Aims

Calcium sulphate has traditionally been used as a filler of dead space arising during surgery. Various complications have been described following the use of Stimulan bio-absorbable calcium sulphate beads. This study is a prospective observational study to assess the safety profile of these beads when used in revision arthroplasty, comparing the complication rates with those reported in the literature.

Aims

To date, there is insufficient evidence available to compare the outcome of cemented and uncemented fixation of the humeral stem in reverse shoulder arthroplasty (RSA).

We report the clinical and radiographic outcomes of 208 consecutive femoral revision arthroplasties performed in 202 patients (119 women, 83 men) between March 1991 and December 2007 using the X-change Femoral Revision System, fresh-frozen morcellised allograft and a cemented polished Exeter stem. All patients were followed prospectively. The mean age of the patients at revision was 65 years (30 to 86). At final review in December 2013 a total of 130 patients with 135 reconstructions (64.9%) were alive and had a non re-revised femoral component after a mean follow-up of 10.6 years (4.7 to 20.9). One patient was lost to follow-up at six years, and their data were included up to this point. Re-operation for any reason was performed in 33 hips (15.9%), in 13 of which the femoral component was re-revised (6.3%). The mean pre-operative Harris hip score was 52 (19 to 95) (n = 73) and improved to 80 (22 to 100) (n = 161) by the last follow-up. Kaplan–Meier survival with femoral re-revision for any reason as the endpoint was 94.9% (95% confidence intervals (CI) 90.2 to 97.4) at ten years; with femoral re-revision for aseptic loosening as the endpoint it was 99.4% (95% CI 95.7 to 99.9); with femoral re-operation for any reason as the endpoint it was 84.5% (95% CI 78.3 to 89.1); and with subsidence ≥ 5 mm it was 87.3% (95% CI 80.5 to 91.8). Femoral revision with the use of impaction allograft bone grafting and a cemented polished stem results in a satisfying survival rate at a mean of ten years’ follow-up.

Cite this article: Bone Joint J 2015; 97-B:771–9.

The Unified Classification System (UCS) emphasises the key principles in the assessment and management of peri-prosthetic fractures complicating partial or total joint replacement.

We tested the inter- and intra-observer agreement for the UCS as applied to the pelvis and femur using 20 examples of peri-prosthetic fracture in 17 patients. Each subtype of the UCS was represented by at least one case. Specialist orthopaedic surgeons (experts) and orthopaedic residents (pre-experts) assessed reliability on two separate occasions.

For the pelvis, the UCS showed inter-observer agreement of 0.837 (95% confidence intervals (CI) 0.798 to 0.876) for the experts and 0.728 (95% CI 0.689 to 0.767) for the pre-experts. The intra-observer agreement for the experts was 0.861 (95% CI 0.760 to 0.963) and 0.803 (95% 0.688 to 0.918) for the pre-experts. For the femur, the UCS showed an inter-observer kappa value of 0.805 (95% CI 0.765 to 0.845) for the experts and a value of 0.732 (95% CI 0.690 to 0.773) for the pre-experts. The intra-observer agreement was 0.920 (95% CI 0.867 to 0.973) for the experts, and 0.772 (95% CI 0.652 to 0.892) for the pre-experts. This corresponds to a substantial and ‘almost perfect’ inter- and intra-observer agreement for the UCS for peri-prosthetic fractures of the pelvis and femur.

We hope that unifying the terminology of these injuries will assist in their assessment, treatment and outcome.

Cite this article: Bone Joint J 2014;96-B:1472–7.

Objectives

Hips with metal-on-metal total hip arthroplasty (MoM THA) have a high rate of adverse local tissue reactions (ALTR), often associated with hypersensitivity reactions. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) measures tissue perfusion with the parameter Ktrans (volume transfer constant of contrast agent). Our purpose was 1) to evaluate the feasibility of DCE-MRI in patients with THA and 2) to compare DCE-MRI in patients with MoM bearings with metal-on-polyethylene (MoP) bearings, hypothesising that the perfusion index Ktrans in hips with MoM THA is higher than in hips with MoP THA.

In this retrospective study, we investigated the results of revision total hip replacement (THR) using a cemented long-stemmed Exeter femoral component, with a minimum length of 205 mm in patients with extensive femoral bone defects. The study included 37 consecutive patients with a mean age of 76 years (39 to 93) and a mean follow-up of nine years (5 to 16). A total of 26 patients (70%) had a pre-operative Endo-Klinik score of 3 or 4. Impaction bone grafting was used in 24 patients (65%). At the time of evaluation, 22 patients (59%) were still alive and were evaluated clinically and radiologically. A total of 14 patients died during follow-up and their data were included until the time of their death. One reconstruction failed after five years and five months owing to recurrent dislocation: the hip was converted to an excision arthroplasty. Intra-operative fractures or fissures were encountered in nine patients (24%), but none occurred during impaction of the bone graft. Post-operative peri-prosthetic fractures occurred in two patients (5%); both were treated with plate fixation. At nine years, survival with the endpoint of all-cause re-revision was 96.3% (95% CI 76.4 to 99.5); including re-operations for any reason, it was 80.7% (95% CI 56.3 to 92.3%). There were no re-revisions for aseptic loosening.

The survival of long stem cemented femoral components following revision THR is satisfactory in a fragile population with extensive femoral defects.

Cite this article: Bone Joint J 2014; 96-B:1207–13.

Periprosthetic joint infection (PJI) is a devastating complication for patients and results in greatly increased costs of care for both healthcare providers and patients. More than 15 500 revision hip and knee procedures were recorded in England, Wales and Northern Ireland in 2013, with infection accounting for 13% of revision hip and 23% of revision knee procedures.

We report our experience of using antibiotic eluting absorbable calcium sulphate beads in 15 patients (eight men and seven women with a mean age of 64.8 years; 41 to 83) as part of a treatment protocol for PJI in revision arthroplasty.

The mean follow-up was 16 months (12 to 22). We report the outcomes and complications, highlighting the risk of hypercalcaemia which occurred in three patients.

We recommend that serum levels of calcium be routinely sought following the implantation of absorbable calcium sulphate beads in orthopaedic surgery.

Cite this article: Bone Joint J 2015;97-B:1237–41.

Aims

The optimal management of intracapsular fractures of the femoral neck in independently mobile patients remains open to debate. Successful fixation obviates the limitations of arthroplasty for this group of patients. However, with fixation failure rates as high as 30%, the outcome of revision surgery to salvage total hip arthroplasty (THA) must be considered. We carried out a systematic review to compare the outcomes of salvage THA and primary THA for intracapsular fractures of the femoral neck.

Objectives

T-cells are considered to play an important role in the inflammatory response causing arthroplasty failure. The study objectives were to investigate the composition and distribution of CD4+ T-cell phenotypes in the peripheral blood (PB) and synovial fluid (SF) of patients undergoing revision surgery for failed metal-on-metal (MoM) and metal-on-polyethylene (MoP) hip arthroplasties, and in patients awaiting total hip arthroplasty.

Data on early morbidity and complications after revision total hip replacement (THR) are limited. The aim of this nationwide study was to describe and quantify early morbidity after aseptic revision THR and relate the morbidity to the extent of the revision surgical procedure. We analysed all aseptic revision THRs from 1st October 2009 to 30th September 2011 using the Danish National Patient Registry, with additional information from the Danish Hip Arthroplasty Registry. There were 1553 procedures (1490 patients) performed in 40 centres and we divided them into total revisions, acetabular component revisions, femoral stem revisions and partial revisions. The mean age of the patients was 70.4 years (25 to 98) and the median hospital stay was five days (interquartile range 3 to 7). Within 90 days of surgery, the readmission rate was 18.3%, mortality rate 1.4%, re-operation rate 6.1%, dislocation rate 7.0% and infection rate 3.0%. There were no differences in these outcomes between high- and low-volume centres. Of all readmissions, 255 (63.9%) were due to ‘surgical’ complications versus 144 (36.1%) ‘medical’ complications. Importantly, we found no differences in early morbidity across the surgical subgroups, despite major differences in the extent and complexity of operations. However, dislocations and the resulting morbidity represent the major challenge for improvement in aseptic revision THR.

Cite this article: Bone Joint J 2014; 96-B:1464–71.

Aims

The purpose of this study was to assess early physical function after total hip or knee arthroplasty (THA/TKA), and the correlation between patient-reported outcome measures, physical performance and actual physical activity (measured by actigraphy).

Previous classification systems of failure of limb salvage focused primarily on endoprosthetic failures and lacked sufficient depth for the effective study of the causes of failure. In order to address these inadequacies, the International Society of Limb Salvage (ISOLS) formed a committee to recommend revisions of the previous systems. The purpose of this study was to report on their recommendations. The modifications were prepared using an earlier, evidence-based model with subclassification based on the existing medical literature. Subclassification for all five primary types of failure of limb salvage following endoprosthetic reconstruction were formulated and a complementary system was derived for the failure of biological reconstruction. An additional classification of failure in paediatric patients was also described.

Limb salvage surgery presents a complex array of potential mechanisms of failure, and a complete and precise classification of types of failure is required. Earlier classification systems lacked specificity, and the evidence-based system outlined here is designed to correct these weaknesses and to provide a means of reporting failures of limb salvage in order to allow the interpretation of outcome following reconstructive surgery.

Cite this article: Bone Joint J 2014;96-B:1436–40.

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 (in situ from 2.9 to 38.1 months) of the withdrawn Rejuvenate modular prosthesis. The mean wear volumes on the flat distal neck piece taper was 3.35 mm³ (0.55 to 7.57), mainly occurring in a characteristic pattern in areas with high mechanical loading. Wear volume tended to increase with time to revision (r² = 0.423, p = 0.001). Implant and patient specific data (offset, stem size, patient’s mass, age and body mass index) did not correlate with the amount of material loss observed (p >  0.078). Bilaterally revised implants showed higher amounts of combined total material loss and similar wear patterns on both sides. The consistent wear pattern found in this study has not been reported previously, suggesting that the device design and materials are associated with the failure of this prosthesis.

Cite this article: Bone Joint J 2015;97-B:1350–7.

We investigated the incidence of soft-tissue lesions after small head metal-on-metal total hip replacement (MoM THR). Between December 1993 and May 1999, 149 patients (195 hips) underwent primary cementless MoM THR.

During the follow-up period, three patients (five THRs) died and eight patients (14 THRs) were lost to follow-up. We requested that all patients undergo CT evaluation. After exclusion of five patients (six THRs) who had undergone a revision procedure, and 22 (28 THRs) who were unwilling to take part in this study, 111 patients (142 THRs) were evaluated. There were 63 men (88 THRs) and 48 women (54 THRs) with a mean age of 45.7 years (37 to 56) at the time of surgery. The mean follow-up was 15.4 years (13 to 19). A soft-tissue lesion was defined as an abnormal peri-prosthetic collection of fluid, solid lesion or asymmetrical soft-tissue mass.

At final follow-up, soft-tissue lesions were found in relation to 28 THRs (19.7%), including 25 solid and three cystic lesions. They were found in 20 men and eight women; 26 lesions were asymptomatic and two were symptomatic. The mean maximal diameter of the soft-tissue lesion was 42.3 mm (17 to 135). The relatively high rate of soft-tissue lesions observed with small head MoM THR remains a concern.

Cite this article: Bone Joint J 2014;96-B:1594–9.

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: Bone Joint J 2015;97-B:1038–45.

We report our experience of revision total hip replacement (THR) using the Revitan curved modular titanium fluted revision stem in patients with a full spectrum of proximal femoral defects. A total of 112 patients (116 revisions) with a mean age of 73.4 years (39 to 90) were included in the study. The mean follow-up was 7.5 years (5.3 to 9.1). A total of 12 patients (12 hips) died but their data were included in the survival analysis, and four patients (4 hips) were lost to follow-up. The clinical outcome, proximal bone regeneration and subsidence were assessed for 101 hips.

The mean Harris Hip Score was 88.2 (45.8 to 100) after five years and there was an increase of the mean Barnett and Nordin-Score, a measure of the proximal bone regeneration, of 20.8 (-3.1 to 52.7). Five stems had to be revised (4.3%), three (2.9%) showed subsidence, five (4.3%) a dislocation and two of 85 aseptic revisions (2.3%) a periprosthetic infection.

At the latest follow-up, the survival with revision of the stem as the endpoint was 95.7% (95% confidence interval 91.9% to 99.4%) and with aseptic loosening as the endpoint, was 100%. Peri-prosthetic fractures were not observed.

We report excellent results with respect to subsidence, the risk of fracture, and loosening after femoral revision using a modular curved revision stem with distal cone-in-cone fixation. A successful outcome depends on careful pre-operative planning and the use of a transfemoral approach when the anatomy is distorted or a fracture is imminent, or residual cement or a partially-secured existing stem cannot be removed. The shortest appropriate stem should, in our opinion, be used and secured with > 3 cm fixation at the femoral isthmus, and distal interlocking screws should be used for additional stability when this goal cannot be realised.

Cite this article: Bone Joint J 2014;96-B:889–95.

We have designed a prospective study to evaluate the usefulness of prolonged incubation of cultures from sonicated orthopaedic implants. During the study period 124 implants from 113 patients were processed (22 osteosynthetic implants, 46 hip prostheses, 54 knee prostheses, and two shoulder prostheses). Of these, 70 patients had clinical infection; 32 had received antibiotics at least seven days before removal of the implant. A total of 54 patients had sonicated samples that produced positive cultures (including four patients without infection). All of them were positive in the first seven days of incubation. No differences were found regarding previous antibiotic treatment when analysing colony counts or days of incubation in the case of a positive result. In our experience, extending incubation of the samples to 14 days does not add more positive results for sonicated orthopaedic implants (hip and knee prosthesis and osteosynthesis implants) compared with a conventional seven-day incubation period.

Cite this article: Bone Joint J 2013;95-B:1001–6.

Aims

We present a case series of ten metal-on-polyethylene total hip arthroplasties (MoP THAs) with delayed dislocation associated with unrecognised adverse local tissue reaction due to corrosion at the trunnion and pseudotumour formation.