Aims

The use of a porous metal shell supported by two augments with the ‘footing’ technique is one solution to manage Paprosky IIIB acetabular defects in revision total hip arthroplasty. The aim of this study was to assess the medium-term implant survival and radiological and clinical outcomes of this technique.

The August 2023 Hip & Pelvis Roundup³⁶⁰ looks at: Using machine learning to predict venous thromboembolism and major bleeding events following total joint arthroplasty; Antibiotic length in revision total hip arthroplasty; Preoperative colonization and worse outcomes; Short stem cemented total hip arthroplasty; What are the outcomes of one- versus two-stage revisions in the UK?; To cement or not to cement? The best approach in hemiarthroplasty; Similar re-revisions in cemented and cementless femoral revisions for periprosthetic femoral fractures in total hip arthroplasty; Are hip precautions still needed?

Aims

Joint registries typically use revision of an implant as an endpoint and report survival rates after a defined number of years. However, reporting lifetime risk of revision may be more meaningful, especially in younger patients. We aimed to assess lifetime risk of revision for patients in defined age groups at the time of primary surgery.

Aims

Total hip arthroplasties (THAs) are performed by surgeons at various stages in training with varying levels of supervision, but we do not know if this is safe practice with comparable outcomes to consultant-performed THA. Our aim was to examine the association between surgeon grade, the senior supervision of trainees, and the risk of revision following THA.

The results of 140 total hip revision procedures for "non-septic" loosening, dislocation, and fracture of the femoral stem or shaft have been personally reviewed and rated by the Harris method. The minimum follow-up period was six months: thirty-three (24 per cent) showed excellent or good results, seventy-two (51 per cent) showed fair or poor results. Subsequent excision arthroplasty was performed in thirty-one patients. The infection rate for these revision procedures was very high, suggesting that many were already infected at the time of revision, and that every "loose" hip must be assumed to be infected until proved otherwise. The mortality rate of 3 per cent was surprisingly low after more than one major surgical procedure in these elderly patients.

During the 11-year-period from 1970 to 1980, 799 total hip arthroplasties with metal-on-plastic prostheses were performed for primary osteoarthritis. In all cases high viscosity cement was used, but not under pressure; acetabular cartilage was removed, but the femoral canal was not plugged. The rate of revision and risk factors were evaluated by survivorship analysis. The overall cumulative revision rates were 11%, 14% and 19% after 8, 10, and 14 years respectively. When prophylactic antibiotics were not used, there was a significant risk of revision for infection. The risk of revision for mechanical loosening of both the acetabular and femoral components was significantly increased for men, younger patients, and if a snap-fit prosthesis with a 35 mm head and short wedged stem was used. The survivorship findings were validated by multivariate statistical analysis.

The need for supplementary screw fixation in acetabular revisions is still widely debated. We carried out 439 acetabular revisions over an eight-year period. In 171 hips with contained or small segmental defects, the Morscher press-fit cup was used. These revisions were followed prospectively. No screws were used for additional fixation.

A total of 123 hips with a mean follow-up of 7.4 years (5 to 10.5) were available for clinical and radiological review. There was no further revision of a press-fit cup for aseptic loosening. Radiological assessment revealed osteolysis in three hips. Of the original 171 hips there was cranial and medial migration of up to 6 mm at two years in 44 (26%). No further migration was seen after the second post-operative year. Acetabular revision without screws is possible with excellent medium-term results in well selected patients.

Aims

We compared the outcome of total hip arthroplasty (THA) in obese patients who previously underwent bariatric surgery and those who did not, in a matched cohort study.

Fifty-nine cases of trochanteric wire revision following hip arthroplasty with trochanteric osteotomy and reattachment were identified and their outcome was studied. Two were infected and were excluded. Five were revised for instability: four became stable while one continued to have persistent dislocation. Fifty-two were revised for pain, 36 by removal of the trochanteric wire and 16 by reattachment of the greater trochanter. Successful relief of pain was obtained in less than half the cases. There was no difference in the incidence of back pain, wiring technique, trochanteric advancement, previous surgery to the same hip, trochanteric size or the pattern of wire breakage in the successfully treated group and the unsuccessful group. Neither was the removal of intact wire from a united trochanter any more certain of relieving pain than removal of broken wire from an un-united trochanter. Six patients later required revision for loosening or infection. These results indicate the need for full radiological and haematological investigation before exploration of the greater trochanter. At exploration for pain the wires should simply be removed as we could show no successful union after late reattachment of the trochanter in the absence of instability.

The use of impacted, morsellised bone grafts has become popular in revision total hip arthroplasty (THA). The initial stability of the reconstruction and the effectiveness of any subsequent process of revitalisation and incorporation will depend on the mechanical integrity of the graft. Our aim in this study was to document the time-dependent mechanical properties of the morsellised graft. This information is useful in clinical application of the graft, in studies of migration of the implant and in the design of the joint.

We used 16 specimens of impacted, morsellised cancellous bone from the sternum of goats to assess the mechanical properties by confined compression creep tests. Consideration of the graft material as a porous, permeable solid, filled with fluid, allowed determination of the compressive modulus of the matrix, and its permeability to fluid flow.

In all specimens the compression tests showed large, irreversible deformations, caused by flow-independent creep behaviour as a result of rolling and sliding of the bone chips. The mean permeability was 8.82 *10⁻¹² m⁴/Ns (SD 43%), and the compressive modulus was 38.7 MPa (SD 34%). No correlation was found between the apparent density and the permeability or between the apparent density and the compressive modulus. The irreversible deformations in the graft could be captured by a creep law, for which the parameters were quantified.

We conclude that in clinical use the graft is bound to be subject to permanent deformation after operation. The permeability of the material is relatively high compared with, for example, human cartilage. The confined compression modulus is relatively low compared with cancellous bone of the same apparent density. Designs of prostheses used in revision surgery must accommodate the viscoelastic and permanent deformations in the graft without causing loosening at the interface.

Aims

The purpose of this study was to compare the long-term results of primary total hip arthroplasty (THA) in young patients using either a conventional (CPE) or a highly cross-linked (HXLPE) polyethylene liner in terms of functional outcome, incidence of osteolysis, radiological wear and rate of revision.

Ninety-seven revisions of total hip replacements are reviewed with a median time of observation of 47 months. Satisfactory pain relief was obtained in 86%. There were six complete failures which were reduced to three by further surgery. One hip became infected and was excised. In 12 cases the revisions were complicated by peroperative fractures and in five by dislocations. Radiographic analysis disclosed a high percentage of periarticular ossification and 25 cases of radiographic loosening of the femoral implant

We report a prospective study of 57 one-stage cemented revisions of total hip replacement for deep infection with an actively discharging sinus. The average follow-up was 7 years 4 months. Seven patients had required rerevisions, but at latest follow-up, infection was under control in 49 (86%). A discharging sinus is not, in itself, a contraindication to one-stage revision of a hip replacement

Aims

Advances in surgical technique and implant design may influence the incidence and mechanism of failure resulting in revision total hip arthroplasty (rTHA). The purpose of the current study was to characterize aetiologies requiring rTHA, and to determine whether temporal changes existed in these aetiologies over a ten-year period.

We have evaluated the extent to which diabetes affects the revision rate following total hip replacement (THR). Through the Danish Hip Arthroplasty Registry we identified all patients undergoing a primary THR (n = 57 575) between 1 January 1996 and 31 December 2005, of whom 3278 had diabetes. The presence of diabetes among these patients was identified through the Danish National Registry of Patients and the Danish National Drug Prescription Database. We estimated the relative risk for revision and the 95% confidence intervals for patients with diabetes compared to those without, adjusting for the confounding factors. Diabetes is associated with an increased risk of revision due to deep infection (relative risk = 1.45 (95% confidence interval 1.00 to 2.09), particularly in those with type 2 diabetes (relative risk = 1.49 (95% confidence interval 1.02 to 2.18)), those with diabetes for less than five years prior to THR (relative risk = 1.69 (95% confidence interval 1.24 to 2.32)), those with complications due to diabetes (relative risk = 2.11 (95% confidence interval 1.41 to 3.17)), and those with cardiovascular comorbidities prior to surgery (relative risk = 2.35 (95% confidence interval 1.39 to 3.98)). Patients and surgeons should be aware of the relatively elevated risk of revision due to deep infection following THR in diabetes particularly in those with insufficient control of their glucose level

We have designed a modular cemented femoral component for revision of failed total hip arthroplasty in which deficiency of the proximal femur is such as to require a variable extrafemoral portion of the stem. We present the results of the first 74 operations in 72 patients; 56 of the patients had grade-3 or grade-4 femoral deficiency as defined by Gustilo and Pasternak and 24 had fractures of the proximal femur, of which 22 were periprosthetic. There was or had been infection in 19 hips. At a mean follow-up of 5 years 9 months (1 to 12 years) nine stems were radiologically loose of which three had been revised. There were no failures in 45 cases in which there was fixation of the distal stem of 10 cm or more. Dislocation occurred in nine patients and there were four cases of infection in the 19 which were, or had been, infected previously. There were no neurovascular complications and no intraoperative femoral fractures. The femoral bone stock improved radiologically in 45 hips of which 29 showed considerable reformation of the proximal femur; 27 remained unchanged and two showed increasing osteoporosis

Our aim was to determine the success rate of repeated debridement and two-stage cementless revision arthroplasty according to the type of infected total hip replacement (THR). We enrolled 294 patients (294 hips) with an infected THR in the study. There were 222 men and 72 women with a mean age of 55.1 years (24.0 to 78.0). The rate of control of infection after the initial treatment and after repeated debridement and two-stage revisions was determined. The clinical (Harris hip score) and radiological results were evaluated. The mean follow-up was 10.4 years (5.0 to 14.0).

The eventual rate of control of infection was 100.0% for early superficial post-operative infection, 98.4% for early deep post-operative infection, 98.5% for late chronic infection and 91.0% for acute haematogenous infection. Overall, 288 patients (98%) maintained a functioning THR at the latest follow-up. All the allografts appeared to be united and there were no failures.

These techniques effectively controlled infection and maintained a functional THR with firm fixation in most patients. Repeated debridement and two-stage or repeated two-stage revisions further improved the rate of control of infection after the initial treatment and increased the likelihood of maintaining a functional THR.

We report the mid-term results of femoral impaction grafting which was used in 53 patients during the second stage of a two-stage revision for an infected total hip replacement. We reviewed all cases performed between 1989 and 1998. All patients underwent a Girdlestone excision arthroplasty, received local and systemic antibiotics and subsequently underwent reconstruction, using femoral impaction grafting.

Four patients had further infection (7.5%), and four died within 24 months of surgery. One patient underwent revision of the stem for a fracture below its tip at ten months. This left 44 patients with a mean follow-up of 53 months (24 to 122). All had improved clinical scores and a satisfactory radiological outcome.

Infection of a total hip replacement (THR) requires component removal and thorough local debridement. Usually, long-term antibiotic treatment in conjunction with a two-stage revision is required. This may take several months. One-stage revision using antibiotic-loaded cement has not gained widespread use, although the clinical and economic advantages are obvious. Allograft bone may be impregnated with high levels of antibiotics, and in revision of infected THR, act as a carrier providing a sustained high local concentration.

We performed 37 one-stage revision of infected THRs, without the use of cement. There were three hips which required further revision because of recurrent infection, the remaining 34 hips (92%) stayed free from infection and stable at a mean follow-up of 4.4 years (2 to 8). No adverse effects were identified. Incorporation of bone graft was comparable with unimpregnated grafts.

Antibiotic-impregnated allograft bone may enable reconstruction of bone stock, insertion of an uncemented implant and control of infection in a single operation in revision THR for infection.

The August 2024 Hip & Pelvis Roundup. 360. looks at: Understanding perceived leg length discrepancy post-total hip arthroplasty: the role of pelvic obliquity; Influence of femoral stem design on revision rates in total hip arthroplasty; Outcomes of arthroscopic labral treatment of femoroacetabular impingement in adolescents; Characteristics and quality of online searches for direct anterior versus posterior approach for total hip arthroplasty; Rapid return to braking after anterior and posterior approach total hip arthroplasty; How much protection does a collar provide?; Timing matters: reducing infection risk in total hip arthroplasty with corticosteroid injection intervals; Identifying pain recovery patterns in total hip arthroplasty using PROMIS data

Aims. Despite higher rates of revision after total hip arthroplasty (THA) being reported for uncemented stems in patients aged > 75 years, they are frequently used in this age group. Increased mortality after cemented fixation is often used as a justification, but recent data do not confirm this association. The aim of this study was to investigate the influence of the design of the stem and the type of fixation on the rate of revision and immediate postoperative mortality, focusing on the age and sex of the patients. Methods. A total of 333,144 patients with primary osteoarthritis (OA) of the hip who underwent elective THA between November 2012 and September 2022, using uncemented acetabular components without reconstruction shells, from the German arthroplasty registry were included in the study. The revision rates three years postoperatively for four types of stem (uncemented, uncemented with collar, uncemented short, and cemented) were compared within four age groups: < 60 years (Young), between 61 and 70 years (Mid-I), between 71 and 80 years (Mid-II), and aged > 80 years (Old). A noninferiority analysis was performed on the most frequently used designs of stem. Results. The design of the stem was found to have no significant influence on the rate of revision for either sex in the Young group. Uncemented collared stems had a significantly lower rate of revision compared with the other types of stem for females in the Mid-I group. There was a significantly higher rate of revision for uncemented stems in females in the Mid-II group compared with all other types of stem, while in males the rate for uncemented stems was only significantly higher than the rate for cemented stems. Cemented stems had a significantly lower revision rate compared with uncemented and short stems for both sexes in the Old cohort, as did females with collared stems. The rate of immediate postoperative mortality was similar for all types of stem in the Old age group, as were the American Society of Anesthesiologists grades. Conclusion. In patients aged > 80 years, uncemented and short stems had significantly higher revision rates compared with cemented and collared stems, especially in females. The design of the stem and type of fixation have to be analyzed in more detail than only considering cemented and uncemented fixation, in order to further improve the success of THA. Cite this article: Bone Joint J 2024;106-B(3 Supple A):130–136

Aims. In UK there are around 76,000 hip fractures occur each year 10% to 15% of which are undisplaced intracapsular. There is considerable debate whether internal fixation is the most appropriate treatment for undisplaced fractures in older patients. This study describes cannulated hip screws survivorship analysis for patients aged ≥ 60 years with undisplaced intra-capsular fractures. Methods. This was a retrospective cohort study of consecutive patients aged ≥ 60 years who had cannulated screws fixation for Garden I and II fractures in a teaching hospital between March 2013 and March 2016. The primary outcome was further same-side hip surgery. Descriptive statistics were used and Kaplan-Meier estimates calculated for implant survival. Results. A total of 114 operations were performed on 112 patients with a mean age of 80.2 years (SD 8.9). The 30-day and one-year mortality were 1% (n = 1) and 13% (n = 15), respectively. Median follow-up was 6.6 years (interquartile range 6.0 to 7.3). Kaplan-Meier estimates showed a survivorship of 95% at one year and 90% at five years (95% confidence interval 84% to 95%) for cannulated screws. Nine patients underwent further hip surgery: four revision to total hip arthroplasty, one revision to hemiarthroplasty, three removals of screws, and one haematoma washout. Posterior tilt was assessable in 106 patients; subsequent surgery was required in two of the six patients identified with a posterior angle > 20° (p = 0.035 vs angle < 20°). Of the 100 patients with angle < 20°, five-year survivorship was 91%, with seven patients requiring further surgery. Conclusion. This study of cannulated hip screw fixation for undisplaced fractures in patients aged ≥ 60 years reveals a construct survivorship without further operation of 90% at five years. Cannulated screws can be considered a safe reliable treatment option for Garden I and II fractures. Caution should be taken if posterior tilt angle on lateral view exceeds 20°, due to a higher failure rate and reoperation, and considered for similar management to Garden III and IV injuries. Cite this article: Bone Jt Open 2022;3(3):182–188

Aims. The aim of this study was to report the medium-term outcomes of impaction bone allograft and fibular grafting for osteonecrosis of the femoral head (ONFH) and to define the optimal indications. Methods. A total of 67 patients (77 hips) with ONFH were enrolled in a single centre retrospective review. Success of the procedure was assessed using the Harris Hip Score (HHS) and rate of revision to total hip arthroplasty (THA). Risk factors were studied, including age, aetiology, duration of hip pain, as well as two classification systems (Association Research Circulation Osseous (ARCO) and Japanese Investigation Committee (JIC) systems). Results. After a mean follow-up period of 8.61 years (SD 1.45), 81.3% (52/64) of enrolled cases had a good or excellent HHS at latest follow-up (declining to 76.0% (38/50) for those with more than eight years of follow-up). Overall survival was 92.1% at eight years’ follow-up (95% CI 83.2% to 96.4%). A total of 12 hips (19.0%) failed (reoperation or HHS < 70 points) at final follow-up. Rate of success was adversely affected by increasing age, duration of pain, and more severe disease as measured using the ARCO and JIC classifications, but not by aetiology of the ONFH. Conclusion. We report favourable medium-term results of this procedure. Best outcomes can be expected in patients matching the following indications: younger than 40 years; less 12-month hip pain before surgery; femoral head collapse being less than 2 mm; and integrated lateral wall of femoral head. Cite this article: Bone Joint J 2020;102-B(7):838–844

Aims. There is evidence that prior lumbar fusion increases the risk of dislocation and revision after total hip arthroplasty (THA). The relationship between prior lumbar fusion and the effect of femoral head diameter on THA dislocation has not been investigated. We examined the relationship between prior lumbar fusion or discectomy and the risk of dislocation or revision after THA. We also examined the effect of femoral head component diameter on the risk of dislocation or revision. Methods. Data used in this study were compiled from several Finnish national health registers, including the Finnish Arthroplasty Register (FAR) which was the primary source for prosthesis-related data. Other registers used in this study included the Finnish Health Care Register (HILMO), the Social Insurance Institutions (SII) registers, and Statistics Finland. The study was conducted as a prospective retrospective cohort study. Cox proportional hazards regression and Kaplan-Meier survival analysis were used for analysis. Results. Prior lumbar fusion surgery was associated with increased risk of prosthetic dislocation (hazard ratio (HR) = 2.393, p < 0.001) and revision (HR = 1.528, p < 0.001). Head components larger than 28 mm were associated with lower dislocation rates compared to the 28 mm head (32 mm: HR = 0.712, p < 0.001; 36 mm: HR = 0.700, p < 0.001; 38 mm: HR = 0.808, p < 0.140; and 40 mm: HR = 0.421, p < 0.001). Heads of 38 mm (HR = 1.288, p < 0.001) and 40 mm (HR = 1.367, p < 0.001) had increased risk of revision compared to the 28 mm head. Conclusion. Lumbar fusion surgery was associated with higher rate of hip prosthesis dislocation and higher risk of revision surgery. Femoral head component of 32 mm (or larger) associates with lower risk of dislocation in patients with previous lumbar fusion. Cite this article: Bone Joint J 2020;102-B(8):1003–1009

Aims

Dual-mobility (DM) components are increasingly used to prevent and treat dislocation after total hip arthroplasty (THA). Intraprosthetic dissociation (IPD) is a rare complication of DM that is believed to have decreased with contemporary implants. This study aimed to report incidence, treatment, and outcomes of contemporary DM IPD.

The February 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Trial of vancomycin and cefazolin as surgical prophylaxis in arthroplasty; Is preoperative posterior femoral neck tilt a risk factor for fixation failure? Cemented versus uncemented hemiarthroplasty for displaced intracapsular fractures of the hip; Periprosthetic fractures in larger hydroxyapatite-coated stems: are collared stems a better alternative for total hip arthroplasty?; Postoperative periprosthetic fracture following hip arthroplasty with a polished taper slip versus composite beam stem; Is oral tranexamic acid as good as intravenous?; Stem design and the risk of early periprosthetic femur fractures following THA in elderly patients; Does powered femoral broaching compromise patient safety in total hip arthroplasty?

Aims

Instability is a common indication for revision total hip arthroplasty (THA). However, even after the initial revision, some patients continue to have recurrent dislocation. The aim of this study was to assess the risk for recurrent dislocation after revision THA for instability.

Aims

The aim of the study was to investigate whether the primary stability of press-fit acetabular components can be improved by altering the impaction procedure.

Aims

Iliopsoas impingement occurs in 4% to 30% of patients after undergoing total hip arthroplasty (THA). Despite a relatively high incidence, there are few attempts at modelling impingement between the iliopsoas and acetabular component, and no attempts at modelling this in a representative cohort of subjects. The purpose of this study was to develop a novel computational model for quantifying the impingement between the iliopsoas and acetabular component and validate its utility in a case-controlled investigation.

Aims

The aim of this study was to determine the clinical outcomes and factors contributing to failure of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, for advanced osteoarthritis secondary to hip dysplasia.

Aims

The Birmingham Hip Resurfacing (BHR) was introduced in 1997 to address the needs of young active patients using a historically proven large-diameter metal-on-metal (MoM) bearing. A single designer surgeon’s consecutive series of 130 patients (144 hips) was previously reported at five and ten years, reporting three and ten failures, respectively. The aim of this study was to extend the follow-up of this original cohort at 25 years.

Aims

Our objective was describing an algorithm to identify and prevent vascular injury in patients with intrapelvic components.

Aims

The Exeter short stem was designed for patients with Dorr type A femora and short-term results are promising. The aim of this study was to evaluate the minimum five-year stem migration pattern of Exeter short stems in comparison with Exeter standard stems.

Aims

Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we sought to determine if a difference in functional outcomes exists between monopolar and bipolar hemiarthroplasty (HA).

C.D. Watts, J.R. Martin, M. T. Houdek, M. P. Abdel, D. G.Lewallen, M. J. Taunton Prior bariatric surgery may decrease the rate of reoperation and revision following total hip arthroplasty. Bone Joint J 2016;98-B:1180–1184

Aims

Prior studies have identified that malseating of a modular dual mobility liner can occur, with previous reported incidences between 5.8% and 16.4%. The aim of this study was to determine the incidence of malseating in dual mobility implants at our institution, assess for risk factors for liner malseating, and investigate whether liner malseating has any impact on clinical outcomes after surgery.

Aims

Femoral cement-in-cement revision is a well described technique to reduce morbidity and complications in hip revision surgery. Traditional techniques for septic revision of hip arthroplasty necessitate removal of all bone cement from the femur. In our two centres, we have been using a cement-in-cement technique, leaving the distal femoral bone cement in selected patients for septic hip revision surgery, both for single and the first of two-stage revision procedures. A prerequisite for adoption of this technique is that the surgeon considers the cement mantle to be intimately fixed to bone without an intervening membrane between cement and host bone. We aim to report our experience for this technique.

Aims

The aim of this study was to conduct a cross-sectional, observational cohort study of patients presenting for revision of a total hip, or total or unicompartmental knee arthroplasty, to understand current routes to revision surgery and explore differences in symptoms, healthcare use, reason for revision, and the revision surgery (surgical time, components, length of stay) between patients having regular follow-up and those without.

Aims

Proximal femoral endoprosthetic replacements (PFEPRs) are the most common reconstruction option for osseous defects following primary and metastatic tumour resection. This study aimed to compare the rate of implant failure between PFEPRs with monopolar and bipolar hemiarthroplasties and acetabular arthroplasties, and determine the optimum articulation for revision PFEPRs.

Aims

Cement-in-cement revision of the femoral component represents a widely practised technique for a variety of indications in revision total hip arthroplasty. In this study, we compare the clinical and radiological outcomes of two polished tapered femoral components.

Aims

Adverse local tissue reactions associated with abnormal wear considerably slowed down the general use of metal-on-metal (MoM) hip resurfacing arthroplasty (HRA), now limited to a few specialized centres. In this study, we provide the clinical results of 400 consecutive MoM HRAs implanted more than 20 years ago in one such centre.

Aseptic loosening of the acetabular component continues to be the most common indication for revision of total hip replacements in younger patients. Early in the evolution of the cemented hip, arthroplasty surgeons switched from removal to retention of the acetabular subchondral bone plate, theorising that unfavourable mechanical forces were the cause of loosening at the bone-cement interface. It is now known that the cause of aseptic loosening is probably biological rather than mechanical and removing the subchondral bone plate may enhance biological fixation of cement to bone. With this in mind, perhaps it is time to revive removal of the subchondral bone as a standard part of acetabular preparation

We investigated 219 revisions of total hip replacement (THR) in 211 patients using a collarless double-taper cemented femoral component. The mean age of the patients was 72 years (30 to 90). The 137 long and 82 standard length stems were analysed separately. The mean follow-up was six years (2 to 18), and no patient was lost to follow-up. Survival of the long stems to re-revision for aseptic loosening at nine years was 98% (95% confidence interval (CI) 94 to 100), and for the standard stems was 93% (95% CI 85 to 100). At five years, one long stem was definitely loose radiologically and one standard stem was probably loose. Pre-operative femoral bone deficiency did not influence the results for the long stems, and corrective femoral osteotomy was avoided, as were significant subsidence, major stress shielding and persistent thigh pain. Because of these reliable results, cemented long collarless double-taper femoral components are recommended for routine revision THR in older patients

Dislocation is a common reason for revision following total hip replacement. This study investigated the relationship between the bearing surface and the risk of revision due to dislocation. It was based on 110 239 primary total hip replacements with a diagnosis of osteoarthritis collected by the Australian Orthopaedic Association National Joint Replacement Registry between September 1999 and December 2007. A total of 862 (0.78%) were revised because of dislocation. Ceramic-on-ceramic bearing surfaces had a lower risk of requiring revision due to dislocation than did metal-on-polyethylene and ceramic-on-polyethylene surfaces, with a follow-up of up to seven years. However, ceramic-on-ceramic implants were more likely to have larger prosthetic heads and to have been implanted in younger patients. The size of the head of the femoral component and age are known to be independent predictors of dislocation. Therefore, the outcomes were stratified by the size of the head and age. There is a significantly higher rate of revision for dislocation in ceramic-on-ceramic bearing surfaces than in metal-on-polyethylene implants when smaller sizes (≤ 28 mm) of the head were used in younger patients (< 65 years) (hazard ratio = 1.53, p = 0.041) and also with larger (> 28 mm) and in older patients (≥ 65 years) (hazard ratio = 1.73, p = 0.016)

We followed prospectively 69 patients with 78 proximal femoral allografts performed for revision of total hip arthroplasty for an average of 36 months (range 29 to 68). Large fragment proximal femoral allografts and cortical strut allografts were successful in 85%. Grafts smaller than 3 cm in length (calcar grafts) were clinically successful in 81%, but 50% underwent significant radiographic resorption. We conclude that large proximal femoral allografts and cortical strut allografts provide dependable reconstruction of bone stock deficiencies during revision total hip arthroplasty

We report 11 patients having revision of total hip arthroplasty using massive structural allografts for failure due to sepsis and associated bone loss. All patients had a two-stage reconstruction and the mean follow-up was 47.8 months (24 to 72). Positive cultures were obtained at the first stage in nine of the 11 patients, with Staphylococcus epidermidis being the most common organism. The other two patients had draining sinuses with negative cultures. There was no recurrence of infection in any patient. The mean increase in the modified Harris hip score was 45 and all the grafts appeared to have united to host bone. Two patients required additional procedures, but only one was related to the allograft. Complications included an incomplete sciatic nerve palsy and one case of graft resorption. Our results support the use of massive allografts in failed septic hip arthroplasty in which there is associated bone loss

Aims

A lack of supporting clinical studies have been published to determine the ideal length of intramedullary nail in fixation of trochanteric fractures of the hip. Nevertheless, there has been a trend to use shorter intramedullary nails for the internal fixation of trochanteric hip fractures. Our aim was to determine if the length of nail affected the outcome.

In ten patients with sickle-cell disease, we used a new technique of cement injection for the treatment of 16 painful hips with a radiographic crescent line or flattening of the articular surface due to avascular necrosis. The necrotic bone and overlying cartilage are elevated by the injection to restore the sphericity of the femoral head. Five days after the operation, full weight-bearing was allowed with the help of crutches for three weeks. The time in hospital averaged eight days; the average blood loss was 100 ml. There was early pain relief and postoperative radiographs showed improvement in the shape of the femoral head. At a mean follow-up of 5 years (3 to 7), 14 of the 16 hips were still improved although some gave slight pain. Only two hips had required revision to total hip arthroplasty, at one year and two years respectively. The increasing longevity of patients with sickle-cell disease means that avascular necrosis will be an increasing problem. Total hip replacement has a poor prognosis because of the risks of infection, high blood loss, and early loosening. Cement injection does not have these problems and allows for earlier, more conservative surgery

It is unusual, if not unique, for three major research papers concerned with the management of the fractured neck of femur (FNOF) to be published in a short period of time, each describing large prospective randomized clinical trials. These studies were conducted in up to 17 countries worldwide, involving up to 80 surgical centers and include large numbers of patients (up to 2,900) with FNOF. Each article investigated common clinical dilemmas; the first paper comparing total hip arthroplasty versus hemiarthroplasty for FNOF, the second as to whether ‘fast track’ care offers improved clinical outcomes and the third, compares sliding hip with multiple cancellous hip screws. Each paper has been deemed of sufficient quality and importance to warrant publication in The Lancet or the New England Journal of Medicine. Although ‘premier’ journals, they only occationally contain orthopaedic studies and thus may not be routinely read by the busy orthopaedic/surgical clinician of any grade. It is therefore our intention with this present article to accurately summarize and combine the results of all three papers, presenting, in our opinion, the most important clinically relevant facts.

Cite this article: Bone Joint Open 2020;1-6:198–202.

Aims

We compared implant and patient survival following intraoperative periprosthetic femoral fractures (IOPFFs) during primary total hip arthroplasty (THA) with matched controls.

We compared the rate of revision for instability after total hip replacement (THR) when lipped and non-lipped acetabular liners were used. We hypothesised that the use of a lipped liner in a modular uncemented acetabular component reduces the risk of revision for instability after primary THR. Using data from the New Zealand Joint Registry, we found that the use of a lipped liner was associated with a significantly decreased rate of revision for instability and for all other indications. Adjusting for the size of the femoral head, the surgical approach and the age and gender of the patient, this difference remained strongly significant (p < 0.001). We conclude that evidence from the New Zealand registry suggests that the use of lipped liners with modular uncemented acetabular components is associated with a decreased rate of revision for instability after primary THR. Cite this article: Bone Joint J 2014;96-B:884–8

Aims

Prosthetic joint infection (PJI) and aseptic loosening in total hip arthroplasty (THA) can present with pain and osteolysis. The Musculoskeletal Infection Society (MSIS) has provided criteria for the diagnosis of PJI. The aim of our study was to analyze the utility of F18-fluorodeoxyglucose (FDG) positron emission tomography (PET) CT scan in the preoperative diagnosis of septic loosening in THA, based on the current MSIS definition of prosthetic joint infection.

We reviewed 1039 revision total hip replacements where an angle-bore acetabular component was used. After a mean follow-up of nine years (0 to 20.6), the incidence of revision for dislocation was 2.1% (22 revisions), a success rate of 97.9%. In 974 revisions, where the indication was other than dislocation, the success rate was 98.5%. Of the 65 revisions for dislocation, 58 (89.2%) were successful after the first revision and a further five after the second revision, an overall success of 96.9%. Two patients elected to have their implants removed. Dislocation after revision of failed total hip replacement is a complex issue. There is often no single cause and no simple solution. The angle-bore acetabular component, in combination with a 22.225-mm diameter femoral head, offers a high level of success

Objectives

Modern metal-on-metal (MoM) hip resurfacing arthroplasty (HRA), while achieving good results with well-orientated, well-designed components in ideal patients, is contraindicated in women, men with head size under 50 mm, or metal hypersensitivity. These patients currently have no access to the benefits of HRA. Highly crosslinked polyethylene (XLPE) has demonstrated clinical success in total hip arthroplasty (THA) and, when used in HRA, potentially reduces metal ion-related sequelae. We report the early performance of HRA using a direct-to-bone cementless mono-bloc XLPE component coupled with a cobalt-chrome femoral head, in the patient group for whom HRA is currently contraindicated.

We describe a technique to salvage a painful hemiarthroplasty due to erosion of the acetabular cartilage in the absence of loosening of the femoral component. A press-fit metallic acetabular component which matched the femoral component was used as a metal-on-metal articulation. The procedure offered a shorter operation time with less blood loss and no risk of femoral fracture as might have occurred during conventional revision to a total hip replacement. The patient made an unremarkable recovery with a good outcome at follow-up of 15 months

Aims

This study describes and compares the operative management and outcomes in a consecutive case series of patients with dislocated hemiarthroplasties of the hip, and compares outcomes with those of patients not sustaining a dislocation.

Aims

The aim of this study was to investigate the differences in 30-day outcomes between patients undergoing revision for an infected total hip arthroplasty (THA) compared with an aseptic revision THA.

The removal of well-fixed bone cement from the femoral canal during revision of a total hip replacement (THR) can be difficult and risks the loss of excessive bone stock and perforation or fracture of the femoral shaft. Retaining the cement mantle is attractive, yet the technique of cement-in-cement revision is not widely practised. We have used this procedure at our hospital since 1989. The stems were removed to gain a better exposure for acetabular revision, to alter version or leg length, or for component incompatibility. We studied 136 hips in 134 patients and followed them up for a mean of eight years (5 to 15). A further revision was required in 35 hips (25.7%), for acetabular loosening in 26 (19.1%), sepsis in four, instability in three, femoral fracture in one and stem fracture in one. No femoral stem needed to be re-revised for aseptic loosening. A cement-in-cement revision of the femoral stem is a reliable technique in the medium term. It also reduces the risk of perforation or fracture of the femoral shaft

In a prospective study, a double crossover wire with a compression spring was used to re-attach 52 un-united trochanters at revision operations on total hip arthroplasties. Bony union was achieved in 42 (81%) and was not influenced by the duration of the nonunion or the separation gap. The new method compared favourably with earlier revisions at which other methods of trochanteric re-attachment had been used

Aims

The aim of this study was to compare the functional and radiological outcomes in patients with a displaced fracture of the hip who were treated with a cemented or a cementless femoral stem.

Hydroxyapatite (HA) granules of 100 to 300 μm, 0.9 to 1.2 mm and 3.0 to 5.0 mm were mixed in a ratio of 10:45:45 and packed into massive bone deficiencies in revision operations for total hip arthroplasty. We did not use additional graft or cup support for deficiencies of the lateral and medial wall. The procedure was carried out in 40 hips between 1986 and 1992. The radiographic spaces seen at the interface between HA and bone immediately after surgery disappeared within three months. Some spaces appeared between HA granules near the bone in the lateral part of two joints, and three sockets migrated in patients with severe segmental and cavitary deficiencies. Direct bonding of HA to bone was observed radiologically without morphological changes, except in the three joints with migration. All patients could walk without pain but the three with definite loosening needed crutches

We investigated the radiographic and clinical course of 31 patients in whom a bulk acetabular allograft had been used during the cementless revision of a total hip replacement. Two patients died and two were lost to follow-up within 24 months, but of the remaining 27 acetabular components, 12 (44%) showed radiographic evidence of instability at a mean of 46 months. Five of these have been revised. In the 12 failures, signs of instability had been noted at an average of 29 months (1 to 60). Failures during the first 24 months were usually due to technical errors, later failures to gradual migration of the cup into the graft. The cups with the greatest amount of their surface supported by grafts were most likely to migrate, but this migration was usually asymptomatic. Screw fixation of the cup, used in 24 cases, appeared to control the mechanism of failure. Femoral head allografts and distal femoral allografts had been used, with failure in 6 of 16, and 6 of 11 respectively; distal femoral allografts were used only for large defects. The insidious course of late cup migration and graft failure necessitates close radiographic follow-up of patients treated with bulk allografts

Our aim was to determine if the serum levels of bone-resorbing cytokines (IL-1β, TNF-α, IL-6, GM-CSF) are altered in patients with aseptic loosening of a total hip prosthesis, and if such levels are influenced by the type of implant. We determined cytokine levels in sera from 35 patients before revision for failed total hip arthroplasty and compared them with those in 25 healthy donors. We also assessed the soluble receptor of interleukin-2 (sIL-2r) in serum as an indication of a specific immune reaction against the implant. Our findings showed that the sIL-2r and TNF-α serum level did not change. The IL-6 level was not significantly altered, but was higher in patients with TiAlV prostheses than in those with a CrCoMo implant and in patients with cemented prostheses. The IL-1β level was found to be higher in those with a TiAlV cemented prosthesis than in the control group (p = 0.0001) and other groups of patients (p = 0.003 v uncemented TiAlV, p = 0.01 v cemented CrCoMo, p = 0.001 v uncemented CrCoMo). The GM-CSF level significantly increased in patients compared with healthy subjects (p = 0.008), and it was higher in those with cemented than with uncemented implants (p = 0.01). Only patients with cementless CrCoMo prostheses had levels of GM-CSF similar to those of the control group. The highest GM-CSF concentrations were observed in patients treated with non-steroidal anti-inflammatory drugs (NSAIDs) in the last months before revision (p = 0.04). In addition, when massive osteolysis was observed, the level of GM-CSF tended to decrease to that of the control group

Aims

Femoral stems with exchangeable (modular) necks were introduced to offer surgeons an increased choice when determining the version, offset and length of the femoral neck during total hip arthroplasty (THA). It was hoped that this would improve outcomes and reduce complications, particularly dislocation. In 2010, the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) first reported an increased rate of revision after primary THA using femoral stems with an exchangeable neck. The aim of this study was to provide a more comprehensive up-to-date analysis of primary THA using femoral stems with exchangeable and fixed necks.

Objectives

The objective of this study was to develop a test for the rapid (within 25 minutes) intraoperative detection of bacteria from synovial fluid to diagnose periprosthetic joint infection (PJI).

Aims

To demonstrate, with concrete examples, the value of in-depth exploration and comparison of data published in National Joint Arthroplasty registry reports.

Aims

We evaluated the short-term functional outcome and prevalence of bearing-specific generation of audible noise in 301 patients (336 hips) operated on with fourth generation (Delta) medium diameter head, ceramic-on-ceramic (CoC) total hip arthroplasties (THAs).

Prophylactic antibiotics can decrease the risk of wound infection and have been routinely employed in orthopaedic surgery for decades. Despite their widespread use, questions still surround the selection of antibiotics for prophylaxis, timing and duration of administration. The health economic costs associated with wound infections are significant, and the judicious but appropriate use of antibiotics can reduce this risk.

This review examines the evidence behind commonly debated topics in antibiotic prophylaxis and highlights the uses and advantages of some commonly used antibiotics.

Cite this article: Bone Joint J 2016;98-B:1014–19.

Aims

We aimed to assess the comparability of data in joint replacement registries and identify ways of improving the comparisons between registries and the overall monitoring of joint replacement surgery.

The orientation of the acetabular component can influence both the short- and long-term outcomes of total hip replacement (THR). We performed a prospective, randomised, controlled trial of two groups, comprising of 40 patients each, in order to compare freehand introduction of the component with introduction using the transverse acetabular ligament (TAL) as a reference for anteversion. Anteversion and inclination were measured on pelvic radiographs.

With respect to anteversion, in the freehand group 22.5% of the components were outside the safe zone versus 0% in the transverse acetabular ligament group (p = 0.002). The mean angle of anteversion in the freehand group was 21° (2° to 35°) which was significantly higher compared with 17° (2° to 25°) in the TAL group (p = 0.004). There was a significant difference comparing the variations of both groups (p = 0.008).

With respect to inclination, in the freehand group 37.5% of the components were outside the safe zone versus 20% in the TAL group (p = 0.14). There was no significant difference regarding the accuracy or variation of the angle of inclination when comparing the two groups.

The transverse acetabular ligament may be used to obtain the appropriate anteversion when introducing the acetabular component during THR, but not acetabular component inclination.

Cite this article: Bone Joint J 2014;96-B:312–18.

We report the five year outcomes of a two-stage approach for infected total hip replacement. This is a single-surgeon experience at a tertiary centre where the more straightforward cases are treated using single-stage exchange. This study highlights the vital role of the multidisciplinary team in managing these cases.

A total of 125 patients (51 male, 74 female) with a mean age of 68 years (42 to 78) were reviewed prospectively. Functional status was assessed using the Harris hip score (HHS). The mean HHS improved from 38 (6 to 78.5) pre-operatively to 81.2 (33 to 98) post-operatively. Staphylococcus species were isolated in 85 patients (68%).

The rate of control of infection was 96% at five years. In all, 19 patients died during the period of the study. This represented a one year mortality of 0.8% and an overall mortality of 15.2% at five years. No patients were lost to follow-up.

We report excellent control of infection in a series of complex patients and infections using a two-stage revision protocol supported by a multidisciplinary approach. The reason for the high rate of mortality in these patients is not known.

Cite this article: Bone Joint J 2014;96-B:1312–18

We compared a new fixation system, the Targon Femoral Neck (TFN) hip screw, with the current standard treatment of cannulated screw fixation. This was a single-centre, participant-blinded, randomised controlled trial. Patients aged 65 years and over with either a displaced or undisplaced intracapsular fracture of the hip were eligible. The primary outcome was the risk of revision surgery within one year of fixation.

A total of 174 participants were included in the trial. The absolute reduction in risk of revision was of 4.7% (95% CI 14.2 to 22.5) in favour of the TFN hip screw (chi-squared test, p = 0.741), which was less than the pre-specified level of minimum clinically important difference. There were no significant differences in any of the secondary outcome measures.

We found no evidence of a clinical difference in the risk of revision surgery between the TFN hip screw and cannulated screw fixation for patients with an intracapsular fracture of the hip.

Cite this article: Bone Joint J 2014;96-B:652–7.

United Kingdom National Institute for Health and Clinical Excellence guidelines recommend the use of total hip replacement (THR) for displaced intracapsular fractures of the femoral neck in cognitively intact patients, who were independently mobile prior to the injury. This study aimed to analyse the risk factors associated with revision of the implant and mortality following THR, and to quantify risk. National Joint Registry data recording a THR performed for acute fracture of the femoral neck between 2003 and 2010 were analysed. Cox proportional hazards models were used to investigate the extent to which risk of revision was related to specific covariates. Multivariable logistic regression was used to analyse factors affecting peri-operative mortality (< 90 days). A total of 4323 procedures were studied. There were 80 patients who had undergone revision surgery at the time of censoring (five-year revision rate 3.25%, 95% confidence interval 2.44 to 4.07) and 137 patients (3.2%) patients died within 90 days. After adjusting for patient and surgeon characteristics, an increased risk of revision was associated with the use of cementless prostheses compared with cemented (hazard ratio (HR) 1.33, p = 0.021). Revision was independent of bearing surface and head size. The risk of mortality within 90 days was significantly increased with higher American Society of Anesthesiologists (ASA) grade (grade 3: odds ratio (OR) 4.04, p < 0.001; grade 4/5: OR 20.26, p < 0.001; both compared with grades 1/2) and older age (≥ 75 years: OR 1.65, p = 0.025), but reduced over the study period (9% relative risk reduction per year).

THR is a good option in patients aged < 75 years and with ASA 1/2. Cementation of the femoral component does not adversely affect peri-operative mortality but improves survival of the implant in the mid-term when compared with cementless femoral components. There are no benefits of using head sizes > 28 mm or bearings other than metal-on-polyethylene. More research is required to determine the benefits of THR over hemiarthroplasty in older patients and those with ASA grades > 2.

This review summarises the opinions and conclusions reached from a symposium on infected total knee replacement (TKR) held at the British Association of Surgery of the Knee (BASK) annual meeting in 2011. The National Joint Registry for England and Wales reported 5082 revision TKRs in 2010, of which 1157 (23%) were caused by infection. The diagnosis of infection beyond the acute post-operative stage relies on the identification of the causative organism by aspiration and analysis of material obtained at arthroscopy. Ideal treatment then involves a two-stage surgical procedure with extensive debridement and washout, followed by antibiotics. An articulating or non-articulating drug-eluting cement spacer is used prior to implantation of the revision prosthesis, guided by the serum level of inflammatory markers. The use of a single-stage revision is gaining popularity and we would advocate its use in certain patients where the causative organism is known, no sinuses are present, the patient is not immunocompromised, and there is no radiological evidence of component loosening or osteitis.

It is our opinion that single-stage revision produces high-quality reproducible results and will soon achieve the same widespread acceptance as it does in infected hip arthroplasty.

We review the history and literature of hip resurfacing arthroplasty. Resurfacing and the science behind it continues to evolve. Recent results, particularly from the national arthroplasty registers, have spread disquiet among both surgeons and patients. A hip resurfacing arthroplasty is not a total hip replacement, but should perhaps be seen as a means of delaying it. The time when hip resurfacing is offered to a patient may be different from that for a total hip replacement. The same logic can apply to the timing of revision surgery. Consequently, the comparison of resurfacing with total hip replacement may be a false one. Nevertheless, the need for innovative solutions for young arthroplasty patients is clear. Total hip replacement can be usefully delayed in many of these patients by the use of hip resurfacing arthroplasty.

Obesity is an epidemic across both the developed and developing nations that is possibly the most important current public health factor affecting the morbidity and mortality of the global population. Obese patients have the potential to pose several challenges for arthroplasty surgeons from the standpoint of the influence obesity has on osteoarthritic symptoms, their peri-operative medical management, the increased intra-operative technical demands on the surgeon, the intra- and post-operative complications, the long term outcomes of total hip and knee arthroplasty. Also, there is no consensus on the role the arthroplasty surgeon should have in facilitating weight loss for these patients, nor whether obesity should affect the access to arthroplasty procedures.

We analysed data from the Oxford hip and knee questionnaires collected by the New Zealand Joint Registry at six months and five years after joint replacement, to determine if there was any relationship between the scores and the risk of early revision. Logistic regression of the six-month scores indicated that for every one-unit decrease in the Oxford score, the risk of revision within two years increased by 9.7% for total hip replacement (THR), 9.9% for total knee replacement (TKR) and 12.0% for unicompartmental knee replacement (UKR). Our findings showed that 70% of the revisions within two years for TKR and 67% for THR and UKR would have been captured by monitoring the lowest 22%, 28% and 28%, respectively, of the Oxford scores. When analysed using the Kalairajah classification a score of < 27 (poor) was associated with a risk of revision within two years of 7.6% for THR, 7.0% for TKR and 24.3% for UKR, compared with risks of 0.7%, 0.7% and 1.8%, respectively, for scores > 34 (good or excellent).

Our study confirms that the Oxford hip and knee scores at six months are useful predictors of early revision after THR and TKR and we recommend their use for the monitoring of the outcome and potential failure in these patients.

We undertook a prospective randomised controlled trial involving 400 patients with a displaced intracapsular fracture of the hip to determine whether there was any difference in outcome between treatment with a cemented Thompson hemiarthroplasty and an uncemented Austin-Moore prosthesis. The surviving patients were followed up for between two and five years by a nurse blinded to the type of prosthesis used.

The mean age of the patients was 83 years (61 to 104) and 308 (77%) were women. The degree of residual pain was less in those treated with a cemented prosthesis (p < 0.0001) three months after surgery. Regaining mobility was better in those treated with a cemented implant (p = 0.005) at six months after operation. No statistically significant difference was found between the two groups with regard to mortality, implant-related complications, re-operations or post-operative medical complications.

The use of a cemented Thompson hemiarthroplasty resulted in less pain and less deterioration in mobility than an uncemented Austin-Moore prosthesis with no increase in complications.

It is accepted that resurfacing hip replacement preserves the bone mineral density (BMD) of the femur better than total hip replacement (THR). However, no studies have investigated any possible difference on the acetabular side.

Between April 2007 and March 2009, 39 patients were randomised into two groups to receive either a resurfacing or a THR and were followed for two years. One patient’s resurfacing subsequently failed, leaving 19 patients in each group.

Resurfaced replacements maintained proximal femoral BMD and, compared with THR, had an increased bone mineral density in Gruen zones 2, 3, 6, and particularly zone 7, with a gain of 7.5% (95% confidence interval (CI) 2.6 to 12.5) compared with a loss of 14.6% (95% CI 7.6 to 21.6). Resurfacing replacements maintained the BMD of the medial femoral neck and increased that in the lateral zones between 12.8% (95% CI 4.3 to 21.4) and 25.9% (95% CI 7.1 to 44.6).

On the acetabular side, BMD was similar in every zone at each point in time. The mean BMD of all acetabular regions in the resurfaced group was reduced to 96.2% (95% CI 93.7 to 98.6) and for the total hip replacement group to 97.6% (95% CI 93.7 to 101.5) (p = 0.4863). A mean total loss of 3.7% (95% CI 1.0 to 6.5) and 4.9% (95% CI 0.8 to 9.0) of BMD was found above the acetabular component in W1 and 10.2% (95% CI 0.9 to 19.4) and 9.1% (95% CI 3.8 to 14.4) medial to the implant in W2 for resurfaced replacements and THRs respectively. Resurfacing resulted in a mean loss of BMD of 6.7% (95% CI 0.7 to 12.7) in W3 but the BMD inferior to the acetabular component was maintained in both groups.

These results suggest that the ability of a resurfacing hip replacement to preserve BMD only applies to the femoral side.

Soaking bone grafts in a bisphosphonate solution before implantation can prevent their resorption and increase the local bone density in rats and humans. However, recent studies suggest that pre-treatment of allografts with bisphosphonate can prevent bone ingrowth into impaction grafts. We tested the hypothesis that excessive amounts of bisphosphonate would also cause a negative response in less dense grafts. We used a model where non-impacted metaphyseal bone grafts were randomised into three groups with either no bisphosphonate, alendronate followed by rinsing, and alendronate without subsequent rinsing, and inserted into bone chambers in rats. The specimens were evaluated histologically at one week, and by histomorphometry and radiology at four weeks. At four weeks, both bisphosphonate groups showed an increase in the total bone content, increased newly formed bone, and higher radiodensity than the controls. In spite of being implanted in a chamber with a limited opportunity to diffuse, even an excessive amount of bisphosphonate improved the outcome. We suggest that the negative results seen by others could be due to the combination of densely compacted bone and a bisphosphonate.

We suggest that bisphosphonates are likely to have a negative influence where resorption is a prerequisite to create space for new bone ingrowth.

Developmental dysplasia of the hip predisposes to premature degenerative hip disease. A number of operations have been described to improve acetabular cover and have achieved varying degrees of success. We present the case of an 84-year-old woman, who underwent a shelf procedure to reconstruct a dysplastic hip 75 years ago. To date, the shelf remains intact and the hip is asymptomatic. We believe this represents the longest documented outcome of any procedure to stabilise the hip.

In a systematic review, reports from national registers and clinical studies were identified and analysed with respect to revision rates after joint replacement, which were calculated as revisions per 100 observed component years.

After primary hip replacement, a mean of 1.29 revisions per 100 observed component years was seen. The results after primary total knee replacement are 1.26 revisions per 100 observed component years, and 1.53 after medial unicompartmental replacement. After total ankle replacement a mean of 3.29 revisions per 100 observed component years was seen.

The outcomes of total hip and knee replacement are almost identical. Revision rates of about 6% after five years and 12% after ten years are to be expected.

Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. However, trials supporting its use have not fully evaluated the risks of wound complications. This study of 1048 total hip/knee replacements records the rates of return to theatre and infection before and after the change from a low molecular weight heparin (tinzaparin) to rivaroxaban as the agent of chemical thromboprophylaxis in patients undergoing lower-limb arthroplasty. During a period of 13 months, 489 consecutive patients undergoing lower-limb arthroplasty received tinzaparin and the next 559 consecutive patients received rivaroxaban as thromboprophylaxis.

Nine patients in the control (tinzaparin) group (1.8%, 95% confidence interval 0.9 to 3.5) returned to theatre with wound complications within 30 days, compared with 22 patients in the rivaroxaban group (3.94%, 95% confidence interval 2.6 to 5.9). This increase was statistically significant (p = 0.046). The proportion of patients who returned to theatre and became infected remained similar (p = 0.10).

Our study demonstrates the need for further randomised controlled clinical trials to be conducted to assess the safety and efficacy of rivaroxaban in clinical practice, focusing on the surgical complications as well as the potential prevention of venous thromboembolism.

The mechanical performance of the cement-in-cement interface in revision surgery has not been fully investigated. The quantitative effect posed by interstitial fluids and roughening of the primary mantle remains unclear. We have analysed the strength of the bilaminar cement-bone interface after exposure of the surface of the primary mantle to roughening and fluid interference. The end surfaces of cylindrical blocks of cement were machined smooth (Ra = 200 nm) or rough (Ra = 5 μm) and exposed to either different volumes of water and carboxymethylcellulose (a bone-marrow equivalent) or left dry. Secondary blocks were cast against the modelled surface. Monoblocks of cement were used as a control group. The porosity of the samples was investigated using micro-CT. Samples were exposed to a single shearing force to failure.

The mean failure load of the monoblock control was 5.63 kN (95% confidence interval (CI) 5.17 to 6.08) with an estimated shear strength of 36 MPa. When small volumes of any fluid or large volumes were used, the respective values fell between 4.66 kN and 4.84 kN with no significant difference irrespective of roughening (p > 0.05). Large volumes of carboxymethylcellulose significantly weakened the interface. Roughening in this group significantly increased the strength with failure loads of 2.80 kN (95% CI 2.37 to 3.21) compared with 0.86 kN (95% CI 0.43 to 1.27) in the smooth variant. Roughening of the primary mantle may not therefore be as crucial as has been previously thought in clinically relevant circumstances.

We aimed to identify variables associated with clinical and radiological outcome following fractures of the acetabulum associated with posterior dislocation of the hip. Using a prospective database of 1076 such fractures, we identified 109 patients with this combined injury managed operatively within three weeks and followed up for two or more years. The patients had a mean age of 42 years (15 to 79), 78 (72%) were male, and 84 (77%) had been involved in motor vehicle accidents. Using multivariate analysis the quality of reduction of the fracture was identified as the only significant predictor of radiological grade, clinical function and the development of post-traumatic arthritis (p < 0.001). All patients lacking anatomical reduction developed arthritis whereas only 25.5% (24 patients) with an anatomical reduction did so (p = 0.05).

The quality of the reduction of the fracture is the most important variable in forecasting the outcome for patients with this injury. The interval to reduction of the dislocation of the hip may be less important than previously described.

Recent publication of reports showing high revision rates for hip and knee replacements carried out in Independent Sector Treatment Centres (ISTCs) has raised doubts regarding their ability to provide high quality healthcare. The high revision rates also create a financial burden to the NHS. The poor quality of data collected at ISTCs makes their performance difficult to evaluate. Funds may be better spent improving existing NHS facilities rather than establishing parallel ISTCs.

Loss of bone stock is a major problem in revision surgery of the hip. Impaction bone grafting of the femur is frequently used when dealing with deficient bone stock. In this retrospective study a consecutive series of 68 patients (69 hips) who had revision of a hip replacement with femoral impaction grafting were reviewed. Irradiated bone allograft was used in all hips. Radiological measurement of subsidence of the stem, incorporation of the graft and remodelling was carried out and showed incorporation of the graft in 26 of 69 hips (38%). However, there was no evidence of trabecular remodelling. Moderate subsidence of 5 mm to 10 mm occurred in ten hips (14.5%), and massive subsidence of > 10 mm in five (7.2%).

The results of this study are less favourable than those of others describing studies of revision of the femoral stem using impaction bone grafting. The absence of the characteristic changes of graft remodelling noted in other series raises the question as to whether irradiated bone graft may be a significant factor influencing the post-operative outcome.

Methicillin-resistant Staphylococcus aureus (MRSA) has become a ubiquitous bacterium in both the hospital and community setting. There are two major subclassifications of MRSA, community-acquired and healthcare-acquired, each with differing pathogenicity and management. MRSA is increasingly responsible for infections in otherwise healthy, active adults. Local outbreaks affect both professional and amateur athletes and there is increasing public awareness of the issue. Health-acquired MRSA has major cost and outcome implications for patients and hospitals. The increasing prevalence and severity of MRSA means that the orthopaedic community should have a basic knowledge of the bacterium, its presentation and options for treatment.

This paper examines the evolution of MRSA, analyses the spectrum of diseases produced by this bacterium and presents current prevention and treatment strategies for orthopaedic infections from MRSA.

This prospective five-year study analyses the impact of methicillin-resistant Staphylococcus aureus (MRSA) on an Irish orthopaedic unit. We identified 318 cases of MRSA, representing 0.76% of all admissions (41 971). A total of 240 (76%) cases were colonised with MRSA, while 120 (37.7%) were infected. Patients were admitted from home (218; 68.6%), nursing homes (72; 22.6%) and other hospitals (28; 8.8%). A total of 115 cases (36.6%) were colonised or infected on admission. Many patients were both colonised and infected at some stage. The length of hospital stay was almost trebled because of the presence of MRSA infection.

Encouragingly, overall infection rates have not risen significantly over the five years of the study despite increased prevalence of MRSA. However, the financial burden of MRSA is increasing, highlighting the need for progress in understanding how to control this resistant pathogen more effectively.

This prospective study evaluates the role of new laboratory markers in the diagnosis of deep implant infection in 78 patients (41 men and 37 women) with a revision total knee or hip replacement.

The mean age at the time of operation was 64.0 years (19 to 90). Intra-operative cultures showed that 21 patients had a septic and 57 an aseptic total joint replacement. The white blood cell count, the erythrocyte sedimentation rate and levels of C-reactive protein, interleukin-6, procalcitonin and tumour necrosis factor (TNF)-α were measured in blood samples before operation. The diagnostic cut-off values were determined by Received Operating Characteristic curve analysis.

C-reactive protein (> 3.2 md/dl) and interleukin-6 (> 12 pg/ml) have the highest sensitivity (0.95). Interleukin-6 is less specific than C-reactive protein (0.87 vs 0.96). Combining C-reactive protein and interleukin-6 identifies all patients with deep infection of the implant. Procalcitonin (> 0.3 ng/ml) and TNF-α (> 40 ng/ml) are very specific (0.98 vs 0.94) but have a low sensitivity (0.33 vs 0.43).

The combination of C-reactive protein and interleukin-6 measurement provide excellent screening tests for infection of a deep implant. A highly specific marker such as procalcitonin and pre-operative aspiration of the joint might be useful in identifying patients with true positive C-reactive protein and/or interleukin-6 levels.

Studies on the migration of an implant may be the only way of monitoring the early performance of metal-on-metal prostheses. The Ein Bild Roentgen Analyse - femoral component analysis (EBRA-FCA) method was adapted to measure migration of the femoral component in a metal-on-metal surface arthroplasty of the hip using standard antero-posterior radiographs. In order to determine the accuracy and precision of this method a prosthesis was implanted into cadaver bones. Eleven series of radiographs were used to perform a zero-migration study. After adjustment of the femoral component to simulate migration of 3 mm the radiographs were repeated. All were measured independently by three different observers.

The accuracy of the method was found to be ± 1.6 mm for the x-direction and ± 2 mm for the y-direction (95% percentile). The method was validated using 28 hips with a minimum follow-up of 3.5 years after arthroplasty. Seventeen were sound, but 11 had failed because of loosening of the femoral component. The normal (control) group had a different pattern of migration compared with that of the loose group. At 29.2 months, the control group showed a mean migration of 1.62 mm and 1.05 mm compared with 4.39 mm and 4.05 mm in the failed group, for the centre of the head and the tip of the stem, respectively (p = 0.001). In the failed group, the mean time to migration greater than 2 mm was earlier than the onset of clinical symptoms or radiological evidence of failure, 19.1 versus 32.2 months (p = 0.001) and 24.8 months (p = 0.012), respectively.

EBRA-FCA is a reliable and valid tool for measuring migration of the femoral component after surface arthroplasty and can be used to predict early failure of the implant. It may be of value in determining the long-term performance of surface arthroplasty.

Revision arthroplasty after infection can often be complicated by both extensive bone loss and a relatively high rate of re-infection. Using allograft to address the bone loss in such patients is controversial because of the perceived risk of bacterial infection from the use of avascular graft material. We describe 12 two-stage revisions for infection in which segmental allografts were loaded with antibiotics using iontophoresis, a technique using an electrical potential to drive ionised antibiotics into cortical bone.

Iontophoresis produced high levels of antibiotic in the allograft, which eluted into the surrounding tissues. We postulate that this offers protection from infection in the high-risk peri-operative period. None of the 12 patients who had two-stage revision with iontophoresed allografts had further infection after a mean period of 47 months (14 to 78).

This retrospective study describes the long-term results of core decompression and placement of a non-vascularised bone graft in the management of avascular necrosis of the femoral head. We treated 80 hips in 65 patients, 18 by a cortical tibial autograft and 62 by a fibular allograft. The mean age of the patients was 36 years (sd 13.2). A total of 78 hips were available for evaluation of which pre-operatively six were Ficat-Arlet stage 0, three stage I, 31 stage IIA, 16 stage IIB, 13 stage III and nine stage IV.

A total of 34 hips (44%) were revised at a mean of four years (sd 3.8). Survivorship analysis using a clinical end-point showed a survival rate of 59% five years after surgery. We found a significant difference (p = 0.002) in survivorship, when using a clinical and radiological end-point, between the two grafts, in favour of the tibial autograft. We considered this difference to be the result of the better quality and increased volume of tibial bone compared with that from the trochanteric region used with the fibular allograft.

This is a relatively simple, extra-articular and reproducible procedure. In our view core decompression, removal of the necrotic tissue and packing of the cancellous grafts into the core track are vital parts of the procedure.

Impacted morsellised allografts have been used successfully to address the problem of poor bone stock in revision surgery. However, there are concerns about the transmission of pathogens, the high cost and the shortage of supply of donor bone. Bone-graft extenders, such as tricalcium phosphate (TCP) and hydroxyapatite (HA), have been developed to minimise the use of donor bone. In a human cadaver model we have evaluated the surgical and mechanical feasibility of a TCP/HA bone-graft extender during impaction grafting revision surgery.

A TCP/HA allograft mix increased the risk of producing a fissure in the femur during the impaction procedure, but provided a higher initial mechanical stability when compared with bone graft alone. The implications of the use of this type of graft extender in impaction grafting revision surgery are discussed.

We studied 217 patients with an unstable trochanteric or subtrochanteric fracture who had been randomly allocated to treatment by either internal fixation with a standard Gamma nail (SGN) or a Medoff sliding plate (MSP, biaxial dynamisation mode). Their mean age was 84 years (65 to 99) and they were reviewed at four and 12 months after surgery. Assessments of outcome included general complications, technical failures, revision surgery, activities of daily living (ADL), hip function (Charnley score) and the health-related quality of life (HRQOL, EQ-5D).

The rate of technical failure in patients with unstable trochanteric fractures was 6.5% (6/93) (including intra-operative femoral fractures) in the SGN group and 5.2% (5/96) in the MSP group. In patients with subtrochanteric fractures, there were no failures in the SGN group (n = 16) and two in the MSP group (n = 12). In the SGN group, there were intra-operative femoral fractures in 2.8% (3/109) and no post-operative fractures. There was a reduced need for revision surgery in the SGN group compared with the MSP group (8.3%; 9/108; p = 0.072). The SGN group also showed a lower incidence of severe general complications (p < 0.05) and a trend towards a lower incidence of wound infections (p = 0.05). There were no differences between the groups regarding the outcome of ADL, hip function or the HRQOL. The reduction in the HRQOL (EQ-5D_indexscore) was significant in both groups compared with that before the fracture (p < 0.005).

Our findings indicate that the SGN showed good results in both trochanteric and subtrochanteric fractures. The limited number of intra-operative femoral fractures did not influence the outcome or the need for revision surgery. Moreover, the SGN group had a reduced number of serious general complications and wound infections compared with the MSP group. The MSP in the biaxial dynamisation mode had a low rate of failure in trochanteric fractures but an unacceptably high rate when used in the biaxial dynamisation mode in subtrochanteric fractures.

The negative influence of an unstable trochanteric or subtrochanteric fracture on the quality of life was significant regardless of the surgical method.