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Aims Total knee arthroplasty (TKA) is a common and safe orthopaedic procedure. Zimmer Biomet's NexGen is the second most popular brand of implant used in the UK. The primary cause of revision after the first year is aseptic loosening. We present our experience of using this implant, with significant concerns around its performance with regards early aseptic loosening of the tibial component. Methods A retrospective, single-surgeon review was carried out of all of the NexGen Legacy Posterior Stabilized (LPS) TKAs performed in this institute. The specific model used for the index procedures was the NexGen Complete Knee System (Legacy Knee-Posterior Stabilized LPS-Flex Articular Surface, LPS-Flex Femoral Component Option, and Stemmed Nonaugmentable Tibial Component Option). Results Between 2013 and 2016, 352 NexGen TKAs were carried out on 331 patients. A total of 62 TKAs have been revised to date, giving an all-cause revision rate of 17.6% at a minimum of five years. Three of these revisions were due to infection. Overall, 59 of the revisions were performed for aseptic loosening (16.7%) of the tibial component. The tibial component was removed intraoperatively without instrumentation due to significant tibial debonding between the implant-cement interface. Conclusion While overall, we believe that early aseptic loosening is multi-factorial in nature, the significantly high aseptic revision rate, as seen by an experienced fellowship-trained arthroplasty surgeon, has led us to believe that there is a fundamental issue with this NexGen implant design. Continued implant surveillance and rigorous review across all regions using this particular implant is warranted based on the concerning findings described here. Cite this article: Bone Jt Open 2022;3(6):495–501.

Background Total knee arthroplasty (TKA) is a common orthopedic procedure with 975,739 performed in the UK between 2003 and 2016. The two most common prosthetics used are P.F.C. Sigma and NexGen. The aim of this study is to compare the experience of a single fellowship-trained arthroplasty surgeon at a single dedicated orthopedic hospital using both of these prosthetics over a 17-year period. Methods This study was carried out as a retrospective review. Information was gathered from a database of primary TKAs and revision TKAs, as well as medical records, correspondence and operative notes. Results A total of 1,511 TKAs were performed between 1999 and 2015 – with a further follow-up period of 2 years. There were 1,161 consecutive P.F.C. primary TKAs done from 1999 to April 2013, after which, 350 consecutive NexGen primary TKAs were performed. Between 2015 and 2017, 26 NexGen revisions were required. 23 (6.6%) of the NexGen knees were carried out for aseptic loosening. The average time for revision from the NexGen index surgery was 30.4 months. The failures all presented similarly – with the tibial component having collapsed into varus and radiographic lucency noted under the implant. Conclusion In spite of changes in orthopedic practice and advances in implant technology over the time period of this study, we would not expect this level of implant failure from a surgeon who had no previous significant issues with aseptic loosening using a different prosthetic. Usage of the NexGen knee has been discontinued at this center.

Proximal femoral osteotomy is a well-accepted joint preserving treatment option in young patients with early symptomatic degenerative hip disease [1]. The main goal of this procedure is to halter the progression of osteoarthritic joint changes and to relieve pain mainly through the realignment of the articular surfaces and redistribution of joint forces [2]. Additionally it preserves bone stock and delay THA and its harmful possible complications especially in young patients [1, 2].

peer-reviewed Prosthetic joints and other orthopaedic implants have improved quality of life for patients world-wide and the use of such devices is increasing. However, while infection rates subsequent to associated surgery are relatively low (

Synchronous quadriceps tendon rupture is rare. A 29-year-old man, an amateur weight lifter, taking androgenic-anabolic steroids (AAS), developed sudden onset bilateral pain and swelling of his anterior thighs when attempting to squat 280 kg (620 lb). Examination revealed gross swelling superior to the patella and palpable gaps in both quadriceps tendons. He underwent successful operative repair. MRI revealed a partial tear of the anterior cruciate ligament (ACL) of the right knee. This was not reconstructed. Only a few case reports of the association between AAS and quadriceps rupture exist in the literature, with none to the best of our knowledge in the past 10 years. ACL rupture coexisting is very rare, with only two reported cases.

Hip pain is a common complaint with many causes. Pathology in the hip can present with pain referred to sites other than the hip and pain in the hip may result from pathology elsewhere. An accurate history and examination is paramount. Chronic painful conditions of the hip summarised in this paper can be classified into three main groups: intra-articular, extra-articular and hip mimickers. The intra-articular conditions include osteoarthritis, rheumatoid arthritis, femoroacetabular impingement, labral tears and snapping hip secondary to loose bodies, synovial chondromatosis or labral tears. Extra-articular conditions include snapping hip, iliopsoas bursitis, piriformis syndrome and greater trochanteric pain syndrome. Hip mimickers include myofascial pain syndrome, osteitis pubis, sacroiliac joint pain and nerve entrapment syndromes.

Total hip replacement produces significant postoperative pain. Psoas compartment block is the most effective block of the lumbar plexus in terms of pain relief and reduced blood loss. It is a proven regional technique for analgesia and anaesthesia during and after total hip replacement conferring a number of benefits to the patient. However, traditional techniques used to produce this block require increased theatre time and are associated with a number of serious complications. We present a surgeon-delivered technique for producing a lumbar plexus block using direct injection into the iliopsoas muscle when it is visible intraoperatively. This study shows a cadaveric model using methylene blue and radiopaque contrast produces injectate spread in a fashion which would produce a successful lumbar plexus block. This novel technique for lumbar plexus block affords the benefits of psoas compartment block with reduced complications and reduced administration time.

Background Acetabular defect reconstruction in revision hip arthroplasty may be achieved with acetabular impaction bone grafting (AIBG) or porous trabecular metal (TM) implantation. We sought to compare clinical and radiological outcomes of both methods at a single institution. Methods 36 patients that were revised using AIBG and 17 patients that were revised with TM were retrospectively reviewed from local joint registry data. 82% of the TM group and 64% of the AIBG group were ≥ Paprosky 2c. Rerevision was considered failure. Radiographs demonstrating 5 mm of migration of femoral head and 5° of acetabular component inclination change were considered loose. Results Age at surgery was earlier in the AIBG group (median 68 years vs. 74 years). Median follow-up was 5.9 years for AIBG and 5.4 years for TM. Harris Hip Scores improved significantly for both groups (mean improvement: 32 vs. 31). There were 4 failures (11%) in the AIBG group and none in the TM group. 3 of the 4 AIBG failures occurred following second-stage revision for prosthetic joint infection. 4 (11%) and 2 (12%) hip reconstructions demonstrated radiological evidence of loosening in AIBG and TM groups respectively. Conclusions AIBG and TM acetabular defect reconstructions achieve good clinical outcome but there is greater success with TM in higher grades of acetabular deficiency regardless of prior infection.

We present our experience over 6 years with the use of uncemented total hip arthroplasty (THA) for developmental dysplasia of the hip (DDH) with a mean follow-up of 3 years. In a 6-year period, 26 THAs were performed in 19 patients with Hartofilakidis grades 2 and 3 dislocation of the hips. Out of 19 patients, seven had bilateral dislocations. Uncemented acetabular and femoral components were used in all patients. Patients with a minimum follow-up of 1 year were included in the study. The average age at the time of surgery was 38 (range 20–69) years. Approaches used include trochanteric osteotomy in 14 (54%) patients and a lateral approach in 12 (46%) patients. In addition, subtrochanteric osteotomy was performed in four (15%) patients. A Mallory-head femoral stem was used in 15 (58%) patients; a DDH femoral stem was in nine (35%), and the S-ROM femoral prosthesis in two (8%). A Mallory head acetabular shell was used in all cases, a 22.2-mm chrome cobalt head was used in 18 (69%), and a 28-mm chrome cobalt head was used in eight (31%). The average follow-up was 3 (range 1–6) years. The Harris hip score (HHS) improved in the cohort from a mean preoperative score of 51 to a mean postoperative score of 86 (p

Prosthetic joints and other orthopedic implants have improved quality of life for patients world-wide and the use of such devices is increasing. However, while infection rates subsequent to associated surgery are relatively low (3%), the consequences of incidence are considerable, encompassing morbidity (including amputation) and mortality in addition to significant social and economic costs. Emphasis, therefore, has been placed on mitigating microbial risk, with clinical microbiologists and surgeons utilizing rapidly evolving molecular laboratory techniques in detection and diagnosis of infection, which still occurs despite sophisticated patient management. Multidisciplinary approaches are regularly adopted to achieve this. In this commentary, we describe an unusual case of Actinomyces infection in total hip arthroplasty and, in that context, describe the perspectives of the clinical microbiology and surgical teams and how they contrasted. More specifically, this case demonstrates an ad hoc approach to structured eradication of biofilms and intracellular bacteria related to biomaterials, as reflected in early usage of linezolid. This is a complex topic and, as described in this case, such accelerated treatment can be effective. This commentary focuses on the merits of such inadvisable use of potent antimicrobials amid the risk of diminishing valuable antimicrobial efficacy, albeit resulting in desirable patient outcomes.

A 68 year old man underwent a femoral neck ostectomy as a palliative procedure for pain in the right hip secondary to an extensive acetabular metastasis from renal cell carcinoma. Excellent pain relief was achieved and he remained mobile until shortly before his death 8 months later. Copyright 2003, Elsevier Science (USA). All rights reserved.

Patients post total hip arthroplasty (THA) remain at high risk of developing Deep Vein Thrombosis (DVT) during the recovery period following surgery. The use of calf muscle neuromuscular electrical stimulation (NMES) during the hospitalized recovery period on this patient group may be effective at preventing DVT. However, the haemodynamic effectiveness and comfort characteristics of NMES in post-THA patients immediately following surgery has yet to be demonstrated. The popliteal veins of 5 patients, who had undergone unilateral total hip replacement surgery on the day previous to the study, were measured using Doppler ultrasound during a 4 hour calf-muscle NMES session. The effect of calf muscle NMES on peak venous velocity and volume flow were compared to resting values. Comfort was assessed using a 100 mm non-hatched visual analogue scale taken before application of NMES, once NMES was initiated and before NMES was withdrawn. Results of the study showed that NMES produces a beneficial hemodynamic response in patients in the early postoperative period following orthopaedic surgery. This patient group found extended periods of calf-muscle NMES tolerable.

We performed a retrospective analysis of all patients admitted to a single unit over 4 years with fractured neck of femur. Of the 760 patients admitted over this period of time 36 (4.7%) were found to also have a fracture of the upper limb. The associated upper limb fractures were distal radius (n=28), olecranon (n=2) and neck of humerus (n=5) and fifth metacarpal (n=1), with the same ratio of intracapsular to extracapsular fractures as the whole group. The female to male ratio in the isolated hip fracture group was 2.4:1 and for the combined fractures group was 8:1 (difference P=0.014). The mean patient age was 77.3 years for isolated hip fractures and 83.9 for the combined group (P=0.037). The mean total length of stay in hospital for isolated hip fracture was 15.6 days and for combined fractures was 20.4 days (P=0.010). We have demonstrated that combined upper limb and neck of femur fractures occur in a population that is older and predominantly female. They are associated with a significant increase in hospital stay and increased difficulties in mobilisation as a consequence of the combined fractures. It is therefore important to recognise this specific subgroup of patients presenting with hip fractures in order to ensure that they receive adequate treatment and rehabilitation and that the use of valuable health care resources are optimised.

To assess the usefulness of traditional recovery room check radiographs after total hip arthroplasty, we retrospectively analysed 2,065 consecutive hip arthroplasty patients. We found a 0.1% rate of radiologic diagnosis of dislocation in the population screened. In 100 patients randomly selected for comparison, the image quality in the recovery room radiographs was significantly inferior to standardized departmental radiographs (P.001), with further significant differences between cup version (P.001), and stem alignment assessments (P=.002). We found good agreement between the authors in the assessments of these radiographs with a weighted kappa statistic of 0.8653 (P.0001). Seven recovery room radiographs needed repetition for poor quality versus none of the departmental films (P=.007). With such poor information and diagnostic yield for follow-up and screening, these investigations should only be performed when clinically indicated.

A 68 year old man underwent a femoral neck ostectomy as a palliative procedure for pain in the right hip secondary to an extensive acetabular metastasis from renal cell carcinoma. Excellent pain relief was achieved and he remained mobile until shortly before his death 8 months later.

In view of the importance placed on the first intermetatarsal angle in the assessment of surgical intervention in hallux valgus, we assessed the reliability with which one measures this angle. The study involved 10 observers of varying experience measuring the angle using a standard technique on 10 weightbearing AP X-rays of the foot on three separate occasions. The margin of error in measuring the angle was ±3.60° with a 95% confidence interval. Increasing and averaging the number of readings per observer or the readings of a number of observers, reduces the error. Experience doesn't improve reliability. In conclusion, improvement in the reliability of the measurements can be achieved by careful technique, performing the measurements at least twice, and averaging them.

Context : Infection of following total hip arthroplasties can be classified based on the timing of infection. Late infections with Actinomyces israelii are extremely rare with only 3 previously reported cases in literature. We present another case of a late infection with Actinomyces israelii in a total hip arthroplasty 9 years following implantation. Case Report : A 71-year-old male with diabetes mellitus presented with right hip pain 9 years following a total hip arthroplasty. Physical examination revealed localised pain and biochemical investigations showed elevated inflammatory markers. X-rays were suspicious for infection and a collection around the prosthesis was confirmed by MRI scan. The patient underwent debridement and removal of prosthesis. Peri-operative specimen cultures isolated Actinomyces israelii . The patient responded to a combination of vancomycin followed by ciprofloxacin and linezolid therapy before undergoing a successful second-stage reimplantation surgery. Conclusion : This is the first reported case of late haematogenous infection by Actinomyces israelii in a total hip arthroplasty in a patient with diabetes mellitus as the only risk factor. The patient was successfully treated with antibiotic therapy and two-stage reimplantation arthroplasty.

Background Patients post total hip arthroplasty (THA) remain at high risk of developing Deep Vein Thrombosis (DVT) during the recovery period following surgery despite the availability of effective pharmacological and mechanical prophylactic methods. The use of calf muscle neuromuscular electrical stimulation (NMES) during the hospitalised recovery period on this patient group may be effective at preventing DVT. However, the haemodynamic effectiveness and comfort characteristics of NMES in post-THA patients immediately following surgery have yet to be established. Methods The popliteal veins of 11 patients, who had undergone unilateral total hip replacement surgery on the day previous to the study, were measured using Doppler ultrasound during a 4 hour neuromuscular electrical stimulation (NMES) session of the calf muscles. The effect of calf muscle NMES on peak venous velocity, mean venous velocity and volume flow were compared to resting values. Comfort was assessed using a 100mm non-hatched visual analogue scale taken before application of NMES, once NMES was initiated and before NMES was withdrawn. Results In the operated limb NMES produced increases in peak venous velocity of 99% compared to resting. Mean velocity increased by 178% compared to resting and volume flow increased by 159% compared to resting. In the un-operated limb, peak venous velocity increased by 288%, mean velocity increased by 354% and volume flow increased by 614% compared to basal flow (p

We performed a consecutive survey of 100 people presenting to a hospital injury clinic to ascertain their attitude to terminology currently used to describe them in our own institution and in the international literature. The results of this demonstrated that the subjects significantly preferred the traditional assignation “patient” rather than terms such as client or customer. This finding reflects the need to remember peoples’ attitudes and expectations from their consultation with their doctor. Although business models undoubtedly help in the provision of an efficient health care service, remaining at the centre of this encounter is a doctor‐patient relationship that involves a more complex interaction than simply a market transaction.

When faced with revision surgery for recurrent congenital vertical talus deformity, the tibialis anterior tendon may be deficient or absent as a result of the initial procedure. This tendon cannot then be used as a dynamic sling to dorsiflex the talar neck. We present two cases in which the peroneus longus tendon was transferred dorsally into the talar neck as an alternative to an absent tibialis anterior tendon. Excellent corrections were achieved and maintained. The use of this tendon has not been described previously in surgery for this condition.

Many of the devices used in the internal fixation of femoral neck fractures are cannulated and require the initial placement of one or more guidewires for accurate positioning. These wires are occasionally advanced inadvertently through the hip joint and the acetabulum. Pelvic visceral damage may follow. To assess this risk, we inserted three guidewires to a depth of 16 cm into each femoral neck of ten cadavers and explored the pelvis during autopsy. Thirty-two of the 60 guidewires had penetrated a pelvic organ. The literature on intrapelvic injuries associated with hip surgery is reviewed, and suggestions are offered on the avoidance of pelvic penetration during hip fracture fixation.

To the Editor.— We would like to discuss some points raised by Black et al. 1 The phenomenally high incidence of deaths from suicides and accidents—32% of all deaths and 67% of excess deaths—remains difficult to comprehend despite an awareness of the increased mortality from suicide in psychiatric populations and the strong association between physical and psychiatric disorder. 2 In our own study, 3 schizophrenics died at a younger age than members of the general population as a result of an excess of cases of pneumonia as well as an increased incidence of suicide (18.9% died of pneumonia; 6.6% committed suicide—9.7% of males and 3.3% of females). One wonders about the difference between American and Irish smoking patterns and the distribution of unnatural deaths among the different subclasses of psychiatric disorder in the study by Black et al. The authors attempt to discover common themes in mortality patterns. It seems