Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants. A total of 39 hip fusion conversions to THA were undertaken in 38 patients by a single surgeon employing a consistent surgical technique and uncemented implants. Parameters assessed included Harris Hip Score (HHS) for function, range of motion (ROM), leg length discrepancy (LLD), satisfaction, and use of walking aid. Radiographs were reviewed for loosening, subsidence, and heterotopic ossification (HO). Postoperative complications and implant survival were assessed.Aims
Methods
This study reports the clinical outcome of reconstruction
of deficient abductor muscles following revision total hip arthroplasty
(THA), using a fresh–frozen allograft of the extensor mechanism
of the knee. A retrospective analysis was conducted of 11 consecutive
patients with a severe limp because of abductor deficiency which
was confirmed on MRI scans. The mean age of the patients (three
men and eight women) was 66.7 years (52 to 84), with a mean follow-up
of 33 months (24 to 41). Following surgery, two patients had no limp, seven had a mild
limp, and two had a persistent severe limp (p = 0.004). The mean
power of the abductors improved on the Medical Research Council
scale from 2.15 to 3.8 (p <
0.001). Pre-operatively, all patients
required a stick or walking frame; post-operatively, four patients
were able to walk without an aid. Overall, nine patients had severe
or moderate pain pre-operatively; ten patients had no or mild pain
post-operatively. At final review, the Harris hip score was good in five patients,
fair in two and poor in four. We conclude that using an extensor mechanism allograft is relatively
effective in the treatment of chronic abductor deficiency of the
hip after THA when techniques such as local tissue transfer are
not possible. Longer-term follow-up is necessary before the technique can be
broadly applied. Cite this article:
Revision total hip replacement (THR) for young
patients is challenging because of technical complexity and the potential
need for subsequent further revisions. We have assessed the survivorship,
functional outcome and complications of this procedure in patients
aged <
50 years through a large longitudinal series with consistent treatment
algorithms. Of 132 consecutive patients (181 hips) who underwent
revision THR, 102 patients (151 hips) with a mean age of 43 years
(22 to 50) were reviewed at a mean follow-up of 11 years (2 to 26)
post-operatively. We attempted to restore bone stock with allograft
where indicated. Using further revision for any reason as an end point,
the survival of the acetabular component was 71% ( This overall perspective on the mid- to long-term results is
valuable when advising young patients on the prospects of revision
surgery at the time of primary replacement. Cite this article:
The purpose of this study was to identify factors
that predict implant cut-out after cephalomedullary nailing of intertrochanteric
and subtrochanteric hip fractures, and to test the significance
of calcar referenced tip-apex distance (CalTAD) as a predictor for
cut-out. We retrospectively reviewed 170 consecutive fractures that had
undergone cephalomedullary nailing. Of these, 77 met the inclusion
criteria of a non-pathological fracture with a minimum of 80 days
radiological follow-up (mean 408 days; 81 days to 4.9 years). The
overall cut-out rate was 13% (10/77). The significant parameters in the univariate analysis were tip-apex
distance (TAD) (p <
0.001), CalTAD (p = 0.001), cervical angle
difference (p = 0.004), and lag screw placement in the anteroposterior
(AP) view (Parker’s ratio index) (p = 0.003). Non-significant parameters
were age (p = 0.325), gender (p = 1.000), fracture side (p = 0.507),
fracture type (AO classification) (p = 0.381), Singh Osteoporosis
Index (p = 0.575), lag screw placement in the lateral view (p =
0.123), and reduction quality (modified Baumgaertner’s method) (p = 0.575).
In the multivariate analysis, CalTAD was the only significant measurement
(p = 0.001). CalTAD had almost perfect inter-observer reliability
(interclass correlation coefficient (ICC) 0.901). Our data provide the first reported clinical evidence that CalTAD
is a predictor of cut-out. The finding of CalTAD as the only significant
parameter in the multivariate analysis, along with the univariate
significance of Parker’s ratio index in the AP view, suggest that
inferior placement of the lag screw is preferable to reduce the
rate of cut-out. Cite this article:
We retrospectively reviewed 44 consecutive patients
(50 hips) who underwent acetabular re-revision after a failed previous
revision that had been performed using structural or morcellised
allograft bone, with a cage or ring for uncontained defects. Of
the 50 previous revisions, 41 cages and nine rings were used with
allografts for 14 minor-column and 36 major-column defects. We routinely
assessed the size of the acetabular bone defect at the time of revision
and re-revision surgery. This allowed us to assess whether host
bone stock was restored. We also assessed the outcome of re-revision
surgery in these circumstances by means of radiological characteristics,
rates of failure and modes of failure. We subsequently investigated
the factors that may affect the potential for the restoration of bone
stock and the durability of the re-revision reconstruction using
multivariate analysis. At the time of re-revision, there were ten host acetabula with
no significant defects, 14 with contained defects, nine with minor-column,
seven with major-column defects and ten with pelvic discontinuity.
When bone defects at re-revision were compared with those at the
previous revision, there was restoration of bone stock in 31 hips, deterioration
of bone stock in nine and remained unchanged in ten. This was a
significant improvement (p <
0.001). Morselised allografting
at the index revision was not associated with the restoration of
bone stock. In 17 hips (34%), re-revision was possible using a simple acetabular
component without allograft, augments, rings or cages. There were
47 patients with a mean follow-up of 70 months (6 to 146) available
for survival analysis. Within this group, the successful cases had
a minimum follow-up of two years after re-revision. There were 22 clinical
or radiological failures (46.7%), 18 of which were due to aseptic
loosening. The five and ten year Kaplan–Meier survival rate was
75% (95% CI, 60 to 86) and 56% (95% CI, 40 to 70) respectively with
aseptic loosening as the endpoint. The rate of aseptic loosening
was higher for hips with pelvic discontinuity (p = 0.049) and less
when the allograft had been in place for longer periods (p = 0.040). The use of a cage or ring over structural allograft bone for
massive uncontained defects in acetabular revision can restore host
bone stock and facilitate subsequent re-revision surgery to a certain
extent. Cite this article:
The use of ilioischial cage reconstruction for
pelvic discontinuity has been replaced by the Trabecular Metal (Zimmer,
Warsaw, Indiana) cup-cage technique in our institution, due to the
unsatisfactory outcome of using a cage alone in this situation.
We report the outcome of 26 pelvic discontinuities in 24 patients
(20 women and four men, mean age 65 years (44 to 84)) treated by
the cup-cage technique at a mean follow-up of 82 months (12 to 113)
and compared them with a series of 19 pelvic discontinuities in
19 patients (18 women and one man, mean age 70 years (42 to 86))
treated with a cage at a mean follow-up of 69 months (1 to 170).
The clinical and radiological outcomes as well as the survivorship
of the groups were compared. In all, four of the cup-cage group
(15%) and 13 (68%) of the cage group failed due to septic or aseptic
loosening. The seven-year survivorship was 87.2% (95% confidence interval
(CI) 71 to 103) for the cup-cage group and 49.9% (95% CI 15 to 84)
for the cage-alone group (p = 0.009). There were four major complications
in the cup-cage group and nine in the cage group. Radiological union
of the discontinuity was found in all successful cases in the cup-cage
group and three of the successful cage cases. Three hips in the
cup-cage group developed early radiological migration of the components,
which stabilised with a successful outcome. Cup-cage reconstruction is a reliable technique for treating
pelvic discontinuity in mid-term follow-up and is preferred to ilioischial
cage reconstruction. If the continuity of the bone graft at the
discontinuity site is not disrupted, early migration of the components
does not necessarily result in failure. Cite this article:
Valid and reliable techniques for assessing performance
are essential to surgical education, especially with the emergence
of competency-based frameworks. Despite this, there is a paucity
of adequate tools for the evaluation of skills required during joint
replacement surgery. In this scoping review, we examine current
methods for assessing surgeons’ competency in joint replacement
procedures in both simulated and clinical environments. The ability
of many of the tools currently in use to make valid, reliable and
comprehensive assessments of performance is unclear. Furthermore,
many simulation-based assessments have been criticised for a lack
of transferability to the clinical setting. It is imperative that
more effective methods of assessment are developed and implemented
in order to improve our ability to evaluate the performance of skills
relating to total joint replacement. This will enable educators
to provide formative feedback to learners throughout the training
process to ensure that they have attained core competencies upon
completion of their training. This should help ensure positive patient
outcomes as the surgical trainees enter independent practice. Cite this article:
In this retrospective study we evaluated the
proficiency of shelf autograft in the restoration of bone stock
as part of primary total hip replacement (THR) for hip dysplasia,
and in the results of revision arthroplasty after failure of the primary
arthroplasty. Of 146 dysplastic hips treated by THR and a shelf
graft, 43 were revised at an average of 156 months, 34 of which
were suitable for this study (seven hips were excluded because of
insufficient bone-stock data and two hips were excluded because
allograft was used in the primary THR). The acetabular bone stock
of the hips was assessed during revision surgery. The mean implant–bone
contact was 58% (50% to 70%) at primary THR and 78% (40% to 100%)
at the time of the revision, which was a significant improvement
(p <
0.001). At primary THR all hips had had a segmental acetabular
defect >
30%, whereas only five (15%) had significant segmental
bone defects requiring structural support at the time of revision.
In 15 hips (44%) no bone graft or metal augments were used during
revision. A total of 30 hips were eligible for the survival study. At a
mean follow-up of 103 months (27 to 228), two aseptic and two septic
failures had occurred. Kaplan-Meier survival analysis of the revision
procedures demonstrated a ten-year survival rate of 93.3% (95% confidence
interval (CI) 78 to 107) with clinical or radiological failure as
the endpoint. The mean Oxford hip score was 38.7 (26 to 46) for
non-revised cases at final follow-up. Our results indicate that the use of shelf autografts during
THR for dysplastic hips restores bone stock, contributing to the
favourable survival of the revision arthroplasty should the primary
procedure fail. Cite this article:
Trabecular metal (TM) augments are a relatively
new option for reconstructing segmental bone loss during acetabular
revision. We studied 34 failed hip replacements in 34 patients that
were revised between October 2003 and March 2010 using a TM acetabular
shell and one or two augments. The mean age of the patients at the
time of surgery was 69.3 years (46 to 86) and the mean follow-up
was 64.5 months (27 to 107). In all, 18 patients had a minor column
defect, 14 had a major column defect, and two were associated with
pelvic discontinuity. The hip centre of rotation was restored in
27 patients (79.4%). The Oxford hip score increased from a mean
of 15.4 points (6 to 25) before revision to a mean of 37.7 (29 to
47) at the final follow-up. There were three aseptic loosenings
of the construct, two of them in the patients with pelvic discontinuity.
One septic loosening also occurred in a patient who had previously
had an infected hip replacement. The augments remained stable in
two of the failed hips. Whenever there was a loose acetabular component
in contact with a stable augment, progressive metal debris shedding
was evident on the serial radiographs. Complications included another
deep infection treated without revision surgery. Good clinical and
radiological results can be expected for bone-deficient acetabula
treated by a TM cup and augment, but for pelvic discontinuities
this might not be a reliable option. Cite this article:
Eighteen hip fusions were converted to total
hip replacements. A constrained acetabular liner was used in three hips.
Mean follow up was five years (two to 15). Two (11%) hips failed,
requiring revision surgery and two patients (11%) had injury to
the peroneal nerve. Heterotopic ossification developed in seven
(39%) hips, in one case resulting in joint ankylosis. No hips dislocated. Conversion of hip fusion to hip replacement carries an increased
risk of heterotopic ossification and neurological injury. We advise
prophylaxis against heterotropic ossification. When there is concern
about hip stability we suggest that the use of a constrained acetabular
liner is considered. Despite the potential for complications, this procedure
had a high success rate and was effective in restoring hip function.
We report the use of porous metal acetabular
revision shells in the treatment of contained bone loss. The outcomes of
53 patients with
Pelvic discontinuity with associated bone loss is a complex challenge in acetabular revision surgery. Reconstruction using ilio-ischial cages combined with trabecular metal acetabular components and morsellised bone (the component-cage technique) is a relatively new method of treatment. We reviewed a consecutive series of 26 cases of acetabular revision reconstructions in 24 patients with pelvic discontinuity who had been treated by the component-cage technique. The mean follow-up was 44.6 months (24 to 68). Failure was defined as migration of a component of >
5 mm. In 23 hips (88.5%) there was no clinical or radiological evidence of loosening at the last follow-up. The mean Harris hip score improved significantly from 46.6 points (29.5 to 68.5) to 76.6 points (55.5 to 92.0) at two years (p <
0.001). In three hips (11.5%) the construct had migrated at one year after operation. The complications included two dislocations, one infection and one partial palsy of the peroneal nerve. Our findings indicate that treatment of pelvic discontinuity using the component-cage construct is a reliable option.
Our aim was to determine if the height of the cup, lateralisation or the abduction angle correlated with functional outcome or survivorship in revision total hip replacement in patients with a previous diagnosis of developmental dysplasia of the hip. A retrospective investigation of 51 patients (63 hips) who had undergone revision total hip replacement was performed. The mean duration of follow-up was 119 months. Forty-one patients (52 hips) were available for both determination of functional outcome and survivorship analysis. Ten patients (11 hips) were only available for survivorship analysis. The height of the cup was found to have a statistically significant correlation with functional outcome and a high hip centre correlated with a worse outcome score. Patients with a hip centre of less than 3.5 cm above the anatomical level had a statistically better survivorship of the cup than those with centres higher than this. Restoration of the height of the centre of the hip to as near the anatomical position as possible improved functional outcome and survivorship of the cup.