Treatment of medial-sided injuries in patients with early bicruciate ligament reconstruction for knee dislocation.

PURPOSE: In knee dislocation with bicruciate ligament and medial side injury (KDIIIM), treatment method of medial side injuries is controversial. The purpose of this study was to evaluate the outcomes of non-operative treatment of proximal and midsubstance and operative treatment of distal avulsion medial collateral ligament (MCL) ruptures in patients with early bicruciate reconstruction. METHODS: One-hundred and forty-seven patients with a knee dislocation and bicruciate ligament injury (KDII-KDV) were identified. Sixty-two patients had KDIIIM injury. Of these, 24 patients were excluded and 13 were lost to follow-up. With a minimum of 2 years of follow-up, IKDC2000 (subjective and objective), Lysholm and Tegner scores and stress radiographs were recorded. RESULTS: Twenty-five patients were available for follow-up: 18 had a proximal or midsubstance grade-III MCL rupture (proximal MCL group) and 7 had a distal MCL avulsion (distal MCL group). In the proximal MCL and distal MCL groups, respectively, median IKDC2000 subjective scores were 80 (range 57-99) and 62 (range 39-87), and median Lysholm scores were 88 (range 57-99) and 75 (range 40-100). The median medial opening (side-to-side difference) was 2.4 mm (range 0.1-9.2) in the proximal MCL group and 2.5 mm (range 0.2-4.8) in the distal MCL group. CONCLUSION: We found acceptable recorded outcomes in patients who underwent non-operative treatment of proximal and midsubstance grade-III MCL rupture and operative treatment of distal MCL avulsion with early bicruciate ligament reconstruction. LEVEL OF EVIDENCE: Level IV.

Fibular head avulsion fractures accompanying operative treated medial tibial plateau fractures.

OBJECTIVE: The aims of this work are to determine how frequently medial tibial plateau fractures are accompanied by fibular head avulsion fractures and evaluate the sensitivity of radiographs detecting them, and also to assess if the presence of fibular fracture is correlated with long-term functional outcome and peroneal nerve damage. MATERIALS AND METHODS: A retrospective chart review of operated patients with medial tibial plateau fractures at level I trauma center during 2002-2008 was performed. From 63 patients imaged preoperatively, 59 had CT and radiographs, three had only CT, and one only radiograph. The presence and fragment size of fibular fracture were retrospectively evaluated. Body mass index (BMI) and functional outcome measurements (the Modified Lysholm knee score and WOMAC) were available for 46 patients. RESULTS: Fourteen out of 63 patients (22.2%) had fibular fractures. Of the 59 patients with both CT and radiographs, 12 had fibular fractures, and of these, nine were seen with both modalities and three only in CT. Functional scores were available for ten patients with fibular fracture. Patients with fibular fracture seen on radiographs had a significantly higher score on WOMAC function (26 vs. 7; p = 0.027). The patients with fibular fractures had also higher BMI (p = 0.035). Of the six patients with peroneal nerve damage, 50% had fibular fracture. CONCLUSIONS: In patients with operatively treated medial tibial plateau fracture, the fibular fractures are relatively common. Detecting it is important, as it may be associated with worse functional scores and peroneal nerve paresis. Some fibular fractures may remain undetected on radiographs, hence preoperative CT is recommended.

Reasons and Risk Factors for Delayed Discharge After Total Knee Arthroplasty Using an Opioid-Sparing Discharge Protocol.

BACKGROUND: In this study, we aimed to assess the length of hospital stay after total knee arthroplasty in a European healthcare setting. We also aimed to investigate risk factors and reasons for delayed discharge when using an opioid-sparing fast-track protocol. METHODS: From our institutional database, we retrospectively identified all primary elective unilateral total knee arthroplasties performed during January to December 2015. Both patient-related and surgery-related variables were collected from our databases. Risk factors were analyzed using multivariable logistic regression analysis. RESULTS: The median length of stay (LOS) was 3 days. Independent risk factors for delayed discharge were higher age, higher American Society of Anesthesiologists score, general anesthesia, surgery performed toward the end of the week, longer duration of surgery, longer stay in the post-anesthesia care unit, and shorter preoperative walking distance. The main reasons for delayed discharge were delayed functional recovery and pain. CONCLUSION: This study identified several independent risk factors for an LOS longer than 3 days. These risk factors add to the current knowledge on which patients have an increased risk of prolonged LOS, and which patients should be targeted when striving to further reduce the LOS.

Infection safety of dexamethasone in total hip and total knee arthroplasty: a study of eighteen thousand, eight hundred and seventy two operations.

PURPOSE: Dexamethasone has been shown to prevent post-operative nausea and vomiting (PONV) and seems to reduce post-operative pain. Both factors, which can extend the hospital stay, delay rehabilitation, and impact patient satisfaction. Because of the immunosuppressive and glucose-rising effects of dexamethasone, there has been concern of its safety in arthroplasty surgery. The purpose of our study was to examine infection safety of dexamethasone in arthroplasty surgery with enough large study material to reliably detect a possible, even small, difference in infection incidence. METHODS: A total of 18,872 consecutive primary and revision hip and knee arthroplasties were analyzed with data gathered from clinical information databases and a surgical site infection surveillance database with prospective data collection. Also, emergency operations due to fractures were included except for hip hemiarthroplasties. RESULTS: During the follow-up, 189 (1.0%) prosthetic joint infections (PJIs) occurred: 0.8% after primary arthroplasty and 1.9% after revision arthroplasty. Dexamethasone was used in 2922 (15.5%) operations. The PJI rate in the dexamethasone group was 1.1% (31/2922) and in the non-dexamethasone group 1.0% (161/15950), with no significant difference in the risk of PJI between the two groups (OR 1.052, 95% CI 0.715-1.548, P = 0.773). CONCLUSIONS: In our study material, the use of a single 5-10 mg dose of dexamethasone did not increase the incidence of post-operative PJI. A low dose of dexamethasone may be safely used to prevent PONV and as part of multimodal analgesia on patients undergoing arthroplasty operation.

A Consultation Phone Service for Patients With Total Joint Arthroplasty May Reduce Unnecessary Emergency Department Visits.

BACKGROUND: Different measures for reducing costs after total joint arthroplasty (TJA) have gained attention lately. At our institution, a free-of-charge consultation phone service was initiated that targeted patients with TJA. This service aimed at reducing unnecessary emergency department (ED) visits and, thus, potentially improving the cost-effectiveness of TJAs. To our knowledge, a similar consultation service had not been described previously. We aimed at examining the rates and reasons for early postdischarge phone calls and evaluating the efficacy of this consultation service. METHODS: During a 2-month period, we gathered information on every call received by the consultation phone service from patients with TJAs within 90 days of the index TJA procedure. Patients were followed for 2 weeks after making a call to detect major complications and self-initiated ED visits. Data were collected from electronic medical charts regarding age, gender, type of surgery, date of discharge, and length of hospital stay. RESULTS: We analyzed 288 phone calls. Calls were mostly related to medication (41%), wound complications (17%), and mobilization issues (15%). Most calls were resolved in the phone consultation. Few patients (13%) required further evaluation in the ED. The consultation service failed to detect the need for an ED visit in 2 cases (0.7%) that required further care. CONCLUSION: The consultation phone service clearly benefitted patients with TJAs. The service reduced the number of unnecessary ED visits and functioned well in detecting patients who required further care. Most postoperative concerns were related to prescribed medications, wound complications, and mobilization issues.

Reasons and risk factors for ninety day re-admission following primary total knee arthroplasty in a high-volume centre.

PURPOSE: We aimed to assess the rates, reasons, and risk factors for 90-day re-admissions after total knee arthroplasty (TKA) in a European healthcare setting. METHODS: We identified all primary elective TKA procedures performed in 2015 at a single high-volume centre. Patients with unplanned re-admissions within 90 days of primary discharge were compared to a 1:4 control cohort of patients having no relevant re-admission. We calculated re-admission rates, recorded the reasons for re-admission, and identified independent predictors of re-admission. RESULTS: The 30-day and 90-day unplanned re-admission rates were 6.5% and 8.0%, respectively. The most common reason for re-admission within 90 days was infection (29.6%), followed by knee pain (14.1%), gastrointestinal complications (8.5%), and haematoma (8.5%). Multivariable logistic regression analysis revealed that the following factors were significant independent predictors of re-admission: asthma, psychiatric disease, pre-operative tibiofemoral valgus angle, and pre-operative knee flexion deficit. CONCLUSIONS: The re-admission rates in our health-care setting were slightly higher than those previously reported. Independent risk factors for re-admissions included pre-operative mechanical axis, range of motion, asthma, and psychiatric disease. Our present results will facilitate the targeting of new subgroups of TKA patients when developing new interventions to further reduce the total re-admission risk after TKA.

Revision Total Hip Arthroplasty for Fractured Ceramic Bearings: A Review of Best Practices for Revision Cases.

BACKGROUND: Total hip arthroplasty revision for a fractured ceramic bearing is rare but offers unique challenges. The purpose of this review was to provide a summary of existing literature on fractured ceramic bearings. METHODS: Two authors performed a literature search of the MEDLINE OVID and PubMed databases with the following search terms: ceramic, fracture, total hip arthroplasty, and revision. RESULTS: The search identified 228 articles of which 199 were selected for review. CONCLUSIONS: It is mandatory to perform a complete synovectomy and thorough debridement of the fractured ceramic fragments. A well-fixed acetabular component should be removed if either the locking mechanism is damaged or the component is malpositioned. If the femoral stem taper is damaged, the femoral stem should be removed. However, if minimal damage is present, the femoral stem may be retained and revised using a fourth generation ceramic head with a titanium sleeve. Metal bearings should be avoided and revision with ceramic bearings should be performed whenever possible.

The current state of orthopaedic residency in 18 European countries.

PURPOSE: The aim of this study was to compare differences in current orthopaedic and trauma training programs across Europe. METHODS: A questionnaire was sent to the FORTE (Federation of Orthopaedic Trainees in Europe) representatives of 25 different European countries, of which 18 responded. The questionnaire included demographic information and information concerning the structure of the training programs, including duration, selection, and mandatory training requirements. RESULTS: The number of trainees per specialist varied between countries from a ratio of 1:2 to 1:7. Residency was generally five to six years in all the countries. In more than half of the countries selection was interview-based. Nearly all countries utilized a logbook. About 80% of the participating countries had a final examination. When assessing the components of training it was found that only one country (the United Kingdom) had mandatory minimum requirements for (1) courses, (2) surgical procedures, (3) research and (4) leadership. Nearly 40% of the participating countries had only one or none of these four components as a mandatory training requirement. CONCLUSIONS: There are many similarities in training programs, but some important differences remain in overall requirements and final qualification. The main limitation of this study was that we were unable to get data from all the European countries. FORTE will continue to serve as a forum for sharing best practices with the ultimate goal of improving and harmonizing the level of orthopaedic training across Europe. Future studies should aim to include further details about training programs as well as to include data from more countries.

Early aseptic loosening of cementless monoblock acetabular components.

PURPOSE: Early aseptic loosening of cementless monoblock acetabular components is a rare complication of total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA). The purpose of this study was to evaluate the incidence and risk factors for early aseptic loosening of the cementless monoblock acetabular components. METHODS: This retrospective analysis consisted of 4,043 cementless hip devices (3,209 THAs and 834 HRAs). We identified 41 patients with early aseptic loosening of the acetabular component. A control group of 123 patients without acetabular component loosening was randomly selected. The demographic data and risk factors for loosening of the acetabular component were evaluated. The mean follow-up time was 4.6 years (range, 1.7-7.8). The end-point was acetabular revision. RESULTS: The incidence of early acetabular component loosening was 1.0 %. Mean time to revision was 1.2 years (SD 1.6, range 0.0-5.4). There was significantly more Dorr type A and C acetabular morphology in patients with early loosening (P = 0.014). The loosened components were implanted to more vertical (P < 0.001) and less anteverted (P = 0.001) position than those of the control group. Presence of acetabular dysplasia or acetabular component type did not associate to early loosening. CONCLUSIONS: Acetabular morphology (Dorr type A and C) and component positioning vertically and less anteverted were more common in patients with early aseptic loosening of cementless acetabular components. Suboptimal cup position most likely reflects challenges to obtain sufficient stability during surgery. We hypothesize that errors in surgical technique are the main reason for early loosening of monoblock acetabular components.

Arthroplasty for unstable pertrochanteric hip fractures may offer a lower re-operation rate as compared to cephalomedullary nailing.

PURPOSE: Cephalomedullary (CM) nailing is widely used for the treatment of pertrochanteric hip fractures. Fixation failures with CM nailing tend to occur in unstable fracture patterns often necessitating revision surgery. The purpose of this study was to compare the complications and clinical outcomes of primary arthroplasty to CM nailing for the treatment of unstable pertrochanteric hip fractures. METHODS: We conducted an age-, sex-, and fracture type-matched case-controlled study and identified 29 patients who underwent hip arthroplasty for an unstable pertrochanteric fracture (AO/OTA classification type 31A2.2/3 and 31.A3) at our institution. Their outcome was compared to a matched control group of 29 patients treated with a CM nail. RESULTS: There was one major complication in the arthroplasty group (3.4 %), whereas there were six major complications in the nailing group (20.7 %) (P = 0.04). We found no significant difference between the groups with regards to blood loss, operative time, hospitalization time and the number of patients discharged to rehabilitation. Clinical outcome measured with Oxford hip score and SF-12 at the time of final follow-up was not significantly different between the groups. CONCLUSIONS: Arthroplasty is a viable option for treatment of unstable pertrochanteric fractures in an elderly population. Arthroplasty may offer a lower re-operation rate in the treatment of unstable pertrochanteric hip fractures as compared to CM nailing.

Closed suction drainage has no benefits in revision total hip arthroplasty: a randomized controlled trial.

PURPOSE: Several studies have failed to show significant benefits of closed suction drainage (CSD) in routine primary total hip arthroplasty (THA). However, blood loss, haematoma formation and wound complications are generally much greater in revision THA as compared to primary THA. The purpose of this study was to determine if CSD is beneficial for revision THA patients. METHODS: We conducted a prospective, randomized, controlled trial at our institution between July 2013 and July 2014. Eighty-eight patients undergoing revision THA were enrolled and randomly assigned to receive a CSD (n = 44) or to not receive a CSD (n = 44). All first-stage revision surgeries for infection were excluded. Primary outcomes were haemoglobin loss and number of patients transfused. Secondary outcomes included functional outcome evaluated with Harris hip score (HHS), pain evaluated with visual analogue scale (VAS), and length of hospital stay. RESULTS: There were significantly more patients in the CSD group that required blood transfusions (20/44 as compared to 11/44, p = 0.04). Patients in the no CSD group were discharged earlier than patients in the CSD group (4.3 days as compared to 5.4 days, p = 0.002). No statistical significant difference was found in the HHS or pain VAS between the groups. CONCLUSIONS: This study did not demonstrate any benefit with the use of CSD for revision THA with regard to wound related complications, infection or early functional outcome. Post-operative blood loss, transfusion rate, and length of hospital stay may be higher with CSD.

The focally constrained liner is a reasonable option for revision of unstable total hip arthroplasty.

PURPOSE: Revision surgery for a patient with previous recurrent dislocations or abductor muscle dysfunction has been considered to be a complication-prone procedure regardless of the type of constrained implant used. We investigated the survivorship of a focally constrained acetabular liner used for revision total hip arthroplasty in patients with abductor insufficiency or previous recurrent dislocations. METHODS: We retrospectively reviewed 98 patients in whom a focally constrained acetabular liner was used to treat abductor insufficiency or previous recurrent dislocations. The mean age was 69.4 years (37-92) and 64 of these were females. Previously, the patients had undergone a mean of two (1-5) revisions. The mean follow-up was 38 (12-66) months. Kaplan-Meier survival curves were calculated and Log-rank test was used to test the difference in survivorship between patients with abductor insufficiency and previous dislocations. RESULTS: Sixteen patients needed a further re-revision for any cause. Thus, the revision-free survivorship was 84.3 % at five years. Five patients suffered a dislocation with a mean of five months post-operatively and were managed with repeat revision. Five patients failed at the implant-host bone interface. Three of these failures occurred after cementing the constrained liner into a pre-existing shell. CONCLUSIONS: The focally constrained liner provided a reasonable option for revision total hip arthroplasty in patients with hip instability. Failures were observed in patients with acetabular osteolysis but seemingly well-fixed component and unrecognized impingement.

Risk factors for intraoperative calcar fracture in cementless total hip arthroplasty.

BACKGROUND AND PURPOSE: Intraoperative periprosthetic femoral fracture is a known complication of cementless total hip arthroplasty (THA). We determined the incidence of--and risk factors for--intraoperative calcar fracture, and assessed its influence on the risk of revision. PATIENTS AND METHODS: This retrospective analysis included 3,207 cementless THAs (in 2,913 patients). 118 intraoperative calcar fractures were observed in these hips (3.7%). A control group of 118 patients/hips without calcar fractures was randomly selected. The mean follow-up was 4.2 (1.8-8.0) years. Demographic data, surgical data, type of implant, and proximal femur morphology were evaluated to determine risk factors for intraoperative calcar fracture. RESULTS: The revision rates in the calcar fracture group and the control group were 10% (95% CI: 5.9-17) and 3.4% (CI: 1.3-8.4), respectively. The revision rate directly related to intraoperative calcar fracture was 7.6%. The Hardinge approach and lower age were risk factors for calcar fracture. In the fracture group, 55 of 118 patients (47%) had at least one risk factor, while only 23 of118 patients in the control group (20%) had a risk factor (p = 0.001). Radiological analysis showed that in the calcar fracture group, there were more deviated femoral anatomies and proximal femur bone cortices were thinner. INTERPRETATION: Intraoperative calcar fracture increased the risk of revision. The Hardinge approach and lower age were risk factors for intraoperative calcar fracture. To avoid intraoperative fractures, special attention should be paid when cementless stems are used with deviant-shaped proximal femurs and with thin cortices.

Complications following conversion of a hip hemiarthroplasty to a total hip arthroplasty.

PURPOSE: Conversion of hip hemiarthroplasty to total hip arthroplasty (CTHA) is a complication-prone procedure with high dislocation rates and early component loosening. The purpose of this study was to evaluate the complications of CTHA performed using contemporary implants. METHODS: Forty-six patients who had CTHA were retrospectively matched to a control group of 46 patients who had a first-time THA revision. The mean follow-up was 47 (range 6-149) and 23 (range 6-139) months for CTHA and control groups, respectively. Radiographs taken at the last follow-up visit were evaluated for signs of loosening or other modes of failure. Clinical outcome was evaluated with the Harris Hip Score (HHS). RESULTS: Complications occurred in five patients (10.9 %) in the CTHA group, and all required repeat revision. Two patients (4.3 %) were revised due to recurrent dislocation. The other re-revisions were done for acetabular or femoral component loosening and deep infection. In the control group, complications occurred in six patients (13.0 %), and three (6.5 %) were revised with a constrained liner due to recurrent dislocations. CONCLUSIONS: Dislocation rates and re-revision for CTHA were not significantly different than those of first-time THA revision when using contemporary revision implants.

Periprosthetic supracondylar femoral fractures following knee arthroplasty: a biomechanical comparison of four methods of fixation.

PURPOSE: The aim of this study was to determine the biomechanical properties of four fixation options for periprosthetic supracondylar femoral fractures. METHODS: Fourth-generation composite femurs were implanted with a posterior-stabilizing femoral component of total knee arthroplasty. All femurs were osteotomized to produce a AO/OTA 33-A3 fracture pattern and four different constructs were tested: (1) non-locking plate; (2) polyaxial locking plate; (3) intramedullary fibular strut allograft with polyaxial locking plate; (4) retrograde intramedullary nail. The composite femurs underwent non-destructive tests to determine construct stiffness in axial and torsional cyclic loading. The final testing consisted of quasi-static axial loading until failure. RESULTS: Under cyclic torsional loading, the retrograde intramedullary nail was less stiff than non-locking plate, polyaxial locking plate and intramedullary fibular strut allograft with polyaxial locking plate (p = 0.046). No differences were detected in cyclic axial loading between the different constructs. During quasi-static axial loading to failure, the intramedullary nail achieved the highest axial stiffness while the non-locking plate showed the lowest (p = 0.036). CONCLUSIONS: The intramedullary fibular strut allograft with polyaxial locking plate did not prove to be significantly better to the polyaxial locking plate only in a periprosthetic distal femur fracture model.

A comprehensive analysis of patients with malreduced ankle fractures undergoing re-operation.

PURPOSE: The present study aimed to determine the most common surgical errors resulting in early re-operation following ankle fracture surgery. METHODS: We performed a chart review to determine the most common types of malreductions that led to early re-operation following ankle fracture surgery. From 2002 to 2011, we identified 5,123 consecutive ankle fracture operations in 5,071 patients. Seventy-nine patients (1.6%) which underwent re-operation due to malreduction detected in postoperative radiographs. These patients were compared with an equal number of age- and sex-matched controls which did not need further surgery. RESULTS: The most common indication for re-operation was syndesmotic malreduction (47 of 79 patients, 59%). Four main types of errors related to syndesmotic reduction or fixation were identified, with the most common being fibular malpositioning within the tibiofibular incisura. Other indications for re-operation were fibular shortening and malreduction of the medial malleolus. Fracture dislocation, fracture type, posterior malleolar fracture, associated medial malleolar fracture, duration of index surgery, and fixation of an associated medial malleolar fracture with other than two parallel screws were also associated with re-operation. Correction of the malreduction was successfully achieved in the majority (84%) of cases needing further surgery. CONCLUSION: Early re-operation after ankle fracture surgery was most commonly caused by errors related to syndesmotic reduction or failure to restore fibular length. In the majority of cases, postoperative malreduction was successfully corrected in the acute setting.

Adherence of hip and knee arthroplasty studies to RSA standardization guidelines. A systematic review.

BACKGROUND AND PURPOSE: Guidelines for standardization of radiostereometry (RSA) of implants were published in 2005 to facilitate comparison of outcomes between various research groups. In this systematic review, we determined how well studies have adhered to these guidelines. METHODS: We carried out a literature search to identify all articles published between January 2000 and December 2011 that used RSA in the evaluation of hip or knee prosthesis migration. 2 investigators independently evaluated each of the studies for adherence to the 13 individual guideline items. Since some of the 13 points included more than 1 criterion, studies were assessed on whether each point was fully met, partially met, or not met. RESULTS: 153 studies that met our inclusion criteria were identified. 61 of these were published before the guidelines were introduced (2000-2005) and 92 after the guidelines were introduced (2006-2011). The methodological quality of RSA studies clearly improved from 2000 to 2011. None of the studies fully met all 13 guidelines. Nearly half (43) of the studies published after the guidelines demonstrated a high methodological quality and adhered at least partially to 10 of the 13 guidelines, whereas less than one-fifth (11) of the studies published before the guidelines had the same methodological quality. Commonly unaddressed guideline items were related to imaging methodology, determination of precision from double examinations, and also mean error of rigid-body fitting and condition number cutoff levels. INTERPRETATION: The guidelines have improved methodological reporting in RSA studies, but adherence to these guidelines is still relatively low. There is a need to update and clarify the guidelines for clinical hip and knee arthroplasty RSA studies.

Dislocation of hip hemiarthroplasty following posterolateral surgical approach: a nested case-control study.

PURPOSE: Hip hemiarthroplasty dislocation is a serious complication in treatment of displaced intracapsular hip fractures. We investigated factors associated with an increased risk of dislocation after cemented hip hemiarthroplasty following the posterolateral approach. METHODS: Between January 2002 and December 2008, 602 hip fractures were treated with cemented unipolar hip hemiarthroplasty. A registry-based analysis was carried out to determine the total number of hemiarthroplasty dislocations in these patients. A control group of 96 patients without dislocation was randomly selected. Logistic regression analysis was performed to evaluate clinical and operative factors associated with dislocation. RESULTS: Thirty-four patients (5.6%) experienced at least one dislocation. Most were the result of a fall and occurred within two months after surgery. There was a trend for increased dislocation in patients who had been operated on more than 48 hours after admission and in patients who had a longer operative time. Smaller centre-edge angle and hip offset were observed in patients with dislocation. Recurrent dislocation was a significant problem, as 18 patients (62%) experienced multiple dislocations. CONCLUSIONS: The risk of hemiarthroplasty dislocation following the posterolateral surgical approach may be reduced by prompt surgical treatment and fall prevention in the early postoperative period. Patients with smaller acetabular coverage seem more predisposed to dislocation after the posterolateral approach and may be more suitable for other surgical approaches.

Low BMD affects initial stability and delays stem osseointegration in cementless total hip arthroplasty in women: a 2-year RSA study of 39 patients.

BACKGROUND AND PURPOSE: Immediate implant stability is a key factor for success in cementless total hip arthroplasty (THA). Low bone mineral density (BMD) and age-related geometric changes of the proximal femur may jeopardize initial stability and osseointegration. We compared migration of hydroxyapatite-coated femoral stems in women with or without low systemic BMD. PATIENTS AND METHODS: 61 female patients with hip osteoarthritis were treated with cementless THA with anatomically designed hydroxyapatite-coated femoral stems and ceramic-ceramic bearing surfaces (ABG-II). Of the 39 eligible patients between the ages of 41 and 78 years, 12 had normal systemic BMD and 27 had osteopenia or osteoporosis. According to the Dorr classification, 21 had type A bone and 18 had type B. Translational and rotational migration of the stems was evaluated with radiostereometric analysis (RSA) up to 2 years after surgery. RESULTS: Patients with low systemic BMD showed higher subsidence of the femoral stem during the first 3 months after surgery than did those with normal BMD (difference = 0.6, 95% CI: 0.1-1.1; p = 0.03). Low systemic BMD (odds ratio (OR) = 0.1, CI: 0.006-1.0; p = 0.02), low local hip BMD (OR = 0.3, CI: 0.1-0.7; p = 0.005) and ageing (OR = 1.1, CI: 1.0-1.2; p = 0.02) were risk factors for delayed translational stability. Ageing and low canal flare index were risk factors for delayed rotational stabilization (OR = 3, CI: 1.1-9; p = 0.04 and OR = 1.1, CI: 1.0-1.2; p = 0.02, respectively). Harris hip score and WOMAC score were similar in patients with normal systemic BMD and low systemic BMD. INTERPRETATION: Low BMD, changes in intraosseous dimensions of the proximal femur, and ageing adversely affected initial stability and delayed osseointegration of cementless stems in women.