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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.

Revision total shoulder arthroplasty is performed for a variety of patient symptoms, including shoulder pain, instability, or stiffness. The technical reasons found for revision include component loosening or malposition. Removing the humeral stem during revision can increase morbidity and blood loss during a procedure. The ability to use a universal stem that can be utilized in both anatomic and reverse shoulder arthroplasty can be beneficial in three main areas. For revision surgeries, cost is much less, OR time is decreased, and complications are much less frequent.

Arthroscopy may be used to diagnose symptomatic glenoid loosening following anatomic total shoulder arthroplasty (aTSA), and arthroscopic glenoid component removal may suffice as treatment for some patients. Arthroscopy may be used to diagnose shoulder prosthetic joint infection (PJI) following aTSA and reverse shoulder arthroplasty (RSA). Tissues are biopsied from multiple sites within the joint and the subdeltoid or subacromial space, and they are cultured for a minimum of 14 days. Postoperative adhesions arising after prosthetic shoulder arthroplasty (PSA) may be released arthroscopically. However, other problems contributing to shoulder stiffness such as component malpositioning or shoulder PJI require additional intervention. Arthroscopy may be used to repair select rotator cuff tears that arise acutely following aTSA, but chronic attritional tears do not heal after repair; therefore, revision to RSA often is needed. Many complications following PSA, such as infection, fixed instability, humeral component loosening, and major humeral or glenoid bone loss, are not adequately treated using arthroscopic techniques. However, arthroscopy following PSA may help to diagnose and treat other complications, even as the precise indications following aTSA and RSA remain unclear.

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.

Reconstructing proximal humeral bone loss in the setting of shoulder arthroplasty can be a daunting task. Proposed techniques include long-stemmed humeral components, allograft-prosthesis composites (APCs), and modular endoprosthetic reconstruction. While unsupported long-stemmed components are at high risk for component loosening, APC reconstruction techniques have been reported with success. However, graft resorption and eventual failure are significant concerns. Modular endoprosthetic systems allow bone deficiencies to be reconstructed with metal, which may allow for a more durable reconstruction.

Over the last decade, there has been an increased use of anatomical total shoulder arthroplasty (TSA) for the treatment of glenohumeral osteoarthritis (OA). In the United States, 29,359 anatomical TSA were implanted in 2011 versus 21,692 reverse shoulder arthroplasty (RSA). Reported complication rate ranges from 10 to 23%. Revision surgery is performed in 8–11% at long-term follow-up. An annualized risk of 1.1–1.4% has been reported.

Severe tibial bone loss is one of the most challenging aspects in revision total knee arthroplasty (TKA). Bone loss can be the result of (1) aseptic failure with component loosening, subsidence, osteolysis, and fracture, (2) septic failure with bone resorption and osteolysis, and (3) iatrogenic bone loss following component removal. Accurate assessment of the severity of the tibial bone loss is necessary, especially in the proximal metaphysis, since it impacts tibial component position and fixation. Despite several classification systems, the radiographic evaluation of the bone defects is often difficult and underestimated [1]. The final determination of tibial bone loss is made at the time of surgery. The most useful classification system is the Anderson Orthopaedic Research Institute (AORI) classification that describes the severity of the tibial bone loss based upon the integrity of the metaphysis and whether one or both plateaus are involved [2].

Over the years, total shoulder arthroplasty (TSA) evolved into a very successful surgery. Two factors led to success. First, the large choice of implant systems provided options for all kinds of surgical situations; second, improved surgeons’ skills and experience made improved the outcome of the procedure. In general, the age of the patient is a risk factor for revision. Overall, the impact of implant design shows improved survival for newer generations of shoulder prostheses. Reasons for revision surgery in TSA are manifold. The two predominant reasons are secondary rotator cuff insufficiency and instability or dislocation, which are mostly contributed to a rotator cuff insufficiency. Both together account for nearly 50% of revision surgeries. In comparison, component loosening and postoperative infections are relatively infrequent causes. Surgical technique has also a major role. Several key steps have to be respected to achieve a good outcome. Accurate preoperative planning is essential for a successful surgery. Adequate soft tissue release and management of subscapularis are other key factors for the survival of a TSA.

Background This study assessed the accuracy of computed tomography (CT) arthrography when evaluating glenoid component stability in the setting of postarthroplasty shoulder pain. Methods We retrospectively reviewed all patients presenting to the clinic during a 5.5-year period to identify those with a painful shoulder arthroplasty more than 1 year after the index procedure. We excluded reverse and hemiarthroplasty procedures, patients with a clearly identifiable cause for pain, such as rotator cuff insufficiency or gross component loosening as seen on plain radiographs, and those with culture-positive aspiration. There were 14 patients with suspected glenoid component loosening but inconclusive plain radiographs. Each of the 14 patients underwent a CT arthrogram that was evaluated by the senior author (J.J.P.W.) for the presence or absence of contrast material underneath the polyethylene component. Operative reports and surgical videos from subsequent arthroscopy were reviewed to assess glenoid component stability as determined by direct arthroscopic visualization. Results CT arthrography suggested glenoid component loosening in 8 of 14 patients (57.1%), and arthroscopic inspection identified loosening in 10 of 14 patients (71.4%). In 3 of 10 patients (30%), CTA suggested a well-fixed glenoid component, but gross loosening was identified during arthroscopy. In this study, CTA yielded a sensitivity of 70%, a specificity of 75%, a positive predictive value of 87.5%, and a negative predictive value of 50.0%. Conclusion CTA had a low negative predictive value (50%), and therefore, the prediction of component stability based on the absence of contrast between the glenoid component and the bone-cement interface does not always reflect true stability.

Background Many shoulder arthroplasties revised for pain, stiffness, or component loosening are culture positive for Propionibacterium . The culture results are unknown until days or weeks after surgery, too late to inform intraoperative surgical decisions and immediate postsurgical antibiotic treatment. The objective of this study was to identify preoperative and intraoperative characteristics that may alert surgeons to an increased likelihood of positive cultures. Methods We analyzed the records of 132 shoulders that underwent surgical revision of a shoulder arthroplasty, 66 of which became culture positive for Propionibacterium and 66 did not. Results Propionibacterium -positive and Propionibacterium- negative shoulders were similar with respect to many characteristics; however, Propionibacterium- negative shoulders were revised sooner after the index procedure and were significantly more likely to be female, to have sustained a fall, to have instability, and to have rotator cuff deficiency. Intraoperatively, Propionibacterium- positive shoulders demonstrated more glenoid erosions, glenoid osteolysis, glenoid loosening, and a higher incidence of a soft tissue membrane between the humeral component and humeral endosteum. Shoulders culture positive for Propionibacterium were more likely to be culture positive for another bacteria. Conclusions Although Propionibacterium- positive and Propionibacterium- negative shoulders have many similarities, factors such as male gender, delayed presentation, glenoid osteolysis and loosening, humeral membrane, and the absence of instability or cuff failure should arouse suspicion of Propionibacterium and suggest the need for deep cultures and consideration of aggressive surgical and medical treatment.

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

Little information is available on the long-term outcome of shoulder arthroplasty in young patients. The purpose of this study was to report the results, complications, and revision rate of total shoulder arthroplasties (TSAs) in patients younger than 50 years at a minimum 20-year follow-up.Between 1976 and 1985, a single surgeon performed 78 Neer hemiarthroplasties (HAs) and 36 Neer TSAs in patients50 years. Fifty-six HAs and 19 TSAs with a minimum 20-year follow-up, or follow-up until reoperation, were analyzed for clinical, radiographic and survivorship outcomes.Both HA and TSA showed significant improvements in pain scores (P.001), abduction (P.01), and external rotation (P = .02). Eighty-one percent of shoulders were rated much better or better than preoperatively. Modified Neer ratings were similar between groups (P = .41). Unsatisfactory ratings in HA were due to reoperations in 25 (glenoid arthrosis in 16) and limited motion, pain, or dissatisfaction in 11. Unsatisfactory ratings in TSA were due to reoperations in 6 (component loosening in 4) and limited motion in 5. Estimated 20-year survival was 75.6% (confidence interval, 65.9-86.5) for HAs and 83.2% (confidence interval, 70.5-97.8) for TSAs.At long-term follow-up, both HA and TSA continue to provide lasting pain relief and improved range of motion. However, there are a large number of unsatisfactory Neer ratings. Whereas both groups have survivorship in excess of 75% at 20 years, surgeons should remain cautious in performing shoulder arthroplasty in the young patient.

Introduction Acetabular component loosening is a leading cause for revision after metal-on-metal hip resurfacing arthroplasty (MMHRA). We aimed to identify potential risk factors and determine radiographic signs associated with this mode of failure. Methods From a series of 1375 hips treated with MMHRA, 21 (20 patients) underwent revision surgery secondary to aseptic loosening of the acetabular component and 6 patients had a radiographically loose acetabular component. A control group of 27 hips (26 patients) was selected among the patients that did not have a revision, and was matched for age, gender, component size and diagnosis. Results Mean time to revision in the loosening group was 103.0 months and the mean time of follow-up in the control group was 161.4 months. We found greater activity levels, range of motion scores, and cup abduction angles in the loosening group. The centre-edge (CE) angle of Wiberg was 10° lower in the loosening group compared with the control group. In addition, 11 of the hips from the study group presented a sclerotic halo superior to the cup on the last radiograph vs. none in the control group. There was no difference in the prevalence of postoperative reaming gaps or radiographic signs of neck-cup impingement between the 2 groups. Discussion Risk factors for acetabular loosening included hip dysplasia with low CE angle, and a large cup abduction angle. The patient's level of activity influences the appearance of symptoms and the time to revision. We recommend selecting patients with a sufficient CE angle and properly orienting the cup.

Osteolysis and aseptic loosening currently contribute 75 % of implant failures. Furthermore, with over four million joint replacements projected to be performed in the United States annually, osteolysis and aseptic loosening may continue to pose a significant morbidity. This paper reviews the osteolysis cascade leading to osteoclast activation and bone resorption at the biochemical level. Additionally, the metal ion release mechanism from metallic implants is elucidated. Even though metal ions are not the predominating initiator of osteolysis, they do increase the concentration of key inflammatory cytokines that stimulate osteoclasts and prove to be a contributor to osteolysis and aseptic loosening. Osteolysis is a competitive mechanism among a number of biological reactions, which includes debris release, macrophage and osteoclast activation, an inflammatory response as well as metal ion release. Pharmacological therapy for component loosening has also been reviewed. A non-surgical treatment of osteolysis has not been found in the literature and thus may become an area of future research. Even though this research is warranted, comprehensively understanding the immune response to orthopedic implants and their metallic ions, and thus, creating improved prostheses appears to be the most cost-effective approach to decrease the morbidity related to osteolysis and to design implants with greater longevity. The ionic forms, cytokines, toxicity, gene expression, biological effects, and hypersensitivity responses of metallic elements from metal implants are summarized as well.

Surface replacement of the hip was established in the 1970s as a bone preserving alternative to total hip replacement. However, problems with femoral neck fracture, osteolysis, and component loosening led to early failures and an abandonment of the procedure. The modern hip resurfacing has improved upon past results with new implant designs and materials. The benefits include the preservation of bone, lower dislocation rate, and more physiologic bone loading, factors which may lead to an ability for a higher activity level. National joint registry results find that a certain group of patients has greater survivorship with resurfacing than with total hip replacement. Therefore, we believe that surface replacement arthroplasty is a viable alternative in this subgroup of patients.

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.

Purpose: As the number of total ankle replacements (TARs) performed has risen, so has the need for revision. The purpose of this investigation was to perform a systematic review of clinical outcomes following a salvage ankle arthrodesis from a failed TAR to identify patient- and technique-specific prognostic factors and to determine the clinical outcomes and complications following an ankle arthrodesis for a failed TAR. Methods: We searched PubMed, Medline, EMBASE, and the Cochrane Central Register of Controlled Trials for studies that analyzed ankle fusion after failed TAR with a minimum follow-up of 1 year. Results: We included 16 studies (193 patients). The majority of patients (41%) underwent the index TAR for rheumatoid arthritis. The majority of these revision surgeries were secondary to component loosening, frequently of the talar component (38%). In the cases that were revised to an ankle arthrodesis, 81% fused after their first arthrodesis procedure. The intercalary bone graft group and the blade plate group had the highest rate of fusion after the first attempt at fusion at 100%, whereas the tibiotalocalcaneal fusion with cage group had the lowest fusion rate at 50%. The overall complication rate was 18.2%, whereas the overall nonunion rate was 10.6%. Conclusion: A salvage ankle arthrodesis for a failed TAR results in favorable clinical end points and overall satisfaction at short-term follow-up if the patients achieve fusion. The bone graft fusion and blade plate group resulted in the highest first-attempt fusion rate, with a low complication rate. Future studies should include prospective, comparative control or surgical groups and use standardized outcome measurements that will make direct comparisons easier. Levels: Level IV: Systematic Review of Level IV Studies

International audience; BACKGROUND:Reverse total shoulder arthroplasty (RSA) is a recent concept that enables good functional outcomes in cases of massive rotator cuff tear and cuff tear arthropathy. Design parameters influence the functional results and complications. The purpose of this study is to present the results of a novel RSA, the Total Evolutive Shoulder System (TESS; Biomet, Warsaw, IN, USA), based on a reverse corolla without a stem.METHODS:We enrolled 101 patients with 105 RSAs in a prospective study, with a minimum follow-up period of 24 months. The analysis concerned 91 RSAs in 87 patients (61 men and 26 women), with a mean age of 73 years, at a mean follow-up of 41 months (range, 24-69 months).RESULTS:Ninety-six percent of patients rated their satisfaction as good or excellent. Mean flexion was 143° (range, 90°-170°), and mean external rotation was 39° (range, 20°-70°). The Constant score improved from 40 points preoperatively to 68 points at last follow-up (P < .001). The mean American Shoulder and Elbow Surgeons score was 24 points. The mean neck-shaft angle was 154° (range, 142°-165°). Inferior scapular notching occurred in 17 cases (19%). The notching rate was higher when the glenometaphyseal angle increased (P < .001), when the inferior tilt decreased (P = .003), and when the neck-shaft angle increased. There was no evidence of component loosening.CONCLUSION:TESS RSA provided encouraging midterm results with favorable outcomes and a low rate of complications. The stemless TESS with a reverse corolla is a reliable, less invasive system.

Background Pigmented villonodular synovitis (PVNS) is a rare, benign, painful proliferation of the synovium previously treated successfully with total hip arthroplasty (THA). Published results come from small series; therefore, the purpose of this study is to investigate the outcomes of THA in the setting of PVNS. Methods We identified 25 patients with histologically confirmed, diffuse PVNS who underwent THA between 1971 and 2013. Mean follow-up and age was 10 years and 39 years. Before arthroplasty, 16 patients (64%) had at least 1 surgical procedure (mean, 1; range, 1-3) to treat PVNS. Twenty (80%) patients had “active” disease and underwent synovectomy. No constrained acetabular components were used. Results The 10-year disease free-survival was 100%. Recurrence occurred in 1 patient at 24 years postoperatively. Nineteen patients (76%) sustained a complication (most commonly component loosening (n = 12 [48%]), and 16 required revision surgery. The 10-year revision-free survival was 66% for conventional polyethylene implants and 100% for highly cross-linked polyethylene devices. Mean Harris Hip Score improved significantly from 48 (range, 23-69) preoperatively to 78 (range, 47-96) postoperatively (P Conclusion THA in the setting of PVNS improves patient function with a low rate of local recurrence. Complication and revision rates are high in this series likely owing to the young and active patient population and the use of conventional polyethylene. Modern bearings theoretically reduce the risk of revision.

Massive, irreparable posterosuperior rotator cuff tears in young patients present a difficult clinical problem. While reverse total shoulder arthroplasty remains a viable option for older, lower demand patients, it is often a poor choice in younger, active patients given the risk of component loosening and subsequent revision. The latissimus dorsi tendon transfer has been utilized by some surgeons to compensate for a deficient posterosuperior rotator cuff attempting to provide an active external rotator, but unfortunately the results are variable. The procedure requires careful patient selection, as a motivated, young patient without glenohumeral arthritis and an intact subscapularis is imperative for a successful outcome.

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.

Osteolysis and aseptic component loosening have been recognized as common mechanisms for late total hip arthroplasty failure. Particulate wear debris from the arthroplasty-bearing surface initiates a process of macrophage-induced, osteoclast-mediated bone resorption around implants. Radiographic patterns of osteolysis differ around cemented and cementless implants based on the patterns of particle access through the effective joint space, and influence the approaches taken during revision surgery. Revision surgery will address the failed bearing surface to decrease the generation of particular debris. The approach to component revision surgery is based on osteolysis lesion size, arthroplasty component stability, locking mechanism integrity, structural bone availability for biologic fixation of revised components, and patient’s health status. This chapter reviews the current knowledge of osteolysis and presents approaches for both conservative and surgical treatment.

Radiolucent lines in total shoulder arthroplasty around the glenoid component are not uncommon in post-operative x-rays and the incidence varies. A certain percentage progress and as the lines enlarge can lead to component loosening. One study reported a 9% incidence at 2 years and 27% incidence at 5 years. A recent long term study (15 to 20 years) reported a 73% incidence. Radiolucent lines can be caused by anatomy (posterior glenoid wear) or pathology (inflammatory arthritis) as well as technical factors such as glenoid implant design (metal back) and improper implantation techniques where the prosthesis is not fully seated or cement is used to fill a defect. Every attempt should be made to avoid lucent lines. Minimal bone should be removed from the glenoid vault and a pressure injection type of insertion is helpful in getting the cement into the cancellous bone. Furthermore a peg type of glenoid implant rather than a keel type is preferred as this has been associated with a lower incidence of radiolucent lines.

Periprosthetic distal femoral fractures can present significant reconstructive challenges when associated with poor bone stock, comminution, or component loosening. Revision arthroplasty with stemmed components or distal femoral replacement arthroplasty often becomes necessary. This retrospective study reviewed the results of femoral revision arthroplasty in 16 knees with acute, extreme distal (Su type 3), supracondylar periprosthetic fractures using cemented, midlevel constrained implants. The mean patient age was 71 years and mean follow-up was 5 years. All fractures united with mean Knee Society scores of 86 and 55, at the last follow-up. All patients returned to preinjury activity level. Complications included one valgus malunion with shortening and one reoperation for functional lateral instability. This treatment modality achieved reliable fracture union and return of function. Moreover, the final salvage option of distal femoral arthroplasty is preserved.

Background Glenoid bone grafting can be useful to restore an asymmetrically eroded glenoid to better support the glenoid component and improve positioning. The purpose of this study was to evaluate the clinical and radiographic results of patients undergoing structural bone grafting for glenoid deficiency with placement of a cemented glenoid component during primary total shoulder arthroplasty. Methods Between January 1, 1976, and December 31, 2008, 24 patients (25 shoulders) of 2607 shoulders undergoing primary total shoulder arthroplasty (0.96%) had structural bone grafting with a humeral head autograft and screw fixation. The mean clinical follow-up was 8.7 years, and the mean radiographic follow-up was 7.6 years. Results Twenty-three shoulders experienced pain relief, and patients expressed satisfaction with the operation in these shoulders. Postoperative active elevation averaged 148°, and external rotation with the arm at the side averaged 60°. On radiographic evaluation, 10 shoulders had glenoids at risk for component loosening. Two of these shoulders were symptomatic and underwent revision surgery to address glenoid component loosening. The Neer result rating was excellent in 18 shoulders, satisfactory in 5, and unsatisfactory in the 2 shoulders undergoing revision. Conclusion Structural bone grafting in primary total shoulder arthroplasty is uncommonly necessary. When it is performed, the clinical outcomes are favorable; however, radiographic analysis shows a moderate rate of failure of glenoid component fixation. It seems likely that alternative treatment methods may prove to be more effective in addressing glenoid wear.

Proper femoral and acetabular component position and leg length equality are important intraoperative considerations during total hip arthroplasty. Unfortunately, traditional surgical techniques often lead to suboptimal component position, and such deviations have been associated with increased rates of prosthetic wear, dislocation, component loosening, and patient dissatisfaction. Although surgical navigation has been shown to improve reproducibility of component alignment, such technology is not universally available and is associated with significant costs and additional surgical/anesthetic time. In the current study, we found that a routine intraoperative pelvic radiograph could successfully identify malpositioned components and leg length inequalities and could allow for successful correction of identified problems. Unexpected component malposition and leg length inequality occurred in only 1.5% of cases where an intraoperative pelvic radiograph was utilized.

The Agility™ Total Ankle Replacement System, almost exclusively without polymethylmethacrylate cement fixation, was the most commonly used implant in the United States from 1998 to 2007. Much attention has been given to the intraoperative complications and incision healing-related problems. However, it is the intermediate- and long-term complications, specifically, aseptic osteolysis, talar component loosening, subsidence, and progressive malalignment, that require careful consideration, because the revision options are limited. We describe a technique for management of extensive talar aseptic osteolysis for revision of Agility™ total ankle replacement systems with use of geometric metal-reinforced polymethylmethacrylate cement augmentation. This technique preserves the subtalar joint, provides immediate component stability and restoration of component alignment and height, and is a cost-effective alternative to other available options and still allows for additional revision should late failure occur.

We evaluated 106 knees that underwent primary total knee arthroplasty (TKA) with the navigation-assisted gap balancing technique using an e.-motion cruciate retaining floating platform (FP) mobile-bearing prosthesis to prospectively assess the survival of the e.-motion FP system after a minimum follow-up of 4 years. There was no evidence of any complications, including dissociation or breakage of the polyethylene liner or component loosening at last follow up (5.1 ± 0.6 years). Four knees, however, required re-operation, three for distal femoral fracture, and one for infection. The estimated 5-year prosthesis survival rates without revision for any reason and for prosthesis-associated problems were 96.2% and 100%, respectively. The e.-motion floating platform, with a cruciate retaining design under navigation guidance, demonstrated excellent clinical results and 5-year survival rate.

Purpose The purpose of this study was to analyze the clinical and radiographic results of revision of loose total hip replacements, using proximal femoral allografts and a cemented implant. Material and methods We retrospectively reviewed of 28 consecutive patients. Twenty patients were available for study. Each patient was scored using a modified Harris Hip Score. Radiographs were examined for endosteal and periosteal reabsorption, allograft-host union, trochanteric migration, component loosening and heterotrophic calcification. Results The mean pre-operative Harris hip Score was 34 points. At the latest follow-up, the meanscore was 80 points. Nineteen cases (95%) had combined femoral defects and one patient (5%) had a segmental defect, according to the AAOS classification. Allograft resorption was seen in eight (40%) hips. There were 18 cases (90%) of allograft union, one (5%) of partial union and one (5%) of nonunion. There was one case of trochanteric migration (more than 1 cm). All femoral components were radiographically stable. The reconstruction was considered successful in 18 patients (90%). Conclusion The use of proximal femoral allografts in femoral revision of loose total hip replacements has high survival and satisfactory clinical results at an average period of eight years postoperatively.

Shoulder arthroplasty is regularly performed in patients with arthritis degeneration to regain their own shoulder functions. Arthritis shoulder often link to glenoid deformation, especially posterior wear resulting in glenoid retroversion. To reconstruct severely retroverted glenoid, placing glenoid prosthesis has been performed. The use of cementless glenoid prosthesis with porous surface has been introduced to shoulder arthroplasty since this enhances bone ingrowth and maximizes fixation. However, research in the success of cementless glenoid prosthesis following arthroplasty in retroverted glenoid has been rarely reported. In this study, we aimed to investigate two different approaches of using cementless glenoid prosthesis, standard and wedged component designs. Finite element method was conducted to compare micromotions obtained from the two approaches. The results showed that the wedged component seemed to be an appropriate approach for reconstructing retroverted glenoid due to the small micromotions obtained. Therefore, the use of wedged prosthesis could prevent component loosening and enhance the success of cementless shoulders arthroplasty.

Total shoulder arthroplasty (TSA) in cases with posterior wear can be addressed by eccentric reaming of the anterior glenoid or by augmenting the posterior glenoid with bone grafting or augmented glenoid implants. We report the results of TSA with posterior glenoid bone grafting (PGBG) with humeral head autograft in patients with shoulder osteoarthritis and severe posterior glenoid wear.A retrospective review of cases from 2004 to 2014 revealed 34 patients. Preoperative and postoperative radiographs were evaluated for glenoid version and humeral head subluxation as well as component loosening. Patient-reported outcomes were compared preoperatively and postoperatively. Complications and reoperations were also evaluated.Of the 34 patients, 28 (82.4%) were available at a minimum of 2 years' follow-up. PGBG corrected glenoid retroversion from -28° ± 4° preoperatively to -4° ± 2° (P .001). Humeral head subluxation also improved after PGBG with respect to the scapular axis and to the midglenoid face (P .001). Radiographic analysis revealed all PGBGs had incorporated. Radiographically, 3 patients (10.7%) had a total of 5 broken or displaced screws. In addition, 3 patients (10.7%) had a broken metal marker in the center peg of the glenoid component. No patients required component revision surgery by final follow-up. Only 1 reoperation occurred for capsular release. Patients showed significant improvements in all patient-reported outcomes.Patients undergoing primary TSA with humeral head autograft PGBG showed significant improvements in glenoid version, humeral head subluxation, patient-reported outcomes, and range of motion at an average of 4 years' follow-up. There was a low revision rate and a high rate of graft incorporation.

Constrained implants are frequently required in revision total knee arthroplasty (TKA) and are associated with an increase in aseptic component loosening and damage or wear to the constraining mechanisms, compared with primary TKA. The purpose of the following study was to evaluate the midterm clinical and radiographic results including the incidence of bearing complications in a group of patients undergoing revision TKA using mobile-bearing revision TKA implants.We retrospectively reviewed 316 consecutive mobile-bearing revision TKAs performed at 2 centers between 2006 and 2010. There were 183 women and 133 men with a mean age of 66 years. The patients were evaluated clinically using the Knee Society scores. A radiographic analysis was performed. Bearing specific complications (ie, instability or dislocation) were recorded.Patients were followed-up for a minimum of 24 months and a median of 59.88 months (range 24-121.2). The average Knee Society knee score and function scores increased from 40.8 and 47.9 points preoperatively to 80 points and 70.3 points, respectively (P.01). The average knee flexion improved from 105.6° preoperatively to 117.4° postoperatively (P.01). Eight patients required subsequent implant revision. No cases of bearing complications were observed.Revision TKA using mobile-bearing revision components demonstrated favorable midterm clinical and radiographic results with no occurrence of bearing instability or dislocation. Longer follow-up is required to evaluate for potential advantages of mobile-bearings over fixed-bearing revision components in terms of polyethylene wear reduction, reduced stress transmission across fixation interfaces, and reduced stress on the polyethylene post.

Background There is interest in uncemented total knee arthroplasty due to the hope for long-term biologic fixation, but limited data are available regarding uncemented tantalum patellar components. The purpose of this study was to evaluate the radiographic outcomes of uncemented tantalum patellar implants at midterm follow-up. Methods We retrospectively reviewed a consecutive series of 30 knees in 29 patients who underwent cementless total knee arthroplasty with an uncemented metal-backed tantalum patella between September 2006 and April 2009. Patients were required to have a minimum radiographic follow-up of 2 years. Anteroposterior and lateral radiographs of the knee were evaluated for signs of implant fracture or gross loosening. Clinical follow-up was obtained by reviewing each patient's most recent orthopedic record. Results Thirty knees in 29 patients met inclusion criteria. The mean age of the cohort was 59.1 years with a mean body mass index of 31.9 kg/m 2 . Mean postoperative radiographic follow-up time was 5.5 years. Six fractures of the patellar component were noted. This represented a fracture rate of 20% among the entire cohort and 35% among the 17 knees with visible patellae on anteroposterior radiograph. All fractures had a transverse pattern. No gross patellar component loosening was noted. Among patients with component fractures, 2 required revisions for instability and 1 revision was for infection. Conclusion Our results suggest a minimum 20% rate of component fracture at midterm follow-up. Although many of these patellar component fractures were asymptomatic, they have the potential to impact revision rates in the longer term.

To avoid inadvertent vertical positioning of the acetabular component during total hip arthroplasty (THA), the authors routinely “cheat” component abduction an additional 10° horizontal (goal=30°). This likely increases the incidence of components placed into abduction of less than 30°, the clinical consequences of which are not well studied. The purpose of this study was to determine the clinical and radiographic outcomes in patients undergoing THA with acetabular components positioned in less than 30° of abduction as compared with those with components positioned between 30° and 50°. A retrospective review was performed of consecutive patients undergoing primary THA with horizontally cheated acetabular component position performed by a single surgeon. Patients were grouped into cohorts with either component abduction less than 30° or between 30° and 50°. Demographic data, operative data, and complications were recorded. Harris Hip Scores (HHS) and radiographic analysis were obtained from preoperative and most recent clinic visits. Between September 2004 and September 2010, 320 consecutive THA procedures were performed. A total of 149 hips had component abduction less than 30° (mean, 25.8°; range, 15.7°–29.4°). No components had greater than 50° of abduction. At an average 37-month follow-up, no significant difference in HHS was found between the 2 cohorts ( P =.137). The horizontal cohort had no dislocations, component loosening, or osteolysis. By cheating the acetabular component more horizontal, an excessively vertical position was avoided. Component abduction less than 30° yielded equivalent clinical outcomes to component abduction between 30° and 50°. [ Orthopedics. 2016; 39(6):e1092–e1096.]

If it be accepted that tissue reaction to UHMWPE particles is the cause of “osteolysis” and component loosening, then it would seem logical to imply that neither improvement in component design nor their fixation would have an effect on the incidence of component loosening.

Position of the stem within the medullary canal in cemented total hip arthroplasties (THA) has been under scrutiny for some time. Initially this was in the context of stem fracture [1] then in relation to the predictability of the long-term outcome of stem fixation [2]. In both these publications only the antero-posterior (AP) radiographs were examined. More recently the attention has been focused on the high incidence of early failures [3] and suggestions made that endosteal cavitation and component loosening may be due to the direct effect of the ultra high molecular weight polyethylene (UHMWPE) wear particles gaining access to the bone cement interface through cement defects. As a result the trend in the design, instrumentation and the surgical technique has been to facilitate central placement of the stem within the medullary canal avoiding stem tip-cortex contact and aiming at a cement mantle of a predetermined thickness. To what extent does the position of the stem within the medullary canal in cemented THA play a part in the long-term outcome has not been established with certainty. Since a prospective study would not be possible, let alone acceptable, and a long-term follow-up would be necessary, [4] we have attempted to answer the question by examining both failed and successful cases retrospectively.

Charnley introduced ultra high molecular weight polyethylene (UHMWPE) in November 1962 as the material for the cup. It followed the rapidly wearing polytetrafluoroethylene (PTFE, Teflon, Fluon) “The Teflon experience” was neither well documented nor widely known. The information gathered was a caution as to the possibility of future problems with plastic wear particles. The extremely low wear of the UHMWPE was a great encouragement. Although studied in some detail, it was, initially, of radiographic rather than clinical interest. There were no indications of possible problems, certainly not in the short or medium term. There was a more urgent issue to be addressed: the explosion of demand for this type of surgery.

Despite good overall clinical results, unicompartmental knee replacements (UKR) are not without their problems and failures have been reported. The most common causes of UKR failure are component loosening, poor patient selection, poor surgical technique, polyethylene wear and progression of arthritis in other compartments. The purpose of this study is to present a series of atraumatic fractures of metallic components in a UKR treated in a single orthopaedic centre.Since 1999, 121 failed unicompartmental knee arthroplasties have been referred to our centre. In six of these, atraumatic breakage of a metal component in the cemented UKR was seen and included in this study. Pre-operative alignment, BMI and implant longevity were documented. The femoral implant failed in 4 patients and the tibial implant in a further 2.All the femoral implant fractures occurred within 3 years of UKR surgery (mean: 22.2 months, SD: 10.6 months). Tibial implant breakage occurred at a mean of 8.5 years (SD: 2.4 months) following UKR. All patients were treated with conversion to a navigated total knee replacement. A primary total knee arthroplasty was used in all cases with one patient requiring a tibial component incorporating a wedge and stem following breakage of the original UKR tibial implant.Fracture of the metallic components is a potential cause of failure of unicompartmental knee arthroplasty. In our experience, the incidence of this complication was 4.9 % of all UKR failures. Patients with a BMI greater than 30 and a progressive deterioration in limb alignment were at greater risk.

Background Malposition of the glenoid component can result in premature component loosening or instability. This study was designed to test the ability of an experienced shoulder surgeon to position the glenoid component using standard preoperative planning and surgical bone preparation. Materials and methods Thirteen patients having primary total shoulder arthroplasty were evaluated using 3-dimensional surgical simulator. Ideal version was considered to have version as close to perpendicular to the plane of the scapula, with complete contact of the back side of the component on glenoid bone and maintenance of the center peg of the component within bone. Results The average retroversion angle was 13° (mean, standard deviation [SD] 12°), with a range of 1-42°. In 7 of these 13 cases, preoperative glenoid retroversion was greater or equal to 10°. In 3 cases, the component was malpositioned with greater than 10° of ideal version. In cases with less than 10° of preoperative retroversion, the glenoid component was placed within 10° of ideal version in all cases. Conclusion Traditional methods to correct moderate to severe glenoid deformity and place the glenoid component within 5° of the ideal position are not consistent. Optimal glenoid component placement can be achieved when there is minimal bone deformity. Retroversion greater or equal to 20° makes it difficult to place a pegged glenoid component perpendicular to the plane of the scapula by asymmetric reaming without center peg perforation.

Recent technologic advances in total hip arthroplasty (THA) have focused on improving the longevity and wear characteristics of bearing surfaces that can withstand the high demands of younger and more active patients. Recent reports of early failures of metal-on-metal THA have introduced doubts to its ability to be a viable long-term hard-on-hard bearing surface for hip arthroplasty. Like metal-on-metal, ceramic-on-ceramic (COC) bearing surfaces have excellent in vitro wear characteristics, but there is little information about their long-term track record in vivo, particularly in those patients who are younger and more active. The purpose of this study is to evaluate the long-term outcomes of COC THA in active patients younger than 50 years of age. We retrospectively reviewed 82 consecutive THAs in 64 patients performed by a single surgeon from 1997 to 2000. There were 42 men and 22 women with an average age of 38.6 years. Of the 82 THAs, 39 were performed for avascular necrosis of the hip, 30 for osteoarthritis, 8 for developmental dysplasia, and 5 for inflammatory or posttraumatic arthritis. Clinical outcomes were evaluated using the Harris hip score, and serial radiographs were evaluated for signs of component loosening. The mean follow-up period was 10.1 (range, 10.0-12.3) years. One patient died, and another was lost to follow-up. The mean Harris hip score was 89.8. There were no implants with subsidence or circumferential radiolucent lines. Two patients required revision surgery of their THA for a ceramic liner fracture. One patient complained of squeaking that required revision. There were no cases of revision for ceramic head fracture, instability, or aseptic loosening. At a minimum 10-year follow-up, the survivorship of the COC THA was 96.3%. Modern COC THA in active patients younger than 50 years of age is durable at a minimum 10-year follow-up; however, patients should be advised of the small chance of squeaking and ceramic fracture.

The purpose of this study was to investigate the results of 113 total hip arthroplasties in 109 patients using highly cross-linked polyethylene (HXLPE) after midterm (minimum 7 years) follow-up retrospectively. The mean age at the time of operation was 57 years. Preoperative diagnosis was osteonecrosis in 81 hips and other diagnosis in 32 hips. There was no component loosening. Acetabular osteolysis was found in 12 hips (10.6 %). Mean linear HXLPE wear rate was 0.031 ± 0.012 mm/y. We analyzed the relationship between HXLPE wear rate and several variables influencing HXLPE wear. Only the cup position was related with wear rate of HXLPE significantly (P < .05). The results of total hip arthroplasties using HXLPE showed excellent results with decreased wear rate and low incidence of osteolysis after midterm follow-up.

An extensive database search was completed to perform a meta-analysis of outcomes of mobile-bearing total knee arthroplasty. Nineteen manuscripts encompassing 3506 total knee arthroplasty met criteria for analysis (average follow-up, 8.6 years). Data were subdivided based on design type and included rotating platform, meniscal bearing, and anterior-posterior glide-rotation subgroups. Fifteen-year survivorship of rotating platform designs (96.4%) was greater than meniscal bearing implants (86.5%). Mean component loosening (0.33%) and bearing instability (

This systematic review compared 2 treatments for hip disease in active young patients: modern metal-on-metal total hip resurfacing and standard total hip arthroplasty. We conducted a literature search to identify relevant randomized and clinical controlled trials and included 968 patients from 4 trials in our analysis. Our results indicated increased rates of revision, femoral neck fractures, and component loosening among patients who received modern metal-on-metal hip resurfacing. No significant differences in the rates of mortality, dislocation, or deep hip joint infection were found between treatment groups. Hip function scores were similar between the 2 groups, but the resurfacing group showed higher activity levels. These results have provided insufficient evidence to determine whether modern metal-on-metal total hip resurfacing offers clinical advantages over standard total hip arthroplasty.

This article determines the incidence and cause of the complications commonly associated with metal-on-metal hip resurfacing implants and the proposed methods to prevent these complications. The literature available in PubMed was reviewed. Complication rates after hip resurfacing are low, and the procedure has shown both safety and efficacy in the hands of surgeons trained in specialized centers. Proper surgical technique can further reduce the incidence of femoral neck fracture, component loosening, and abnormal wear of the prosthesis. A more systematic detection of adverse local tissue reactions is needed to provide accurate assessments of their prevalence.

Our initial experience with mobile bearing medial compartment unicompartmental arthroplasty (UKA) is presented to highlight lessons that have been learned to avoid short-term failures. Consecutive cases of the Oxford medial UKA performed between February 2001 and April 2006 were reviewed to derive those cases that were revised to total knee arthroplasty (TKA). There were 545 patients available with mean age and body mass index of 65.0 and 30.1, respectively. At final follow-up, 32 patients were revised for lateral compartment arthritis, aseptic component loosening, persisting medial or anterior pain and dislocated meniscal bearing. Revisions were performed with primary unconstrained TKA implants with no stems or wedges required. Our results seem to reflect those seen in registries confirming an earlier higher revision rate and highlight the technical issues of overstuffing the compartment, inadequate cementation technique, and strict adherence to patient selection.

Background Aseptic loosening of glenoid components is a common problem associated with total shoulder arthroplasty and one cause for failure. A new cementless fluted glenoid component was developed and has shown excellent bony ingrowth in a canine model. Hypothesis Clinical utilization of this cementless fluted pegged glenoid component in total shoulder arthroplasty would lower rates of radiolucent lines and aseptic loosening. Materials and methods Between January 2005 and December 2007, 83 primary shoulder arthroplasties with a minimum of 2 years' follow-up were performed with the uncemented fluted pegged glenoid component. Radiographs and records were reviewed to determine stability and survival of the glenoid component. Results All cementless fluted pegged glenoid components had survived at the most recent clinical follow-up. Radiographs showed no evidence of component loosening or radiolucent lines. Evidence of fingerlike projections of bone between the flanges of the implant was found in 24 cases (29%). Conclusions A cementless fluted pegged glenoid component showed excellent initial clinical survival and integration. Further studies regarding continued durability of this component appear warranted.