We compared the clinical and radiological outcomes
of two cementless femoral stems in the treatment of patients with
a Garden III or IV fracture of the femoral neck. A total of 70 patients At final follow-up there were no statistically significant differences
between the short anatomical and the conventional stems with regard
to the mean Harris hip score (85.7 (66 to 100) Our study demonstrated that despite the poor bone quality in
these elderly patients with a fracture of the femoral neck, osseo-integration
was obtained in all hips in both groups. However, the incidence
of thigh pain, pulmonary microemboli and peri-prosthetic fracture
was significantly higher in the conventional stem group than in
the short stem group.
The February 2014 Research Roundup360 looks at: blood supply to the femoral head after dislocation; diabetes and hip replacement; bone remodelling over two decades following hip replacement; sham surgery as good as arthroscopic meniscectomy; distraction in knee osteoarthritis; whether joint replacement prevent cardiac events; tranexamic acid and knee replacement haemostasis; cartilage colonisation in bipolar ankle grafts; CTs and proof of fusion; atorvastatin for muscle re-innervation after sciatic nerve transection; microfracture and short-term pain in cuff repair; promising early results from L-PRF augmented cuff repairs; and fatty degeneration in a rodent model.
We measured the tension in the interosseous membrane
in six cadaveric forearms using an Cite this article:
We reviewed the long-term results at ten to 12 years of 118 total hip replacements in 109 patients using a second-generation hemispherical cementless acetabular component (Reflection) designed to address the problem of backside wear. Five patients (five hips) died and six patients (seven hips) were lost to follow-up. The remaining 98 patients (106 hips) had a mean age of 62.9 years (34.0 to 86.2) A rate of revision for aseptic loosening of 0.9%, and predictable results were found with respect to radiological evidence of fixation, lack of pain, walking ability, range of movement and function. One component was revised for aseptic loosening, and of the 101 hips (95.2%) that did not have a revision, minor osteolytic lesions of the pelvis were seen in six (5.9%). Kaplan-Meier survival analysis for the total cohort of 118 hips revealed a 96.4% survival at both ten (95% confidence interval 90 to 98) and 12 years (95% confidence interval 86 to 98).
We have evaluated the clinical effectiveness
of a metal resurfacing inlay implant for osteochondral defects of
the medial talar dome after failed previous surgical treatment.
We prospectively studied 20 consecutive patients with a mean age
of 38 years (20 to 60), for a mean of three years (2 to 5) post-surgery.
There was statistically significant reduction of pain in each of
four situations (i.e., rest, walking, stair climbing and running;
p ≤ 0.01). The median American Orthopaedic Foot and Ankle Society
ankle-hindfoot score improved from 62 (interquartile range (IQR)
46 to 72) pre-operatively to 87 (IQR 75 to 95) at final follow-up
(p <
0.001). The Foot and Ankle Outcome Score improved on all
subscales (p ≤ 0.03). The mean Short-Form 36 physical component
scale improved from 36 (23 to 50) pre-operatively to 45 (29 to 55)
at final follow-up (p = 0.001); the mental component scale did not
change significantly. On radiographs, progressive degenerative changes
of the opposing tibial plafond were observed in two patients. One
patient required additional surgery for the osteochondral defect.
This study shows that a metal implant is a promising treatment for
osteochondral defects of the medial talar dome after failed previous
surgery. Cite this article:
Cementless acetabular fixation has demonstrated superior long-term durability in total hip replacement, but most series have studied implants with porous metal surfaces. We retrospectively evaluated the results of 100 consecutive patients undergoing total hip replacement where a non-porous Allofit component was used for primary press-fit fixation. This implant is titanium alloy, grit-blasted, with a macrostructure of forged teeth and has a biradial shape. A total of 81 patients (82 hips) were evaluated at final follow-up at a mean of 10.1 years (8.9 to 11.9). The Harris Hip Score improved from a mean 53 points (23 to 73) pre-operatively to a mean of 96 points (78 to 100) at final review. The osseointegration of all acetabular components was radiologically evaluated with no evidence of loosening. The survival rate with revision of the component as the endpoint was 97.5% (95% confidence interval 94 to 100) after 11.9 years. Radiolucency was found in one DeLee-Charnley zone in four acetabular components. None of the implants required revision for aseptic loosening. Two patients were treated for infection, one requiring a two-stage revision of the implant. One femoral stem was revised for osteolysis due to the production of metal wear debris, but the acetabular shell did not require revision. This study demonstrates that a non-porous titanium acetabular component with adjunct surface fixation offers an alternative to standard porous-coated implants.
Alumina–alumina bearings are among the most resistant
to wear in total hip replacement. Examination of their surfaces
is one way of comparing damage caused by wear of hip joints simulated We found that long-term alumina wear in association with a loose
acetabular component could be categorised into three groups. Of
20 specimens, four had ‘low wear’, eight ‘crescent wear’ and eight
‘severe wear’, which was characterised by a change in the physical
shape of the bearing and a loss of volume. This suggests that the
wear in alumina–alumina bearings in association with a loose acetabular
component may be variable in pattern, and may explain, in part,
why the wear of a ceramic head
In skeletally immature patients, resection of
bone tumours and reconstruction of the lower limb often results
in leg-length discrepancy. The Stanmore non-invasive extendible
endoprosthesis, which uses electromagnetic induction, allows post-operative
lengthening without anaesthesia. Between 2002 and 2009, 55 children
with a mean age of 11.4 years (5 to 16) underwent reconstruction
with this prosthesis; ten patients (18.2%) died of disseminated
disease and one child underwent amputation due to infection. We
reviewed 44 patients after a mean follow-up of 41.2 months (22 to
104). The mean Musculoskeletal Tumor Society score was 24.7 (8 to
30) and the Toronto Extremity Salvage score was 92.3% (55.2% to
99.0%). There was no local recurrence of tumour. Complications developed
in 16 patients (29.1%) and ten (18.2%) underwent revision. The mean length gained per patient was 38.6 mm (3.5 to 161.5),
requiring a mean of 11.3 extensions (1 to 40), and ten component
exchanges were performed in nine patients (16.4%) after attaining
the maximum lengthening capacity of the implant. There were 11 patients
(20%) who were skeletally mature at follow-up, ten of whom had equal
leg lengths and nine had a full range of movement of the hip and
knee. This is the largest reported series using non-invasive extendible
endoprostheses after excision of primary bone tumours in skeletally
immature patients. The technique produces a good functional outcome,
with prevention of limb-length discrepancy at skeletal maturity.
Our aim in this prospective study was to evaluate the outcome of total shoulder replacement in the treatment of young and middle-aged active patients with primary glenohumeral osteoarthritis. We reviewed 21 patients (21 shoulders) with a mean age of 55 years (37 to 60). The mean follow-up was seven years (5 to 9). The same anatomical, third-generation, cemented implant had been used in all patients. All the patients were evaluated radiologically and clinically using the Constant and Murley score. No patients required revision. In one a tear of the supraspinatus tendon occurred. Overall, 20 patients (95%) were either very satisfied (n = 18) or satisfied (n = 2) with the outcome. Significant differences (p <
0.0001) were found for all categories of the Constant and Murley score pre- and post-operatively. The mean Constant and Murley score increased from 24.1 points (10 to 45) to 64.5 points (39 to 93), and the relative score from 30.4% (11% to 50%) to 83% (54% to 116%). No clinical or radiological signs of loosening of the implant were seen. For young and middle-aged patients with osteoarthritis, third-generation total shoulder replacement is a viable method of treatment with a low rate of complications and excellent results in the mid-term.
We prospectively evaluated the long-term outcome of 158 consecutive patients who underwent revision total hip replacement using uncemented computer-assisted design-computer-assisted manufacture femoral components. There were 97 men and 61 women. Their mean age was 63.1 years (34.6 to 85.9). The mean follow-up was 10.8 years (10 to 12). The mean Oxford, Harris and Western Ontario and McMaster hip scores improved from 41.1, 44.2 and 52.4 pre-operatively to 18.2, 89.3 and 12.3, respectively (p <
0.0001, for each). Six patients required further surgery. The overall survival of the femoral component was 97% (95% confidence interval 94.5 to 99.7). These results are comparable to those of previously published reports for revision total hip replacement using either cemented or uncemented components.
This prospective study compares the outcome of
157 hydroxyapatite (HA)-coated tibial components with 164 cemented
components in the ROCC Rotating Platform total knee replacement
in 291 patients. The mean follow-up was 7.6 years (5.2 to 11). There
were two revisions for loosening: one for an HA-coated and one for
a cemented tibial component. Radiological evaluation demonstrated
no radiolucent lines with the HA-coated femoral components. A total
of three HA-coated tibial components exhibited radiolucent lines
at three months post-operatively and these disappeared after three
further months of protected weight-bearing. With HA-coated components
the operating time was shorter (p <
0.006) and the radiological
assessment of the tibial interface was more stable (p <
0.01).
Using revision for aseptic loosening of the tibial component as
the end point, the survival rates at nine years was identical for
both groups at 99.1%. Our results suggest that HA-coated components perform at least
as well as the same design with cemented components and compare
favourably with those of series describing cemented or porous-coated
knee replacements, suggesting that fixation of both components with
hydroxyapatite is a reliable option in primary total knee replacement.
This prospective study presents the ten-year (5 to 16) clinical and radiological results of 55 primary total hip replacements (THR) using a cementless modular femoral component (S-ROM). All patients had a significant anatomical abnormality which rendered the primary THR difficult. The mean Harris hip score was 36 (12 to 72) pre-operatively, 83 (44 to 100) at five years, and 85 (45 to 99) at ten years. The Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and short-form (SF)-12 scores were recorded from the year 2000. The mean SF-12 score at five years after surgery was 45.24 (22.74 to 56.58) for the physical component and 54.14 (29.20 to 66.61) for the mental component. By ten years the SF-12 scores were 42.86 (21.59 to 58.95) and 51.03 (33.78 to 61.40), respectively. The mean WOMAC score at five years post-operatively was 25 (0 to 59), and at ten years was 27 (2 to 70). No femoral components were radiologically loose, although five had osteolysis in Gruen zone 1, three had osteolysis in zone 7, and two showed osteolysis in both zones 1 and 7. No osteolysis was observed around or distal to the prosthetic sleeve. No femoral components were revised, although three hips underwent an acetabular revision and two required a liner exchange. At a mean of ten years’ follow-up the S-ROM femoral component implanted for an anatomically difficult primary THR has excellent clinical and radiological results.
The dysplasia cup, which was devised as an adjunct to the Birmingham Hip Resurfacing system, has a hydroxyapatite-coated porous surface and two supplementary neutralisation screws to provide stable primary fixation, permit early weight-bearing, and allow incorporation of morcellised autograft without the need for structural bone grafting. A total of 110 consecutive dysplasia resurfacing arthroplasties in 103 patients (55 men and 48 women) performed between 1997 and 2000 was reviewed with a minimum follow-up of six years. The mean age at operation was 47.2 years (21 to 62) and 104 hips (94%) were Crowe grade II or III. During the mean follow-up of 7.8 years (6 to 9.6), three hips (2.7%) were converted to a total hip replacement at a mean of 3.9 years (2 months to 8.1 years), giving a cumulative survival of 95.2% at nine years (95% confidence interval 89 to 100). The revisions were due to a fracture of the femoral neck, a collapse of the femoral head and a deep infection. There was no aseptic loosening or osteolysis of the acetabular component associated with either of the revisions performed for failure of the femoral component. No patient is awaiting a revision. The median Oxford hip score in 98 patients with surviving hips at the final review was 13 and the 10th and the 90th percentiles were 12 and 23, respectively.
We report the findings of an independent review
of 230 consecutive Birmingham hip resurfacings (BHRs) in 213 patients
(230 hips) at a mean follow-up of 10.4 years (9.6 to 11.7). A total
of 11 hips underwent revision; six patients (six hips) died from
unrelated causes; and 13 patients (16 hips) were lost to follow-up.
The survival rate for the whole cohort was 94.5% (95% confidence
interval (CI) 90.1 to 96.9). The survival rate in women was 89.1%
(95% CI 79.2 to 94.4) and in men was 97.5% (95% CI 92.4 to 99.2).
Women were 1.4 times more likely to suffer failure than men. For
each millimetre increase in component size there was a 19% lower
chance of a failure. The mean Oxford hip score was 45.0 (median
47.0, 28 to 48); mean University of California, Los Angeles activity
score was 7.4 (median 8.0, 3 to 9); mean patient satisfaction score
was 1.4 (median 1.0, 0 to 9). A total of eight hips had lysis in
the femoral neck and two hips had acetabular lysis. One hip had
progressive radiological changes around the peg of the femoral component.
There was no evidence of progressive neck narrowing between five
and ten years. Our results confirm that BHR provides good functional outcome
and durability for men, at a mean follow-up of ten years. We are
now reluctant to undertake hip resurfacing in women with this implant.
Peri-prosthetic osteolysis and subsequent aseptic
loosening is the most common reason for revising total hip replacements.
Wear particles originating from the prosthetic components interact
with multiple cell types in the peri-prosthetic region resulting
in an inflammatory process that ultimately leads to peri-prosthetic
bone loss. These cells include macrophages, osteoclasts, osteoblasts
and fibroblasts. The majority of research in peri-prosthetic osteolysis
has concentrated on the role played by osteoclasts and macrophages.
The purpose of this review is to assess the role of the osteoblast
in peri-prosthetic osteolysis. In peri-prosthetic osteolysis, wear particles may affect osteoblasts
and contribute to the osteolytic process by two mechanisms. First,
particles and metallic ions have been shown to inhibit the osteoblast
in terms of its ability to secrete mineralised bone matrix, by reducing
calcium deposition, alkaline phosphatase activity and its ability
to proliferate. Secondly, particles and metallic ions have been
shown to stimulate osteoblasts to produce pro inflammatory mediators Cite this article:
We report a multicentre prospective consecutive
study assessing the long-term outcome of the proximally hydroxyapatite
(HA)-coated ABG II monobloc femoral component in a series of 1148
hips in 1053 patients with a mean age at surgery of 64.77 years
(22 to 80) at a mean follow-up of 10.84 years (10 to 15.25). At
latest follow-up, the mean total Harris hip score was 94.7 points
( Cite this article:
A total of 397 hips were randomised to receive
Metasul metal-on-metal (MoM), metal-on-conventional polyethylene (MoP)
or ceramic-on-polyethylene (CoP) bearings using a cemented triple-tapered
polished femoral component (MS-30). There were 129 MoM hips in 123
patients (39 male and 84 female, mean age 63.3 years (40.7 to 72.9)),
137 MoP hips in 127 patients (39 male and 88 female, mean age 62.8
years (24.5 to 72.7)) and 131 CoP hips in 124 patients (51 male
and 73 female, mean age 63.9 years (30.6 to 73.8)). All acetabular
components were cemented Weber polyethylene components with the
appropriate inlay for the MoM articulation. Clinical evaluation
was undertaken using the Harris hip score (HHS) and radiological
assessments were made at two, five and seven years. The HHS and radiological
analysis were available for 341 hips after seven years. The MoM
group had the lowest mean HHS (p = 0.124), a higher rate of revision
(p <
0.001) and a higher incidence of radiolucent lines in unrevised
hips (p <
0.001). In all, 12 revisions had been performed in
12 patients: eight in the MoM group (four for infection, four for
aseptic loosening, three in the MoP group (one each of infection,
dislocation and pain) and one in the CoP group (infection). Our findings reveal no advantage to the MoM bearing and identified
a higher revision rate and a greater incidence of radiolucent lines
than with the other articulations. We recommend that patients with
a 28 mm Metasul MoM bearing be followed carefully. Cite this article:
We have previously described the short-term outcome of the use of reverse shoulder arthroplasty in the treatment of acute complex proximal humeral fractures in the elderly. We now report the clinical and radiological outcome of 36 fractures at a mean of 6.6 years (1 to 16). Previously, at a mean follow-up of 6 years (1 to 12) the mean Constant score was 58.5; this was reduced to 53 points with the further follow-up. A total of 23 patients (63%) had radiological evidence of loosening of the glenoid component. Nevertheless, only one patient had aseptic loosening of the baseplate at 12 years’ follow-up. The reduction in the mean Constant score with longer follow-up and the further development of scapular notching is worrying. New developments in design, bearing surfaces and surgical technique, and further follow-up, will determine whether reverse shoulder arthroplasty has a place in the management of complex proximal humeral fractures in the elderly.