Aims. Iliopsoas pathology is a relatively uncommon cause of pain following total hip arthroplasty (THA), typically presenting with symptoms of groin pain on active flexion and/or extension of the hip. A variety of conservative and surgical treatment options have been reported. In this retrospective cohort study, we report the incidence of iliopsoas pathology and treatment outcomes. Methods. A retrospective review of 1,000 patients who underwent THA over a five-year period was conducted, to determine the incidence of patients diagnosed with iliopsoas pathology. Outcome following non-surgical and surgical management was assessed. Results. In all, 24 patients were diagnosed as having developed symptomatic iliopsoas pathology giving an incidence of 2.4%. While the mean age for receiving a THA was 65 years, the mean age for developing iliopsoas pathology was 54 years (28 to 67). Younger patients and those receiving THA for conditions other than primary osteoarthritis were at a higher risk of developing this complication. Ultrasound-guided steroid injection/physiotherapy resulted in complete resolution of symptoms in 61% of cases, partial resolution in 13%, and no benefit in 26%. Eight out of 24 patients (who initially responded to injection) subsequently underwent surgical intervention including tenotomy (n = 7) and revision of the acetabular component (n = 1). Conclusion. This is the largest case series to estimate the incidence of iliopsoas pathology to date. There is a higher incidence of this condition in younger patients, possibly due to the differing surgical indications. Arthoplasty for Perthes' disease or developmental dysplasia of the hip (DDH) often results in leg length and horizontal offset being increased. This, in turn, may increase tension on the iliopsoas tendon, possibly resulting in a higher risk of psoas irritation. Image-guided steroid injection is a low-risk, relatively effective treatment. In refractory cases, tendon release may be considered. Patients should be counselled of the risk of persisting groin pain when undergoing THA. Cite this article: Bone Joint J 2021;103-B(2):305–308

Aims

Treatment outcomes for methicillin-resistant Staphylococcus aureus (MRSA) periprosthetic joint infection (PJI) using systemic vancomycin and antibacterial cement spacers during two-stage revision arthroplasty remain unsatisfactory. This study explored the efficacy and safety of intra-articular vancomycin injections for PJI control after debridement and cement spacer implantation in a rat model.

Aims. To evaluate the outcomes of terrible triad injuries (TTIs) in mid-term follow-up and determine whether surgical treatment of the radial head influences clinical and radiological outcomes. Methods. Follow-up assessment of 88 patients with TTI (48 women, 40 men; mean age 57 years (18 to 82)) was performed after a mean of 4.5 years (2.0 to 9.4). The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder and Hand (DASH) score were evaluated. Radiographs of all patients were analyzed. Fracture types included 13 Mason type I, 16 type II, and 59 type III. Surgical treatment consisted of open reduction and internal fixation (ORIF) in all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) was performed if reconstruction was not possible. Results. At follow-up the mean MEPS was 87.1 (20 to 100); mean OES, 36.9 (6 to 48); and mean DASH score, 18.6 (0 to 90). Mean movement was 118° (30° to 150°) for extension to flexion and 162° (90° to 180°) for pronation to supination. The overall reoperation rate was 24%, with nine ORIF, ten RHA, and two patients without treatment to the radial head needing surgical revision. When treated with RHA, Mason type III fractures exhibited significantly inferior outcomes. Suboptimal results were also identified in patients with degenerative or heterotopic changes on their latest radiograph. In contrast, more favourable outcomes were detected in patients with successful radial head reconstruction after Mason type III fractures. Conclusion. Using a standardized protocol, sufficient elbow stability and good outcomes can be achieved in most TTIs. Although some bias in treatment allocation, with more severe injuries assigned to RHA, cannot be completely omitted, treatment of radial head fractures may have an independent effect on outcome, as patients subjected to RHA showed significantly inferior results compared to those subjected to reconstruction, in terms of elbow function, incidence of arthrosis, and postoperative complications. As RHA showed no apparent advantage in Mason type III injuries between the two treatment groups, we recommend reconstruction, providing stable fixation can be achieved. Cite this article: Bone Joint J 2020;102-B(12):1620–1628

Aims. We investigated patient characteristics and outcomes of Vancouver type B periprosthetic fractures treated with femoral component revision and/or osteosynthesis. Patients and Methods. The study utilized data from the Swedish Hip Arthroplasty Register (SHAR) and information from patient records. We included all primary total hip arthroplasties (THAs) performed in Sweden since 1979, and undergoing further surgery due to Vancouver type B periprosthetic femoral fracture between 2001 and 2011. The primary outcome measure was any further reoperation between 2001 and 2013. Cross-referencing with the National Patient Register was performed in two stages, in order to identify all surgical procedures not recorded on the SHAR. Results. Out of 1381 Vancouver type B fractures that fulfilled the inclusion criteria, 257 underwent further reoperation by the end of 2013. Interprosthetic and Type B1 fractures had a higher risk for reoperation. For B1 fractures, the rate of reoperation did not differ (p = 0.322) after use of conventional (26%) or locking plate osteosynthesis (19%). No significant differences were observed between cemented, cementless monoblock, and cementless modular revision components for the treatment of type B2 and B3 fractures. Conclusion. In this country-specific study, the choice of locking or conventional plates for the treatment of type B1, and cemented or cementless femoral components fixation for B2 and B3 fractures, had no significant influence on risk for reoperation. Interprosthetic fractures adversely affected the outcome of treatment of type B fractures. Differences in the patient characteristics of the compared groups were observed. Cite this article: Bone Joint J 2019;101-B:1447–1458

Aims. Aseptic loosening is a major cause of failure in cemented endoprosthetic reconstructions. This paper presents the long-term outcomes of a custom-designed cross-pin fixation construct designed to minimize rotational stress and subsequent aseptic loosening in selected patients. The paper will also examine the long-term survivorship and modes of failure when using this technique. Patients and Methods. A review of 658 consecutive, prospectively collected cemented endoprosthetic reconstructions for oncological diagnoses at a single centre between 1980 and 2017 was performed. A total of 51 patients were identified with 56 endoprosthetic implants with cross-pin fixation, 21 of which were implanted following primary resection of tumour. Locations included distal femoral (n = 36), proximal femoral (n = 7), intercalary (n = 6), proximal humeral (n = 3), proximal tibial (n = 3), and distal humeral (n = 1). Results. The median follow-up was 132 months (interquartile range (IQR) 44 to 189). In all, 20 stems required revision: eight for infection, five for structural failure, five for aseptic loosening, and two for tumour progression. Mechanical survivorship at five, ten, and 15 years was 84%, 78%, and 78%, respectively. Mechanical failure rate varied by location, with no mechanical failures of proximal femoral constructs and distal femoral survivorship of 82%, 77%, and 77% at five, ten, and 15 years. The survivorship of primary constructs at five years was 74%, with no failure after 40 months, while the survivorship for revision constructs was 89%, 80%, and 80% at five, ten, and 15 years. . Conclusion. The rate of mechanical survivorship in our series is similar to those reported for other methods of reconstruction for short diaphyseal segments, such as compressive osseointegration. The mechanical failure rate differed by location, while there was no substantial difference in long-term survival between primary and revision reconstructions. Overall, custom cross-pin fixation is a viable option for endoprosthetic reconstruction of short metaphyseal segments with an acceptable rate of mechanical failure. Cite this article: Bone Joint J 2019;101-B:724–731

Aims. Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort. Methods. We have prospectively monitored a series of 22 cases (21 patients) with a mean follow-up of 32 months (13 to 59). Results. The mean patient age was 79 years (67 to 87), and the mean ASA score was 3.3 (3 to 5). Three patients had high-energy injuries and 18 had low-energy injuries. All cases were associated fractures (Letournel classification: anterior column posterior hemitransverse, n = 13; associated both column, n = 6; transverse posterior wall, n = 3) with medialization of the femoral head. Mean operative time was 93 minutes (61 to 135). There have been no revisions to date. Of the 21 patients, 20 were full weight-bearing on day 1 postoperatively. Mean length of hospital stay was 12 days (5 to 27). Preoperative mobility status was maintained in 13 patients. At one year, mean Merle d’Aubigné score was 13.1 (10 to 18), mean Oxford Hip Score was 38.5 (24 to 44), mean EuroQol five-dimension five-level (EQ-5D-5L) health score was 68 (30 to 92), and mean EQ-5D-5L index score was 0.68 (0.335 to 0.837); data from 14 patients. Mortality was 9.5% (2/21) at one year. There have been no thromboembolic events, deep infections, or revisions. Conclusion. The coned hemipelvis reconstruction bypasses the fracture, creating an immediately stable construct that allows immediate full weight-bearing. The posterior approach minimizes the operative time and physiological insult in this vulnerable patient population. Early results suggest this to be a safe addition to current surgical options, targeted at the most medically frail elderly patient with a complex displaced acetabular fracture. Cite this article: Bone Joint J 2020;102-B(2):155–161

Aims

BoneMaster is a thin electrochemically applied hydroxyapatite (HA) coating for orthopaedic implants that is quickly resorbed during osseointegration. Early stabilization is a surrogacy marker of good survival of femoral stems. The hypothesis of this study was that a BoneMaster coating yields a fast early and lasting fixation of stems.

Aims. Spinal fusion remains the gold standard in the treatment of idiopathic scoliosis. However, anterior vertebral body tethering (AVBT) is gaining widespread interest, despite the limited data on its efficacy. The aim of our study was to determine the clinical efficacy of AVBT in skeletally immature patients with idiopathic scoliosis. Methods. All consecutive skeletally immature patients with idiopathic scoliosis treated with AVBT enrolled in a longitudinal, multicentre, prospective database between 2013 and 2016 were analyzed. All patients were treated by one of two surgeons working at two independent centres. Data were collected prospectively in a multicentre database and supplemented retrospectively where necessary. Patients with a minimum follow-up of two years were included in the analysis. Clinical success was set a priori as a major coronal Cobb angle of < 35° at the most recent follow-up. Results. A total of 57 patients were included in the study. Their mean age was 12.7 years (SD 1.5; 8.2 to 16.7), with 95% being female. The mean preoperative Sanders score and Risser grade was 3.3 (SD 1.2), and 0.05 (0 to 3), respectively. The majority were thoracic tethers (96.5%) and the mean follow-up was 40.4 months (SD 9.3). The mean preoperative major curve of 51° (SD 10.9°; 31° to 81°) was significantly improved to a mean of 24.6° (SD 11.8°; 0° to 57°) at the first postoperative visit (45.6% (SD 17.6%; 7% to 107%); p < 0.001)) with further significant correction to a mean of 16.3° (SD 12.8°; -12 to 55; p < 0.001) at one year and a significant correction to a mean of 23° (SD 15.4°; -18° to 57°) at the final follow-up (42.9% (-16% to 147%); p < 0.001). Clinical success was achieved in 44 patients (77%). Most patients reached skeletal maturity, with a mean Risser score of 4.3 (SD 1.02), at final follow-up. The complication rate was 28.1% with a 15.8% rate of unplanned revision procedures. Conclusion. AVBT is associated with satisfactory correction of deformity and an acceptable complication rate when used in skeletally immature patients with idiopathic scoliosis. Improved patient selection and better implant technology may improve the 15.8% rate of revision surgery in these patients. Further scrutiny of the true effectiveness and long-term risks of this technique remains critical. Cite this article: Bone Joint J 2020;102-B(12):1703–1708

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Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common orthopaedic procedures requiring postoperative radiographs to confirm implant positioning and identify complications. Artificial intelligence (AI)-based image analysis has the potential to automate this postoperative surveillance. The aim of this study was to prepare a scoping review to investigate how AI is being used in the analysis of radiographs following THA and TKA, and how accurate these tools are.

Aims

Treatment of end-stage anteromedial osteoarthritis (AMOA) of the knee is commonly approached using one of two surgical strategies: medial unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA). In this study we aim to investigate if there is any difference in outcome for patients undergoing UKA or TKA, when treated by high-volume surgeons, in high-volume centres, using two different clinical guidelines. The two strategies are ‘UKA whenever possible’ vs TKA for all patients with AMOA.

Aims. Recurrent infection following two-stage revision total hip arthroplasty (THA) for prosthetic joint infection (PJI) is a devastating complication. The purpose of this study was to report the survival of repeat two-stage revision hip arthroplasty, describe complications, and identify risk factors for failure. Patients and Methods. We retrospectively identified 19 hips (19 patients) that had undergone repeat two-stage revision THA for infection between 2000 to 2013. There were seven female patients (37%) and the mean age was 60 years (30 to 85). Survival free from revision was assessed via Kaplan–Meier analysis. The patients were classified according to the Musculoskeletal Infection Society (MSIS) system, and risk factors for failure were identified. Mean follow-up was four years (2 to 11). Results. Gram-positive bacteria were responsible for 16/17 (94%) of the re-infections where microbes were identified. Following the repeat two-stage exchange arthroplasty, survival free from any revision was 74% (95% confidence interval (CI) 56% to 96%, 14 at risk) at two years and 45% (95% CI 25% to 75%, five at risk) at five years. Failure to control infection resulted in re-operation or revision in 42%A of patients (8/19). Survival free from revision was not dependent on host grade. Conclusion. Re-infection after two-stage exchange hip arthroplasty for PJI presents a challenging scenario. Repeat two-stage exchange arthroplasty has a low survival free from revision at five years (45%) and a high rate of re-infection (42%). Cite this article: Bone Joint J 2018;100-B:1157–61

Aims. The aim of this study was to identify predictors of return to work (RTW) after revision lower limb arthroplasty in patients of working age in the United Kingdom. Patients and Methods. We assessed 55 patients aged ≤ 65 years after revision total hip arthroplasty (THA). There were 43 women and 12 men with a mean age of 54 years (23 to 65). We also reviewed 30 patients after revision total knee arthroplasty (TKA). There were 14 women and 16 men with a mean age of 58 years (48 to 64). Preoperatively, age, gender, body mass index, social deprivation, mode of failure, length of primary implant survival, work status and nature, activity level (University of California, Los Angeles (UCLA) score), and Oxford Hip and Knee Scores were recorded. Postoperatively, RTW status, Oxford Hip and Knee Scores, EuroQol-5D (EQ-5D), UCLA score, and Work, Osteoarthritis and Joint-Replacement Questionnaire (WORQ) scores were obtained. Univariate and multivariate analysis was performed. Results. Overall, 95% (52/55) of patients were working before their revision THA. Afterwards, 33% (17/52) RTW by one year, 48% (25/52) had retired, and 19% (10/52) were receiving welfare benefit. RTW was associated with age, postoperative Oxford Hip Score, early THA failure (less than two years), mode of failure dislocation, and contralateral revision (p < 0.05). No patient returned to work after revision for dislocation. Only age remained a significant factor on multivariate analysis (p = 0.003), with 79% (11/14) of those less than 50 years of age returning to work, compared with 16% (6/38) of those aged fifty years or over. Before revision TKA, 93% (28/30) of patients were working. Postoperatively only 7% (2/28) returned to work by one year, 71% (20/28) had retired, and 21% (6/28) were receiving welfare benefits. UCLA scores improved after 43% of revision THAs and 44% of revision TKAs. Conclusion. After revision THA, age is the most significant predictor of RTW: only 16% of those over 50 years old return to work. Fewer patients return to work after early revision THA and none after revision for dislocation. After revision TKA, patients rarely return to work: none return to heavy or moderate manual work. Cite this article: Bone Joint J 2018;100-B:1043–53

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This systematic review aims to compare the precision of component positioning, patient-reported outcome measures (PROMs), complications, survivorship, cost-effectiveness, and learning curves of MAKO robotic arm-assisted unicompartmental knee arthroplasty (RAUKA) with manual medial unicompartmental knee arthroplasty (mUKA).

Aims. To evaluate the histopathological examination of peri-implant tissue samples as a technique in the diagnosis of postoperative spinal implant infection (PSII). Methods. This was a retrospective analysis. Patients who underwent revision spinal surgery at our institution were recruited for this study. PSII was diagnosed by clinical signs, histopathology, and microbiological examination of intraoperatively collected samples. Histopathology was defined as the gold standard. The sensitivity for histopathology was calculated. A total of 47 patients with PSII and at least one microbiological and histopathological sample were included in the study. Results. PSII occurred in approximately 28% of the study population. Histopathology showed a sensitivity of 51.1% in the diagnosis of PSII. The most commonly found pathogens were Cutibacterium acnes and gram-positive staphylococci. Conclusion. Histopathology has low sensitivity for detecting PSII. In particular, infections caused by low-virulence microorganisms are insufficiently detected by histopathology. Cite this article: Bone Joint J 2020;102-B(7):899–903

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A functional anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) has been assumed to be required for patients undergoing unicompartmental knee arthroplasty (UKA). However, this assumption has not been thoroughly tested. Therefore, this study aimed to assess the biomechanical effects exerted by cruciate ligament-deficient knees with medial UKAs regarding different posterior tibial slopes.