Revision of double-tapered, titanium, fully hydroxyapatite-coated femoral stems: ease of extraction and subsequent reconstruction.

BACKGROUND: Fully hydroxyapatite coated, double-tapered, titanium stems are the most commonly used uncemented implants in the UK with survivorship reported at 96.3% at 23 years however there is no literature on the consequences of revision. We aimed to explore the reasons for failure, ease of stem extraction, extent of bone loss and complexity of the subsequent reconstruction. METHODS: Between December 2012 and March 2019, 104 cases requiring removal of the Corail® stem (DePuy Synthes, Warsaw, IN, USA) were identified from the National Joint Registry (NJR) and our local revision database. Indication for revision, surgical/reconstruction technique, complications and follow-up data were reviewed. RESULTS: The common reasons for revision were aseptic loosening 45.2%, infection 23.5%, instability 4.8% and peri-prosthetic fracture 12.5%. Removal of the implant without extended trochanteric osteotomy (ETO) was achieved in 94.2% of cases. Of those revised for aseptic loosening 23% were proximal, 38% were proximal/mid stem and 38% all zones. Significant bone loss is not a common feature of the failure of this stem with 95% graded as a Paprosky grade 2 or less. In terms of reconstruction, 69.2% were revised to a primary cemented stem. CONCLUSIONS: In the majority of cases revision can be achieved without an ETO and reconstruction possible using a primary stem as significant bone loss is not a common feature of failure of this stem design. We conclude that this stem is safe to use in younger patients who may outlast any type of primary implant and would inevitably face revision in their lifetime.

Proximal femoral replacement in non-neoplastic revision hip arthroplasty : five-year results.

AIMS: With increasing burden of revision hip arthroplasty (THA), one of the major challenges is the management of proximal femoral bone loss associated with previous multiple surgeries. Proximal femoral arthroplasty (PFA) has already been popularized for tumour surgeries. Our aim was to describe the outcome of using PFA in these demanding non-neoplastic cases. METHODS: A retrospective review of 25 patients who underwent PFA for non-neoplastic indications between January 2009 and December 2015 was undertaken. Their clinical and radiological outcome, complication rates, and survival were recorded. All patients had the Stanmore Implant - Modular Endo-prosthetic Tumour System (METS). RESULTS: At mean follow-up of 5.9 years, there were no periprosthetic fractures. Clearance of infection was achieved in 63.6% of cases. One hip was re-revised to pseudo arthroplasty for deep infection. Instability was noted in eight of the hips (32%), of which seven needed further surgery. Out of these eight hips with instability, five had preoperative infection. Deep infection was noted in five of the hips (20%), of which four were primarily revised for infection. One patient had aseptic loosening of the femoral component and awaits revision surgery. The Kaplan-Meier survivorship free of revision of any component for any reason was 72% (95% confidence interval (CI) 51.3% to 92.7%), and for revisions of only femoral component for any reason was 96% (95% CI 86.3% to 105.7%) at five years. CONCLUSION: Dislocation and infection remain the major cause for failure, particularly in patients with pre-existing infection. The use of dual mobility cups, silver-coated implants, and less aggressive postoperative rehabilitation regimens would possibly aid in the reduction of complications. PFA performed in patients with periprosthetic fracture seem to fair better. This study supports the judicious use of PFA in non-oncological revision hip arthroplasties, and that they be performed by experienced revision arthroplasty surgeons. Cite this article: Bone Jt Open 2022;3(3):229-235.

Early Functional Outcomes After Evolutionary Total Knee Arthroplasty: A Randomized Controlled Trial. Is New Always Better?

Total knee replacement (TKR) designs continue to evolve with the aim of improving patient outcomes; however, there remains a significant patient dissatisfaction rate. We report the early functional outcomes of an evolutionary knee design in the context of a single-blinded, noninferiority, randomized controlled trial. METHODS: Patients were randomized to receive either the P.F.C. SIGMA or ATTUNE knee implant systems (DePuy Synthes). All implants were fixed-bearing, cruciate-retaining, and cemented constructs. Patients were assessed at baseline and 6 weeks, 3 months, and 1 year postoperatively using clinical and functional outcome measures, including range of motion, Oxford Knee Score (OKS), Oxford Knee Score-Activity and Participation Questionnaire (OKS-APQ), Patient Knee Implant Performance (PKIP) score, 5-Level EuroQol 5 Dimensions (EQ-5D-5L), and Short Form-36 outcome measures. RESULTS: There were 150 patients who underwent a surgical procedure (76 with the ATTUNE implant and 74 with the P.F.C. SIGMA implant), with 147 patients remaining at the final review. No differences were observed in any of the outcome measures between the groups at any time point. Tourniquet time was significantly shorter in the P.F.C. SIGMA arm (p = 0.001); however, this had no clinical impact on the OKS (analysis of covariance [ANCOVA] test) at the final review (p = 0.825). There was no difference in the numbers of patients achieving the minimal clinically important difference for the OKS between the groups (p = 0.817). CONCLUSIONS: This trial did not show inferiority of the ATTUNE implant when compared with the P.F.C. SIGMA implant. The authors believe that implant innovation should continue and that modern implants should be introduced into the market following randomized controlled trials. Further work should assess the effect of non-implant-related factors on patient outcomes. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Is patient satisfaction related to patient reported sounds from ceramic on ceramic total hip arthroplasty? A study of 265 hips.

INTRODUCTION: The ideal method and implant to perform total hip arthroplasty (THA) is still a debated topic. Ceramic on ceramic (CoC) bearings have favourable wear properties, but squeaking has been reported as an unwanted side effect. We aimed to determine the rate of noise generation from CoC hips and investigate whether there is a relationship with patient satisfaction. METHODS: A total of 246 consecutive CoC bearing uncemented THA were retrospectively identified in a single institution. Post-operatively patients were sent a postal questionnaire to evaluate their reported sounds and satisfaction with their THA. Uni- and multi-variate analyses were performed to identify potential predictor variables for reported post-operative sounds. RESULTS: Questionnaires were returned by 172 patients (70% return rate). 24% reported sounds from their hips with 11% reporting a squeak. Median satisfaction levels were minimally, but significantly less for "noisy" (9/10) than "quiet" hips (10/10) (median difference = - 1, 95% CI - 2 to 0, p < 0.001). Compared to those with "noisy" hips, patients with "quiet" hips were 1.7 times (95% CI 1.3-2.5, p = 0.0002) more likely to report a "forgotten" hip. Younger age (p < 0.043) and increased anteversion (p < 0.021) were predictors for reported sounds. CONCLUSION: We have identified a high rate of "noisy" hips in this series of CoC THA with a significant inverse relationship between "noisy" hips and patient satisfaction levels. In our unit, we are moving towards the use of ceramic on cross-linked polyethylene bearings as a result of these findings and the excellent survivorship of this bearing combination.

Wear rate and medium-term survival of a cemented, moderately cross-linked polyethylene acetabular prosthesis.

INTRODUCTION: The moderately cross-linked Depuy Marathon® cemented acetabular component was introduced into the UK in 2007. The wear rate for the previously introduced Marathon® uncemented acetabular component has been reported to range from 0.06 to 0.01 mm/year. The aim of this study was to present the medium-term results and wear rate of the Marathon® cemented prosthesis used in primary total hip arthroplasty. METHODS: 103 Marathon® cemented acetabular components were implanted between 2008 and 2009 in primary arthroplasty, who were eligible for this study. All patients received a metal 28-mm head. Mean age was 68 years (range 27-87). Mean clinical follow-up was 55 months (range 50-61). Mean radiological follow-up was 46 months (range 24-57). Wear was calculated on AP radiographs using computer-assisted uni-radiographic technique. RESULTS: The mean wear was 0.37 mm (range 0.0-0.78 mm). The wear rate was calculated as 0.03 mm/year (95% confidence interval 0.02-0.06). Postoperative complications included deep vein thrombosis (2%) and dislocation (0.8%); there were no deep infections. There were no revisions for failure of the Marathon® cemented acetabular component. CONCLUSIONS: The Marathon® cemented acetabular component demonstrates satisfactory wear rates and survivorship at medium-term follow-up.

Intrarater and interrater reliability of the socket version marker in total hip replacement.

The aim of this study was to evaluate the intraobserver and interobserver variability in determining the socket version using the wire marker. 100 anteroposterior pelvis radiographs of cemented primary total hip replacements were reviewed by two orthopaedic consultants and registrars, twice. Intrarater and interrater reliability were assessed using Cohen's kappa. Intrarater kappas for junior doctors were 0.78 and 0.80, 0.73 and 0.62 for Consultants. Interrater kappas were 0.60 between the two Consultants and 0.63 between the two Junior Doctors. The kappas between Consultant A and Junior Doctor A was 0.61, between Consultant A and Junior Doctor B was 0.59, between Consultant B and Junior Doctor A was 0.53 and between Consultant B and Junior Doctor B was 0.46. Intrarater reliability was substantial for the two junior doctors and the two consultants. Interrater reliability was moderate-to-substantial between the two consultants, between the two junior doctors and between each pair of junior doctors/consultants.

Clinical experience of revision of metal on metal hip arthroplasty for aseptic lymphocyte dominated vasculitis associated lesions (ALVAL).

There has been growing concern regarding the systemic and local effects of metal ions released from metal-on-metal hip resurfacings and total hip replacements, including the development of aseptic lymphocyte dominated vasculitis associated lesions (ALVAL). We describe our experience of treating 13 patients with failed metal on metal bearing hip prostheses secondary to this condition. Hip revision occurred at mean of 45 months following primary surgery. Groin pain was present in all patients. Other common features included large bursal swelling and mechanical symptoms. 3 patients developed their symptoms immediately postoperatively. The mean time to presentation was 21 months. Radiographic abnormalities noted included 3 patients with cup loosening and 2 patients with neck thinning. The mean cup inclination was 52 degrees. Surgical findings included bursal swellings and creamy brown fluid. Osteolysis was rarely seen. 12 revisions were achieved with primary implants and all patients had immediate symptomatic improvement. One patient was left with a pseudoarthrosis due to extensive soft tissue destruction. Diagnosis of ALVAL was confirmed histologically. The diagnosis of ALVAL should be considered in patients with unexplained pain from a metal on metal bearing hip arthroplasty. Surgical findings are typical and symptoms tend to resolve reliably following conversion to an alternative bearing surface.

Medium-term results with the Press Fit Condylar (PFC) Sigma knee prosthesis the Wrightington experience.

The PFC Sigma total knee was introduced in 1997, incorporating a number of design changes. We report the mid-term results of a consecutive series of PFC Sigma knee arthroplasties performed between November 1997 and December 1998. Out of a total of 156 patients (166 knees), 5 patients (5 knees) were lost to follow-up and 6 patients (6 knees) died of unrelated causes. This left 145 patients (155 knees), 90 female and 55 male, with a mean age of 70 years (range, 53-88) and an average follow-up of 90 months (range, 84-96). Posterior cruciate retaining components were used in 136 knees (88%) and posterior-stabilized in 19 (12%). The patella was resurfaced in 74 (48%) knees. Follow-up was at 3, 6 and 12 months, then yearly. Preoperative American Knee Society and Oxford scores were compared with follow-up scores. The Knee Society radiological score was used for radiographic assessment. One knee (0.6%) was revised due to aseptic loosening. One knee (0.6%) had superficial wound infection, which settled with oral antibiotics. Two knees became deeply infected. Of these, one resolved following early debridement, the other developed chronic infection. Using revision for any reason as the end-point our cumulative success rate was 99.4%. The mean preoperative Knee score improved from 45 (30-65) to 84 (45-92), Functional score from 38 (25-55) to 73 (50-95) and Oxford score from 43 (33-52) to 17 (14-29). Radiographic review showed radiolucent lines in 54 (35%) tibial and 17 (11%) femoral components. The Radiological Knee Society score was less than 4 in all except one tibia where the score was 7. Our study shows excellent clinical results with the PFC Sigma total knee replacement after almost eight years follow-up.