 0.0001). Before operation there was no difference in WOMAC and SF-36 scores, except for function, in which patients awaiting THR were worse than those awaiting a BHR.

At one year patients with a BHR reported significantly better WOMAC pain scores (p = 0.04) and in all SF-36 domains (p < 0.05). Patients undergoing BHR report a significantly greater improvement in general health compared with those with a THR.

Increased femoral head size may reduce dislocation rates following total hip replacement. The National Joint Registry for England and Wales has highlighted a statistically significant increase in the use of femoral heads ≥ 36 mm in diameter from 5% in 2005 to 26% in 2009, together with an increase in the use of the posterior approach. The aim of this study was to determine whether rates of dislocation have fallen over the same period. National data for England for 247 546 procedures were analysed in order to determine trends in the rate of dislocation at three, six, 12 and 18 months after operation during this time. The 18-month revision rates were also examined.

Between 2005 and 2009 there were significant decreases in cumulative dislocations at three months (1.12% to 0.86%), six months (1.25% to 0.96%) and 12 months (1.42% to 1.11%) (all p < 0.001), and at 18 months (1.56% to 1.31%) for the period 2005 to 2008 (p < 0.001). The 18-month revision rates did not significantly change during the study period (1.26% to 1.39%, odds ratio 1.10 (95% confidence interval 0.98 to 1.24), p = 0.118). There was no evidence of changes in the coding of dislocations during this time.

These data have revealed a significant reduction in dislocations associated with the use of large femoral head sizes, with no change in the 18-month revision rate.

In May 2012, in airports across the globe, seven orthopaedic surgeons bravely said goodbye to their loved ones, and slowly turned towards their respective aircraft. Filled with expectation and mild trepidation they stepped into the unknown… the ABC fellowship of 2012.

As many as 25% to 40% of unicompartmental knee replacement (UKR) revisions are performed for pain, a possible cause of which is proximal tibial strain. The aim of this study was to examine the effect of UKR implant design and material on cortical and cancellous proximal tibial strain in a synthetic bone model. Composite Sawbone tibiae were implanted with cemented UKR components of different designs, either all-polyethylene or metal-backed. The tibiae were subsequently loaded in 500 N increments to 2500 N, unloading between increments. Cortical surface strain was measured using a digital image correlation technique. Cancellous damage was measured using acoustic emission, an engineering technique that detects sonic waves (‘hits’) produced when damage occurs in material.

Anteromedial cortical surface strain showed significant differences between implants at 1500 N and 2500 N in the proximal 10 mm only (p < 0.001), with relative strain shielding in metal-backed implants. Acoustic emission showed significant differences in cancellous bone damage between implants at all loads (p = 0.001). All-polyethylene implants displayed 16.6 times the total number of cumulative acoustic emission hits as controls. All-polyethylene implants also displayed more hits than controls at all loads (p < 0.001), more than metal-backed implants at loads ≥ 1500 N (p < 0.001), and greater acoustic emission activity on unloading than controls (p = 0.01), reflecting a lack of implant stiffness. All-polyethylene implants were associated with a significant increase in damage at the microscopic level compared with metal-backed implants, even at low loads. All-polyethylene implants should be used with caution in patients who are likely to impose large loads across their knee joint.

Cite this article: Bone Joint J 2013;95-B:1339–47.

Recently the National Patient Safety Agency in the United Kingdom published a report entitled “Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur”. A total of 26 deaths had been reported to them when cement was used at hemiarthroplasty between October 2003 and October 2008. This paper considers the evidence for using cement fixation of a hemiarthroplasty in the treatment of hip fractures.

We present the extended follow-up (≥ 20 years) of a series of fully hydroxyapatite-coated femoral components used in 72 primary total hip replacements (THRs). Earlier results of this cohort have been previously published. All procedures were performed between 1986 and 1991. The series involved 45 women and 15 men with 12 bilateral procedures. Their mean age at the time of surgery was 60 years (46 to 80) and the mean duration of follow-up was 22.5 years (20 to 25). At final follow-up, the mean Merle d’Aubigné and Postel hip scores were 5.5 (4.5 to 6), 3.8 (3.5 to 5) and 3.3 (3.0 to 5.0) for pain, mobility and function, respectively. Of the patients 92% were very satisfied at the time of final follow-up.

There were seven revisions: six of the acetabular component for aseptic loosening and one of both the stem and the acetabular component for loosening due to deep infection. The survival of this prosthesis at 22.5 years with revision for any reason as the endpoint was 91.7% (95% confidence interval (CI) 84 to 99). Survival with aseptic loosening of the stem as the endpoint was 100% (95% CI 90 to 100).

This prosthesis provides pain relief in the long term. Survival of this component is comparable to the best results for primary THR with any means of fixation.

Cite this article: Bone Joint J 2013;95-B:467–71.

We report the follow-up at 12 years of the use of the Elite Plus total hip replacement (THR). We have previously reported the results at a mean of 6.4 years. Of the 217 patients (234 THRs), 83 had died and nine had been lost to follow-up. The patients were reviewed radiologically and clinically using the Oxford hip score.

Of the 234 THRs, 19 (8.1%) had required a revision by the final follow-up in all but one for aseptic loosening. Survivorship analysis for revision showed a survival of 93.9% (95% confidence interval (CI) 89.2 to 96.5) at ten years, and of 88.0% (95% CI 81.8 to 92.3) at 12 years. At the final follow-up survival analysis showed that 37% (95% CI 37.3 to 44.7) of the prostheses had either failed radiologically or had been revised. Patients with a radiologically loose femoral component had a significantly poorer Oxford hip score than those with a well-fixed component (p = 0.03). Radiological loosening at 6.4 years was predictive of failure at 12 years.

Medium-term radiographs and clinical scores should be included in the surveillance of THR to give an early indication of the performance of specific implants.

We evaluated the impact of pre-coating the tibial component with polymethylmethacrylate (PMMA) on implant survival in a cohort of 16 548 primary NexGen total knee replacements (TKRs) in 14 113 patients. In 13 835 TKRs a pre-coated tray was used while in 2713 TKRs the non-pre-coated version of the same tray was used. All the TKRs were performed between 2001 and 2009 and were cemented. TKRs implanted with a pre-coated tibial component had a lower cumulative survival than those with a non-pre-coated tibial component (p = 0.01). After adjusting for diagnosis, age, gender, body mass index, American Society of Anesthesiologists grade, femoral coupling design, surgeon volume and hospital volume, pre-coating was an independent risk factor for all-cause aseptic revision (hazard ratio 2.75, p = 0.006). Revision for aseptic loosening was uncommon for both pre-coated and non-pre-coated trays (rates of 0.12% and 0%, respectively). Pre-coating with PMMA does not appear to be protective of revision for this tibial tray design at short-term follow-up.

Cite this article: Bone Joint J 2013;95-B:367–70.

There has been a recent increase in interest for non-cemented fixation in total knee arthroplasty (TKA), however the superiority of cement fixation is an ongoing debate.

Whereas the results based on Level III and IV evidence show similar survivorship rates between the two types of fixation, Level I and II evidence strongly support cemented fixation. United Kingdom, Australia, Sweden, and New Zealand registry data show lower failure rates and greater usage of cemented than non-cemented fixation. Case series studies have also indicated greater functional outcomes and lower revision rates among cemented TKAs. Non-cemented fixation involves more patellofemoral complications, including increased susceptibility to wear due to a thinner polyethylene bearing on the cementless metal-backed component. The combination of results from registry data, prospective randomised studies, and meta-analyses support the current superiority of cemented fixation in TKAs.

We reviewed the results at nine to 13 years of 125 total hip replacements in 113 patients using the monoblock uncemented Morscher press-fit acetabular component. The mean age at the time of operation was 56.9 years (36 to 74). The mean clinical follow-up was 11 years (9.7 to 13.5) and the mean radiological follow-up was 9.4 years (7.7 to 13.1). Three hips were revised, one immediately for instability, one for excessive wear and one for deep infection.

No revisions were required for aseptic loosening. A total of eight hips (7.0%) had osteolytic lesions greater than 1 cm, in four around the acetabular component (3.5%). One required bone grafting behind a well-fixed implant. The mean wear rate was 0.11 mm/year (0.06 to 0.78) and was significantly higher in components with a steeper abduction angle.

Kaplan-Meier survival curves at 13 years showed survival of 96.8% (95% confidence interval 90.2 to 99.0) for revision for any cause and of 95.7% (95% confidence interval 88.6 to 98.4) for any acetabular re-operation.

Smart trials are total knee tibial trial liners with load bearing and alignment sensors that will graphically show quantitative compartment load-bearing forces and component track patterns. These values will demonstrate asymmetrical ligament balancing and misalignments with the medial retinaculum temporarily closed. Currently surgeons use feel and visual estimation of imbalance to assess soft-tissue balancing and tracking with the medial retinaculum open, which results in lower medial compartment loads and a wider anteroposterior tibial tracking pattern. The sensor trial will aid the total knee replacement surgeon in performing soft-tissue balancing by providing quantitative visual feedback of changes in forces while performing the releases incrementally. Initial experience using a smart tibial trial is presented.

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.