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Background: Modular titanium fluted tapered (TFT) stems have demonstrated excellent clinical success for femoral revision total hip arthroplasty (THA) surgery. This study reports the short-term outcomes of a novel modern monoblock TFT stem used for revision and complex primary THA with a minimum of 2 years of follow-up., Methods: We identified 126 patients who received a single monoblock TFT stem: 26 patients for complex THA (failed fracture fixation) and 100 patients for revision THA. The reasons for revision THA included 40 for previous periprosthetic joint infection, 42 for aseptic loosening, 9 for trunnionosis, and 9 for periprosthetic fractures. The Paprosky grading for femoral bone loss at the time of surgery and the measured subsidence of femoral stems at 3-month follow-up were determined. We evaluated the number and indications for reoperations., Results: The mean time from surgery was 3.9 years (range, 2.0 to 6.9). A paired t-test analysis showed significant improvement from preoperative versus postoperative clinical outcome scores (P < .001) for Harris Hip Score (38.76 ± 15.24 versus 83.42 ± 15.38), Western Ontario and McMaster Universities Arthritis Index (45.6 ± 19.0 versus 69.9 ± 21.3), Veterans RAND 12 Item Health Survey Physical component (31.7 ± 8.1 versus 37.8 ± 11.3), and Veterans RAND 12 Item Health Survey Mental component (48.2 ± 12.2 versus 51.6 ± 12.5). The Paprosky grading for femoral bone loss was Grade 1 (3.9%), Grade 2 (35.7%), Grade 3A (47.6%), Grade 3B (11.1%), and Grade 4 (1.6%) cases. There were 18 reoperations (14.7%), with 13 for periprosthetic joint infection (7 treated with implant retention and 6 treated with a 2-stage revision), 4 for instability, and 1 for acetabular aseptic loosening. There were no aseptic failures of the stem., Conclusions: This novel modern monoblock TFT stem provided reliable femoral fixation and has increasingly supplanted the use of modular TFT stems for complex primary and revision surgery in our institution., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Periprosthetic joint infection (PJI) continues to be one of the leading causes of failure following total hip arthroplasty (THA). The objectives of the study were to (1) determine the minimum 2-year infection-free survivorship of 2-stage revision THA, (2) determine the causative organisms for repeat 2-stage revision THA, and (3) characterize the results of failed 2-stage revisions and evaluate patient-reported outcome measures (PROMs)., Methods: A retrospective chart review was completed for patients who underwent 2-stage revision THA for PJI. Prospective data were collected on each patient, including demographics, causative organisms, complications, and type of reoperation. The PROMs, including Harris Hip Score, 12-item Short-Form Health Survey, and Western Ontario and McMaster Universities Osteoarthritis Index scores were obtained prior to 2-stage revision THA surgery and annually as part of standard clinical and radiographic follow-up., Results: A total of 328 patients who underwent a 2-stage revision THA for a PJI were included in the study (mean age 67 years [range, 28 to 90], mean body mass index of 30.6 [range, 15 to 57]). The overall infection-free survivorship for 2-stage revision THA was 73.8% at a minimum of 2 years (range, 2 to 20). Overall, 194 (59.1%) patients who had successful infection eradication underwent a 2-revision THA only. The most common single organisms infected were Staphylococcus aureus (12.5%) and Staphylococcus epidermidis (11%). Higher reoperation rates were found in cases with methicillin-resistant Staphylococcus aureus and polymicrobial infections. All PROMs showed statistical improvement from preoperatively to the latest follow-up appointment., Conclusions: Two-stage revision THA is associated with a good success rate in the treatment of PJIs at mid-term to long-term follow-up. Polymicrobial and methicillin-resistant Staphylococcus aureus infections are poor prognostic factors, making the eradication of infection more difficult. The management of PJIs continues to be one of the most important orthopaedic challenges to treat., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Bicruciate-stabilized (BCS) total knee arthroplasty (TKA) designs attempt to approximate natural knee mechanics. Multiple surgical techniques, including gap balancing (GB) and measured resection (MR), have been developed to provide optimal implant positioning and soft-tissue balance. The goal of this study was to determine the effect of surgical technique on BCS TKA contact kinematics. Secondary goals included investigating the change of kinematics over time and comparing BCS TKA kinematics to a posterior-stabilized (PS) design., Methods: The study included the BCS-GB, BCS-MR, and PS-MR groups. The BCS-GB and BCS-MR groups underwent weight-bearing radiostereometric analysis for multiple knee flexion angles at 3 months and 1 year postoperatively, whereas the PS-MR group was imaged at 1 year postoperatively. The medial and lateral contact kinematics were determined from implant poses., Results: There were no differences in BCS TKA kinematics between the GB and MR techniques. There were differences in the mid-flexion ranges when comparing the 3-month and 1-year kinematics of the BCS design; however, they were less than 1.5 mm. Differences existed between the kinematics of the BCS and PS designs at all flexion angles for the medial condyle (P < .0006) and at 0° of flexion on the lateral condyle (P < .0001)., Conclusions: Contact kinematics for a BCS design were similar for both surgical techniques, suggesting both are appropriate for this design. Small, likely clinically insignificant differences were found between 3-month and 1-year kinematics. The BCS TKA kinematics differed from the PS design; however, it is unclear whether these differences improve clinical outcomes., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Routine patellar resurfacing during primary total knee arthroplasty (TKA) remains controversial. To our knowledge, there are no studies reporting the long-term performance of a cemented biconvex all-polyethylene inlay component implanted at the time of primary TKA. The purpose of this study was to examine the 15-year survivorship and long-term clinical outcomes of this biconvex inlay patella used at our institution., Methods: We retrospectively reviewed our prospectively collected institutional database and identified 2,530 patients who underwent cemented TKA with a single prosthetic design (from 1996 to 2007) where the patella was resurfaced using this cemented biconvex inlay patella. The mean age at surgery was 68 years (range, 29 to 93). The mean body mass index was 33.0 (range, 16.4 to 76.3), with 61.9% women. At the time of analysis, the mean time from surgery was 20.4 years (range, 15 to 26). We used Kaplan-Meier analysis to calculate survivorship at 15 years. We analyzed clinical outcomes using 3 patient-reported outcome measures collected prospectively., Results: The 15-year survivorship with revision surgery for all causes as the end point was 97.1% (95% confidence interval 96.1 to 98.1%). The 15-year survivorship with revision surgery for a patella-related complication as the end point was 99.7% (95% confidence interval 99.4 to 1.0). At the final follow-up, patients showed significant improvement in scores for the Knee Society Clinical Rating System (P < .001), Western Ontario and McMaster University Osteoarthritis Index (P < .001), and Veterans Rand 12-Item Health Survey physical component (P < .001)., Conclusions: Routine patellar resurfacing using a biconvex inlay patellar component has excellent survivorship and a low rate of complications at 15 years post-TKA., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The objective of this study was to identify the rate and risk factors for revision total knee arthroplasty (TKA) within the first 5 years postoperative. Our secondary objective was to identify the rate of additional surgical procedures and death., Methods: We conducted a retrospective cohort study among patients in Ontario, Canada who underwent an elective, primary TKA between April 1, 2007, and March 31, 2014, for osteoarthritis. We excluded patients under 40 years and who had undergone a TKA within the previous 15 years. Our final study cohort included 94,193 patients. We reported the proportion of the study cohort who experienced revision surgery within 2 and 5 years of the primary TKA; secondary surgery within 5 years. We conducted Cochran-Armitage tests for trends to assess changes in the proportion of patients who experienced each of the study outcomes, and multivariable logistic regressions to evaluate predictors of a revision TKA., Results: There were 3,112 (3.3%) patients who had a revision within 5 years, and 1,866 (2.0%) within 2 years of their primary TKA. 3,316 (3.5%) had a secondary surgery (0.6% patellar resurfacing; 1.6% manipulation; 1.3% synovectomy; 0.5% washout; 0.9% debridement). Lower age, men, lower income, higher comorbidity score, depression, previous arthroscopy, lower surgeon volume, and general anesthesia were all significant positive predictors of revision., Conclusions: In our study cohort, 2.0% of patients had a revision TKA within 2 years, and 3.3% within 5 years of their primary TKA. Preoperative identification of risk factors may reduce the future prevalence of revision TKAs., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Subsidence remains a concern when utilizing tapered fluted titanium (TFT) femoral stems and may lead to leg length discrepancy, impingement, instability, and failure to obtain osseointegration. This study aims to compare stem subsidence across 3 modern TFT stems. Our secondary aim was to investigate the influence of bicortical contact or "scratch fit" on subsidence, as well as the role of intraoperative imaging in maximizing bicortical contact and preventing stem subsidence., Methods: A retrospective review of 271 hip arthroplasties utilizing modern TFT stems at a single institution was performed. Three stem designs were included in the analysis: 1 monoblock TFT stem (n = 91) and 2 modular TFT stems (n = 90; n = 90). Patient demographics, Paprosky femoral bone loss classification, bicortical contact, utilization of intraoperative imaging, and stem subsidence (comparison of initial postoperative radiograph to the latest follow-up radiograph-minimum 3 months) were recorded., Results: There was no statistically significant difference in overall subsidence (P = .191) or the incidence of subsidence >5 millimeters between stems (P = .126). Subgroup analysis based on femoral bone loss grading showed no difference in subsidence between stems. Increased bicortical contact was associated with reduced subsidence (P = .004). Intraoperative imaging was used in 46.5% (126 of 271) of cases; this was not correlated with bicortical contact (P = .673) or subsidence (P = .521)., Conclusion: All 3 modern TFT stems were highly successful and associated with low rates of subsidence, regardless of modular or monoblock design. Surgeons should select the stem that they feel is most clinically appropriate., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Hybrid fixation, utilizing diaphyseal press-fit stems and cement fixation in the tibial and femoral metaphyseal areas, has long been a strategy for revision total knee arthroplasty (rTKA). The purpose of this study was to evaluate the clinical outcomes and survivorships of hybrid fixation using a single rTKA revision system with a minimum of 5 years follow-up., Methods: We reviewed our prospectively collected database to identify 281 patients who underwent rTKA using a single revision system with hybrid fixation and press-fit stems between July 2006 and August 2016. We reviewed the clinical outcome scores, including the Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis index, and Veterans RAND 12 Item Health Survey. We also evaluated the 5 and 10-year survivorships and the indications for reoperations. The cohort had a mean age of 70 years (range, 45.2 to 92.0) and a mean body mass index of 33.4 (range, 17.3 to 55.8). The mean time from rTKA surgery was 11.1 years (range, 5.3 to 15.5)., Results: Paired t-test analyses showed significant improvements from preoperative versus postoperative clinical outcome scores (P < .001) for Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis, and Veterans RAND 12 Item Health Survey Physical component. Prosthetic joint infections after index rTKA were the most common failure mode with 29 patients requiring reoperations. Rerevision due to aseptic loosening was uncommon (6 patients) with a cumulative survival rate of 95.2% at 5 years and 94.2% at 10 years., Conclusion: The use of this single rTKA system utilizing press fit stems combined with hybrid fixation provided significant improvements in the clinical outcomes and excellent survivorships at 5 and 10 years., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Contact kinematics in total knee arthroplasty (TKA) has been shown to affect tibial component migration. However, previous studies correlating kinematic variables to implant migration were completed with older TKA designs. The goal of this study was to determine if there are associations between contact kinematics and tibial component migration for a cemented, bicruciate stabilized (BCS) TKA system., Methods: A total of 54 knees implanted with a BCS TKA system were analyzed using radiostereometric analysis (RSA). Patients underwent RSA exams at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years post operation to measure tibial component migration. At 1 year, contact kinematics was evaluated during a quasi-static deep knee bend. Linear regression analyses were performed between kinematic variables and migration values., Results: Significant correlations were found between contact kinematics and tibial component migration. Excursion on the lateral condyle was the most consistent variable correlating with implant migration. Six patients had > 0.2 mm migrations from 1 to 2 years post operation indicating continuously migrating tibial components, and most had atypical contact kinematics., Conclusion: Kinematics was shown to influence tibial component migration. Reduced lateral excursion, suggesting a more constrained lateral condyle, resulted in greater implant migration. The 6 patients who had continuously migrating tibial components had demographic factors that may limit the ability to endure unintended force transmissions caused by abnormal kinematics. These results highlight the importance of restoring knee kinematics with this BCS TKA design to minimize improper force transmissions and resultant increased implant migrations., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The prevalence and outcomes of unexpected positive intraoperative cultures (UPC) in presumed aseptic revision total knee arthroplasty (TKA) are unclear. The purpose of this study was to determine the prevalence of UPC and infection-free implant survival in this patient population. Secondly, we aimed to compare the infection-free implant survival between cohorts based on number of UPCs and antibiotic treatment., Methods: We reviewed our institutional database from 2006 to 2019 for all TKA revisions (n = 1795) to identify all presumed aseptic TKA revisions with intraoperative culture(s). After exclusions, 775 revisions were eligible and those with UPC were included in the Kaplan-Meier analysis to determine infection-free implant survival for the cohorts., Results: The prevalence of UPC was 9.8%. The 2- and 5-year infection-free survival was 97.4% and 95.3%, respectively. The 5-year infection-free survival from the same microorganism as the UPC was 98.7%. Infection-free survival was similar for the 1 versus ≥2 UPC cohorts (P = .416), however was poorer for the cohort treated with antibiotics (P = .021). Only one of 3 subsequent PJI-related implant failures was caused by the same microorganism (polymicrobial) as the UPC. There were no subsequent infections in patients with a single UPC not treated with antibiotics., Conclusions: The prevalence of UPC was 9.8% and the infection-free implant survival is excellent. Infection-free survivorship from PJI caused by the same UPC microorganism is outstanding. Comparisons between cohorts must be interpreted with caution due to study limitations. A single UPC in patents without other signs of infection does not require antibiotic treatment., Level of Evidence: IV., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

Background: In March 2020, an emergency was declared in the province of Ontario owing to the COVID-19 pandemic. From March 19 to May 26, all elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures were deferred. The purpose of this study was to review the unit sales data of THA and TKA procedures in Ontario over this time period to identify any trends in surgical activity., Methods: Unit sales data for all THA and TKA procedures performed in Ontario between January 2019 and December 2020 were reviewed. All orthopedic companies contributed to the data set. Femoral stems were considered an indicator of THA procedures, while primary femurs were considered an indicator of TKA procedures. Data were analyzed to determine trends in THA and TKA procedures during the deferral period and the relative change in THA and TKA activity following resumption., Results: There was a 53% reduction in THA activity between March and May of 2020 when compared to the same interval in 2019. From June to September of 2019, THA sales activity was 87.3% that of TKA. From June to September of 2020, THA sales activity was 122.8% that of TKA., Conclusion: Provincial directives aimed at controlling the outbreak of COVID-19 contributed to a substantial reduction in THA and TKA activity in 2020. Compared to 2019, there was a disproportionate increase in THA compared to TKA activity in 2020 following resumption of surgical services. These data have implications in recovery planning for the surgical backlog of THA in Ontario., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

Background: Oxidized zirconium (OxZi) femoral heads combine the decreased abrasive properties of ceramics with the toughness of metal alloys to lower wear and increase the durability of total hip arthroplasty. The purpose of this study was to compare the 10-year polyethylene wear rates between OxZi/XLPE and cobalt chrome (CoCr)/XLPE articulations., Methods: A radiostereometric analysis (RSA) was performed on two cohorts of 23 patients who underwent total hip arthroplasty using either OxZi/XLPE or CoCr/XLPE at a minimum of 10-year follow-up. Cohorts were matched for age, gender, body mass index (BMI), and diagnosis. Polyethylene wear was measured using RSA to determine total and steady-state wear rates for both cohorts. Preoperative and postoperative patient-reported outcome measures (SF12, HHS, and Western Ontario and McMaster Universities Arthritis Index scores) were compared., Results: The mean total head penetration rate was found to be statistically different between the entire cohorts (OxZi 0.048 ± 0.021 mm/y, CoCr 0.035 ± 0.017 mm/y, P = .02) but not when 28-mm heads only (OxZi 0.045 ± 0.016 mm/y, CoCr 0.034 ± 0.017 mm/y, P = .066) were directly compared. The mean steady-state wear rate was not significantly different between the entire cohorts (OxZi 0.031 ± 0.021 mm/y, CoCr 0.024 ± 0.019 mm/y, P = .24) or 28-mm head cohorts (OxZi 0.028 ± 0.019 mm/y, CoCr 0.024 ± 0.019 mm/y, P = .574). Outcome measures showed no statistical difference except for the Harris Hip Score where the OxZi cohort demonstrated higher median scores., Conclusion: Using RSA to evaluate the 10-year in-vivo head penetration, there was no statistically significant difference in steady-state wear rates between OxZi and CoCr articulations. Both bearing combinations demonstrated wear rates well below the threshold for osteolysis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Bone loss remains an anticipated challenge in revision total knee arthroplasty (rTKA). Recent efforts to enhance rTKA fixation and stability have focused on metaphyseal implants, namely cones and sleeves. We sought to compare cone and sleeve implant survivorship in rTKA., Methods: One hundred eighty patients who underwent rTKA with metaphyseal implants from 2005 to 2018 were retrospectively reviewed. A total of 83 cones (22 femoral, 62 tibial) and 121 sleeves (58 femoral, 63 tibial) were identified. The mean age at the time of surgery was 72 years (range 43-97). Intraoperative Anderson Orthopaedic Research Institute bone loss classifications included the following: type 2A (25), type 2B (98), and type 3 (81). Mean follow-up was 41 months., Results: Revision-free survival for cones was 91.3% vs 92.2% for sleeves (P = .29). Twelve knees (4 cones, 8 sleeves) underwent irrigation, debridement, and polyethylene exchange with metaphyseal implant retention for acute postoperative periprosthetic joint infection (PJI). Development of chronic PJI warranted removal of 7 cones (8.4%), 6 of which were initially placed as part of a 2-stage revision TKA. Eight sleeves (6.6%) were removed for PJI, with all initially placed during a second stage reimplantation. In the absence of infection, survival was 100% and 99.1% for cones and sleeves, respectively. One sleeve was revised for periprosthetic fracture., Conclusion: Metaphyseal cones and sleeves offer equally durable survivorship in revision TKA. PJI was the most common mode of implant failure in this series. Importantly, no cases of cone or sleeve aseptic loosening were observed., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Implant migration and altered kinematics have been thought to impact patient-reported outcome measures (PROMs) and postoperative patient satisfaction. In this study comparing satisfied and dissatisfied total knee arthroplasty (TKA) patients, we hypothesized that dissatisfied patients will have greater continuous implant migration and that there will be differences in joint kinematics, objective functional measurements, and PROMs between satisfied and dissatisfied patients., Methods: The Knee Society Score Satisfaction Subsection questions regarding satisfaction with function were used at least 6 months postoperation to split 50 patients into satisfied and dissatisfied groups. Patients underwent radiostereometric analysis to evaluate migration and kinematics. A wearable sensor system obtained objective measurements of patient function during timed up and go tests. PROMs were recorded preoperation and postoperation., Results: No statistically significant differences were found in migration between satisfied and dissatisfied groups. Statistical kinematic differences existed in lateral anteroposterior contact location at 20° and 40° of flexion at 1 year, where the dissatisfied group had more anteriorly located lateral contact. No statistically significant differences were present in objective functional measurements. Satisfied and dissatisfied groups had differing PROMs at 4 timepoints or greater for each questionnaire., Conclusions: No differences were found in tibial component migration or objectively measured function between satisfied and dissatisfied patients. Functionally dissatisfied patients had more anteriorly positioned contact on the lateral condyle in early flexion and reported more pain and unmet expectations. These findings suggest that improving the functional satisfaction of TKA requires restoration of kinematics in early flexion and management of patient's pain and expectations., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The goal of this study is to investigate the migration and inducible displacement of a bicruciate-stabilized (BCS) total knee arthroplasty implanted using gap balancing (GB) or measured resection (MR) surgical techniques. We hypothesized equal migration and displacement between the techniques., Methods: The study is a single-blinded, prospective, randomized controlled trial, with allocation of 71 patients to either GB or MR groups. Fifteen patients were withdrawn, resulting in 31 patients in the GB group and 25 in the MR group. Patients received the JOURNEY II™ BCS implant. Migration and inducible displacement were evaluated using radiostereometric analysis and patient examinations were performed at a 2-week baseline, and at 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperation., Results: No differences (P > .05) existed between GB and MR groups for any measurement of tibial or femoral migration. Both groups had tibial migrations below 0.5 mm from baseline to 6 months, and below 0.2 mm from both 6 months to 1 year and 1-2 years postoperation. No differences (P > .05) were found between GB and MR groups for inducible displacement., Conclusion: No differences were found in implant migration or inducible displacement between GB and MR groups. The BCS implant can be expected to have migration risks on par with industry standards and both surgical techniques are safe and effective options for implantation of this implant design., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The rise in total hip arthroplasty (THA) has led to a concomitant increase in revision THAs. Tracking implant performance therefore remains a significant element of scientific inquiry to garner and maintain public trust in this procedure. There are few available reports of outcomes of a single manufacturer's total hip system outside registry data., Methods: We performed a retrospective review of a prospectively generated database to evaluate outcomes of a single manufacturer's femoral stem and acetabular shell for THA. We report the functional outcomes, revision data, and survivorship for this total hip system., Results: A total of 1942 primary THAs were implanted into 1672 patients. There were of 57 revisions. There were no cases of acetabular failure at 10-year follow-up. All functional outcome scores demonstrated significant improvements following THA. Kaplan-Meier survival analysis for all-cause revisions demonstrated 2-year implant survival of 97.6% (95% confidence interval [CI], 96.9-98.3), 5-year implant survival of 97.3% (95% CI, 96.5-98.1), and 10-year implant survival of 97.0% (95% CI, 96.0-98.0). When infection was excluded, implant survivorship improved to 99.2% (95% CI, 98.8-99.6) at 2 years, 98.9% (95% CI, 98.5-99.4) at 5 years, and 98.7% (95% CI, 98.1-99.4) at 10 years., Conclusion: This THA implant system comprising an uncemented press-fit acetabulum used alongside a triple-tapered femoral stem is an excellent option for THA. Implant survivorship at 2, 5, and 10 years is among the best reported for any total hip system in the world., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Rotating hinge knee prostheses (with or without distal femoral replacement) are indicated in cases of unreconstructible bony or soft tissue compromise. Despite their versatility, these implants have demonstrated high rates of mechanical failure. We aimed to review clinical outcomes of a novel hinged knee arthroplasty system., Methods: We reviewed all cases in a prospective database of hinged total knee arthroplasty (with and without distal femoral arthroplasty) involving a single manufacturer's implant system at a large tertiary-level academic health sciences center. We collected reasons for surgery, implant survivorship, reasons for revision, and clinical outcomes (Short Form 12, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee Society Scores)., Results: Seventy-six cases of hinged knee implants using the knee system under investigation were performed (39 hinged total knee and 37 distal femoral replacements) between 2011 and 2018, inclusive. Indications for surgery varied, with second-stage reimplantation most common for rotating hinge and fracture most common for distal femoral arthroplasty. There were 6 revisions in the rotating hinge group (none for aseptic loosening) and 5 in the distal femoral arthroplasty group (1 for aseptic loosening). Average follow-up was 2.89 ± 2.09 years. Postoperative Short Form 12 (Physical Component), Western Ontario and McMaster Universities Osteoarthritis Index, and Knee Society Scores were 30.12 ± 10.17, 55.90 ± 21.51, and 115.62 ± 45.20, respectively., Conclusion: This novel hinged knee system is a highly durable option for complex and revision knee arthroplasty. Early failures tend to be secondary to infection. We observed only a single case of aseptic loosening. Although these early results are encouraging, ongoing follow-up is required to determine long-term prognosis in patients receiving this implant., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The aim of the present study is to assess the long-term clinical and radiological outcomes of a proximal porous-coated, dual-offset, tapered titanium alloy uncemented stem at a minimum of 15 years of follow-up., Methods: We reviewed 210 total hip arthroplasties (in 193 patients) performed between 1996 and 1999 and followed prospectively in our database who received the Synergy stem. We report a Kaplan-Meier survival analysis as well as the Harris Hip Score, the Western Ontario and McMaster University Arthritis Index, and the Short Form Health Survey-12 scores. Radiographs were evaluated for evidence of subsidence, osteolysis, osteointegration, or loosening., Results: The average follow-up was 16 years (range, 15-17.7 years). Kaplan-Meier survival analysis with revision of stem for aseptic mechanical loosening (1 stem) as the end point revealed a cumulative survival rate of 99.5% at 16 years. The Harris Hip Score, the Western Ontario and McMaster University Arthritis Index, and the Short Form Health Survey-12 physical scores were all significantly improved (P < .001) from the preoperative period to latest follow-up. Minor osteolysis was observed proximally in 14 hips (6.6%) with no osteolysis distal to the porous coating., Conclusion: To our knowledge, this study represents the largest series reporting the longest clinical follow-up of this third-generation, dual-offset, proximal ingrowth, tapered cementless stem. The Synergy stem design has achieved excellent clinical outcomes, predictable osteointegration, and outstanding survivorship of 99.5% at a minimum of 15 years follow-up, representing the standard for femoral stems at our institution., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The purpose of this study is to compare surgical and clinical outcomes between matched groups of morbidly obese (body mass index [BMI] >40 kg/m 2 ) and non-morbidly obese (BMI <40 kg/m 2 ) patients undergoing first-time revision total knee arthroplasty with a minimum 5-year follow-up., Methods: Two groups of 87 patients (BMI >40 or <40 kg/m 2 ) were matched 1:1 based on age at the time of revision, gender, and diagnosis for revision (aseptic or septic causes)., Results: The morbidly obese group had a significantly greater incidence of re-operation (34.5% [30/87] vs 16.1% [14/87], P = .005) and re-revision (27.6% [24/87] vs 12.6% [11/87], P = .014) with a significantly lower 10-year survivorship for re-operation (P = .05) and subsequent revision (P = .014). In particular, the aseptic sub-group had a greater incidence of re-operation (29.9% [20/67] vs 13.4% [9/67], P = .021) and re-revision (26.9% [18/67] vs 11.9% [8/67], P = .029). The non-morbidly obese group demonstrated higher final Western Ontario and McMaster Universities Index scores (63.1 ± 19.5 vs 55.5 ± 22.5, P = .030) and a greater change between pre-operative and final KSS (45.6 ± 44.3 vs 39.7 ± 48.4, P = .040) and SF-12 Mental component (3.6 ± 10.8 vs -1.4 ± 10.3, P = .013)., Conclusion: Morbidly obese patients undergoing revision total knee arthroplasty have a greater risk of re-operation and re-revision while experiencing lower clinical outcome scores compared to non-morbidly obese patients. These patients should be informed of the higher potential for re-operation and the possibility of poor results., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Although it has been shown that morbidly obese patients experience good outcomes following primary total hip arthroplasty (THA), it is unclear whether this also applies to revision surgery. The purpose of this study was to examine the effect of a high body mass index (BMI) on the outcome of revision THA., Methods: We identified 56 patients with a BMI >40 kg/m 2 who had undergone revision THA between 1994 and 2009 at our hospital (group B). Mean age, BMI, and follow-up were 66.4 years, 45.7 kg/m 2 , and 11.7 years, respectively. This was matched with a second group of patients with a BMI between 30 and 40 kg/m 2 according to age, gender, and date of index procedure (group A). Mean age, BMI, and follow-up were 66.6 years, 33.6 kg/m 2 , and 12 years, respectively. Outcome measures included the rate of subsequent revision, implant survival, and the Harris hip score (HHS)., Results: Patients with a BMI >40 kg/m 2 had a significantly increased risk of revision surgery (27% vs 12%, P = .036). Cumulative implant survival was 85% (95% CI, 69-92) in group A and 69% (95% CI, 54-80) in group B at 15 years. HHS increased significantly following surgery in both groups (group A: 26.3-79.3) and (group B: 37.6-69.9; P < .001). However, HHS at last follow-up was significantly higher in group A (79.3 vs 69.9, P = .042)., Conclusion: Morbid obesity appears to be associated with an increased risk of failure and lower functional scores following revision THA. Patients should be well informed of this before surgery., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Several treatment modalities exist for the treatment of perioperative anemia. We determined the effect of oral iron supplementation on preoperative anemia, and the use of blood-conserving interventions before total hip arthroplasty (THA) and total knee arthroplasty (TKA)., Methods: A total of 3435 total joint arthroplasties (1461 THAs and 1974 TKAs) were analyzed during 2 phases of a blood conservation program. The first phase used erythropoietin alfa (EPO) or intravenous (IV) iron for patients at risk for perioperative anemia. The second phase included these interventions, as well as preoperative iron supplementation. The effect on preoperative hemoglobin (Hb) and serum ferritin, as well as EPO and IV iron utilization, was determined., Results: Oral iron therapy increased preoperative Hb level by 6 g/L (P < .001) and 7 g/L (P < .001) in the hip and knee cohorts, respectively. Serum ferritin level rose by 80 μg/L (P < .001) and 52 μg/L (P < .001) in the hip and knee cohorts, respectively. The number of patients with an Hb level <130 g/L was significantly reduced (P < .001 for both cohorts), as were patients with serum ferritin levels <35 μg/L (P = .002 for hip and P < .001 for knee cohorts). Utilization of EPO reduced from 16% to 6% (P < .001) and 18% to 6% (P < .001) in the hip and knee cohorts, respectively. Utilization of IV iron reduced from 4% to 2% (P = .05) and 5% to 2% (P < .001) in the hip and knee cohorts, respectively., Conclusion: Oral iron therapy reduced the burden of perioperative anemia and reduced utilization of other blood-conserving therapies before THA and TKA. Future research should delineate the cost-effectiveness of oral iron therapy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: There are various possible methods of skin closure in total hip arthroplasty (THA) through a lateral skin incision. The cost and time required for each can vary between techniques. The objective of this study was to determine whether there is a difference in patient and surgeon rating of scar outcome using a combination of subcuticular suture and skin adhesive (subcuticular MONOCRYL and DERMABOND [SMD]) vs staples for skin closure after THA., Methods: Patients undergoing THA were recruited from a university hospital. Patients were randomized to staples or SMD. Patient and Observer Scar Assessment Scale data were collected postoperatively. In addition, visual analog scale pain scores, wound drainage, length of stay, time to closure, and total cost were collected., Results: One hundred twenty-nine patients were available for final analysis. There was no significant difference in Patient and Observer Scar Assessment Scale scores at 6 weeks or 3 months (P = .71). There was no difference in visual analog scale pain scores (P = .64, P = .49). The staple group had a higher rate of discharge on postoperative days 1 and 3 (P < .001, P < .001) but had a 1.6-minute shorter time of closure (P < .001). There was no significant difference in length of stay or total cost (P = .5)., Conclusion: Although there are some small initial advantages to each method of skin closure, there is little difference in scar outcome when comparing SMD and staples., (Copyright © 2017. Published by Elsevier Inc.)

Background: The purpose of this study was to examine the 15-year survivorship and long-term clinical outcomes of the GENESIS II total knee arthroplasty (TKA)., Methods: Patients who underwent TKA with the GENESIS II system between 1995 and 1999 were retrieved from our institutional database. We report a Kaplan-Meier survival analysis as well as Western Ontario and McMaster Universities Arthritis Index, the Short Form Health Survey-12 (SF-12), and the Knee Society Scores at a mean of 16 years., Results: Four-hundred sixty-nine TKAs were performed with a mean patient age of 68 years. Patients were followed up prospectively for a mean of 16 years (range, 14.8-19.5 years). The Kaplan-Meier survival analysis at 15 years, with revision for any reason as the end point, was 96.4% (95.5%-97.3%). The Western Ontario and McMaster Universities Arthritis Index and the Knee Society Scores were significantly improved (P < .001) from the preoperative period to the latest follow-up. Patients had a significant improvement (P < .001) from the preoperative to the latest follow-up on the Physical Health Composite Score of the SF-12, but no change was noted on the Mental Health Composite Score of the SF-12., Conclusion: The unique design features of the GENESIS II TKA system have remained a constant over the duration of its clinical use, a rarity for contemporary TKA systems which are often altered before the publication of long-term results. The GENESIS II continues to demonstrate excellent long-term survivorship and improvements in health-related outcomes at a mean of 15 years, representing the standard for TKA systems at our institution., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Coronal plane alignment is one of the contributing factors to polyethylene wear in total knee arthroplasty., Methods: Based on 95 retrieved polyethylene inserts, wear and damage patterns were analyzed in relationship to the overall mechanical alignment and to the position of the tibial component., Results: A progression of wear was observed with progressively mechanical varus alignment. However, there was significantly more damage in the lateral compartment in the mild and moderate varus group compared to the valgus group. No difference in damage was seen between all groups for tibial component positioning in valgus or varus., Conclusion: Progressive wear was observed with progressively varus alignment with more damage at the lateral side. This observation is unique and might be explained by lateral condylar lift-off inducing impact and shear loading in the varus group., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Acetabular component positioning is crucial to a successful total hip arthroplasty (THA). This study evaluated the effect of absolute acetabular component position as well as acetabular position relative to bony anatomy on patient-reported functional outcomes after primary THA., Methods: Primary, press fit, hemispherical metal-on-polyethylene THA performed between 2003 and 2011 were analyzed. Western Ontario and McMaster Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), Short Form-12 scores, and radiographs between 2 and 3 years after the index procedure were assessed., Results: Of the 1241 primary THA included, the mean abduction and anteversion angles were 44.4 ± 6.94 and 21.7 ± 11.9 degrees, respectively. The mean anterior and lateral overhang were 1.9 ± 3.6 and 2.5 ± 3.4 mm, respectively. There was no correlation between functional outcomes and acetabular inclination. A weak positive correlation between anteversion and HHS (P < .001) and WOMAC (P = .02) scores was found. For relative position, anterior overhang of the acetabular component beyond the bone resulted in inferior Short Form-12 physical function (P = .001), HHS (P = .004), and WOMAC (P < .001) scores compared to those with bony coverage. Mean HHS pain score was 41.20 ± 5.69 in patients with lateral overhang and 41.97 ± 5.04 in those who had bony coverage of the lateral edge of the acetabular component (P = .02)., Conclusion: The tribology and biomechanics of acetabular component position have been extensively studied without examination of how it affects patient function. Although statistical significance was seen, clinical outcome scores were not sensitive enough to show a clinically significant effect of the absolute or relative position of the acetabular component., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Fracture location is an important consideration in managing supracondylar periprosthetic femur fractures. The outcomes of locked plating and intramedullary (IM) nail fixation were therefore compared based on fracture location, being above or at/below the total knee arthroplasty (TKA) flange., Methods: Fifty-seven patients were identified from surgical records as being treated for supracondylar periprosthetic femur fracture with either a locking plate (n = 38) or IM nail (n = 19). Based on fracture location, either above or at/below the TKA flange, both groups were assessed for time to full weight bearing, time to radiographic union, number of postoperative complications, subsequent surgery, transfusion requirements, as well as range of motion, pain, and instability at most recent follow-up. Radiographs were reviewed to assess fracture alignment with comparisons made immediately postoperative to most recent., Results: Mean follow-up for IM nail and locking plate fixation was 13.9 and 15.6 months, respectively. There was no statistical difference between groups in the mean time to fully weight bear, the incidence of postoperative pain, range of motion, use of gait aids, time to full radiographic union, or the overall radiographic alignment of a healed fracture (P > .05). Comparison based on fracture location yielded similar outcomes. Nonunion was only demonstrated in the IM nail cohort, particularly for fractures below the TKA flange (n = 2)., Conclusion: The use of either IM nail or locking plate fixation for supracondylar periprosthetic fractures provides comparable clinical outcomes. Caution is recommended in using IM nails for fractures below the flange where limited fixation may increase the risk of nonunion., (Copyright © 2016. Published by Elsevier Inc.)

Background: Multiple periprosthetic joint infections (MPJIs) are uncommon. We determine the prevalence of developing a second-site periprosthetic joint infection., Methods: Our institutional arthroplasty database was reviewed. Those who developed a second-site infection had a retrospective chart review to determine the pathogen, timing of infection, comorbidities, and results of treatment., Results: Thirteen of 206 (6.3%) patients at-risk for MPJI experienced a second periprosthetic joint infection. Mode of the second infection was hematogenous in 6, all of whom were being treated for the index periprosthetic joint infection. Seven secondary infections did not relate to the index infection. Two patients were lost to follow-up, 5 continued on suppressive antibiotics, and 6 successfully cleared infection., Conclusion: The prevalence of MPJI has decreased compared with previous reports., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Wear in posterior-stabilized (PS) polyethylene tibial inserts depends on component position, limb alignment, and ligament balancing. Valgus-varus constrained (VVC) inserts are likely to be affected similarly. We aimed to compare wear characteristics of VVC and PS inserts and identify associated factors., Methods: This was a retrieval analysis (macroscopic and radiographic) of all 18 VVC liners collected from patients who underwent revision surgery from 1999 to 2011. These patients were matched to another group with PS inserts who underwent revision in the same time period., Results: There was significantly more damage in the posts of the VVC group (13.0 ± 5.0, compared to 4.7 ± 1.9 in the PS group; P < .001). Within the VVC group, the total damage score and cold flow damage were significantly higher with excessive joint line changes (≥5 mm; P = .01). The excessive joint line elevation was associated with rotational wear pattern of the post (P = .004). Damage scores were increased with femoral component malposition (P = .04), anterior tibial slope (P = .04), and tibial component malposition (P = .04)., Conclusion: Joint line elevation, femoral and tibial component malposition, and anterior tibial slope resulted in significantly more wear in the VVC inserts. Joint line elevation of >5 mm resulted in wear of the medial and lateral aspects of the post, femoral valgus resulted in cold flow wear of the anterior post, and tibial valgus and anterior slope resulted in wear of lateral aspect of the post., (Copyright © 2015 Elsevier Inc. All rights reserved.)

This study compared the damage scores and damage patterns in 19 tibial inserts from rotating hinge (RH) implants with 19 inserts from highly constrained (HC) implants. Each insert was divided into 16 damage zones and each zone was subjectively graded from a scale of 0-3 for seven different damage modes. The overall damage scores were comparable for the two groups (RH: 64.1 ± 15.4; HC: 66.1 ± 29.0; P = 0.59). The HC group, however, had greater post damage (compared to the post-hole of RH) while the RH group had greater backside damage. The pattern of damage was also different, with burnishing and cold flow being more common in HC group while pitting, scratching and embedded debris were more common in the RH group., (Copyright © 2016 Elsevier Inc. All rights reserved.)

This study examines the damage and wear on the polyethylene (PE) inserts from 52 retrieved Genesis II total knee replacements to identify differences in tribological performance between matched pairs of cobalt-chromium (CoCr) and oxidized zirconium (OxZr) femoral components. Observer damage scoring and microcomputed tomography were used to quantify PE damage and wear, respectively. No significant differences were found between CoCr and OxZr groups in terms of PE insert damage, surface penetration, or wear. No severe damage such as cracking or delamination was noted on any of the 52 PE inserts. Observer damage scoring did not correlate with penetrative or volumetric PE wear. The more costly OxZr femoral component does not demonstrate clear tribological benefit over the standard CoCr component in the short term with this total knee replacement design., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Current discussion exists whether to position a total knee arthroplasty (TKA) in slight undercorrection in varus osteoarthritis. The goal of this study was to analyse the effect of wear and lateral lift-off in primary TKA on coronal plane alignment and the implication to future constrained revision TKA. Seventy-six retrieved tibial inserts were analysed for the ratio of wear (RW), lateral lift-off and implications for future constrained revision surgery according to the coronal plane alignment. The RW significantly affects the coronal plane alignment in TKA. Progressive wear and lateral lift-off were seen with progressive varus alignment. However, there was no difference in constrained revision between mild varus and moderate varus aligned TKAs., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Increased modularity of total hip arthroplasty components has occurred, with theoretical advantages and disadvantages. Recent literature indicates the potential for elevated revision rates of modular neck systems and the potential for local pseudotumor and metallosis formation at the modular neck/stem site. Retrieval analysis of one modular neck implant design including SEM (SCANNING ELECTRON MICROSCOPY) assessment was done and correlated with FEA (finite element analysis) as well as clinical features of patient demographics, implant and laboratory analysis. Correlation of the consistent corrosion locations to FEA indicates that the material and design features of this system may result in a biomechanical reason for failure. The stem aspect of the modular neck/stem junction may be at particular risk., (Copyright © 2014 Elsevier Inc. All rights reserved.)

We sought to determine what dimensional changes occurred from wear testing of a total knee implant, as well as any changes within the polyethylene subsurface. Three fixed bearing implants underwent wear simulator testing to 6.1 million cycles. Gravimetric analysis and micro-CT scans were performed pre-test, mid-test, and post-test. Wear volume and surface deviations were greater during 0-3.2 million cycles (91 ± 12mm(3)) than from 3.2 to 6.1 million cycles (52 ± 18mm(3)). Deviations (wear and creep) occurred across all surfaces of the tibial inserts, including the articular surface, backside surface, sides, and locking mechanism. No subsurface changes were found. The micro-CT results were a useful adjunct to gravimetric analysis, defining the dimensional changes that occurred with testing and ruling out subsurface fatigue., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The purpose of this study was to assess the feasibility, effectiveness and costs of a web-based follow-up compared to in-person assessment following primary total hip or total knee arthroplasty. Patients who were at least 12 months postoperative were randomized to follow-up method. We excluded patients who had revision surgery, osteolysis, complications or identified radiographic issues. 229 patients (118 Web, 111 in-person) completed the study. There were no patients who had an issue missed by the web-based follow-up. Patients in the web-based group travelled less (28.2km vs 103.7km, (P<0.01)), had lower associated costs ($10.45 vs $21.36, (P<0.01)) and took less time to complete (121.7min web vs 228.7min usual). Web-based follow-up is a feasible, clinically effective alternative with lower associated costs than in-person clinic assessment., (Copyright © 2014 Elsevier Inc. All rights reserved.)

We sought to identify outcomes of the Restoration Modular Hip System in cases of severe femoral bone stock deficiency. We performed a retrospective review of 55 revTHAs with a mean follow-up of 32 months (24-60 months). Outcomes included the WOMAC and HHS. Preoperative bone loss was categorized as Paprosky 3A (n = 13), 3B (n = 14), and 4 (n = 17). Periprosthetic fractures were classified as Vancouver B2 (n = 6) and B3 (n = 5). 53 of 55 stems were in situ at time of final review. WOMAC improved from 46 ± 18 to 70 ± 22 and HHS improved from 47 ± 15 to 78 ± 15. Complications were identified in 9 patients, which included dislocation (3), subsidence (2), infection (2), and periprosthetic fracture (2). In cases of significant proximal femoral bone deficiency, this stem demonstrated improvement in clinical outcomes with good results at short-term follow up., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The purpose of this study was to determine agreement between responses on electronic and paper versions of the WOMAC and SF-12(v2) questionnaires following total hip and total knee arthroplasty. Patients completed both electronic and paper questionnaires with a one week interval in-between. The order in which they completed the two versions was randomly assigned. A total of 53 patients completed the study, with a mean age of 69 years (range 50-90 years). The intraclass correlation coefficients (ICC) were high, indicating excellent agreement (WOMAC ICC = 0.96, 95% CI 0.94-0.98), SF-12 (PCS) ICC = 0.95, 95% CI 0.92-0.97; SF-12 (MCS) ICC = 0.92, 95%CI 0.86-0.95). Online data collection may be substituted for the traditional paper method with no significant effect on the criterion validity of the questionnaires., (© 2014.)

A novel alternative to conventional instrumentation for femoral component insertion in hip resurfacing is a patient specific, computed tomography based femoral alignment guide. A benchside study using cadaveric femora was performed comparing a custom alignment guide to conventional instrumentation and computer navigation. A clinical series of twenty-five hip resurfacings utilizing a custom alignment guide was conducted by three surgeons experienced in hip resurfacing. Using cadaveric femora, the custom guide was comparable to conventional instrumentation with computer navigation proving superior to both. Clinical femoral component alignment accuracy was 3.7° and measured within ± 5° of plan in 20 of 24 cases. Patient specific femoral alignment guides provide a satisfactory level of accuracy and may be a better alternative to conventional instrumentation for initial femoral guidewire placement in hip resurfacing., (Crown Copyright © 2014. All rights reserved.)

This was a retrieval analysis of 83 PS inserts to assess the effect of limb alignment, implant position and joint line position on the pattern of wear in posterior stabilized (PS) tibial inserts. The total damage score was significantly higher in knees with postoperative varus alignment more than 3° (P = 0.03). The total damage score to the post was significantly more in knees with joint line elevation more than 5 mm (9.7 ± 3.9, compared to 6.5 ± 3.7 in knees with less joint line elevation) (P = 0.05). Limb malalignment and joint line elevation resulted in more damage in PS inserts. An external rotation subluxation damage pattern was found in joint line elevation., (Copyright © 2014 Elsevier Inc. All rights reserved.)

A total of 6275 consecutive TKA patients were divided into three groups based on their age: <55, 55-70 and >70 years. There was a statistically significant difference in the change in WOMAC score (32 vs 31 vs 26, P<0.001) and Knee Society Score (78.9 vs 76.0 vs 69.0, P<0.001) favoring the younger populations. However, the revision rate was higher in the younger patients with a Kaplan-Meier survivorship at 5 years of 95.5%, 97.2% and 98.1% and at 10 years of 92.2%, 95.9% and 97.6%. Infection was the most frequent cause for failure in all groups although aseptic loosening and instability accounted for the increased revision rate in the younger patients. Younger patients may experience slightly better clinical outcomes following TKA but lower survivorship, when compared to older patient populations., (© 2013 Elsevier Inc. All rights reserved.)

Several new porous ingrowth surfaces for acetabular component fixation have recently been developed. The purpose of this study was to compare the in vivo fixation achieved by two different porosity ingrowth surfaces using radiostereometric analysis (RSA). Sixty-two patients undergoing primary total hip arthroplasty (THA) were randomized to receive a cementless acetabular component with either a 61% high porosity asymmetric titanium porous surface (StikTite, Smith and Nephew, TN, USA) or a 45% low porosity sintered bead porous surface (Roughcoat, Smith and Nephew, TN, USA). RSA and clinical follow-up examinations were done post-operatively, 6-weeks, 3-months, 6-months, 1-year and 2-years. Both the high porosity StikTite and lower porosity Roughcoat surfaces provided excellent biologic fixation., (© 2013.)

Revision total knee arthroplasty (TKA) has been associated with an increased risk of perioperative blood loss. Tranexamic acid (TXA) has been proven to be safe and effective in preventing blood loss in primary TKA. The purpose of this study was to evaluate the effect of TXA on blood loss and transfusion rates in revision TKA. We performed a retrospective comparative study on 424 patients who had undergone revision TKA between January 2006 and March 2010. A total of 178 patients did not receive TXA while 246 patients received one intraoperative dose of 20mg/kg of TXA given prior to tourniquet release. There was a significant reduction in hemoglobin loss (42±16g/L vs 38±15g/L, P=0.005), transfusion rates (30.3% vs 16.7%, P=0.001) and average amount transfused (1.1±1.9units vs 0.5±1.1units, P=0.001) in the TXA group. There was no significant difference in recorded major adverse events with the administration of TXA., (© 2013.)

Previous literature suggested highly cross-linked acetabular liners demonstrated notching patterns that may be a point of crack origin and rim failure. We examined (1) whether notching patterns and rim cracks existed and demonstrated similar morphological properties in retrieved highly cross-linked and non-cross-linked liners and (2) whether the dimensions of these notches correlated with their duration of implantation. We retrieved a series of 14 identical liners out to an average of 2.03 years. Liners were microscopically examined and then scanned using microcomputed tomography. All liners demonstrated identical notching patterns. Microcomputed tomographic scans demonstrated no signs of crack initiation or rim failure but were able to accurately quantify the notch dimensions. The notching patterns were likely caused by liner-cup micromotion and are better characterized as creep deformation because they did not progress markedly over longer durations of implantation., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The treatment goals of Vancouver type B2 periprosthetic femoral fractures in elderly patients with a limited life expectancy are early weight bearing without compromising the fracture healing. Thirty-one patients with a mean age of 82 years were treated with a long cemented stem with additional allograft or plate fixation, followed by immediate full weight bearing. Seven major complications occurred within the first 3 months postoperatively. Forty-three percent of patients had died within the first year with their implant in place. Sixteen patients had survived more than 1 year. None of the implants had to be revised at a mean follow-up of 46 months. The results of this series suggest that this technique can provide acceptable results and offers the advantages of reduced cost and early weight bearing., (Crown Copyright © 2012. Published by Elsevier Inc. All rights reserved.)

Geometric wear analysis techniques require unworn geometries to serve as a reference in wear measurement. A method to create a reference geometrical model is described for retrieval studies when the actual unworn geometry is unavailable. Never-implanted tibial inserts were scanned with micro-computed tomography. Two, 3, or 6 insert surfaces were coaligned and averaged to create reference geometries. Individual inserts were compared with each other (manufacturing variability) and with the reference geometries (reference variability). The 3-dimensional deviations between the surfaces were recorded. The reference variability was reduced to 8.3 ± 39 μm, vs manufacturing variability of 15 ± 59 μm. Deviations were smallest on the articular surfaces where most wear occurs and were significantly less than the reported insert wear rate of 20 μm/y., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Three cases of a dislocated polyethylene insert in a fixed-bearing total knee arthroplasty are presented. This brief report demonstrates the presentation of this rare mode of failure and highlights the unique complications associated with its treatment., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Micro-computed tomography (micro-CT) has previously been validated for measuring wear volume in polyethylene acetabular liners. The creation of 3-dimensional (3D) articular and backside surface deviation maps using micro-CT is described. An acetabular liner was retrieved after 16.7 years of implantation and scanned with micro-CT along with a new, never-implanted liner of the same size and type. The liner surface geometries were reconstructed and co-aligned. A 3D comparison and cross-sectional analysis was performed. Maximum 3D deviation of the articular surface was -2.48 +/- 0.02 mm, with maximum backside deviation of 0.46 +/- 0.02 mm. Micro-CT can measure surface deviation and therefore calculate the volume of wear plus creep of retrieved acetabular liners, and may be applicable for wear simulator studies and analyzing other polyethylene components including tibial inserts., (2010 Elsevier Inc. All rights reserved.)

This case-control study was performed to investigate the hypothesis that metal-on-metal (M-M) bearings reduce the risk of aseptic component loosening when compared with metal-on-polyethylene (M-PE) bearings. Cases were identified from a computerized joint database as patients who had received a primary total hip arthroplasty using an M-M or M-PE bearing and had documented revision or radiographic loosening of the stem or cup. Multiple controls were matched to each case for gender, age, diagnosis, hospital, operation date, follow-up, stem type, and cup design. Odds ratios were determined to identify the risk of component loosening for either bearing surface. In all, 505 cases and 1,605 controls were identified. M-M bearings demonstrated a lower risk of aseptic stem and/or cup loosening than M-PE bearings; however, this was not statistically significant.

Osteolysis, usually associated with polyethylene wear, has become one of the most prevalent complications associated with total hip arthroplasty inserted without cement. Management of osteolysis is challenging because the disorder tends to develop silently and surgical intervention can result in complications. In addition, long-term outcomes are unknown. We discuss the current knowledge and data available on polyethylene wear and pelvic osteolysis with modular uncemented acetabular components. We also outline an algorithm for evaluation and treatment of patients. In general, we see patients with well-fixed components every 2 years, and we base follow-up visits after 6 years on predicted polyethylene wear rates and the presence or absence of pelvic osteolysis.