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Unicompartmental knee arthroplasty (UKA) has become increasingly more common, indicating the necessity to better understand factors that may impact outcomes and survivorship. Overcorrection or undercorrection of a varus deformity can increase the risk of postoperative complications including contralateral, lateral compartmental osteoarthritis, component loosening, and component wear following medial UKA. There is no general consensus on the amount of alignment correction to optimise outcomes. The purpose of this article is to provide an overview of the current literature related to alignment, intraoperative alignment correction, and the impact on outcomes and survivorship following medial UKA as well as to explore alternative surgical techniques including patient-specific instrumentation and robotic assistance when managing the varus-malaligned knee with medial UKA. Understanding each of these factors and how they interact is vital in providing patients with promising outcomes following UKA. The ideal alignment is unknown; however, the key is to avoid severe undercorrection and overcorrection of varus malalignment for superior outcomes following medial UKA.

A 56-year-old male laborer with severe superior and medial acetabular protusio was treated with a cementless left total hip arthroplasty (THA) using an inexpensive technique that preserved the incarcerated femoral head in situ. The head was never dislocated, so the ligamentum was not disrupted. Wires stabilized the femoral head while reaming to prevent it from spinning, and multiple screws united the cup, autograft, and pelvis. At 2-year follow-up, the patient has pain-free hip function, radiographic union, and no component loosening or graft resorption. Keywords: Total hip arthroplasty, Acetabular protrusio, Femoral head bone autograft, Acetabular augment

Background The Universal 2 is a widely used total wrist implant that aims to maintain function of the wrist. Purpose Promising mid-term results of the Universal 2 total wrist implant are described in the literature. This study evaluates the long-term results in terms of implant survival and patient satisfaction. Patients and Methods Patients who received a Universal 2 implant between 2004 and 2009 were retrospectively identified through a database search. Clinical outcome and complications of the implant were assessed by examination of the patient's medical records, X-rays, and a questionnaire, consisting of the Patient-Rated Wrist and Hand Evaluation questionnaire (PRWHE) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaires and additional questions. Results Twenty-five patients (26 wrists) were included in this study. Twenty-one (81%) Universal 2 implants remained in situ after a mean follow-up of 11 years. Moderate PRWHE (44) and QuickDASH (41) scores were found in these cases. Five Universal 2 implants failed and were converted to a total wrist arthrodesis after a mean period of 9.2 years due to distal component loosening (n = 3), recurrent luxation (n = 1), or recurrent synovitis (n = 1). Twenty-three (92%) patients were (very) satisfied with the Universal 2 implant. Conclusion The Universal 2 demonstrates a high (81%) implant survival with a high patient satisfaction after a mean follow-up of 11 years. Prospective studies of the Universal 2 implant are necessary to objectify improvement in wrist function and to provide a better comparison to other fourth generation wrist implants.

Introduction Total knee arthroplasty (TKA) is one of the most common orthopedic procedures performed in the United States. Obtaining radiographs in the post-anesthesia care unit (PACU) has been the standard of care at most hospitals. The purpose of this study was to examine the utility and cost-effectiveness of immediate, postoperative radiographs in regards to operative decision-making to prevent complications within 90 days after primary TKA. Methods A retrospective review of 4,830 consecutive patients who underwent cemented or uncemented TKA between January 2016 and June 2019 at a large, regional medical center was performed. International Classification of Diseases, Tenth Revision (ICD-10) codes were used to track any readmissions within 90 days of TKA. If readmission was for a mechanical complication, including fracture, dislocation, or component loosening, PACU radiographs were reviewed for any abnormalities that may have prevented readmission. Results There were 195 readmissions (195 patients), of which 17 were due to mechanical complications. There was no evidence of fracture or abnormality appreciated on any of the reviewed PACU radiographs by either the reading radiologist or the senior authors. Assuming all fractures were noted on immediate, postoperative radiographs, the cost associated with identifying a single fracture in 2,415 patients was $1,072,260. Conclusion Routine radiographs in the recovery room after an uncomplicated primary TKA are not a reliable mechanism for preventing mechanical complications and do not alter patient care.

Background: The radiological phenomenon of subsidence following the implantation of uncemented short-stem reverse prostheses (USSP) has not yet been described. The purpose of this study was to describe the rate and potential risk factors for subsidence. We hypothesized that subsidence may be a frequent finding and that a subsidence of &gt, 5 mm (mm) is associated with an inferior clinical outcome. Methods: A total of 139 patients with an average age of 73 &plusmn, 9 years were included. The clinical and radiological outcome was evaluated at a minimum follow-up (FU) of 12 months. Results: No humeral component loosening was present at a mean FU of 18 (range, 12&ndash, 51) months. Mean Constant Score (CS) and Subjective Shoulder Value (SSV) improved significantly from 34.3 &plusmn, 18.0 points and 37.0 &plusmn, 19.5% preoperatively to 72.2 &plusmn, 13.4 points and 80.3 &plusmn, 16.5% at final FU (p &lt, 0.001). The average subsidence of the USSP was 1.4 &plusmn, 3.7 mm. Subsidence of &gt, 5 mm was present in 15 patients (11%). No association between a subsidence &gt, 5 mm and CS or SSV was found (p = 0.456, p = 0.527). However, a subsidence of &gt, 5 mm resulted in lower strength at final FU (p = 0.022). Complications occurred in six cases (4.2%), and the revision rate was 3.5% (five cases). Conclusions: Although subsidence of USSP is a frequent radiographic finding it is not associated with loosening of the component or a decrease in the clinical outcome at short term FU. Level of evidence: Level 4, retrospective study.

Background In cases of Oxford unicompartmental knee arthroplasty (UKA), an increase in anteroposterior and medial-lateral length is usually disproportional when comparing AA and A-sized tibial components. Asynchronous increments may cause tibial keel impingement leading to complications. Methods Radiographic measurements were performed in five patients with AA-sized tibial implants. The posterior cortex of proximal tibia had two angles recorded as ∠ M1 and ∠ M2. The minimum distance between the tibial component keel and outer margin of the posterior tibial cortex (mDKC) was measured, and the correlation between the preoperative posterior slope angle (PSA), ∠ M1, and mDKC was analyzed. Results All patients showed an acceptable component positioning. Only one patient had an mDKC of < 4 mm that fulfilled the criteria for the posterior tibial cortex at risk. The patient had an increased PSA and ∠ M1 compared to other patients. A negative correlation was found between preoperative PSA and mDKC (r = − 0.935, p = 0.0193); and ∠ M1 and mDKC (r = − 0.969, p = 0.0032). However, no stem tip pain, periprosthetic fracture, or component loosening were observed. Conclusions The distance between the tibial keel and posterior tibial cortex was reduced in AA-sized patients with a large PSA and ∠M1; therefore, the risk of the tibial cortex injury should be considered.

Purpose Low-field MRI, allowing imaging in supine and weight-bearing position, may be utilized as a non-invasive and affordable tool to differentiate between causes of dissatisfaction after TKA (‘problematic TKA’). However, it remains unclear whether low-field MRI results in sufficient image quality with limited metal artefacts. Therefore, this feasibility study explored the diagnostic value of low-field MRI concerning pathologies associated with problematic TKA’s’ by comparing low-field MRI findings with CT and surgical findings. Secondly, differences in patellofemoral parameters between supine and weight-bearing low-field MRI were evaluated. Methods Eight patients with a problematic TKA were scanned using low-field MRI in weight-bearing and supine conditions. Six of these patients underwent revision surgery. Scans were analysed by a radiologist for pathologies associated with a problematic TKA. Additional patellofemoral and alignment parameters were measured by an imaging expert. MRI observations were compared to those obtained with CT, the diagnosis based on the clinical work-up, and findings during revision surgery. Results MRI observations of rotational malalignment, component loosening and patellofemoral arthrosis were comparable with the clinical diagnosis (six out of eight) and were confirmed during surgery (four out of six). All MRI observations were in line with CT findings (seven out of seven). Clinical diagnosis and surgical findings of collateral excessive laxity could not be confirmed with MRI (two out of eight). Conclusion Low-field MRI shows comparable diagnostic value as CT and might be a future low cost and ionizing radiation free alternative. Differences between supine and weight-bearing MRI did not yield clinically relevant information. The study was approved by the Medical Research Ethics Committees of Twente (Netherlands Trial Register: Trial NL7009 (NTR7207). Registered 5 March 2018, https://www.trialregister.nl/trial/7009).

Arthroscopy is a powerful tool in the management of the painful total shoulder arthroplasty and should be considered when evaluating cases in which a clear cause of pain is not present. Patients may present with a painful shoulder arthroplasty due to a number of causes-occult infection, instability, component loosening, malposition, or rotator cuff pathology. In certain cases, advanced imaging may not be diagnostic, given the presence of metal artifact. It is our routine clinical practice to evaluate arthroscopically such cases in which the diagnosis is not readily evident. The most common indication for shoulder arthroscopy is pain with no clear cause or loss of motion (39%), followed by biopsy to rule out occult infection (25%), and finally rotator cuff assessment (19%).

Background Non-cemented acetabular cup components demonstrated different clinical performance depending on their surface texture or bearing couple. However, clinical osseointegration needs to be proved for each total joint arthroplasty (TJA) design. Aim of this study was to detect the in vivo migration pattern of a non-cemented cup design, using model-based roentgen stereophotogrammetric analysis with elementary geometrical shape models (EGS-RSA) to calculate early cup migration. Methods Interchangeable applicability of the model-based EGS-RSA method next to gold standard marker-based RSA method was assessed by clinical radiographs. Afterwards, in vivo acetabular cup migration for 39 patients in a maximum follow up of 120 months (10 years) was calculated using model-based EGS-RSA. Results For the axes with the best predictive capability for acetabular cup loosening, mean (±SD) values were calculated for migration and rotation of the cup. The cup migrated 0.16 (±0.22) mm along the cranio-caudal axis after 24 months and 0.36 (±0.72) mm after 120 months, respectively. It rotated − 0.61 (±0.57) deg. about the medio-lateral axis after 24 months and − 0.53 (±0.67) deg. after 120 months, respectively. Conclusions Interchangeable applicability of model-based EGS-RSA next to gold standard marker-based RSA method could be shown. Model-based EGS-RSA enables an in vivo migration measurement without the necessity of TJA specific surface models. Migration of the investigated acetabular cup component indicates significant migration values along all the three axes. However, migration values after the second postoperative year were within the thresholds reported in literature, indicating no risk for later aseptic component loosening of this TJA design.

Ultraporous acetabular components were developed to improve osseointegration and fit for increased longevity and better outcomes after total hip arthroplasty. There is a paucity of literature detailing this acetabular component’s clinical performance, with even less detailing those with screw fixation. We identify 5 patients at our institution who underwent revision total hip arthroplasty for early aseptic acetabular cup loosening of an ultraporous acetabular component known as the Tritanium primary cup with secondary screw fixation. They all presented with groin and hip pain after index surgery and underwent follow-up radiographic examination consistent with component loosening requiring revision surgery. This case series reports on the risk of early acetabular cup loosening and its associated clinical presentation, workup, and surgical management in patients with the Tritanium primary cup augmented with screws.

Reverse total shoulder arthroplasty (RTSA) is an established treatment for elderly patients with irreparable rotator cuff tears, complex proximal humerus fractures, and revision arthroplasty; however, with the increasing indications for RTSA over the last decade and younger implant recipients, post-operative complications have become more frequent, which has driven advances in computational modeling and simulation of reverse shoulder biomechanics. The objective of this study was to provide a review of previously published studies that employed computational modeling to investigate complications associated with RTSA. Models and applications were reviewed and categorized into four possible complications that included scapular notching, component loosening, glenohumeral joint instability, and acromial and scapular spine fracture, all of which remain a common cause of significant functional impairment and revision surgery. The computational shoulder modeling studies reviewed were primarily used to investigate the effects of implant design, intraoperative component placement, and surgical technique on postoperative shoulder biomechanics after RTSA, with the findings ultimately used to elucidate and mitigate complications. The most significant challenge associated with the development of computational models is in the encapsulation of patient-specific anatomy and surgical planning. The findings of this review provide a basis for future direction in computational modeling of the reverse shoulder.

Introduction Walch type B2 has biconcave glenoid with posterior erosion, bone loss and humeral head subluxation. This leads to decreased glenohumeral contact area and increased contact pressure. During total shoulder arthroplasty(TSA), uncorrected retroversion causes eccentric loading and failure of glenoid component. It also leads to humeral head decentring with posterior rim loading, early glenoid wear and component loosening. This study aims to review anatomical restoration of glenoid version and humeral head centring in TSA with B2 glenoid using CT scans. Methods This is a retrospective review of TSA for glenohumeral osteoarthritis with B2 Glenoid morphology. All polyethylene posterior wedge augmented glenoid component was used. All patients underwent pre and post surgery CT Scans. Glenoid version was calculated using neoglenoid line and medial scapular border as reference point. Post-operative humeral head centering was calculated using offset of centre of rotation of humeral head with plane of scapula on axial CT-Scan. Results Study had 10 patients with 11 TSA between June 2017 and July 2018. Mean age was 59(45–80)years. Mean preoperative retroversion was 16(13–23)degrees. This was corrected to a mean of 0° retroversion postoperatively. 63% had good radiological correction (0–5° retroversion). Humeral head was well centered post-operatively with mean humeral scapula alignment offset of 2.1(0.8–4.5) mm posteriorly. All cases had well-centered humeral head postoperatively with offset less than 5 mm. Conclusions Total shoulder replacement in B2 glenoid is technically demanding. Our radiological results show favourable outcome in terms of correction of gelenoid retroversion and eliminating posterior instability using wedge glenoid component. Level of evidence IV.

Implant loosening is a common cause of reoperation after THA. Plain radiographs have been the default modality to evaluate loosening, although radiographs provide a relatively insensitive assessment of integration; cross-sectional modalities may provide a more detailed evaluation but traditionally have suffered from metal-related artifacts. We sought to determine whether MRI is capable of reliably detecting operatively confirmed component loosening in patients after hip arthroplasty.(1) Is assessing implant integration using MRI (with multiacquisition variable resonance image combination, [MAVRIC]) repeatable between readers? (2) What is the sensitivity and specificity of MRI with MAVRIC to evaluate component loosening, using intraoperative assessment as a gold standard? (3) How does the sensitivity and specificity of MRI with MAVRIC for surgically confirmed component loosening compare with those of radiographs?Between 2012 and 2017, 2582 THAs underwent revision at one institution. Of those, 219 had a preoperative MRI with MAVRIC. During that period, the most common indication for obtaining an MRI was evaluation of potential adverse local tissue reaction. The surgeons' decision to proceed with revision was based on their overall assessment of clinical, imaging, and laboratory findings, with MRI findings cited as contributing to the decision to revise commonly occurring in the setting of recalled implants. Of the THAs that underwent MRI, 212 were included in this study, while seven were excluded due to equivocal operative notes (5) and excessively poor quality MRI (2). MRI was performed at 1.5T using a standardized arthroplasty imaging protocol, including MARS (metal artifact reduction sequencing) and MAVRIC techniques. Two independent musculoskeletal fellowship-trained readers (one with 26 and one with 5 years of experience) blinded to operative findings scored a subset of 57 hips for implant integration based on Gruen zone and component loosening (defined as complete circumferential loss of integration around a component) to evaluate interobserver reliability. A third investigator blinded to imaging findings reviewed operative notes for details on the surgeon's assessment of intraoperative loosening.Gwet's agreement coefficients (AC) were used to describe interobserver agreement; these are similar to Cohen's kappa but are more resistant to certain paradoxes, such as unexpectedly low values in the setting of very high or low trait prevalence, or good agreement between readers on marginal counts. Almost perfect interobserver agreement (AC2 = 0.81-1.0) was demonstrated for all acetabular zones and all femoral Gruen zones on MRI, while perfect (AC1 = 1.0) agreement was demonstrated for the overall assessment of acetabular component loosening and near perfect agreement was shown for the assessment of femoral component loosening (AC1 = 0.98). MRI demonstrated a sensitivity and specificity of 83% (95% CI, 65-96) and 98% (95% CI, 97-100), respectively, for acetabular component loosening and 75% (95% CI, 55-94) and 100% (95% CI, 100-100), respectively, for femoral component loosening. Radiographs demonstrated a sensitivity and specificity of 26% (95% CI, 12-47) and 100% (95% CI, 96-100), respectively, for acetabular component loosening and 20% (95% CI, 9-47) and 100% (95% CI, 100-100), respectively, for femoral component loosening.MRI may provide a repeatable assessment of implant integration and demonstrated greater sensitivity than radiographs for surgically confirmed implant loosening in patients undergoing revision THA at a single institution. Additional multi-institutional studies may provide more insight into the generalizability of these findings.Level III, diagnostic study.

BACKGROUND: Implant loosening is a common cause of reoperation after THA. Plain radiographs have been the default modality to evaluate loosening, although radiographs provide a relatively insensitive assessment of integration; cross-sectional modalities may provide a more detailed evaluation but traditionally have suffered from metal-related artifacts. We sought to determine whether MRI is capable of reliably detecting operatively confirmed component loosening in patients after hip arthroplasty. QUESTIONS/PURPOSES: (1) Is assessing implant integration using MRI (with multiacquisition variable resonance image combination, [MAVRIC]) repeatable between readers? (2) What is the sensitivity and specificity of MRI with MAVRIC to evaluate component loosening, using intraoperative assessment as a gold standard? (3) How does the sensitivity and specificity of MRI with MAVRIC for surgically confirmed component loosening compare with those of radiographs? METHODS: Between 2012 and 2017, 2582 THAs underwent revision at one institution. Of those, 219 had a preoperative MRI with MAVRIC. During that period, the most common indication for obtaining an MRI was evaluation of potential adverse local tissue reaction. The surgeons’ decision to proceed with revision was based on their overall assessment of clinical, imaging, and laboratory findings, with MRI findings cited as contributing to the decision to revise commonly occurring in the setting of recalled implants. Of the THAs that underwent MRI, 212 were included in this study, while seven were excluded due to equivocal operative notes (5) and excessively poor quality MRI (2). MRI was performed at 1.5T using a standardized arthroplasty imaging protocol, including MARS (metal artifact reduction sequencing) and MAVRIC techniques. Two independent musculoskeletal fellowship-trained readers (one with 26 and one with 5 years of experience) blinded to operative findings scored a subset of 57 hips for implant integration based on Gruen zone and component loosening (defined as complete circumferential loss of integration around a component) to evaluate interobserver reliability. A third investigator blinded to imaging findings reviewed operative notes for details on the surgeon’s assessment of intraoperative loosening. RESULTS: Gwet’s agreement coefficients (AC) were used to describe interobserver agreement; these are similar to Cohen’s kappa but are more resistant to certain paradoxes, such as unexpectedly low values in the setting of very high or low trait prevalence, or good agreement between readers on marginal counts. Almost perfect interobserver agreement (AC(2) = 0.81–1.0) was demonstrated for all acetabular zones and all femoral Gruen zones on MRI, while perfect (AC(1) = 1.0) agreement was demonstrated for the overall assessment of acetabular component loosening and near perfect agreement was shown for the assessment of femoral component loosening (AC(1) = 0.98). MRI demonstrated a sensitivity and specificity of 83% (95% CI, 65–96) and 98% (95% CI, 97–100), respectively, for acetabular component loosening and 75% (95% CI, 55–94) and 100% (95% CI, 100–100), respectively, for femoral component loosening. Radiographs demonstrated a sensitivity and specificity of 26% (95% CI, 12–47) and 100% (95% CI, 96–100), respectively, for acetabular component loosening and 20% (95% CI, 9–47) and 100% (95% CI, 100–100), respectively, for femoral component loosening. CONCLUSION: MRI may provide a repeatable assessment of implant integration and demonstrated greater sensitivity than radiographs for surgically confirmed implant loosening in patients undergoing revision THA at a single institution. Additional multi-institutional studies may provide more insight into the generalizability of these findings. LEVEL OF EVIDENCE: Level III, diagnostic study.

Background The biconcave (B2) glenoid is characterized by preservation of the anterior portion of the native glenoid with asymmetric wear of the posterior glenoid. Surgical options for glenoid correction have evolved. The goal of shoulder arthroplasty is to place the implants in such a manner to return the humeral head to a centered position and restore the joint line to a neutral position. There is no current consensus on method of treatment and correction. Methods The current and historical literature on total shoulder arthroplasty was used to examine technique viability. Results Asymmetric remaining can be used to address up to 15° of version correction without compromise of cortical bone. It is important to have the proper presurgical planning, to understand the limitations of correction, and to have other options available to treat the biconcave glenoid.

Introduction Measurement of early subsidence of uncemented femoral stems can be used to evaluate the likelihood of long term stem component loosening and therefore clinical failure. Our aim was to evaluate the factors associated with subsidence in collared and uncollared versions of the Corail femoral stem. Methods 121 hips in 113 consecutive patients were studied, operated on by two surgeons in our hospital differing in their choice of Corail stem. This gave two groups of patients with 66 hips having collared stems and 55 hips having uncollared. We recorded patients’ age, sex, ASA grade and BMI. Radiographs post-operatively at day 1, 6 weeks and 1 year were evaluated measuring subsidence, angulation, signs of stability and fixation, and canal fill ratio at the metaphysis and diaphysisafter correcting for magnification errors by calibration using femoral head size. Results Clinically significant subsidence (>3 mm) occurred in 7.6% of collared and 10.9% of uncollared stems, all within 6–8 weeks, but did not reach statistical significance (p = 0.345). Revision for symptomatic loosening was required in 1 patient in each group (1.5% collared versus 1.8% uncollared). Discussion Early subsidence of Corail femoral stem should alert surgeons to closer patient follow-up as the rate of early revision is 18% in stems with >3 mm of subsidence. However, the presence of a collar does not seem to be protective.

Background The results of ceramic-on-ceramic (CoC) total hip arthroplasty (THA) in younger patients were not univocal. This study aims to evaluate the results of CoC bearing THA in patients younger than 50 years. Methods A total of 90 younger patients performed CoC THAs during March 2003 and May 2008 were included in this study. Hip function and activity were evaluated with Harris hip score and University of California Los Angeles activity score. We had discussed survival rates, radiological findings of component loosening or osteolysis, and ceramic-related complications in these patients. Results The mean Harris hip score increased from 46.3 ± 12.0 points (range, 28-70 points) before surgery to 92.5 ± 5.6 points (range, 78-100 points) at the final follow-up. The mean preoperative University of California Los Angeles activity score was 4.2 ± 1.1 points (range, 2-6 points), which improved to a mean of 7.2 ± 1.3 points (range, 4-10 points). At the time of the last follow-up, there was found to be 1 occurrence of hip dislocation, 1 squeaking, and 2 "sandwich" ceramic liners fractured during normal activity of daily living. No hips showed osteolysis or required revision for aseptic loosening. Kaplan-Meier survivorship with revision due to loosening or osteolysis was 100% and with revision due to ceramic fracture was 97.3% (95% confidence interval, 93.7%-100%) at a mean of 9.4 years. Conclusions This study with the use of CoC bearings THAs in younger patients have shown promising results and higher rate of survivorship without evidence of osteolysis.

Background: In the 1970s and 1980s, hip resurfacing was largely unsuccessful, due to impingement, wear, and component loosening. Today, the availability of better technique and highly cross-linked polyethylene avoids the early causes of failure and provides a successful solution to younger, active patients with advanced osteoarthritis. Methods: The author reviewed the results of 2,154 hip resurfacing arthroplasties he performed over a 21- year period. The procedures used a cementless titanium metal-backed acetabular implant and highly cross- linked polyethylene liner. Results: At a mean follow-up period of 9.5 years (range, 5–21 years), the Kaplan-Meier survivorship was 97.5%, the mean Harris Hip Score was 97, and the UCLA activity score was 8. There were 32 deaths unrelated to the procedure and 35 patients were lost to follow-up. Complications leading to revision included femoral loosening (n=9), infection (n=3), femoral neck fracture (n=12), and these were revised successfully to total hip replacement. Another five patients underwent revision resurfacing for acetabular loosening. There was no evidence of wear through of the polyethylene and examination of retrieved polyethylene components showed a low wear rate from 0.003 to 0.07 mm per year. Conclusions: Hip resurfacing today has proven to be a successful procedure with results as good as or better survivorship than total hip replacement and better function. It is a reliable procedure that meets the physical demands of younger, active patients.

Component malpositioning during Birmingham hip resurfacing increases the risk for component wear, metallosis, component loosening, and the likelihood of dislocation and revision surgery. Computer-assisted navigation can increase the accuracy to which components are placed, and the utilization of this technology in Birmingham hip resurfacing is increasing. The present report summarizes the accuracy of acetabular component positioning in a Birmingham hip resurfacing case utilizing navigation. Intraoperative C-arm fluoroscopy following the use of the navigation tool confirmed excellent seating, positioning, and stability of the acetabular component. In addition, post-operative antero-posterior radiographs confirmed device accuracy and revealed a stable joint with no evidence of acetabular loosening or femoral fracture. Computer-assisted navigation may therefore be an effective tool to improve the accuracy of component positioning during Birmingham hip resurfacing.

The outcomes of total shoulder arthroplasty (TSA) for painful arthritis of the glenohumeral joint are excellent with significant improvement in pain and function. Increased use of total shoulder arthroplasty over the past decade has led to identification of common complications. Although the complication rate is low, accurate and timely diagnosis, appropriate management, and implementation of methods for prevention are critical to a successful long-term outcome. The most common complications include infection, glenoid and humeral component loosening, rotator cuff tear, periprosthetic fracture, and neurologic injury. The purpose of this review is to outline the best practices for diagnosing, managing, and preventing these complications.

BACKGROUND The aim of this paper is to present the results of hip joint arthroplasty with the use of the Taperloc stem. MATERIAL AND METHODS The study group consisted of 117 patients (75 women and 42 men) who underwent 121 hip joint arthroplasties with Taperloc stems. Mean age of the patients at surgery was 53.8 years (range: 2475 years). Mean follow-up period was 159.5 months. RESULTS Pre-operative Merle d'Aubigne-Postel scores (modified by Charnley) of the study group were poor in all patients. Mean post-operative improvement was 6.6 points. Excellent results were obtained in 86 cases, good in 19, fair in 9 and poor in 7 cases. Poor results were always associated with implant component loosening: 5 cases of acetabular cup loosening, 1 case of a loosened stem and 1 septic loosening of the entire endoprosthesis. In six cases (4.9%), patients developed heterotopic ossification. According to the Kaplan-Meier estimator, 10 years' survival probability was 94.21% for the whole endoprosthesis and 98.34% for the stem alone. CONCLUSIONS 1. Our follow-up data covering a mean period of over 13 years showed that the use of the Ta-perloc stem substantially reduces hip pain and results in a good lasting clinical outcome. 2. With good surgical technique and in the absence of complications, the risk of aseptic loosening is minimal.

Recommendations for cup containment and impingement may provide conflicting directions for component orientation in total hip arthroplasty. For optimal containment, the cup is positioned with respect to the acetabular bone, resulting in coincidence of the rim of the cup and the acetabulum. This results in good coverage and symmetric load transfer, leading to good long-term stability, but occasionally necessitates more abduction of the cup than that recommended by the safe zone. On the other hand, placement of the cup for an optimal range of motion would lead to only partial containment, with a higher risk of component loosening and revision. The most effective compromise is to use a prosthesis that has a large safe zone, realised by a high head-to-neck ratio, and orienting the cup such that a good containment is achieved and the safe zone is respected. Computer navigation or smart aiming devices may help to find the best relative orientation.

Purpose.To evaluate the outcome of autologous morselised bone grafting for a medial tibial defect of ≥10 mm deep in 45 total knee arthroplasties (TKAs).Methods.38 patients aged 46 to 85 (mean, 73) years underwent 45 TKAs and autologous morselised bone grafting for a medial tibial defect of ≥10 (range, 10–25) mm in depth by a single surgeon. In the first 19 TKAs, 2 resected subchondral bone plates from the lateral tibial plateau were driven into 2 gutters made on the floor of the medial tibial defect as bony support posts. Morselised cancellous bone grafts were then impacted around these posts. In the remaining 26 TKAs, multiple drill holes were made on the floor of the defect to decrease the remodelling time. Morselised cancellous bone grafts were impacted to fill the defects. The tibial components were fixed with cemented (n=34) or non-cemented (n=11) technique. Internal fixation devices were not used; stem extension was used in only 2 TKAs (in a patient with Charcot joint and a patient undergoing revision TKA).Results.After a mean follow-up duration of 65 (range, 24–174) months, no patient showed gait disturbance. The mean knee flexion angle was 113.8° (range, 90°–130°). No absorption or collapse of the grafted bone, or component loosening were noted on radiographs. The grafted bone completely incorporated into the host bone, with bony trabeculae crossing the interface within 2 years in the first 19 TKAs and within one year in the latter 26 TKAs. The margin of the grafted area resembled bony cortex in 30 TKAs.Conclusion.Autologous morselised bone grafting is a viable option for most medial tibial defects during TKA.

Total femoral replacement (TFR) is a salvage arthroplasty procedure used as an alternative to lower limb amputation. Since its initial description in the mid-20(th) century, this procedure has been used in a variety of oncologic and non-oncologic indications. The most compelling advantage of TFR is the achievement of immediate fixation which permits early mobilization. It is anticipated that TFR will be increasingly performed as the rate of revision arthroplasty rises worldwide. The existing literature is mainly composed of a rather heterogeneous mix of retrospective case series and a wide assortment of case reports. Numerous TFR prostheses are currently available and the surgeon must understand the unique implications of each implant design. Long-term functional outcomes are dependent on adherence to proper technique and an appropriate physical therapy program for postoperative rehabilitation. Revision TFR is mainly performed for periprosthetic infection and the severe femoral bone loss associated with aseptic revisions. Depending on the likelihood of attaining infection clearance, it may sometimes be advisable to proceed directly to hip disarticulation without attempting salvage of the TFR. Other reported complications of TFR include hip joint instability, limb length discrepancy, device failure, component loosening, patellar maltracking and delayed wound healing. Further research is needed to better characterize the long-term functional outcomes and complications associated with this complex procedure.

We evaluated the effect of local infiltration of NSAIDs on prosthetic fixation at mid- to long-term follow-up of total hip arthroplasties. Intra-articular local NSAID (ketorolac) was injected into hip joints and surrounding tissues intraoperatively and postoperatively as a part of multimodal pain management protocol. Clinical and radiographic evaluation was performed for any evidence of component loosening or failure and clinical outcomes in 100 total hip joint arthroplasties with a mean follow-up of 7.3 years (4.9 to 11 yrs). Radiographic analysis at the most recent follow-up showed no evidence of loosening, subsidence, or migration and no evidence of impending failure. Clinical outcomes showed improved Harris hip scores. Intra-articular NSAID used in the intraoperative/postoperative period in hip arthroplasty showed no evidence of prosthetic loosening at mid- to long-term follow-up.

High revision rates attributable to adverse reactions to metal debris have been reported for total hip arthroplasties (THAs) with metal-on-metal implants and hip resurfacings. The effect of revision on blood metal ion levels is described only in small series, the clinical results of revisions have been contradictory, and concerns regarding component loosening have been presented.We asked: (1) Did revision surgery result in a reduction to normal for whole blood cobalt (Co) and chromium (Cr) levels (2) What changes to the Oxford Hip Score were observed after revision of these hips with metal-on-metal implants? (3) Were there radiologic signs of component loosening observed on 1-year followup radiographs?Between September 2010 and April 2013, 154 patients (166 hips) who had THAs with implantation of the Articular Surface Replacement (ASR™) system and 44 patients (49 hips) who had hip resurfacings of the ASR™ implant underwent revision surgery for adverse reactions to metal debris at our institution, after recall of these components in August 2010. General indications for revision of these implants included a symptomatic hip and/or a predominantly solid pseudotumor seen on cross-sectional imaging. Since recall, patients were systematically followed after revision with Oxford Hip Score questionnaires, blood Co and Cr measurements (analyzed from whole blood with dynamic reaction-cell inductively coupled plasma-mass spectrometry), and plain radiographs at 2 and 12 months after revision surgery, and thereafter at 2-year intervals. Preoperative and 1-year postoperative blood Co and Cr values were available for 93% (185 of 198 patients), Oxford Hip Score for 76% (151 of 198 patients), and plain radiographs for all patients.Whole-blood levels of Co decreased below the 7 ppb cut-off value in all patients with revision of unilateral THA or resurfacing, however, blood Cr levels remained elevated in four of 90 patients (4%) in the unilateral THA group and four of 34 patients (12%) in the unilateral resurfacing group. All had ultrahigh (40 ppb) preoperative Cr levels. Cr levels remained elevated in six of the patients at the 3-year followup. The median Oxford Hip Score improved from preoperative to 1-year postoperative in the unilateral THA group (38 [4-48] to 40 [9-48], p = 0.049) and in the unilateral hip resurfacing group (37.5 [9-48] to 44 [13-48], p = 0.011). No improvement was seen in patients who had bilateral THAs (37 [14-48] to 41 [9-48], p = 0.196). Only minor radiographic abnormalities were seen, with no suspicion of component loosening.Metal-on-metal THAs and resurfacings have raised concerns and an emerging rate of revisions has been seen for many different metal-on-metal hip prostheses worldwide. Revision surgery seems to be effective for removal of the systemic metal ion burden, even though blood Cr remained elevated in a few patients for more than 3 years after removal of the metal-on-metal implant. In patients with bilateral metal-on-metal hip replacements the remaining metal-on-metal implant still supplies the body with Co and Cr ions after a unilateral revision, and therefore followup should be continued. Adverse reactions to metal debris do not seem to compromise implant ingrowth after revision surgery. However, as some of our patients still had a poor functional outcome at 12 months after revision surgery, additional research is warranted to determine the optimal time for patients to undergo revision surgery for suspected adverse reactions to metal debris.Level IV, therapeutic study.

Purpose. To compare the long-term outcome of patients diagnosed with complex regional pain syndrome–type 1 (CRPS-1) after total knee arthroplasty (TKA) with those of uncomplicated TKA knees and preoperative osteoarthritic knees. Methods. Medical records of 1280 patients who underwent TKA for osteoarthritis were retrospectively reviewed; 8 were diagnosed as having symptoms and signs consistent with CRPS after TKA. Patients with primary inflammatory arthritis, signs of component loosening, malpositioning, or of infected arthroplasty were excluded. No patient had signs of CRPS prior to operative intervention. The 8 patients were compared with 2 groups of age- and sex-matched controls: uncomplicated TKA knees and preoperative osteoarthritic knees. Patients were followed up for a mean of 54 (range, 13–111) months and their range of movement, Western Ontario and McMaster Universities Osteoarthritis Index, SF-36 questionnaire scores, and Knee Society scores were assessed and compared. Results. After appropriate treatment, most CRPS complicated patients had similar scores on SF-36, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee Society scores when compared with uncomplicated TKA patients. Scores for CRPS complicated patients were significantly improved when compared with preoperative osteoarthritic patients. The incidence of CRPS after TKA was 0.7%. Conclusion. When managed early, patients complicated with CRPS after TKA have a similar prognosis to patients with uncomplicated TKA.

PCL retaining fixed-bearing TKA is a highly successful operation with the need for more surgery occurring at the rate of approximately 0.4% per year over the first 27 years. The most common cause for revision surgery is related to polyethylene insert failure and accounts for approximately 50% of re-operations. Late metastatic infection is the next most frequent cause followed by patellar problems, late instability and component loosening in decreasing frequency. A myriad of rare miscellaneous problems can also occur.

Pigmented villonodular synovitis (PVNS) following total knee arthroplasty (TKA) is a rare condition. We reported a case of PVNS following TKA; initially, arthroscopic synovectomy was performed; however, recurrence of PVNS happened. We performed second arthroscopic synovectomy and moderate dose radiotherapy (total dose 44 cGy/22 fractions to posterior fossa, 36 cGy/18 fractions to knee) for the patient. Unfortunately, distal femur osteonecrosis with femoral and tibial component loosening happened 2 months after completing the radiotherapy procedure. Revision TKA with Legacy Constrained Condylar Knee was done. Radiotherapy is not recommended for recurrent PVNS after TKA.

Stabilization of a pelvic discontinuity with a posterior column plate with or without an associated acetabular cage sometimes results in persistent micromotion across the discontinuity with late fatigue failure and component loosening. Acetabular distraction offers an alternative technique for reconstruction in cases of severe bone loss with an associated pelvic discontinuity.We describe the acetabular distraction technique with porous tantalum components and evaluate its survival, function, and complication rate in patients undergoing revision for chronic pelvic discontinuity.Between 2002 and 2006, we treated 28 patients with a chronic pelvic discontinuity with acetabular reconstruction using acetabular distraction. A porous tantalum elliptical acetabular component was used alone or with an associated modular porous tantalum augment in all patients. Three patients died and five were lost to followup before 2 years. The remaining 20 patients were followed semiannually for a minimum of 2 years (average, 4.5 years; range, 2-7 years) with clinical (Merle d'Aubigné-Postel score) and radiographic (loosening, migration, failure) evaluation.One of the 20 patients required rerevision for aseptic loosening. Fifteen patients remained radiographically stable at last followup. Four patients had early migration of their acetabular component but thereafter remained clinically asymptomatic and radiographically stable. At latest followup, the average improvement in the patients not requiring rerevision using the modified Merle d'Aubigné-Postel score was 6.6 (range, 3.3-9.6). There were no postoperative dislocations; however, one patient had an infection, one a vascular injury, and one a bowel injury.Acetabular distraction with porous tantalum components provides predictable pain relief and durability at 2- to 7-year followup when reconstructing severe acetabular defects with an associated pelvic discontinuity.Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

We postulated that certain patient characteristics have different effects on early THA component loosening. With two matched case-control studies we assessed 3,028 cups and 5,224 stems. Loosening was defined using signs of mechanical component failure on routine follow-up radiographs or revision for aseptic loosening. Women and men had similar cup-loosening odds, but women had lower odds for stem loosening (p < 0.0001). Odds for cup loosening decreased by 2.1% per additional year of age (p = 0.0004), those for stem loosening by 2.4% (p < 0.0001). Each additional kilogram of weight decreased cup loosening odds by 1.3% (p = 0.0051). Each additional unit of BMI increased stem loosening odds (p = 0.0109). Charnley classes B and C were protective factors against loosening of both components. There were no risk differences for the various main diagnoses. Certain patient characteristics differently affected early cup and stem loosening, although some characteristics had the same protective or harmful effect on component survival.

Improved cementing techniques have been shown to decrease the rate of aseptic loosening of femoral components of cemented total hip replacements at five to seven years. We now report our results in 105 hips in 93 patients at 10 to 12.7 years (mean 11.2). The improved techniques included use of a medullary plug, a cement gun, a doughy mix of Simplex P and a collared stem of chrome cobalt. Only three femoral components had definitely loosened, none were probably loose and 24 were graded as possibly loose. In contrast, the incidence of radiographic loosening on the acetabular side was 42%. Improved cementing techniques have produced a marked reduction in the rate of aseptic loosening of the femoral component, but the incidence of acetabular loosening is unchanged.

Purpose: The purpose of this study was to analyze complications after reverse total shoulder arthroplasty and report the clinical outcomes with review of previously reported studies. Materials and Methods: Complications after reverse total shoulder arthroplasty were analyzed for 98 patients who underwent reverse total shoulder arthroplasty and were followed-up for at least 6 months. Of 98 patients, 22 were men and 76 were women. The mean age was 75.0±6.5 years (range, 59-92 years) with a mean follow-up period of 22±19 months (range, 6-74 months). The types and time of occurrence of complications, methods of treatment, and clinical outcomes at the final follow-up were analyzed. Results: Complications occurred in 18 of 98 patients (18.4%). Seven of them received operative treatment and 11 were treated conservatively. Two cases had postoperative dislocations and were addressed with open reduction. In 2 cases, periprosthetic fractures occurred and were treated with open reduction and plate fixation. Two acromial stress fractures and 8 cases of heterotopic ossification were managed conservatively. Infection and humeral component loosening occurred in one case, respectively, and were treated with revision arthroplasty. Glenoid component loosening occurred in 2 cases, one of which was treated with revision arthroplasty and the other was managed conservatively. At the final follow-up, clinical outcomes showed a statistically significant improvement. Compared to groups with no complications, there were no significant differences in final clinical outcomes. Scapular notching occurred in 43.9% (43/98 cases). No statistically significant differences of clinical outcomes were observed between the scapular notching group and the no notching group (p＞0.05). Conclusion: In our study, 18% of complications occurred after reverse total shoulder arthroplasty and final clinical outcomes of these complications showed significant improvement. Scapular notching developed in 44% and did not provide a significant clinical effect at short term follow-up.

We measured preoperative plain radiographs and computed tomograghs (CT) of hip osteoarthritis secondary to acetabular dysplasia in 34 cases. All patients were female, ranging in age from 37 to 76 years (mean 57 years). We studied the preoperative estimation of socket size and position, and compared this to the actual socket size.Preoperative measurement using CT was useful in the determination of socket size. Differences in the estimated and actual sizes were within 2mm in 81% of cases. For a case with over 50 degrees in the Sharp angle, massive bone grafting or high positioning of the socket during THA may be required.In regard to component loosening, larger socket size is useful for planning and actual setting intraoperatively, because larger sockets reduce the amount of bone graft and are set in a lower position.

From 1975 through 1995, 45,025 knee arthroplasties were recorded in the prospective Swedish Knee Arthroplasty study. By the end of 1995, 1,135 of 14,772 primary unicompartmental knee arthroplasties (UKA) for localized, mainly medial arthrosis had been revised. The Marmor/Richards and St. Georg sledge/Endo-Link prostheses were used in 65%. Mean age at revision was 72 (71) years. 232 revisions were performed as an exchange UKA (partial in 97) and 750 as a total knee arthroplasty (TKA). 153 were revised by other modes. In medial UKA, the indication for revision was component loosening in 45% and joint degeneration in 25% and in lateral UKA, the corresponding figures were 31% and 35%, respectively. In 94 cases, unicompartmental components were added to the initially untreated compartment, in 14 with partial exchange of a component. The CRRR was estimated using survival statistics. After only 5 years, the risk of having a second revision was more than three times higher for failed UKAs revised to a new UKA (cumulative rerevision rate (CRRR 26%) than for those revised to a TKA (CRRR 7%). This difference remained, even if those revised before 1985, when modern operating technique was introduced, were excluded (CRRR 31% and 5%, respectively). UKA is a safe primary procedure, when performed with well-designed components and modern surgical technique. It gives documented good patient satisfaction, range of motion, pain relief and relatively few serious complications. However, once failed, the knee should be revised to a TKA. This applies to most modes of failure. Not even joint degeneration of the unoperated compartment can be safely treated by adding contralateral components; CRRR after this procedure was 17%, while it was 7% when converted to a TKA.

16 patients who underwent Olerud and Karistrdm (1985) acetabular augmentation following recurrent dislocation of total hip replacement were reviewed 3 (1-6) years later. 14 had no further dislocation, and no signs of component loosening at the time of review.

The authors are analysing the radiological and clinical significance of radiolucent lines and their relationship with cemented glenoid component loosening in total shoulder arthroplasty (TSA). The difficulties in radiological interpretation and evaluation of radiolucency are explained. In the literature different factors were analyzed clinically or biomechanically and proposed as potential causes of radiolucency and glenoid loosening. In this paper, the influence of surgical technique and glenoid implant are analyzed. The authors draw the conclusion that cause of the glenoid loosening is probably multifactorial and if meticulous attention is given to the surgical technique for TSA, the incidence of component loosening should decrease. Greater the reliability of initial glenoid fixation, probably greater is the chance the glenoid component has to resist the negative factors promoting glenoid loosening.

In a series of 213 consecutive total hip replacements a.m. Lubinus, the clinical course after 72 revisions and 141 primary procedures was compared after 5 years. The revised THRs were uncemented Ring prostheses. Dislocation and peroperative fracture were more common in the revision group. Two failures because of aseptic loosening occurred in the revision group and 3 in the control group. No excisional arthroplasty was required, and no infections occurred. Radiographic evaluation of prosthetic positioning, component loosening, calcar resorption, and paraarticular ossification disclosed only slightly inferior results in the revision group. Clinically, the revised cases were not inferior to the primary ones. Revision of the uncemented hip seems less difficult than of the cemented hip.

INTRODUCTION Nonpigmented villonodular synovitis (non-PVNS) is a benign proliferative disease involving the synovium. It is a rare condition that is little recognized. Non-PVNS has been reported as a cause of total knee replacement failure. PRESENTATION OF CASE We report a case of extensive diffuse non-PVNS in a patient with tibial component loosening after total knee replacement and review the related literature. DISCUSSION It is reported that pigmented villonodular synovitis (PVNS) occurs less frequently than non-PVNS after knee replacement. However, there are many more case reports of PVNS than non-PVNS after knee arthroplasty in the English-language literature. CONCLUSION Previously, there were no reported cases of extensive diffuse non-PVNS after total knee arthroplasty (TKA). This case study highlights an unusual case of non-PVNS as a cause of TKA failure. We propose that non-PVNS should be considered as a differential diagnosis in patients after TKA who present with recurrent pain and effusion/hemarthrosis of the knee, and that it is one of the causes of implant loosening after TKA.

Component loosening of prosthetic hip replacements was evaluated solely by plain films in 56 patients and solely by arthrography in 49. Radiographic results and surgical findings were compared in all cases. Arthrography was associated with fewer errors. For acetabular component loosening, there were 11% fewer errors made by arthrography (26% versus 15%). However, for femoral component loosening, the number of errors decreased by only 3% (15% versus 12%). The errors associated with evaluation of the acetabular component were predominately false-positive, both on plain films and arthrography. For femoral component evaluation, plain films and arthrography were predominately associated with false-negative errors.