There remains confusion in the literature with regard to the spinopelvic relationship, and its contribution to ideal acetabular component position. Critical assessment of the literature has been limited by use of conflicting terminology and definitions of new concepts that further confuse the topic. In 2017, the concept of a Hip-Spine Workgroup was created with the first meeting held at the American Academy of
We reviewed the results of 71 revisions of the acetabular component in total hip replacement, using impaction of bone allograft. The mean follow-up was 7.2 years (1.6 to 9.7). All patients were assessed according to the American Academy of
We retrospectively reviewed 40 hips in 36 patients who had undergone acetabular reconstruction using a titanium Kerboull-type acetabular reinforcement device with bone allografts between May 2001 and April 2006. Impacted bone allografts were used for the management of American Academy of
Deficiencies of acetabular bone stock at revision hip replacement were reconstructed with two different types of allograft using impaction bone grafting and a Burch-Schneider reinforcement ring. We compared a standard frozen non-irradiated bone bank allograft (group A) with a freeze-dried irradiated bone allograft, vitalised with autologous marrow (group B). We studied 78 patients (79 hips), of whom 87% (69 hips) had type III acetabular defects according to the American Academy of
Pelvic discontinuity is a rare but increasingly common complication of total hip arthroplasty (THA). This single-centre study evaluated the performance of custom-made triflange acetabular components in acetabular reconstruction with pelvic discontinuity by determining: 1) revision and overall implant survival rates; 2) discontinuity healing rate; and 3) Harris Hip Score (HHS). Retrospectively collected data of 38 patients (39 hips) with pelvic discontinuity treated with revision THA using a custom-made triflange acetabular component were analyzed. Minimum follow-up was two years (mean 5.1 years (2 to 11)).Aims
Methods
The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population. We performed a post hoc exploratory analysis of a fitter cohort of patients from the HEALTH trial. Participants were aged over 50 years and had sustained a low-energy displaced femoral neck fracture (FNF). The fittest participant cohort was defined as participants aged 70 years or younger, classified as American Society of Anesthesiologists grade I or II, independent walkers prior to fracture, and living at home prior to fracture. Multilevel models were used to estimate the effect of THA versus HA on functional outcomes. In addition, a sensitivity analysis of the definition of the fittest participant cohort was performed.Aims
Methods
Total hip arthroplasty (THA) with dual-mobility components (DM-THA) has been shown to decrease the risk of dislocation in the setting of a displaced neck of femur fracture compared to conventional single-bearing THA (SB-THA). This study assesses if the clinical benefit of a reduced dislocation rate can justify the incremental cost increase of DM-THA compared to SB-THA. Costs and benefits were established for patients aged 75 to 79 years over a five-year time period in the base case from the Canadian Health Payer’s perspective. One-way and probabilistic sensitivity analysis assessed the robustness of the base case model conclusions.Aims
Methods
This study investigates head-neck taper corrosion with varying head size in a novel hip simulator instrumented to measure corrosion related electrical activity under torsional loads. In all, six 28 mm and six 36 mm titanium stem-cobalt chrome head pairs with polyethylene sockets were tested in a novel instrumented hip simulator. Samples were tested using simulated gait data with incremental increasing loads to determine corrosion onset load and electrochemical activity. Half of each head size group were then cycled with simulated gait and the other half with gait compression only. Damage was measured by area and maximum linear wear depth.Aims
Methods
This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time. Overall, 37,708 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked with data in the Norwegian Patient Registry. Hospitals treating hip fractures were characterized according to their hip fracture care. Waiting time (hours from admission to start of surgery), surgery within regular working hours, and surgery on the day of or on the day after admission, i.e. ‘expedited surgery’ were estimated.Aims
Methods
While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty. In 2017, our institution introduced a standardized interdisciplinary hip fracture protocol. We retrospectively reviewed adult patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fracture between July 2012 and March 2020, and compared patient characteristics and outcomes between those treated before and after the introduction of the protocol.Aims
Methods
A typical pattern of blood loss associated with total hip arthroplasty (THA) is 200 ml intraoperatively and 1.3 l in the first 48 postoperative hours. Tranexamic acid (TXA) is most commonly given as a single preoperative dose only and is often withheld from patients with a history of thromboembolic disease as they are perceived to be “high-risk” with respect to postoperative venous thromboembolism (VTE). The TRanexamic ACid for 24 hours trial (TRAC-24) aimed to identify if an additional 24-hour postoperative TXA regime could further reduce blood loss beyond a once-only dose at the time of surgery, without excluding these high-risk patients. TRAC-24 was a prospective, phase IV, single centre, open label, parallel group, randomized controlled trial (RCT) involving patients undergoing primary unilateral elective THA. The primary outcome measure was the indirect calculated blood loss (IBL) at 48 hours. The patients were randomized into three groups. Group 1 received 1 g intravenous (IV) TXA at the time of surgery and an additional oral regime for 24 hours postoperatively, group 2 only received the intraoperative dose, and group 3 did not receive any TXA.Aims
Methods
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. All rTHAs performed at a single institution from 2009 to 2019 were identified. Demographic information and mode of implant failure was obtained for all patients. Data for rTHA were stratified into two time periods to assess for temporal changes: 2009 to 2013, and 2014 to 2019. Operative reports, radiological imaging, and current procedural terminology (CPT) codes were cross-checked to ensure the accurate classification of revision aetiology for each patient.Aims
Methods
This single-centre observational study aimed to describe the results of extensive bone impaction grafting of the whole acetabular cavity in combination with an uncemented component in acetabular revisions performed in a standardized manner since 1993. Between 1993 and 2013, 370 patients with a median age of 72 years (interquartile range (IQR) 63 to 79 years) underwent acetabular revision surgery. Of these, 229 were more than ten years following surgery and 137 were more than 15 years. All revisions were performed with extensive use of morcellized allograft firmly impacted into the entire acetabular cavity, followed by insertion of an uncemented component with supplementary screw fixation. All types of reoperation were captured using review of radiographs and medical charts, combined with data from the local surgical register and the Swedish Hip Arthroplasty Register.Aims
Methods
The aim of this study was to analyze the effect of a lateral rim mesh on the survival of primary total hip arthroplasty (THA) in young patients, aged 50 years or younger. We compared a study group of 235 patients (257 hips) who received a primary THA with the use of impaction bone grafting (IBG) with an additional lateral rim mesh with a group of 306 patients (343 hips) who received IBG in the absence of a lateral rim mesh during the same period from 1988 to 2015. In the mesh group, there were 74 male and 183 female patients, with a mean age of 35 years (13 to 50). In the no-mesh group, there were 173 male and 170 female patients, with a mean age of 38 years (12.6 to 50). Cox regression analyses were performed to study the effect of a lateral rim mesh on acetabular component survival. Kaplan–Meier analyses with 95% confidence intervals (CIs) were performed to estimate the survival of the acetabular implant.Aims
Patients and Methods
The management of acetabular defects at the time of revision hip arthroplasty surgery is a challenge. This study presents the results of a long-term follow-up study of the use of irradiated allograft bone in acetabular reconstruction. Between 1990 and 2000, 123 hips in 110 patients underwent acetabular reconstruction for aseptic loosening, using impaction bone grafting with frozen, irradiated, and morsellized femoral heads and a cemented acetabular component. A total of 55 men and 55 women with a mean age of 64.3 years (26 to 97) at the time of revision surgery are included in this study.Aims
Patients and Methods
The primary aim of this paper was to outline the processes involved in building the Partners Arthroplasty Registry (PAR), established in April 2016 to capture baseline and outcome data for patients undergoing arthroplasty in a regional healthcare system. A secondary aim was to determine the quality of PAR’s data. A tertiary aim was to report preliminary findings from the registry and contributions to quality improvement initiatives and research up to March 2019. Structured Query Language was used to obtain data relating to patients who underwent total hip or knee arthroplasty (THA and TKA) from the hospital network’s electronic medical record (EMR) system to be included in the PAR. Data were stored in a secure database and visualized in dashboards. Quality assurance of PAR data was performed by review of the medical records. Capture rate was determined by comparing two months of PAR data with operating room schedules. Linear and binary logistic regression models were constructed to determine if length of stay (LOS), discharge to a care home, and readmission rates improved between 2016 and 2019.Aims
Methods
The purpose of this retrospective study was to evaluate the minimum
five-year outcome of revision total hip arthroplasty (THA) using
the Kerboull acetabular reinforcement device (KARD) in patients
with Paprosky type III acetabular defects and destruction of the
inferior margin of the acetabulum. We identified 36 patients (37 hips) who underwent revision THA
under these circumstances using the KARD, fresh frozen allograft
femoral heads, and reconstruction of the inferior margin of the
acetabulum. The Merle d’Aubigné system was used for clinical assessment.
Serial anteroposterior pelvic radiographs were used to assess migration
of the acetabular component.Aims
Patients and Methods
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. This was a retrospective review of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, between 2012 and 2017, using Current Procedural Terminology (CPT) codes for patients undergoing a revision THA (27134, 27137, 27138). International Classification of Diseases Ninth Revision/Tenth Revision (ICD-9-CM, ICD-10-CM) diagnosis codes for infection of an implant or device were used to identify patients undergoing an infected revision THA. CPT-27132 coupled with ICD-9-CM/ICD-10-CM codes for infection were used to identify patients undergoing a two-stage revision. A total of 13 556 patients were included; 1606 (11.8%) underwent a revision THA due to infection and there were 11 951 (88.2%) aseptic revisions.Aims
Patients and Methods
The aims of this study were to characterize antibiotic choices for perioperative total knee arthroplasty (TKA) and total hip arthroplasty (THA) prophylaxis, assess antibiotic allergy testing efficacy, and determine rates of prosthetic joint infection (PJI) based on perioperative antibiotic regimen. We evaluated all patients undergoing primary TKA or THA at a single academic institution between January 2004 and May 2017, yielding 29 695 arthroplasties (22 705 patients), with 3411 arthroplasties in 2576 patients (11.5%) having undergone preoperative allergy testing. A series of institutional databases were combined to identify allergy consultation outcomes, perioperative antibiotic regimen, and infection-free survivorship until final follow-up.Aims
Patients and Methods
Custom flange acetabular components (CFACs) are a patient-specific option for addressing large acetabular defects at revision total hip arthroplasty (THA), but patient and implant characteristics that affect survivorship remain unknown. This study aimed to identify patient and design factors related to survivorship. A retrospective review of 91 patients who underwent revision THA using 96 CFACs was undertaken, comparing features between radiologically failed and successful cases. Patient characteristics (demographic, clinical, and radiological) and implant features (design characteristics and intraoperative features) were collected. There were 74 women and 22 men; their mean age was 62 years (31 to 85). The mean follow-up was 24.9 months (Aims
Patients and Methods
Until now, there has been no consensus as to whether stemmed
acetabular components are appropriate for use in patients undergoing
revision total hip arthroplasty (THA) who have major acetabular
defects or pelvic discontinuity. We wished to address this deficiency
in the literature. We carried out a retrospective study of 35 patients (six men
and 29 women) with a mean age of 68 years (37 to 87), with major
acetabular defects who underwent revision THA between 2000 and 2012.Aim
Patients and Methods
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. The diagnosis was not suspected in nine of the ten patients (six
female/four male; mean age 66 years), despite treatment in a specialist
unit (mean time from index surgery to revision was 58 months, 36
to 84). It was identified at revision surgery and subsequently confirmed
by histological examination of resected tissue. Pre-operative assessment
and culture results ruled out infection. A variety of treatment
strategies were used, including resection of the pseudotumour and
efforts to avoid recurrent dislocation. Aims
Methods
As adverse events related to metal on metal hip
arthroplasty have been better understood, there has been increased
interest in toxicity related to the high circulating levels of cobalt ions.
However, distinguishing true toxicity from benign elevations in
cobalt levels can be challenging. The purpose of this review is
to examine the use of cobalt alloys in total hip arthroplasty, to
review the methods of measuring circulating cobalt levels, to define
a level of cobalt which is considered pathological and to review
the pathophysiology, risk factors and treatment of cobalt toxicity.
To the best of our knowledge, there are 18 published cases where
cobalt metal ion toxicity has been attributed to the use of cobalt-chromium
alloys in hip arthroplasty. Of these cases, the great majority reported
systemic toxic reactions at serum cobalt levels more than 100 μg/L.
This review highlights some of the clinical features of cobalt toxicity,
with the goal that early awareness may decrease the risk factors
for the development of cobalt toxicity and/or reduce its severity. Take home message: Severe adverse events can arise from the release
of cobalt from metal-on-metal arthroplasties, and as such, orthopaedic
surgeons should not only be aware of the presenting problems, but
also have the knowledge to treat appropriately. Cite this article:
We present the results of 62 consecutive acetabular
revisions using impaction bone grafting and a cemented polyethylene
acetabular component in 58 patients (13 men and 45 women) after
a mean follow-up of 27 years (25 to 30). All patients were prospectively
followed. The mean age at revision was 59.2 years (23 to 82). We performed Kaplan–Meier (KM) analysis and also a Competing
Risk (CR) analysis because with long-term follow-up, the presence
of a competing event (i.e. death) prevents the occurrence of the
endpoint of re-revision. A total of 48 patients (52 hips) had died or had been re-revised
at final review in March 2011. None of the deaths were related to
the surgery. The mean Harris hip score of the ten surviving hips
in ten patients was 76 points (45 to 99). The KM survivorship at 25 years for the endpoint ‘re-revision
for any reason’ was 58.0% (95% confidence interval (CI) 38 to 73)
and for ‘re-revision for aseptic loosening’ 72.1% (95% CI 51 to
85). With the CR analysis we calculated the KM analysis overestimates
the failure rate with respectively 74% and 93% for these endpoints.
The current study shows that acetabular impaction bone grafting
revisions provide good clinical results at over 25 years. Cite this article:
Adverse reaction to wear and corrosion debris
is a cause for concern in total hip arthroplasty (THA). Modular junctions
are a potential source of such wear products and are associated
with secondary pseudotumour formation. We present a consecutive series of 17 patients treated at our
unit for this complication following metal-on-highly cross-linked
polyethylene (MoP) THA. We emphasise the risk of misdiagnosis as
infection, and present the aggregate laboratory results and pathological
findings in this series. The clinical presentation was pain, swelling or instability.
Solid, cystic and mixed soft-tissue lesions were noted on imaging
and confirmed intra-operatively. Corrosion at the head–neck junction
was noted in all cases. No bacteria were isolated on multiple pre-
and intra-operative samples yet the mean erythrocyte sedimentation
rate was 49 (9 to 100) and C-reactive protein 32 (0.6 to 106) and
stromal polymorphonuclear cell counts were noted in nine cases. Adverse soft–tissue reactions can occur in MoP THA owing to corrosion
products released from the head–neck junction. The diagnosis should
be carefully considered when investigating pain after THA. This
may avoid the misdiagnosis of periprosthetic infection with an unidentified
organism and mitigate the unnecessary management of these cases
with complete single- or two-stage exchange. Cite this article:
The aim of this study was to assess the role
of synovial C-reactive protein (CRP) in the diagnosis of chronic periprosthetic
hip infection. We prospectively collected synovial fluid from 89
patients undergoing revision hip arthroplasty and measured synovial
CRP, serum CRP, erythrocyte sedimentation rate (ESR), synovial white
blood cell (WBC) count and synovial percentages of polymorphonuclear
neutrophils (PMN). Patients were classified as septic or aseptic
by means of clinical, microbiological, serum and synovial fluid
findings. The high viscosity of the synovial fluid precluded the
analyses in nine patients permitting the results in 80 patients
to be studied. There was a significant difference in synovial CRP
levels between the septic (n = 21) and the aseptic (n = 59) cohort.
According to the receiver operating characteristic curve, a synovial
CRP threshold of 2.5 mg/l had a sensitivity of 95.5% and specificity
of 93.3%. The area under the curve was 0.96. Compared with serum
CRP and ESR, synovial CRP showed a high diagnostic value. According
to these preliminary results, synovial CRP may be a useful parameter
in diagnosing chronic periprosthetic hip infection. Cite this article:
Persistent groin pain after seemingly successful
total hip replacement (THR) appears to have become more common.
Recent studies have indicated a high incidence after metal-on-polyethylene
and metal-on-metal conventional THR and it has been documented in
up to 18% of patients after metal-on-metal resurfacing. There are many
causes, including acetabular loosening, stress fracture, and iliopsoas
tendonitis and impingement. The evaluation of this problem requires
a careful history and examination, plain radiographs and an algorithmic approach
to special diagnostic imaging and tests. Non-operative treatment
is not usually successful. Specific operative treatment depending
on the cause of the pain usually involves revision of the acetabular
component, iliopsoas tenotomy or other procedures, and is usually
successful. Here, an appropriate algorithm is described.
We reviewed the clinical and radiological results of 131 patients who underwent acetabular revision for aseptic loosening with impacted bone allograft and a cemented acetabular component. The mean follow-up was 51.7 months (24 to 156). The mean post-operative Merle D’Aubigné and Postel scores were 5.7 points (4 to 6) for pain, 5.2 (3 to 6) for gait and 4.5 (2 to 6) for mobility. Radiological evaluation revealed migration greater than 5 mm in four acetabular components. Radiological failure matched clinical failure. Asymptomatic radiolucent lines were observed in 31 of 426 areas assessed (7%). Further revision was required in six patients (4.5%), this was due to infection in three and mechanical failure in three. The survival rate for the reconstruction was 95.8% (95% confidence interval 92.3 to 99.1) overall, and 98%, excluding revision due to sepsis. Our study, from an independent centre, has reproduced the results of the originators of the method.
We present an update of the clinical and radiological results of 62 consecutive acetabular revisions using impacted morsellised cancellous bone grafts and a cemented acetabular component in 58 patients, at a mean follow-up of 22.2 years (20 to 25). The Kaplan-Meier survivorship for the acetabular component with revision for any reason as the endpoint was 75% at 20 years (95% confidence interval (CI) 62 to 88) when 16 hips were at risk. Excluding two revisions for septic loosening at three and six years, the survivorship at 20 years was 79% (95% CI 67 to 93). With further exclusions of one revision of a well-fixed acetabular component after 12 years during a femoral revision and two after 17 years for wear of the acetabular component, the survivorship for aseptic loosening was 87% at 20 years (95% CI 76 to 97). At the final review 14 of the 16 surviving hips had radiographs available. There was one additional case of radiological loosening and four acetabular reconstructions showed progressive radiolucent lines in one or two zones. Acetabular revision using impacted large morsellised bone chips (0.5 cm to 1 cm in diameter) and a cemented acetabular component remains a reliable technique for reconstruction, even when assessed at more than 20 years after surgery.
The increasing need for total hip replacement
(THR) in an ageing population will inevitably generate a larger number
of revision procedures. The difficulties encountered in dealing
with the bone deficient acetabulum are amongst the greatest challenges
in hip surgery. The failed acetabular component requires reconstruction
to restore the hip centre and improve joint biomechanics. Impaction
bone grafting is successful in achieving acetabular reconstruction
using both cemented and cementless techniques. Bone graft incorporation
restores bone stock whilst providing good component stability. We
provide a summary of the evidence and current literature regarding impaction
bone grafting using both cemented and cementless techniques in revision
THR. Cite this article:
Based on the first implementation of mixing antibiotics
into bone cement in the 1970s, the Endo-Klinik has used one stage
exchange for prosthetic joint infection (PJI) in over 85% of cases.
Looking carefully at current literature and guidelines for PJI treatment,
there is no clear evidence that a two stage procedure has a higher
success rate than a one-stage approach. A cemented one-stage exchange
potentially offers certain advantages, mainly based on the need
for only one operative procedure, reduced antibiotics and hospitalisation time.
In order to fulfill a one-stage approach, there are obligatory pre-,
peri- and post-operative details that need to be meticulously respected,
and are described in detail. Essential pre-operative diagnostic
testing is based on the joint aspiration with an exact identification
of any bacteria. The presence of a positive bacterial culture and
respective antibiogram are essential, to specify the antibiotics
to be loaded to the bone cement, which allows a high local antibiotic
elution directly at the surgical side. A specific antibiotic treatment
plan is generated by a microbiologist. The surgical success relies
on the complete removal of all pre-existing hardware, including
cement and restrictors and an aggressive and complete debridement
of any infected soft tissues and bone material. Post-operative systemic
antibiotic administration is usually completed after only ten to
14 days. Cite this article:
We retrospectively evaluated 42 hips which had undergone acetabular reconstruction using the Kerboull acetabular reinforcement device between September 1994 and December 1998. We used autogenous bone chips from the ilium and ceramic particle morsellised grafts, even in large acetabular bone defects, in the early stages of the study. Thereafter, femoral head allograft was used as bulk graft in patients with large acetabular defects. Ceramic blocks and the patients’ contralateral femoral head were also used as bulk graft. The mean follow-up period was 8.7 years (4.3 to 12). Survivorship analysis was performed using radiological failure of the acetabular component, irrespective of whether it was revised, or not, as the end-point. The survival rate of the morsellised graft group (25 hips) and the bulk graft group (17 hips) at ten years was 53% (95% confidence interval (CI) 42.5% to 63.5%) and 82% (95% CI 72.4% to 91.6%), respectively. The mid-term results of revision total hip replacement with the Kerboull device were better when bulk graft was used in any size of bone defect.
We evaluated the use of a stemmed acetabular component in the treatment of severe acetabular deficiency during revision and complex primary total hip arthroplasty. There were 31 hips of which 24 were revisions (20 for aseptic loosening, four for infection) and the remainder were complex primary arthroplasties. At a mean follow-up of 10.7 years (6 to 12.8), no component had been revised for aseptic loosening; one patient had undergone a revision of the polyethylene liner for wear. There was one failure because of infection. At the latest follow-up, the cumulative survival rate for aseptic loosening, with revision being the end-point, was 100%; for radiographic loosening it was 92% and for infection and radiographic loosening it was 88%. These results justify the continued use of this stemmed component for the reconstruction of severe acetabular deficiency.
We have carried out in 24 patients, a two-stage revision arthroplasty of the hip for infection with massive bone loss. We used a custom-made, antibiotic-loaded cement prosthesis as an interim spacer. Fifteen patients had acetabular deficiencies, eight had segmental femoral bone loss and one had a combined defect. There was no recurrence of infection at a mean follow-up of 4.2 years (2 to 7). A total of 21 patients remained mobile in the interim period. The mean Merle D’Aubigné and Postel hip score improved from 7.3 points before operation to 13.2 between stages and to 15.8 at the final follow-up. The allograft appeared to have incorporated into the host bone in all patients. Complications included two fractures and one dislocation of the cement prosthesis. The use of a temporary spacer maintains the function of the joint between stages even when there is extensive loss of bone. Allograft used in revision surgery after septic conditions restores bone stock without the risk of recurrent infection.
Despite the worldwide usage of the cemented Contemporary
acetabular component (Stryker), no published data are available
regarding its use in patients aged <
50 years. We undertook a
mid- to long-term follow-up study, including all consecutive patients
aged
<
50 years who underwent a primary total hip replacement using
the Contemporary acetabular component with the Exeter cemented stem
between January 1999 and January 2006. There were 152 hips in 126
patients, 61 men and 65 women, mean age at surgery 37.6 years (16
to 49 yrs). One patient was lost to follow-up. Mean clinical follow-up of all implants was 7.6 years (0.9 to
12.0). All clinical questionnaire scores, including Harris hip score,
Oxford hip score and several visual analogue scales, were found
to have improved. The eight year survivorship of all acetabular
components for the endpoints revision for any reason or revision
for aseptic loosening was 94.4% (95% confidence interval (CI) 89.2
to 97.2) and 96.4% (95% CI 91.6 to 98.5), respectively. Radiological follow-up
was complete for 146 implants. The eight year survival for the endpoint
radiological loosening was 93.1% (95% CI 86.2 to 96.6). Three surviving
implants were considered radiologically loose but were asymptomatic.
The presence of acetabular osteolysis (n = 17, 11.8%) and radiolucent
lines (n = 20, 13.9%) in the 144 surviving cups indicates a need
for continued observation in the second decade of follow-up in order
to observe their influence on long-term survival. The clinical and radiological data resulting in a ten-year survival
rate >
90% in young patients support the use of the Contemporary
acetabular component in this specific patient group. Cite this article:
The practice of removing a well-fixed cementless
femoral component is associated with high morbidity. Ceramic bearing
couples are low wearing and their use minimises the risk of subsequent
further revision due to the production of wear debris. A total of
165 revision hip replacements were performed, in which a polyethylene-lined acetabular
component was revised to a new acetabular component with a ceramic
liner, while retaining the well-fixed femoral component. A titanium
sleeve was placed over the used femoral trunnion, to which a ceramic
head was added. There were 100 alumina and 65 Delta bearing couples
inserted. The mean Harris hip score improved significantly from 71.3 (9.0
to 100.0) pre-operatively to 91.0 (41.0 to 100.0) at a mean follow
up of 4.8 years (2.1 to 12.5) (p <
0.001). No patients reported
squeaking of the hip. There were two fractures of the ceramic head, both in alumina
bearings. No liners were seen to fracture. No fractures were observed
in components made of Delta ceramic. At 8.3 years post-operatively
the survival with any cause of failure as the endpoint was 96.6%
(95% confidence interval (CI) 85.7 to 99.3) for the acetabular component and
94.0% (95% CI 82.1 to 98.4) for the femoral component. The technique of revising the acetabular component in the presence
of a well-fixed femoral component with a ceramic head placed on
a titanium sleeve over the used trunnion is a useful adjunct in
revision hip practice. The use of Delta ceramic is recommended. Cite this article:
We report the long-term results of revision total
hip replacement using femoral impaction allografting with both uncemented
and cemented Freeman femoral components. A standard design of component
was used in both groups, with additional proximal hydroxyapatite
coating in the uncemented group. A total of 33 hips in 30 patients received
an uncemented component and 31 hips in 30 patients a cemented component.
The mean follow-up was 9.8 years (2 to 17) in the uncemented group
and 6.2 years (1 to 11) in the cemented group. Revision procedures
(for all causes) were required in four patients (four hips) in the
uncemented group and in five patients (five hips) in the cemented
group. Harris hip scores improved significantly in both groups and
were maintained independently of the extent of any migration of
the femoral component within the graft or graft–cement mantle.
The long-term results of grafting with hydroxyapatite granules for acetabular deficiency in revision total hip replacement are not well known. We have evaluated the results of revision using a modular cup with hydroxyapatite grafting for Paprosky type 2 and 3 acetabular defects at a minimum of ten years’ follow-up. We retrospectively reviewed 49 acetabular revisions at a mean of 135 months (120 to 178). There was one type 2B, ten 2C, 28 3A and ten 3B hips. With loosening as the endpoint, the survival rate was 74.2% (95% confidence interval 58.3 to 90.1). Radiologically, four of the type 3A hips (14%) and six of the type 3B hips (60%) showed aseptic loosening with collapse of the hydroxyapatite layer, whereas no loosening occurred in type 2 hips. There was consolidation of the hydroxyapatite layer in 33 hips (66%). Loosening was detected in nine of 29 hips (31%) without cement and in one of 20 hips (5%) with cement (p = 0.03, Fisher’s exact probability test). The linear wear and annual wear rate did not correlate with loosening. These results suggest that the long-term results of hydroxyapatite grafting with cement for type 2 and 3A hips are encouraging.
Between 1990 and 2000, 123 hips in 110 patients were reconstructed for aseptic loosening using impaction bone grafting with frozen, irradiated, morsellised femoral heads and cemented acetabular components. This series was reported previously at a mean follow-up of five years. We have extended this follow-up and now describe the outcome of 86 hips in 74 patients at a mean of ten years. There have been 19 revisions, comprising nine for infection, seven for aseptic loosening and three for dislocation. In surviving acetabular reconstructions, union of the graft had occurred in 64 of 67 hips (95.5%). Survival analysis for all indications at ten years was 83.3% (95% confidence interval (CI) 68 to 89) and 71.3% (95% CI 58 to 84) at 15 years. Acetabular reconstruction using irradiated allograft and a cemented acetabular component is an effective method of reconstruction, providing results in the medium- to long-term comparable with those of reported series where non-irradiated freshly-frozen bone was used.
The clinical and radiological results of 50 consecutive acetabular reconstructions in 48 patients using impaction grafting have been retrospectively reviewed. A 1:1 mixture of frozen, ground irradiated bone graft and Apapore 60, a synthetic bone graft substitute, was used in all cases. There were 13 complex primary and 37 revision procedures with a mean follow-up of five years (3.4 to 7.6). The clinical survival rate was 100%, with improvements in the mean Harris Hip Scores for pain and function. Radiologically, 30 acetabular grafts showed evidence of incorporation, ten had radiolucent lines and two acetabular components migrated initially before stabilising. Acetabular reconstruction in both primary and revision surgery using a 1:1 mixture of frozen, ground, irriadiated bone and Apapore 60 appears to be a reliable method of managing acetabular defects. Longer follow-up will be required to establish whether this technique is as effective as using fresh-frozen allograft.
The Norwegian Arthroplasty Register has shown that several designs of uncemented femoral stems give good or excellent survivorship. The overall findings for uncemented total hip replacement however, have been disappointing because of poor results with the use of metal-backed acetabular components. In this study, we exclusively investigated the medium-to long-term performance of primary uncemented metal-backed acetabular components. A total of 9113 primary uncemented acetabular components were implanted in 7937 patients between 1987 and 2007. These were included in a prospective, population-based observational study. All the implants were modular and metal-backed with ultra-high-molecular-weight polyethylene liners. The femoral heads were made of stainless steel, cobalt-chrome (CoCr) alloy or alumina ceramic. In all, seven different designs of acetabular component were evaluated by the Kaplan-Meier survivorship method and Cox regression analysis. Most acetabular components performed well up to seven years. When the endpoint was revision of the acetabular component because of aseptic loosening, the survival ranged between 87% and 100% at ten years. However, when the endpoint was revision for any reason, the survival estimates were 81% to 92% for the same implants at ten years. Aseptic loosening, wear, osteolysis and dislocation were the main reasons for the relatively poor overall performance of the acetabular components. Prostheses with alumina heads performed slightly better than those with stainless steel or CoCr alloy in subgroups. Whereas most acetabular components performed well at seven years, the survivorship declined with longer follow-up. Fixation was generally good. None of the metal-backed uncemented acetabular components with ultra-high-molecular-weight polyethylene liners in our study had satisfactory long-term results because of high rates of wear, osteolysis, aseptic loosening and dislocation.
We report a systematic review and meta-analysis of published randomised controlled trials evaluating the efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion in total hip replacement (THR). The data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. We identified 11 clinical trials which were suitable for detailed extraction of data. There were no trials that used TXA in revision THR. A total of seven studies (comprising 350 patients) were eligible for the blood loss outcome data. The use of TXA reduced intra-operative blood loss by a mean of 104 ml (95% confidence interval (CI) −164 to −44, p = 0.0006, heterogeneity I2 0%), postoperative blood loss by a mean of 172 ml (95% CI −263 to −81, p = 0.0002, heterogeneity I2 63%) and total blood loss by a mean of 289 ml (95% CI −440 to −138, p <
0.0002, heterogeneity I2 54%). TXA led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion (risk difference −0.20, 95% CI −0.29 to −0.11, p <
0.00001, I2 15%). There were no significant differences in deep-vein thrombosis, pulmonary embolism, infection rates or other complications among the study groups.
We report the use of an allograft prosthetic composite for reconstruction of the skeletal defect in complex revision total hip replacement for severe proximal femoral bone loss. Between 1986 and 1999, 72 patients (20 men, 52 women) with a mean age of 59.9 years (38 to 78) underwent reconstruction using this technique. At a mean follow-up of 12 years (8 to 20) 57 patients were alive, 14 had died and one was lost to follow-up. Further revision was performed in 19 hips at a mean of 44.5 months (11 to 153) post-operatively. Causes of failure were aseptic loosening in four, allograft resorption in three, allograft nonunion in two, allograft fracture in four, fracture of the stem in one, and deep infection in five. The survivorship of the allograft-prosthesis composite at ten years was 69.0% (95% confidence interval 67.7 to 70.3) with 26 patients remaining at risk. Survivorship was statistically significantly affected by the severity of the pre-operative bone loss (Paprosky type IV; p = 0.019), the number of previous hip revisions exceeding two (p = 0.047), and the length of the allograft used (p = 0.005).
Failure of total hip arthroplasty with acetabular deficiency occurred in 55 patients (60 hips) and was treated with acetabular revision using morsellised allograft and a cemented metal-backed component. A total of 50 patients (55 hips) were available for clinical and radiological evaluation at a mean follow-up of 5.8 years (3 to 9.5). No hip required further revision of the acetabular component because of aseptic loosening. All the hips except one had complete incorporation of the allograft demonstrated on the radiographs. A complete radiolucent line of >
1 mm was noted in two hips post-operatively. A good to excellent result occurred in 50 hips (91%). With radiological evidence of aseptic loosening of the acetabular component as the end-point, the survivorship at a mean of 5.8 years after surgery was 96.4%. The use of impacted allograft chips in combination with a cemented metal-backed acetabular component and screw fixation can achieve good medium-term results in patients with acetabular bone deficiency.
Bone allografts can store and release high levels of vancomycin. We present our results of a two-stage treatment for infected hip arthroplasty with acetabular and femoral impaction grafting using vancomycin-loaded allografts. We treated 29 patients (30 hips) by removal of the implants, meticulous debridement, parenteral antibiotic therapy and second-stage reconstruction using vancomycin-supplemented impacted bone allografts and a standard cemented Charnley femoral component. The mean follow-up was 32.4 months (24 to 60). Infection control was obtained in 29 cases (re-infection rate of 3.3%; 95% confidence interval 0.08 to 17) without evidence of progressive radiolucent lines, demarcation or graft resorption. One patient had a further infection ten months after revision caused by a different pathogen. Associated post-operative complications were one traumatic periprosthetic fracture at 14 months, a single dislocation in two hips and four displacements of the greater trochanter. Vancomycin-supplemented allografts restored bone stock and provided sound fixation with a low incidence of further infection.
We report the clinical and radiological outcome of 86 revisions of cemented hip arthroplasties using JRI-Furlong hydroxyapatite-ceramic-coated acetabular and femoral components. The acetabular component was revised in 62 hips and the femoral component in all hips. The mean follow-up was 12.6 years and no patient was lost to follow-up. The mean age of the patients was 71.2 years. The mean Harris hip and Oxford scores were 82 (59 to 96) and 23.4 (14 to 40), respectively. The mean Charnley modification of the Merle d’Aubigné and Postel score was 5 (3 to 6) for pain, 4.9 (3 to 6) for movement and 4.4 (3 to 6) for mobility. Migration of the acetabular component was seen in two hips and the mean acetabular inclination was 42.6°. The mean linear polyethylene wear was 0.05 mm/year. The mean subsidence of the femoral component was 1.9 mm and stress shielding was seen in 23 (28%) with bony ingrowth in 76 (94%). Heterotopic ossification was seen in 12 hips (15%). There were three re-revisions, two for deep sepsis and one for recurrent dislocation and there were no re-revisions for aseptic loosening. The mean EuroQol EQ-5D description scores and health thermometer scores were 0.69 (0.51 to 0.89) and 79 (54 to 95), respectively. With an end-point of definite or probable loosening, the probability of survival at 12 years was 93.9% and 95.6% for the acetabular and femoral components, respectively. Overall survival at 12 years, with removal or further revision of either component for any reason as the end-point, was 92.3%. Our study supports the continued use of this arthroplasty and documents the durability of hydroxyapatite-ceramic-coated components.
