The purpose of this study was to determine patient-reported
outcomes of patients with mild to moderate developmental dysplasia
of the hip (DDH) and femoroacetabular impingement (FAI) undergoing
arthroscopy of the hip in the treatment of chondrolabral pathology.
A total of 28 patients with a centre-edge angle between 15° and
19° were identified from an institutional database. Their mean age
was 34 years (18 to 53), with 12 female and 16 male patients. All
underwent labral treatment and concomitant correction of FAI. There
were nine reoperations, with two patients requiring revision arthroscopy,
two requiring periacetabular osteotomy and five needing total hip arthroplasty. Patients who required further major surgery were more likely
to be older, male, and to have more severe DDH with a larger alpha
angle and decreased joint space. At a mean follow-up of 42 months (24 to 89), the mean modified
Harris hip score improved from 59 (20 to 98) to 82 (45 to 100; p
<
0.001). The mean Western Ontario and McMaster Universities
Osteoarthritis Index score improved from 30 (1 to 61) to 16 (0 to
43; p <
0.001). Median patient satisfaction was 9.0/10 (1 to
10). Patients reported excellent improvement in function following
arthroscopy of the hip. This study shows that with proper patient selection, arthroscopy
of the hip can be successful in the young patient with mild to moderate
DDH and FAI. Cite this article:
We present the results of 62 consecutive acetabular
revisions using impaction bone grafting and a cemented polyethylene
acetabular component in 58 patients (13 men and 45 women) after
a mean follow-up of 27 years (25 to 30). All patients were prospectively
followed. The mean age at revision was 59.2 years (23 to 82). We performed Kaplan–Meier (KM) analysis and also a Competing
Risk (CR) analysis because with long-term follow-up, the presence
of a competing event (i.e. death) prevents the occurrence of the
endpoint of re-revision. A total of 48 patients (52 hips) had died or had been re-revised
at final review in March 2011. None of the deaths were related to
the surgery. The mean Harris hip score of the ten surviving hips
in ten patients was 76 points (45 to 99). The KM survivorship at 25 years for the endpoint ‘re-revision
for any reason’ was 58.0% (95% confidence interval (CI) 38 to 73)
and for ‘re-revision for aseptic loosening’ 72.1% (95% CI 51 to
85). With the CR analysis we calculated the KM analysis overestimates
the failure rate with respectively 74% and 93% for these endpoints.
The current study shows that acetabular impaction bone grafting
revisions provide good clinical results at over 25 years. Cite this article:
The early failure and revision of bimodular primary
total hip arthroplasty prostheses requires the identification of the
risk factors for material loss and wear at the taper junctions through
taper wear analysis. Deviations in taper geometries between revised
and pristine modular neck tapers were determined using high resolution
tactile measurements. A new algorithm was developed and validated
to allow the quantitative analysis of material loss, complementing
the standard visual inspection currently used. The algorithm was applied to a sample of 27 retrievals ( Cite this article:
We report patient-reported outcomes and complications
associated with contemporary periacetabular osteotomy (PAO) surgery
in treating symptomatic acetabular dysplasia and compare these outcomes
with total hip arthroplasty (THA) in patients with similar demographic
details. Two consecutive cohorts included patients between aged
18 to 40 years who had undergone either PAO (100 hips; 24 male,
76 female) or THA (55 hips; 18 male, 37 female). At a mean follow-up
of 5.9 years (2 to 13), there was significant improvement in the
modified Harris hip pain (p <
0.001, PAO and p <
0.001, THA),
function (p <
0.001, PAO and p = 0.001, THA), and total scores
(p <
0.001, PAO and p <
0.001, THA) within each cohort. There
were no significant differences in the clinical outcome scores between
the groups. Complication rates were low and similar in each cohort
(p = 0.68). Similar to THA, contemporary PAO surgery is a clinically
effective procedure that improves function and activity levels,
provides pain relief and is associated with an acceptable complication
rate. Cite this article:
We investigated the changes seen on serial metal
artefact reduction magnetic resonance imaging scans (MARS-MRI) of
metal-on-metal total hip arthroplasties (MoM THAs). In total 155
THAs, in 35 male and 100 female patients (mean age 70.4 years, 42
to 91), underwent at least two MRI scans at a mean interval of 14.6
months (2.6 to 57.1), at a mean of 48.2 months (3.5 to 93.3) after
primary hip surgery. Scans were graded using a modification of the
Oxford classification. Progression of disease was defined as an
increase in grade or a minimum 10% increase in fluid lesion volume
at second scan. A total of 16 hips (30%) initially classified as
‘normal’ developed an abnormality on the second scan. Of those with
‘isolated trochanteric fluid’ 9 (47%) underwent disease progression,
as did 7 (58%) of ‘effusions’. A total of 54 (77%) of hips initially
classified as showing adverse reactions to metal debris (ARMD) progressed,
with higher rates of progression in higher grades. Disease progression
was associated with high blood cobalt levels or an irregular pseudocapsule
lining at the initial scan. There was no association with changes
in functional scores. Adverse reactions to metal debris in MoM THAs
may not be as benign as previous reports have suggested. Close radiological
follow-up is recommended, particularly in high-risk groups. Cite this article:
Sciatic nerve palsy following total hip arthroplasty
(THA) is a relatively rare yet potentially devastating complication.
The purpose of this case series was to report the results of patients
with a sciatic nerve palsy who presented between 2000 and 2010,
following primary and revision THA and were treated with neurolysis.
A retrospective review was made of 12 patients (eight women and
four men), with sciatic nerve palsy following THA. The mean age
of the patients was 62.7 years (50 to 72; standard deviation 6.9).
They underwent interfascicular neurolysis for sciatic nerve palsy,
after failing a trial of non-operative treatment for a minimum of
six months. Following surgery, a statistically and clinically significant
improvement in motor function was seen in all patients. The mean
peroneal nerve score function improved from 0.42 (0 to 3) to 3 (1
to 5) (p <
0.001). The mean tibial nerve motor function score
improved from 1.75 (1 to 4) to 3.92 (3 to 5) (p = 0.02).The mean
improvement in sensory function was a clinically negligible 1 out
of 5 in all patients. In total, 11 patients reported improvement
in their pain following surgery. We conclude that neurolysis of the sciatic nerve has a favourable
prognosis in patients with a sciatic nerve palsy following THA.
Our findings suggest that surgery should not be delayed for >
12
months following injury. Cite this article:
There is an increased risk of fracture following
osteoplasty of the femoral neck for cam-type femoroacetabular impingement
(FAI). Resection of up to 30% of the anterolateral head–neck junction
has previously been considered to be safe, however, iatrogenic fractures
have been reported with resections within these limits. We re-evaluated
the amount of safe resection at the anterolateral femoral head–neck
junction using a biomechanically consistent model. In total, 28 composite bones were studied in four groups: control,
10% resection, 20% resection and 30% resection. An axial load was
applied to the adducted and flexed femur. Peak load, deflection
at time of fracture and energy to fracture were assessed using comparison
groups. There was a marked difference in the mean peak load to fracture
between the control group and the 10% resection group (p <
0.001).
The control group also tolerated significantly more deflection before
failure (p <
0.04). The mean peak load (p = 0.172), deflection
(p = 0.547), and energy to fracture (p = 0.306) did not differ significantly between
the 10%, 20%, and 30% resection groups. Any resection of the anterolateral quadrant of the femoral head–neck
junction for FAI significantly reduces the load-bearing capacity
of the proximal femur. After initial resection of cortical bone,
there is no further relevant loss of stability regardless of the
amount of trabecular bone resected. Based on our findings we recommend any patients who undergo anterolateral
femoral head–neck junction osteoplasty should be advised to modify
their post-operative routine until cortical remodelling occurs to
minimise the subsequent fracture risk. Cite this article:
A number of studies have reported satisfactory
results from the isolated revision of an acetabular component. However,
many of these studies reported only the short- to intermediate-term
results of heterogeneous bearing surfaces in a mixed age group. We present our experience of using a ceramic-on-ceramic (CoC)
bearing for isolated revision of an uncemented acetabular component
in 166 patients (187 hips) who were under the age of 50 years at
the time of revision. There were 78 men and 88 women with a mean
age of 47.4 years (28 to 49). The most common reason for revision
was polyethylene wear and acetabular osteolysis in 123 hips (66%),
followed by aseptic loosening in 49 hips (26%). We report the clinical and radiological outcome, complication
rate, and survivorship of this group. The mean duration of follow-up
was 15.6 years (11 to 19). The mean pre-operative Harris hip score was 33 points (1 to 58),
and improved to a mean of 88 points (51 to 100) at follow-up. The
mean pre-operative total Western Ontario and McMaster Universities
Osteoarthritis Index score was 63.2 (43 to 91) and improved to 19.8
points (9 to 61) post-operatively. Overall, 153 of 166 patients
(92%) were satisfied with their outcome. Kaplan–Meier survivorship
analysis, with revision or radiological evidence of implant failure
(13 patients, 8%) as end-points, was 92% at 15 years (95% confidence
interval 0.89 to 0.97). Isolated revision of a cementless acetabular component using
a CoC bearing gives good results in patients under 50 years of age. Cite this article:
The long term biological effects of wear products
following total hip arthroplasty (THA) are unclear. However, the indications
for THA are expanding, with increasingly younger patients undergoing
the procedure. This prospective, randomised study compared two groups of patients
undergoing THA after being randomised to receive one of two different
bearing surfaces: metal-on-polyethylene (MoP) n = 22 and metal-on-metal
(MoM) n = 23. We investigated the relationship between three variables:
bearing surface (MoP Our results demonstrated significantly higher mean cobalt and
chromium (Co and Cr) blood levels in the MoM group at all follow-up
points following surgery (p <
0.01), but there were no significant
differences in the chromosomal aberration indices between MoM and
MoP at two or five years (two years: p = 0.56, p = 0.08, p = 0.91, p
= 0.51 and five years: p = 0.086, p = 0.73, p = 0.06, p = 0.34)
for translocations, breaks, loss and gain of chromosomes respectively.
Regression analysis showed a strong linear relationship between
Cr levels and the total chromosomal aberration indices in the MoM
group (R2 = 0.90016), but this was not as strong for
Co (R2 = 0.68991). In the MoP group, the analysis revealed
a poor relationship between Cr levels and the total chromosomal
aberration indices (R2 = 0.23908) but a slightly stronger
relationship for Co (R2 = 0.64292). Across both groups,
Spearman’s correlation detected no overall association between Co and Cr
levels and each of the studied chromosomal aberrations. There remains
no clear indication which THA bearing couple is the most biocompatible,
especially in young active patients. While THA continues to be very
successful at alleviating pain and restoring function, the long-term
biological implications of the procedure still require further scrutiny. 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:
When fracture of an extensively porous-coated
femoral component occurs, its removal at revision total hip arthroplasty
(THA) may require a femoral osteotomy and the use of a trephine.
The remaining cortical bone after using the trephine may develop
thermally induced necrosis. A retrospective review identified 11
fractured, well-fixed, uncemented, extensively porous-coated femoral
components requiring removal using a trephine with a minimum of
two years of follow-up. The mean time to failure was 4.6 years (1.7 to 9.1, standard
deviation ( A total of four patients (36.4%) required further revision: three
for instability and one for fracture of the revision component.
There was no statistically significant difference in the mean Harris
hip score before implant fracture (82.4; These findings suggest that removal of a fractured, well-fixed,
uncemented, extensively porous-coated femoral component using a
trephine does not compromise subsequent fixation at revision THA
and the patient’s pre-operative level of function can be restored.
However, the loss of proximal bone stock before revision may be associated
with a high rate of dislocation post-operatively. Cite this article:
This study investigates and defines the topographic
anatomy of the medial femoral circumflex artery (MFCA) terminal
branches supplying the femoral head (FH). Gross dissection of 14
fresh–frozen cadaveric hips was undertaken to determine the extra
and intracapsular course of the MFCA’s terminal branches. A constant
branch arising from the transverse MFCA (inferior retinacular artery;
IRA) penetrates the capsule at the level of the anteroinferior neck,
then courses obliquely within the fibrous prolongation of the capsule
wall (inferior retinacula of Weitbrecht), elevated from the neck,
to the posteroinferior femoral head–neck junction. This vessel has
a mean of five (three to nine) terminal branches, of which the majority
penetrate posteriorly. Branches from the ascending MFCA entered
the femoral capsular attachment posteriorly, running deep to the
synovium, through the neck, and terminating in two branches. The
deep MFCA penetrates the posterosuperior femoral capsular. Once
intracapsular, it divides into a mean of six (four to nine) terminal
branches running deep to the synovium, within the superior retinacula
of Weitbrecht of which 80% are posterior. Our study defines the
exact anatomical location of the vessels, arising from the MFCA
and supplying the FH. The IRA is in an elevated position from the
femoral neck and may be protected from injury during fracture of
the femoral neck. We present vascular ‘danger zones’ that may help
avoid iatrogenic vascular injury during surgical interventions about
the hip. Cite this article:
Periprosthetic femoral fracture (PFF) is a potentially
devastating complication after total hip arthroplasty, with historically
high rates of complication and failure because of the technical
challenges of surgery, as well as the prevalence of advanced age
and comorbidity in the patients at risk. This study describes the short-term outcome after revision arthroplasty
using a modular, titanium, tapered, conical stem for PFF in a series
of 38 fractures in 37 patients. The mean age of the cohort was 77 years (47 to 96). A total of
27 patients had an American Society of Anesthesiologists grade of
at least 3. At a mean follow-up of 35 months (4 to 66) the mean
Oxford Hip Score (OHS) was 35 (15 to 48) and comorbidity was significantly
associated with a poorer OHS. All fractures united and no stem needed
to be revised. Three hips in three patients required further surgery
for infection, recurrent PFF and recurrent dislocation and three
other patients required closed manipulation for a single dislocation.
One stem subsided more than 5 mm but then stabilised and required
no further intervention. In this series, a modular, tapered, conical stem provided a versatile
reconstruction solution with a low rate of complications. Cite this article:
This study reports the clinical outcome of reconstruction
of deficient abductor muscles following revision total hip arthroplasty
(THA), using a fresh–frozen allograft of the extensor mechanism
of the knee. A retrospective analysis was conducted of 11 consecutive
patients with a severe limp because of abductor deficiency which
was confirmed on MRI scans. The mean age of the patients (three
men and eight women) was 66.7 years (52 to 84), with a mean follow-up
of 33 months (24 to 41). Following surgery, two patients had no limp, seven had a mild
limp, and two had a persistent severe limp (p = 0.004). The mean
power of the abductors improved on the Medical Research Council
scale from 2.15 to 3.8 (p <
0.001). Pre-operatively, all patients
required a stick or walking frame; post-operatively, four patients
were able to walk without an aid. Overall, nine patients had severe
or moderate pain pre-operatively; ten patients had no or mild pain
post-operatively. At final review, the Harris hip score was good in five patients,
fair in two and poor in four. We conclude that using an extensor mechanism allograft is relatively
effective in the treatment of chronic abductor deficiency of the
hip after THA when techniques such as local tissue transfer are
not possible. Longer-term follow-up is necessary before the technique can be
broadly applied. Cite this article:
The interaction between the lumbosacral spine
and the pelvis is dynamically related to positional change, and
may be complicated by co-existing pathology. This review summarises
the current literature examining the effect of sagittal spinal deformity
on pelvic and acetabular orientation during total hip arthroplasty
(THA) and provides recommendations to aid in placement of the acetabular
component for patients with co-existing spinal pathology or long
spinal fusions. Pre-operatively, patients can be divided into four
categories based on the flexibility and sagittal balance of the
spine. Using this information as a guide, placement of the acetabular
component can be optimal based on the type and significance of co-existing
spinal deformity. Cite this article:
Adverse reaction to wear and corrosion debris
is a cause for concern in total hip arthroplasty (THA). Modular junctions
are a potential source of such wear products and are associated
with secondary pseudotumour formation. We present a consecutive series of 17 patients treated at our
unit for this complication following metal-on-highly cross-linked
polyethylene (MoP) THA. We emphasise the risk of misdiagnosis as
infection, and present the aggregate laboratory results and pathological
findings in this series. The clinical presentation was pain, swelling or instability.
Solid, cystic and mixed soft-tissue lesions were noted on imaging
and confirmed intra-operatively. Corrosion at the head–neck junction
was noted in all cases. No bacteria were isolated on multiple pre-
and intra-operative samples yet the mean erythrocyte sedimentation
rate was 49 (9 to 100) and C-reactive protein 32 (0.6 to 106) and
stromal polymorphonuclear cell counts were noted in nine cases. Adverse soft–tissue reactions can occur in MoP THA owing to corrosion
products released from the head–neck junction. The diagnosis should
be carefully considered when investigating pain after THA. This
may avoid the misdiagnosis of periprosthetic infection with an unidentified
organism and mitigate the unnecessary management of these cases
with complete single- or two-stage exchange. Cite this article:
The aim of this cadaver study was to identify
the change in position of the sciatic nerve during arthroplasty
using the posterior surgical approach to the hip. We investigated
the position of the nerve during this procedure by dissecting 11
formalin-treated cadavers (22 hips: 12 male, ten female). The distance
between the sciatic nerve and the femoral neck was measured before
and after dislocation of the hip, and in positions used during the
preparation of the femur. The nerve moves closer to the femoral
neck when the hip is flexed to >
30° and internally rotated to 90° (90°
IR). The mean distance between the nerve and femoral neck was 43.1
mm (standard deviation ( This study demonstrates that the sciatic nerve becomes closer
to the operative field during hip arthroplasty using the posterior
approach with progressive flexion of the hip. Cite this article:
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:
The aims of this study were to determine the
functional impact and financial burden of isolated and recurrent dislocation
after total hip arthroplasty (THA). Our secondary goal was to determine
whether there was a difference between patients who were treated
non-operatively and those who were treated operatively. We retrospectively reviewed 71 patients who had suffered dislocation
of a primary THA. Their mean age was 67 years (41 to 92) and the
mean follow-up was 3.8 years (2.1 to 8.2). Because patients with recurrent dislocation were three times
more likely to undergo operative treatment (p <
0.0001), they
ultimately had a significantly higher mean Harris Hip Score (HHS)
(p = 0.0001), lower mean Western Ontario and McMaster Universities
Arthritis Index (WOMAC) scores (p = 0.001) and a higher mean SF-12
score (p <
0.0001) than patients with a single dislocation. Likewise,
those who underwent operative treatment had a higher mean HHS (p
<
0.0001), lower mean WOMAC score (p <
0.0001) and a higher
mean SF-12 score (p <
0.0001) than those who were treated non-operatively. Recurrent dislocation and operative treatment increased costs
by 300% (£11 456;
p <
0.0001) and 40% (£5217; p <
0.0001), respectively. The operative treatment of recurrent dislocation results in significantly
better function than non-operative management. Moreover, the increase
in costs for operative treatment is modest compared with that of
non-operative measures. Cite this article: