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During revision total hip arthroplasty (THA), a constrained acetabular liner (CAL) may be inserted to enhance hip stability. It is unclear, however, whether cementation of a CAL into a retained cup offers an advantage compared to revision of the acetabular cup and insertion of an uncemented CAL. The purpose of our study was to compare outcomes and survivorship between the 2 methods.We identified a total of 177 patients who underwent revision THA with a specific CAL at our center between July 2004 and May 2019 (114 cup revisions and insertion of an uncemented CAL, 63 cementations of a CAL into a retained cup). Kaplan-Meier (KM) survival analysis was performed for implant survival free from aseptic failure of the CAL for both cohorts.The average follow-up time was 7.2 and 7.02 years for the cemented and uncemented cohort, respectively (P = .55). Five patients (7.93%) in the cemented CAL group experienced failure of the CAL, whereas 10 patients (8.77%) in the uncemented CAL cohort experienced failure (P = .21). Kaplan-Meier (KM) survival analysis demonstrated comparable survivorship at 10 years (P = .055).The results of our study suggest comparable survivorship between cementing a CAL into a retained cup and inserting an uncemented CAL in a revised acetabular cup. As a result of these findings along with the benefits associated with cementing a CAL, we encourage surgeons to readily consider this option in the management of recurrent instability.

To study the direction and biomechanical consequences of hip center of rotation (HCOR) migration in Crowe type III and VI hips after total hip arthroplasty, post-operative radiographs and CT scans of several unilaterally affected hips were evaluated. Using a three-dimensional model of the human hip, the HCOR was moved in all directions, and joint reaction force (JRF) and abductor muscle force (AMF) were calculated for single-leg stance configuration. Comparing to the normal side, HCOR had displaced medially and inferiorly by an average of 23.4% and 20.8%, respectively, of the normal femoral head diameter. Significant decreases in JRF (13%) and AMF (46.13%) were observed in a presumptive case with that amount of displacement. Isolated inferior displacement had a small, increasing effect on these forces. In Crowe type III and IV hips, the HCOR migrates inferiorly and medially after THA, resulting in a decrease in JRF, AMF, and abductor muscle contraction force.

Background: Acetabular component malposition is a major cause of dislocation following total hip arthroplasty (THA). Intellijoint HIP is an imageless navigation tool that has been shown to provide accurate intraoperative measurement of cup position during primary THA without substantially increasing operative time. However, its accuracy in revision THA has not been evaluated. This study therefore aims to assess the accuracy of Intellijoint HIP in measuring cup inclination and anteversion in comparison with computed tomography (CT) during revision THA. Methods: Intellijoint HIP was used to measure the position of the preexisting cup in 53 consecutive patients undergoing revision THA between December 2018 and February 2020. Two authors blinded to the intraoperative navigation measurements also independently measured cup position using preoperative CT according to Murray’s radiographic definitions. Pearson correlation coefficients with 95% confidence intervals (CIs), paired t tests and Bland–Altman plots were used to assess agreement between navigation- and CT-measured cup position. Statistical analysis was performed using GraphPad Prism, with p values less than 0.05 indicating statistical significance. Results: There was excellent agreement between navigation and CT measurements for both cup inclination (r = 0.89, 95% CI 0.81–0.93) and anteversion (r = 0.93, 95% CI 0.88–0.96), with the mean absolute difference being 5.2o (standard deviation [SD] 4.0o) for inclination and 4.8o (SD 5.4o) for anteversion. The navigation measurement was within 10o of the radiographic measurement in 47 of 53 (88.7%) cases for inclination and 46 of 53 (86.8%) cases for anteversion. Conclusion: Imageless navigation demonstrated excellent correlation and agreement with CT measurements for both inclination and anteversion over a wide range of acetabular component positions.

Porous tantalum augments are versatile tools in reconstructing complex acetabular defects during revision total hip arthroplasty (THA). This study examines the clinical and radiographic outcomes of porous tantalum augments placed in the type I (flying buttress) configuration at two to 17-year follow-up in the largest cohort to-date in the literature.We retrospectively analyzed 59 consecutive revision THAs involving the use of flying buttress augments between 2003 and 2018. The mean patient age and follow-up duration were 63.9 ± 11.6 years (range, 35-87) and 8 years (range, 2-17), respectively. The Oxford hip score was used to assess clinical outcome. The modified Moore classification was used to assess acetabular augment and shell osseointegration. Kaplan-Meier survival analysis with 95% confidence interval (CI) was used to assess implant survivorship.The mean Oxford hip score improved from 15.9 ± 6.2 preoperatively to 35.0 ± 6.5 at a mean follow-up of eight years (P.0001). Radiographic assessment using the modified Moore classification demonstrated five signs of osseointegration in 49 hips (83.1%), four signs in six hips (10.2%), three signs in one hip (1.7%), and one sign in one hip (1.7%). Kaplan-Meier analysis demonstrated ten-year survivorship of 88.9% (95% CI 74.4-95.4) with all-cause revision as end point and 94.3% (95% CI 83.1-98.2) with revision for acetabular aseptic loosening as end point.Treatment of superolateral acetabular defects during revision THA using porous tantalum augments placed in the type I (flying buttress) configuration provides excellent implant survivorship and favorable clinical outcomes at mid-term follow-up.Therapeutic Level IV.

INTRODUCTION The Zimmer Modular Revision hip (ZMR) system is available in two stem options, a porous-coated cylindrical (PCM) and a taper (TM) stem. Several concerns have been reported regarding modular implants. Specifically, because of early junctional fractures, the ZMR system was redesigned with a wider modular interface. As such, we designed a study assessing long-term ZMR survivorship and functional and radiographic outcomes. METHODS AND MATERIALS A search of our institutional research database was performed. A minimum 10-year follow-up was selected. The following two cohorts were created: PCM and TM stems. The Kaplan-Meier survival analysis was performed, and causes of stem failure requiring revision surgery were collected. Functional outcomes as per the Harris Hip Score and radiographic stem stability were assessed as per the Engh classification. RESULTS A total of 146 patients meeting the inclusion criteria were available for follow-up (PCM = 68, TM = 78). The mean follow-up was 13.4 years clinically and 11.1 years radiographically for the PCM cohort. Similarly, the TM cohort had a follow-up of 11.1 years clinically and 10.5 years radiographically. The Kaplan-Meier survivorships were 87.1% and 87.8% at 15 years for the PCM and TM cohorts, respectively. The most common cause of failure requiring revision surgery overall was aseptic loosening (PCM = 1.4%, TM = 5.6%). The mean postoperative Harris Hip Score was as follows: PCM = 71.2 and TM = 64.7. Engh type I or II stem ingrowth was as follows: PCM = 85% and TM = 68%. DISCUSSION Good survivorship using the ZMR stem system can be expected at up to 15 years. Aseptic loosening remains the most commonly encountered problem for both PCM and TM stems. Previously identified modular junctional weakness seem to have been addressed.

Acetabular reconstruction in the context of massive acetabular bone loss is challenging. In rare scenarios where the extent of bone loss precludes shell placement (cup-cage), reconstruction at our center consisted of a cage combined with highly porous metal augments. This study evaluates survivorship, complications, and functional outcomes using this technique.Patients with minimum 2-year follow-up were included. Baseline characteristics were collected. Preintervention and postintervention ambulatory scores were collected. Kaplan-Meier (KM) survival analysis for cage failure requiring revision surgery was conducted. Binomial regression analysis was performed to assess for correlation of aseptic cage failure with baseline characteristics. Preintervention and postintervention ambulatory aid requirements were compared.A total of 41 patients were identified. Mean follow-up was 6.4 years (range 2.8-11.0). Four (9.8%) aseptic cage revisions were identified. Aseptic KM survival analysis was 87.4% (95% confidence interval 75.3-99.6) at 10 years. Aseptic KM survival was 45.0% versus 92.8% at 9 years (P = .14) for patients with vs without pelvic discontinuity. KM survival for all-cause failure was 61.6% (95% confidence interval 44.0-79.2) at 10 years. Binomial regression did not demonstrate correlation of cage failure with baseline characteristics. Wilcoxon signed-rank test demonstrated a significant reduction in ambulatory aide requirement after surgery (mean rank 11.47 vs 9.00, Z = -2.95, P = .003).In scenarios of massive acetabular bone loss where a cup-cage is not a viable option, good survivorship free from aseptic cage failure can be expected at mid-term follow-up using an antiprotrusio cage combined with porous metal augments. Success requires extensive experience in revision surgery.

Conversion of hip arthrodesis to total hip arthroplasty is associated with significant challenges, including accurate restoration of leg length and proper orientation of the acetabular component. Computer-assisted navigation provides real-time data on these parameters that may be a useful augment during hip fusion takedown surgery. Here, we present the case of a 64-year-old woman who presented with symptoms related to a left hip arthrodesis. The patient underwent a left-sided hip arthrodesis takedown and conversion to a total hip arthroplasty (THA). Due to the altered anatomical architecture of the fused hip, imageless navigation was used to assist with the conversion to THA. This case demonstrates that in complex hip arthroplasty procedures, where anatomical morphology is altered, navigation technology can be beneficial in addressing the challenges of achieving optimal placement of acetabular components and establishing appropriate leg length and offset.

Symptomatic osteochondral defects of the knee in young patients can cause substantial disability and predispose to osteoarthritis. Fresh osteochondral allografts (FOCAs) are a treatment option for such defects. With our institution having one of the longest-running FOCA programs, we investigated the long-term outcomes of bulk FOCA in the knee, focusing on graft survivorship, function, complications, and reoperation.A total of 244 patients underwent bulk FOCA in the knee from 1972 to 2018, with a mean age of 37.8 years (range, 10 to 75 years) and a mean follow-up of 9.0 years (range, 1.0 to 29.8 years). Cartilage defects were very large and uncontained, such that they were not amenable to plug transplantation. Survivorship according to Kaplan-Meier analysis was the primary outcome, and failure was defined as conversion to total knee arthroplasty, repeat allograft, graft removal, knee arthrodesis, or amputation. Functional outcome was evaluated with use of the modified Hospital for Special Surgery (mHSS) score, and radiographic evidence of osteoarthritis was classified with use of the Kellgren-Lawrence grading scale.Graft survivorship was 86.6% at 5 years, 73.3% at 10 years, 58.1% at 15 years, 43.7% at 20 years, 31.9% at 25 years, and 22.6% at 30 years. The most common complications were pain (14.8%), malalignment (13.9%), and stiffness (5.8%). A total of 93 grafts (38.1%) failed at a mean of 11.0 years (range, 0.5 to 34.0 years). The mean mHSS score improved significantly, from 68.7 (range, 19 to 91) preoperatively to 80.3 (range, 52 to 100) at the time of the latest follow-up (p0.001). Preoperative mHSS score had a negative correlation with Kellgren-Lawrence grade at the time of the latest follow-up. Multivariate analysis revealed that graft location (i.e., medial-sided or multiple grafts) and increased age were significantly negatively associated with survival. Ten-year survival was80% in patients below 50 years old, but40% in patients60 years old.Bulk FOCA provided promising long-term graft survival and functional improvement in patients50 years old. It can delay or prevent the need for total knee arthroplasty in young patients. Older patients and patients with a medial-sided graft, or multiple grafts within the same knee, had a less favorable prognosis.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Aims Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants. Methods A total of 39 hip fusion conversions to THA were undertaken in 38 patients by a single surgeon employing a consistent surgical technique and uncemented implants. Parameters assessed included Harris Hip Score (HHS) for function, range of motion (ROM), leg length discrepancy (LLD), satisfaction, and use of walking aid. Radiographs were reviewed for loosening, subsidence, and heterotopic ossification (HO). Postoperative complications and implant survival were assessed. Results At mean 12.2 years (2 to 24) follow-up, HHS improved from mean 34.2 (20.8 to 60.5) to 75 (53.6 to 94.0; p < 0.001). Mean postoperative ROM was flexion 77° (50° to 95°), abduction 30° (10° to 40°), adduction 20° (5° to 25°), internal rotation 18° (2° to 30°), and external rotation 17° (5° to 30°). LLD improved from mean -3.36 cm (0 to 8) to postoperative mean -1.14 cm (0 to 4; p < 0.001). Postoperatively, 26 patients (68.4%) required the use of a walking aid. Complications included one (2.5%) dislocation, two (5.1%) partial sciatic nerve injuries, one (2.5%) deep periprosthetic joint infection, two instances of (5.1%) acetabular component aseptic loosening, two (5.1%) periprosthetic fractures, and ten instances of HO (40%), of which three (7.7%) were functionally limiting and required excision. Kaplan-Meier Survival was 97.1% (95% confidence interval (CI) 91.4% to 100%) at ten years and 88.2% (95% CI 70.96 to 100) at 15 years with implant revision for aseptic loosening as endpoint and 81.7% (95% CI 70.9% to 98.0%) at ten years and 74.2% (95% CI 55.6 to 92.8) at 15 years follow-up with implant revision for all cause failure as endpoint. Conclusion The use of an optimal and consistent surgical technique and cementless implants can result in significant functional improvement, low complication rates, long-term implant survival, and high patient satisfaction following conversion of hip fusion to THA. The possibility of requiring a walking aid should be discussed with the patient before surgery. Cite this article: Bone Joint J 2021;103-B(7 Supple B):129–134.

Nonunion and proximal trochanteric migration is a known complication of trochanteric osteotomy. This study examines the effect of osteotomy length on proximal greater trochanter (GT) migration.We analyzed 113 modified trochanteric slide osteotomies and 73 extended trochanteric osteotomies performed between 2008 and 2016. All osteotomies were fixed using cerclage wires and had minimum 6-month radiographic follow-up. Spearman correlations were used to assess association between osteotomy length and GT migration distance. Chi-squared test and logistic regression were used to assess association between patient and surgical factors and GT migration1 cm. Receiver operating characteristic curves were constructed to determine the optimal cutoff osteotomy length for predicting GT migration1cm.Mean osteotomy length was 6.1 cm (range 3-12) for modified trochanteric slide osteotomies and 14.8 cm (range 8-23) for extended trochanteric osteotomies. Osteotomy length was negatively correlated (r = -0.340, P.001) with GT migration distance. Longer osteotomy length was protective against GT migration1 cm (odds ratio 0.67, P = .002). Receiver operating characteristic curve analysis demonstrated an optimal cutoff osteotomy length of 9.8 cm for predicting GT migration1 cm (sensitivity 0.971, specificity 0.461). Among osteotomies10 cm, those fixed using at least one distal wire below the lesser trochanter and vastus ridge demonstrated less mean GT migration (3.86 vs 7.12 mm, P = .009) and higher mean union rate (68.8% vs 31.2%, P.001).Osteotomies shorter than 10 cm are at higher risk of developing proximal GT migration1 cm. A distal cerclage wire below the lesser trochanter and vastus ridge may help decrease the amount of GT migration.Prognostic Level IV.

AimsThe aim of this study was to report the outcome of femoral condylar fresh osteochondral allografts (FOCA) with concomitant realignment osteotomy with a focus on graft survivorship, complications, reoperation, and function.Patients and MethodsWe identified 60 patients (16 women, 44 men) who underwent unipolar femoral condylar FOCA with concomitant realignment between 1972 and 2012. The mean age of the patients was 28.9 years (10 to 62) and the mean follow-up was 11.4 years (2 to 35). Failure was defined as conversion to total knee arthroplasty, revision allograft, or graft removal. Clinical outcome was evaluated using the modified Hospital for Special Surgery (mHSS) score.ResultsA total of 14 grafts (23.3%) failed at a mean of 8.6 years (1.4 to 20.1). Graft survivorship was 87.3% (95% confidence interval (CI) 79.0 to 96.6), 85.0% (95% CI 75.8 to 95.3), 74.8% (95% CI 62.2 to 90.0), 65.2% (95% CI 49.9 to 85.2), and 59.8% (95% CI 43.5 to 82.1) at five, ten, 15, 20, and 25 years, respectively. A total of 23 patients (38.3%) developed complications, and 26 (43.3%) had a further operation. Persistent postoperative malalignment occurred more frequently in failed grafts (28.6% vs 4.3%; p = 0.023), and was a risk factor for graft failure (hazard ratio 6.55; 95% CI 1.61 27.71; p = 0.009). The mean mHSS score improved from 74.1 (40 to 91) preoperatively to 89.0 (66 to 100) at final follow-up (p < 0.001).ConclusionFemoral condylar FOCA with concomitant realignment osteotomy provides excellent long-term graft survival and reliable functional improvement. Persistent malalignment may increase the risk for graft failure.

Case A 34-year-old woman with developmental dysplasia of the hip (DDH) presented with chronic left hip pain related to a femoral head cyst. The patient strongly preferred a joint-preserving option. Periacetabular osteotomy (PAO) has shown reliable options for managing DDH, and femoral head fresh osteochondral allograft (FOCA) can be performed for cysts. We performed these procedures concomitantly for the first time. At 1-year follow-up, the patient had functional, pain-free motion and high satisfaction. Conclusion PAO and femoral head FOCA can be performed concomitantly with a common, anterior hip approach. They are a viable, joint-preserving option for patients with DDH and osteochondral lesions.

Background:Osteochondral allograft (OCA) transplantation has evolved into a first-line treatment for large chondral and osteochondral defects, aided by advancements in storage protocols and a growing body of clinical evidence supporting successful clinical outcomes and long-term survivorship. Despite the body of literature supporting OCAs, there still remains controversy and debate in the surgical application of OCA, especially where high-level evidence is lacking.Purpose:To develop consensus among an expert group with extensive clinical and scientific experience in OCA, addressing controversies in the treatment of chondral and osteochondral defects with OCA transplantation.Study Design:Consensus statement.Methods:A focus group of clinical experts on OCA cartilage restoration participated in a 3-round modified Delphi process to generate a list of statements and establish consensus. Questions and statements were initially developed on specific topics that lack scientific evidence and lead to debate and controversy in the clinical community. In-person discussion occurred where statements were not agreed on after 2 rounds of voting. After final voting, the percentage of agreement and level of consensus were characterized. A systematic literature review was performed, and the level of evidence and grade were established for each statement.Results:Seventeen statements spanning surgical technique, graft matching, indications, and rehabilitation reached consensus after the final round of voting. Of the 17 statements that reached consensus, 11 received unanimous (100%) agreement, and 6 received strong (80%-99%) agreement.Conclusion:The outcomes of this study led to the establishment of consensus statements that provide guidance on surgical and perioperative management of OCAs. The findings also provided insights on topics requiring more research or high-quality studies to further establish consensus and provide stronger evidence.

Case A 24-year-old competitive rower suffered a severe road injury to the medial aspect of his knee. He was referred to us for a partial joint transplantation consisting of a medial tibiofemoral fresh osteochondral allograft (FOCA), medial collateral ligament, meniscal allograft, and osteotomy. Two years after reconstruction, the patient won a bronze medal in the Summer Paralympics. At the 6-year follow-up, he demonstrates excellent clinical and radiographic outcomes and high satisfaction. Conclusion For extensive knee injuries with large, complex defects, FOCA with concomitant meniscal allograft transplantation, ligamentous allograft, and osteotomy may be considered in high-demand athletes who wish to return to play.

Background Constrained acetabular liners (CALs) are used in both primary and revision total hip arthroplasty in cases where stability and abductor deficiency are of concern. The efficacy of CALs has been shown to be design dependent. There is clear evidence that the use of small head sizes and shorter offset in unconstrained total hip arthroplasty is associated with higher rates of dislocation. To our knowledge, no such study has assessed the effect of femoral head size, neck length, and offset for CALs. Methods We performed a retrospective study assessing the outcomes of CALs with minimum 2-year follow-up. A Kaplan-Meier survivorship analysis was conducted for all patients and for patients revised for instability. A binomial regression analysis was performed to assess for variables significantly associated with CAL failure. Results A total of 285 CALs in 281 patients were identified with a mean follow-up of 5.7 years. Ten-year Kaplan-Meier survival analyses were as follows: all indication 91.9% vs instability 85.5% (P = .15). Increasing neck length was associated with lower rates of failure (odds ratio, 0.81; P = .042). Femoral head size, offset, and abductor reconstruction were not significantly associated with CAL failure. Conclusion Larger head size has not been demonstrated to lead to lower failure in CALs. Increasing neck length was associated with lower failure rate. Surgeons should be cautious when attempting to ream to larger acetabular shell sizes for the purpose of using larger heads with CALs. Increasing neck length may instead be targeted intraoperatively.

Fibrous dysplasia (FD) results from an abnormality in lamellar bone formation and most frequently involves the proximal femur. This can lead to the development of osteoarthritis requiring total hip arthroplasty (THA). Such cases are challenging, and there is a lack of information guiding best management. As such, we devised a study assessing the outcomes and complications in patients with FD undergoing THA with modern implant technology, and we outlined our preferred surgical technique.A search of our institutional arthroplasty database was performed to identify patients who underwent THA for FD between January 2001 and July 2018 at Mount Sinai Hospital in Toronto, Canada. Data regarding implants used and the use of allograft material or metal augments or both were obtained. Complications and revision requirements were noted. Radiographic and clinical leg length discrepancies were assessed.A total of 10 hips in 9 patients who underwent THA for FD were identified. Mean follow-up time was 6.0 years (range 0.5 to 10.3 yr). The majority of patients underwent THA using uncemented femoral and acetabular components with large femoral heads on highly cross-linked polyethylene liners. Most cases (80% of hips) required allograft to the proximal femur. A single complication requiring revision was noted. In 90% of hip surgeries, the patient required transfusion of packed red blood cells. Mean radiographic and clinical leg length discrepancies were 0.9 cm (range -2.4 to 2.4 cm) and 0.9 cm (range -4 to 0 cm), respectively.Contrary to previous reports, low complication and revision rates were observed with cementless components and routine use of allograft material. The challenging nature of such cases warrants use of an experienced arthroplasty treatment team.La dysplasie fibreuse (DF) découle d’une anomalie de la formation de l’os lamellaire et affecte le plus souvent le fémur proximal. Elle peut aussi aboutir à l’arthrose qui nécessitera une arthroplastie totale de la hanche (ATH). Or, ces cas sont complexes car on manque d’information sur la meilleure façon de les traiter. Nous avons donc conçu une étude afin d’évaluer l’issue et les complications chez les patients atteints de DF qui subissent une ATH au moyen de techniques d’implants modernes, et nous indiquons la technique chirurgicale que nous privilégions.Nous avons interrogé la base de données de notre établissement sur les arthroplasties pour recenser les patients ayant subi une ATH en raison de la DF entre janvier 2001 et juillet 2018 à l’Hôpital du Mont-Sinaï de Toronto, au Canada. Nous avons obtenu les données sur les implants utilisés et le recours à du matériel de comblement à base d’allogreffes ou de métal ou les deux. Nous avons consigné les complications et les cas où une révision a été nécessaire. Nous avons évalué les inégalités de longueur des membres inférieurs aux plans clinique et radiographique.En tout, 10 hanches chez 9 patients ont fait l’objet d’une ATH en raison de la DF. Le suivi moyen a duré 6,0 ans (de 0,5 à 10,3 ans). La majorité des patients ont subi une ATH avec des prothèses à composants fémoraux et acétabulaires non cimentés dotées de têtes fémorales volumineuses, sur des revêtements de polyéthylène hautement réticulé. La plupart des cas (80 % des hanches) ont nécessité une allogreffe au fémur proximal. Une seule complication nécessitant une révision a été notée. Dans 90 % des chirurgies de la hanche, les patients ont eu besoin de transfusions de culots globulaires. Les inégalités cliniques et radiographiques moyennes de la longueur des membres inférieurs ont été de 0,9 cm (entre –2,4 et 2,4 cm) et de 0,9 cm (de –4 à 0 cm), respectivement.Contrairement à de précédents rapports, les taux de complications et de révisions observés ont été faibles avec les composants non cimentés et l’utilisation de routine d’allogreffes. La nature complexe de ces cas justifie que l’on fasse appel à une équipe chevronnée pour l’arthroplastie.

Measuring outcomes following articular cartilage repair should be performed using instruments that have demonstrated content validity as well as adequate psychometric properties including reliability, construct validity and responsiveness in this population of interest. As per the International Cartilage Repair Society (ICRS) recommendation, the primary outcome for articular cartilage surgery should be either the Knee Injury and Osteoarthritis Outcome Score (KOOS) or the International Knee Documentation Committee (IKDC). Secondary outcomes should include an activity scale as well as a measure of generic health-related quality of life (QoL) which can concomitantly allow for an evaluation of the cost-effectiveness of a group of interventions. Such a biopsychosocial approach towards outcome measurement will allow for a comprehensive understanding of how patients experience articular cartilage pathology and how they respond to treatment over time.

This chapter provides a comprehensive approach to evaluating patients with articular cartilage defects, as well as a description of treatment algorithms and surgical techniques. During the initial workup (history, physical exam, imaging), a thorough lower extremity assessment is emphasized such that comorbidities including ligamentous instability, malalignment, and meniscal deficiency can be concomitantly addressed. Patient and defect-specific factors pertinent to surgical decision-making are discussed along with an evidence-based and technical overview of common surgical approaches including microfracture, osteochondral (OC) autograft/allograft, and autologous chondrocyte implantation (ACI). An approach to patients with a failed index cartilage procedure is also described.

The goals of managing patients with symptomatic chondral defects of the knee include optimizing clinical and functional outcomes, generating durable hyaline or hyaline-like cartilage with low procedure-associated morbidity, utilizing cost-effective technology, and ultimately delaying the development of osteoarthritis. The objective of this chapter is to provide an overview of the different types of commercially available bioengineered cartilage grafts including cell-based therapies, microfracture augmentation techniques, and the use of particulated articular cartilage, as well as examples of scaffold and synthetic materials that can be used in isolation.

Articular cartilage serves as a lubricated, wear-resistant, friction-reducing self-maintaining material that is slightly compressible to evenly distribute forces onto the bone. Articular cartilage macromolecular composition and architecture and its biomechanical properties are well adapted to withstand mechanical loads increasingly for a ten-decade lifetime. The three-dimensional orientation of the structural molecules and various levels of compartmentalization, namely, the horizontal zones from the articular surface to the underlying subchondral bone as well as interstitially from the surface of the chondrocytes, enable articular cartilage function by facilitating smooth knee movements by reducing friction and absorbing the impact of loading. Coupled with the biomechanical function of articular cartilage in its entirety, articular cartilage lubrication mechanisms provide almost frictionless surfaces between moving joints and do this throughout life adapting to both age and arthritic disease.

Inaccurate component placement during total hip arthroplasty (THA) can have significant and costly consequences. Malpositioning of the acetabular cup components can lead to dislocation and revision surgery, while postoperative discrepancies in leg length – the primary driver for litigation against orthopaedic surgeons – can lead to biomechanical imbalances, causing chronic low back pain. Current methods for monitoring these parameters intraoperatively rely on manual methods such as tissue tensioning or on the surgeon's experience, both of which are subject to inaccuracies. Computer-assisted navigation, while currently used in only a small percentage of THA procedures, is an emerging technology that has the potential to improve the accuracy with which surgeons place components during THA by providing real-time, intraoperative data. One innovative navigation system – Intellijoint HIP® (Intellijoint Surgical, Waterloo, ON) – has demonstrated its accuracy, time-neutrality, safety and effectiveness in several clinical studies and has the potential to improve outcomes and reduce re-admissions and revision during both primary and revision THA.

Controversy remains over the surgical management of large osteochondral lesions of the femoral head in young, active patients. The purpose of this study is to assess midterm clinical and radiographic outcomes after fresh osteochondral allograft transplantation (OAT) for large femoral head lesions at minimum 2-year follow-up.A retrospective review of prospectively collected data was performed for 22 patients under the age of 50 years with defined femoral head osteochondral lesions who underwent fresh OAT between 2008 and 2015. Patients were assessed clinically using the modified Harris Hip Score (mHHS) preoperatively and at each follow-up visit. Postoperative radiographs were evaluated for graft integrity and KellgrenLawrence Grade for osteoarthritis severity. Complications and reoperation were assessed by chart review. Kaplan-Meier survivorship analyses with 95% confidence intervals were performed for the end point of conversion to total hip arthroplasty.At a mean follow-up of 68.8 months (26-113), the mean mHHS improved significantly (P.001) from 48.9 (19-84) to 77.4 (35-98). Sixteen of 22 patients (72.7%) had an mHHS ≥70 at the latest follow-up. Arthritic progression, as indicated by an increase in the KellgrenLawrence Grade, occurred in 4 of 22 hips (18.2%). Five patients (22.7%) underwent conversion to total hip arthroplasty. Graft survivorship was 86.4 ± 7.3% at 2 years, 78.5 ± 10.0% at 5 years, and 67.3 ± 13.5% at 9 years.Fresh OAT may be a viable treatment option for osteochondral defects of the femoral head in young, active patients with minimal preexisting joint deformity.

Aims It may not be possible to undertake revision total hip arthroplasty (THA) in the presence of massive loss of acetabular bone stock using standard cementless hemispherical acetabular components and metal augments, as satisfactory stability cannot always be achieved. We aimed to study the outcome using a reconstruction cage and a porous metal augment in these patients. Patients and Methods A total of 22 acetabular revisions in 19 patients were performed using a combination of a reconstruction cage and porous metal augments. The augments were used in place of structural allografts. The mean age of the patients at the time of surgery was 70 years (27 to 85) and the mean follow-up was 39 months (27 to 58). The mean number of previous THAs was 1.9 (1 to 3). All patients had segmental defects involving more than 50% of the acetabulum and seven hips had an associated pelvic discontinuity. Results Three failures were observed in two hips, both of which had undergone a previous resection of a tumour affecting the acetabulum. Other complications included a late arterial injury, a sciatic nerve palsy, a dislocation treated with a femoral revision, a deep infection treated with irrigation and debridement and a fracture of the greater trochanter treated conservatively. The mean Oxford Hip Score significantly increased from 13.9 (2 to 23) to 28.7 (13 to 38) (p < 0.00001). The mean vertical distance between the centre of rotation of the hip and its normal location decreased from 30 mm to 10 mm. Conclusions Acceptable early survivorship can be achieved using this novel technique, but it may be unsuitable for use in patients who have previously undergone the resection of a tumour involving the acetabulum. Cite this article: Bone Joint J 2017;99-B:607–13.

Total hip arthroplasty (THA) is increasingly performed in younger patients despite the lack of comprehensive assessment of long-term outcomes. We systematically reviewed the contemporary literature to assess the 1) indications, 2) implant selection and long-term survivorship, 3) complication and reoperation rates and 4) radiographic and functional outcomes of primary THA in patients younger than 55 years.We searched the Embase and MEDLINE databases for English-language articles published between 2000 and 2018 that reported outcomes of primary THA in patients younger than 55 years with a minimum follow-up duration of 10 years.Thirty-two studies reporting on 3219 THA procedures performed in 2434 patients met our inclusion criteria. The most common preoperative diagnoses were avascular necrosis (1044 [32.4%]), osteoarthritis (870 [27.0%]) and developmental dysplasia of the hip (627 [19.5%]). Modular implants (3001 [93.2%]), cementless fixation (2214 [68.8%]) and metal-on-polyethylene bearings (1792 [55.7%]) were frequently used. The mean 5- and 10-year survival rates were 98.7% and 94.6%, respectively. Data on survival beyond 10 years were heterogeneous, with values of 27%–99.5% at 10–14 years, 59%–84% at 15–19 years, 70%–77% at 20–24 years and 60% at 25–30 years. Rates of dislocation, deep infection and reoperation for any reason were 2.4%, 1.2% and 16.3%, respectively. The mean Harris Hip Score improved from 43.6/100 to 91.0/100.Total hip arthroplasty in patients younger than 55 years provides reliable outcomes at up to 10 years. Future studies should evaluate the outcomes of THA in this population at 15–20 years’ follow-up.On effectue de plus en plus d’arthroplasties totales de la hanche (ATH) chez des patients qui ne sont pas âgés, malgré l’absence d’évaluation exhaustive des issues à long terme. Nous avons procédé à une revue systématique de la littérature récente pour analyser 1) les indications, 2) la sélection des implants et la survie à long terme, 3) les taux de complications et de réintervention, et 4) les résultats radiographiques et fonctionnels des ATH primaires chez les patients de moins de 55 ans.Nous avons interrogé les bases de données Embase et MEDLINE pour recenser les articles de langue anglaise publiés entre 2000 et 2018 qui faisaient état des issues d’ATH primaires chez des patients de moins de 55 ans suivis pendant au moins 10 ans.Trente-deux études portant sur 3219 ATH effectuées chez 2434 patients répondaient à nos critères d’inclusion. Les diagnostics préopératoires les plus fréquents étaient la nécrose avasculaire (1044 [32,4 %]), l’arthrose (870 [27,0 %]) et la dysplasie développementale de la hanche (627 [19,5 %]). Les implants modulaires (3001 [93,2 %]), la fixation non cimentée (2214 [68,8 %]) et le couple métal–polyéthylène (1792 [55,7 %]) ont été fréquemment utilisés. Les taux de survie moyens à 5 et à 10 ans étaient de 98,7 % et de 94,6 %, respectivement. Les données sur la survie au-delà de 10 ans étaient hétérogènes, allant de 27 % à 99,5 % après 10 à 14 ans, de 59 % à 84 % après 15 à 19 ans, de 70 % à 77 % après 20 à 24 ans et de 60 % après 25 à 30 ans. Les taux de dislocation, d’infection profonde et de réintervention, toutes causes confondues, étaient de 2,4 %, de 1,2 % et de 16,3 %, respectivement. Le score de Harris moyen s’est amélioré, passant de 43,6/100 à 91,0/100.L’arthroplastie totale de la hanche chez les patients de moins de 55 ans donne des résultats fiables pour les 10 premières années après l’intervention. Les prochaines études devraient évaluer les issues de l’arthroplastie de la hanche dans cette population après 15 à 20 ans de suivi.

BACKGROUND Dislocation of dynamic antibiotic hip spacers during the treatment of periprosthetic joint infection is a well-described complication. Unfortunately, the repercussions of such events after reimplantation of the definitive prosthesis remain largely unknown. As such, we devised a study comparing the perioperative and postoperative outcomes of patients having undergone reimplantation with and without spacer dislocation. METHODS A search of our institutional database was performed. Two retrospective cohorts were created: dislocated and nondislocated hip spacers. The radiographic and clinical outcomes for each cohort were collected. RESULTS The two retrospective cohorts contained 24 patients for the dislocated group and 66 for the nondislocated group. Continuous variables noted to be significantly different between the dislocated and nondislocated groups were as follows: clinical leg-length discrepancy (1.35 cm vs 0.41 cm, P = .027), acetabular center of rotation (1.34 cm vs 0.60 cm, P = .011), total packed red blood cell transfusions (4.05 vs 2.37, P = .019), operative time (177.4 min vs 147.3 min, P = .002), and hospital length of stay (7.79 days vs 5.89 days, P = .018). Categorical variables noted to be significantly different were requirement for complex acetabular reconstruction (58.3% vs 13.7%, P < .001), requirement of constrained liners (62.5% vs 37.3%, P = .040), and dislocation after second stage (20.8% vs 6.1%, P = .039). CONCLUSION Dislocation of dynamic hip spacers leads to inferior clinical results and perioperative outcomes after reimplantation of the definitive prosthesis. Additionally, complex acetabular reconstruction is often required. As such, every effort should be made to prevent hip spacer dislocation.

Background When performing total hip arthroplasty (THA) on a dysplastic hip, proper positioning of the acetabular component may not allow for more than 70% coverage. Structural support in the form of an autograft or a high porosity metal augment may be necessary. The purpose of the study was to investigate the value of pre-operative templating and deformity classification in predicting cup coverage and the need for structural support. Methods 65 cases of THA for DDH were retrospectively analysed. 2 observers independently classified each dysplastic hip according to Hartofilakidis and determined the extent of cup coverage via templating software on pre-operative digital AP pelvic radiographs. Results Weighted kappa interobserver agreement was 0.68 for cup coverage and 0.76 for Hartofilakidis type. Structural support was necessary in 10 hips. No structural support was necessary in Hartofilakidis type 1, dysplasia cases. However, 27-30% of cases with type 2 or type 3 dysplasia required structural support. All cases with templated cup coverage of 65% or less required structural support. Templated coverage within 65-75% and over 75% resulted in 20% and 10% of patients receiving structural augmentation, respectively. Conclusions Pre-Operative planning for THA in the setting of hip dysplasia is crucial and can provide valuable insight to the need for column augmentation. However, the 3-D severity of the deformity may be underestimated in the 2-D radiographs.

Osteoarthritis is a ubiquitous condition, affecting 26 million Americans each year, with up to 17% of adults over age 75 suffering from one variation of arthritis. The hip is one of the most commonly affected joints and while there are conservative options for treatment, as symptoms progress, many patients eventually turn to surgery to manage their pain and dysfunction. Early surgical options such as osteotomy or arthroscopy are reserved for younger, more active patients with less severe disease and symptoms. Total hip arthroplasty offers a viable solution for patients with severe degenerative changes; however, post-surgical discrepancies in leg length, offset and component malposition are common and cause significant complications. Such discrepancies are associated with consequences such as low back pain, neurological deficits, instability and overall patient dissatisfaction. Current methods for managing leg length and offset during hip arthroplasty are either inaccurate and susceptible to error or are cumbersome, expensive and lengthen surgical time. There is currently no viable option that provides accurate, real-time data to surgeons regarding leg length, offset and cup position in a cost-effective manner. As such, we hypothesize that a procedural gap exists in hip arthroplasty, a gap into which fall a large majority of arthroplasty patients who are at increased risk of complications following surgery. These complications and associated treatments place significant stress on the healthcare system. The costs associated with addressing leg length and offset discrepancies can be minor, requiring only heel lifts and short-term rehabilitation, but can also be substantial, with revision hip arthroplasty costs of up to $54,000 per procedure. The need for a cost-effective, simple to use and unobtrusive technology to address this procedural gap in hip arthroplasty and improve patient outcomes is of increasing importance. Given the aging of the population, the projected increases in the volume of procedures over the coming decades and the economic pressures associated with downward pricing pressure and bundled payments, the need to address this gap is underscored.

The burden of revision total hip arthroplasty continues to rise exponentially, which is a reflection of the increasing number of primary total hip arthroplasty (THA) procedures being performed, lower surgeon thresholds for THA due to excellent mid- to long-term success rates and improved survival of the general population. Acetabular bone loss encountered at the time of revision surgery can present a significant pre- and intra-operative surgical challenge. This review covers the causes, a classification system and surgical options for treatment of acetabular bone loss at revision surgery.

Background:Cartilage lesions of the patellofemoral joint constitute a frequent abnormality. Patellofemoral conditions are challenging to treat because of complex biomechanics and morphology.Purpose:To develop a consensus statement on the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint using a modified Delphi technique.Study Design:Consensus statement.Methods:A working group of 4 persons generated a list of statements related to the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint to form the basis of an initial survey for rating by a group of experts. The Metrics of Osteochondral Allografts (MOCA) expert group (composed of 28 high-volume cartilage experts) was surveyed on 3 occasions to establish a consensus on the statements. In addition to assessing agreement for each included statement, experts were invited to propose additional statements for inclusion or to suggest modifications of existing statements with each round. Predefined criteria were used to refine statement lists after each survey round. Statements reaching a consensus in round 3 were included within the final consensus document.Results:A total of 28 experts (100% response rate) completed 3 rounds of surveys. After 3 rounds, 36 statements achieved a consensus, with over 75% agreement and less than 20% disagreement. A consensus was reached in 100.00% of the statements relating to functional anatomy of the patellofemoral joint, 88.24% relating to surgical indications, 100.00% relating to surgical technical aspects, and 100.00% relating to rehabilitation, with an overall consensus of 95.5%.Conclusion:This study established a strong expert consensus document relating to the functional anatomy, surgical indications, donor graft considerations for osteochondral allografts, surgical technical aspects, and rehabilitation concepts for the management of large chondral and osteochondral defects in the patellofemoral joint. Further research is required to clinically validate the established consensus statements and better understand the precise indications for surgery as well as which techniques and graft processing/preparation methods should be used based on patient- and lesion-specific factors.

Background The optimal system for greater trochanteric fixation following osteotomy or fracture remains unknown. This systematic review aims to synthesize the available English-language literature on 5 commonly reported trochanteric fixation methods to quantify and compare rates of complications and reoperation. Methods A comprehensive search of MEDLINE and Embase databases from January 1946 to June 2017 was performed for articles in English describing fixation of trochanteric osteotomies and fractures using wires, cables, cable-plate devices, claw or locking plates, and trochanteric bolts. Pooled mean rates of complications and reoperation with 95% confidence intervals (CIs) were analyzed using a random-effects model. Results Fifty-seven studies involving 10,956 hips were eligible for inclusion. Five studies had Level-III evidence and 52 had Level-IV evidence. The pooled mean rate of nonunion was 4.17% (95% CI, 3.21% to 5.13%; I = 79%) for wires, 5.07% (95% CI, 0.37% to 9.77%; I = 74%) for cables, 16.11% (95% CI, 10.85% to 21.37%; I = 89%) for cable-plate systems, 9.60% (95% CI, 2.23% to 16.97%; I = 59%) for claw or locking plates, and 12.42% (95% CI, 3.41% to 21.43%; I = 75%) for trochanteric bolts. Substantial heterogeneity in the data precluded formal statistical comparison of outcomes and complications between implants. Conclusions Available literature on the various trochanteric fixation implants is heterogeneous and consists primarily of retrospective case series. Based on the current literature, it is difficult to support the use of one implant over another. Despite superior mechanical properties, rates of complication and reoperation following cable-plate fixation remains suboptimal, especially in complex revision scenarios. Additional rigorous prospective randomized and cohort studies are needed to make definitive recommendations regarding the most reliable method of trochanteric fixation. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND Over the past decade, revelations of inappropriate financial relationships between surgeons and surgical device manufacturers have challenged the presumption that surgeons can collaborate with surgical device manufacturers without damaging public trust in the surgical profession. We explored postoperative Canadian patients' knowledge and opinions about financial relationships between surgeons and surgical device manufacturers. METHODS This complex issue was explored using qualitative methods. We conducted semistructured face-to-face interviews with postoperative patients in follow-up arthroplasty clinics at an academic hospital in Toronto, Canada. Interviews were audiotaped, transcribed and analyzed. Patient-derived concepts and themes were uncovered. RESULTS We interviewed 33 patients. Five major themes emerged: 1) many patients are unaware of the existence of financial relationships between surgeons and surgical device manufacturers; 2) patients approve of financial relationships that support innovation and research but are opposed to relationships that involve financial incentives that benefit only the surgeon and the manufacturer; 3) patients do not support disclosure of financial relationships during the consent process as it may shift focus away from the more important risks; 4) patients support oversight at the professional level but reject the idea of government involvement in oversight; and 5) patients entrust their surgeons to make appropriate patient-centred choices. CONCLUSION This qualitative study deepens our understanding of financial relationships between surgeons and industry. Patients support relationships with industry that provide potential benefit to current or future patients. They trust our ability to self-regulate. Disclosure combined with appropriate oversight will strengthen public trust in professional collaboration with industry.

Several studies have failed to show significant benefits of closed suction drainage (CSD) in routine primary total hip arthroplasty (THA). However, blood loss, haematoma formation and wound complications are generally much greater in revision THA as compared to primary THA. The purpose of this study was to determine if CSD is beneficial for revision THA patients. We conducted a prospective, randomized, controlled trial at our institution between July 2013 and July 2014. Eighty-eight patients undergoing revision THA were enrolled and randomly assigned to receive a CSD (n = 44) or to not receive a CSD (n = 44). All first-stage revision surgeries for infection were excluded. Primary outcomes were haemoglobin loss and number of patients transfused. Secondary outcomes included functional outcome evaluated with Harris hip score (HHS), pain evaluated with visual analogue scale (VAS), and length of hospital stay. There were significantly more patients in the CSD group that required blood transfusions (20/44 as compared to 11/44, p = 0.04). Patients in the no CSD group were discharged earlier than patients in the CSD group (4.3 days as compared to 5.4 days, p = 0.002). No statistical significant difference was found in the HHS or pain VAS between the groups. This study did not demonstrate any benefit with the use of CSD for revision THA with regard to wound related complications, infection or early functional outcome. Post-operative blood loss, transfusion rate, and length of hospital stay may be higher with CSD.

This study reports the clinical outcome of reconstruction of deficient abductor muscles following revision total hip arthroplasty (THA), using a fresh–frozen allograft of the extensor mechanism of the knee. A retrospective analysis was conducted of 11 consecutive patients with a severe limp because of abductor deficiency which was confirmed on MRI scans. The mean age of the patients (three men and eight women) was 66.7 years (52 to 84), with a mean follow-up of 33 months (24 to 41). Following surgery, two patients had no limp, seven had a mild limp, and two had a persistent severe limp (p = 0.004). The mean power of the abductors improved on the Medical Research Council scale from 2.15 to 3.8 (p < 0.001). Pre-operatively, all patients required a stick or walking frame; post-operatively, four patients were able to walk without an aid. Overall, nine patients had severe or moderate pain pre-operatively; ten patients had no or mild pain post-operatively. At final review, the Harris hip score was good in five patients, fair in two and poor in four. We conclude that using an extensor mechanism allograft is relatively effective in the treatment of chronic abductor deficiency of the hip after THA when techniques such as local tissue transfer are not possible. Longer-term follow-up is necessary before the technique can be broadly applied. Cite this article: Bone Joint J 2015;97-B:1050–5.

Current approaches to cartilage tissue engineering require a large number of chondrocytes. Although chondrocyte numbers can be expanded in monolayer culture, the cells dedifferentiate and unless they can be redifferentiated are not optimal to use for cartilage repair. We took advantage of the differential effect of culture conditions on the ability of passaged and primary chondrocytes to form cartilage tissue to dissect out the extracellular matrix (ECM) molecules produced and accumulated in the early stages of passaged cell cartilage tissue formation as we hypothesized that passaged bovine cells that form cartilage accumulate a pericellular matrix that differs from cells that do not form cartilage. Twice passaged bovine chondrocytes (P2) (cartilage forming), or as a control primary chondrocytes (P0) (which do not generate cartilage), were cultured on three-dimensional membrane inserts in serum-free media. P2 redifferentiation was occurring during the first 8 days as indicated by increased expression of the chondrogenic genes Sox9, collagen type II, aggrecan, and COMP, suggesting that this is an appropriate time period to examine the ECM. Mass spectrometry showed that the P2 secretome (molecules released into the media) at 1 week had higher levels of collagen types I, III, and XII, and versican while type II collagen and COMP were found at higher levels in the P0 secretome. There was increased collagen synthesis and retention by P2 cells compared to P0 cells as early as 3 days of culture. Confocal microscopy showed that types XII, III, and II collagen, aggrecan, versican, and decorin were present in the ECM of P2 cells. In contrast, collagen types I, II, and III, aggrecan, and decorin were present in the ECM of P0 cells. As primary chondrocytes grown in serum-containing media, a condition that allows for the generation of cartilage tissue in vitro, also accumulate versican and collagen XII, this study suggests that these molecules may be necessary to provide a microenvironment that supports hyaline cartilage formation. Further study is required to determine if these molecules are also accumulated by passaged human chondrocytes and their role in promoting hyaline cartilage formation.

This is a relatively new technique that provides a viable option for the treatment of complex severe acetabular defects and pelvic discontinuity [1]. A porous trabecular metal acetabular shell (titanium and tantalum) and a bridging ilioischial cage are used to achieve mechanical construct stability and biologic fixation of the acetabular shell [2]. It was first presented at the 2007 annual meeting of American Association of Orthopaedic Surgeons [3, 4].

Cartilage defects of the hip cause significant pain and may lead to arthritic changes that necessitate hip replacement. We propose the use of fresh osteochondral allografts as an option for the treatment of such defects in young patients. Here we present the results of fresh osteochondral allografts for cartilage defects in 17 patients in a prospective study. The underlying diagnoses for the cartilage defects were osteochondritis dissecans in eight and avascular necrosis in six. Two had Legg-Calve-Perthes and one a femoral head fracture. Pre-operatively, an MRI was used to determine the size of the cartilage defect and the femoral head diameter. All patients underwent surgical hip dislocation with a trochanteric slide osteotomy for placement of the allograft. The mean age at surgery was 25.9 years (17 to 44) and mean follow-up was 41.6 months (3 to 74). The mean Harris hip score was significantly better after surgery (p < 0.01) and 13 patients had fair to good outcomes. One patient required a repeat allograft, one patient underwent hip replacement and two patients are awaiting hip replacement. Fresh osteochondral allograft is a reasonable treatment option for hip cartilage defects in young patients.Cite this article: Bone Joint J 2014;96-B(11 Supple A):11–16.

We hypothesised that a modified ETO in patients undergoing revision total hip arthroplasty (THA) for treatment of Vancouver B2/B3 peri-prosthetic fractures would be associated with good clinical outcomes. A retrospective review was conducted of 34 patients (mean age 73 years). At mean follow-up of 57 months, the ETO had healed in all patients. Two patients had subsidence of the femoral stem at two and three years postoperatively requiring revision, and one patient had a dislocation 3 months after surgery. The mean Harris Hip Score at the time of the final follow-up was 76.9 (range, 46–95); 23/34 patients had an excellent result, 7/34 a good result, and 4/34 a poor result. We conclude that satisfactory outcomes can be obtained using this technique.

This study assessed failures of allograft prosthesis composites (APC) and revisions with a new APC. Twenty-one patients with failed APC's after revision hip arthroplasty with severe proximal femoral bone loss underwent revision with a new APC. Causes of failure were aseptic loosening (18 patients), infection (3 patients). Of these 21 APC revisions, two patients failed (after 60, 156 months). The 5 and 10 year survival rates were 83.5% (95% CI, 79-100%, number at risk 12 and 6 accordingly). In addition, two patients had non-union at the host-allograft bone junction and were augmented with bone autograft and plate. These results suggest that failed APCs may be revised to a new APC with a predictable outcome.

The use of ilioischial cage reconstruction for pelvic discontinuity has been replaced by the Trabecular Metal (Zimmer, Warsaw, Indiana) cup-cage technique in our institution, due to the unsatisfactory outcome of using a cage alone in this situation. We report the outcome of 26 pelvic discontinuities in 24 patients (20 women and four men, mean age 65 years (44 to 84)) treated by the cup-cage technique at a mean follow-up of 82 months (12 to 113) and compared them with a series of 19 pelvic discontinuities in 19 patients (18 women and one man, mean age 70 years (42 to 86)) treated with a cage at a mean follow-up of 69 months (1 to 170). The clinical and radiological outcomes as well as the survivorship of the groups were compared. In all, four of the cup-cage group (15%) and 13 (68%) of the cage group failed due to septic or aseptic loosening. The seven-year survivorship was 87.2% (95% confidence interval (CI) 71 to 103) for the cup-cage group and 49.9% (95% CI 15 to 84) for the cage-alone group (p = 0.009). There were four major complications in the cup-cage group and nine in the cage group. Radiological union of the discontinuity was found in all successful cases in the cup-cage group and three of the successful cage cases. Three hips in the cup-cage group developed early radiological migration of the components, which stabilised with a successful outcome. Cup-cage reconstruction is a reliable technique for treating pelvic discontinuity in mid-term follow-up and is preferred to ilioischial cage reconstruction. If the continuity of the bone graft at the discontinuity site is not disrupted, early migration of the components does not necessarily result in failure. Cite this article: Bone Joint J 2014;96-B:195–200.

This study was conducted to examine the long-term survivorship and functional outcome of distal femoral varus osteotomy with fresh osteochondral allograft following failed lateral tibial plateau fracture surgery. We hypothesized that this procedure would be associated with a low rate of conversion to total knee arthroplasty (TKA) at medium to long-term follow-up. A consecutive series of 27 of distal femoral varus osteotomy combined with fresh osteochondral allograft following (27 patients) conducted between January 1981 and January 2005 for failed lateral tibial plateau fracture was retrospectively reviewed. Outcome measures included the Knee Society Knee Score (KSKS) and Knee Society Function Score (KSFS) and conversion rates to TKA. The study group consisted of 15 females (55.6 %) and 12 males (44.4 %), with a median age of 41.2 years (range 17–62 years). The median follow-up was 13.3 years (range 2–31 years). The knee function scores improved significantly at 2 years post-surgery (p

Down’s syndrome is associated with a number of musculoskeletal abnormalities, some of which predispose patients to early symptomatic arthritis of the hip. The purpose of the present study was to review the general and hip-specific factors potentially compromising total hip replacement (THR) in patients with Down’s syndrome, as well as to summarise both the surgical techniques that may anticipate the potential adverse impact of these factors and the clinical results reported to date. A search of the literature was performed, and the findings further informed by the authors’ clinical experience, as well as that of the hip replacement in Down Syndrome study group. The general factors identified include a high incidence of ligamentous laxity, as well as associated muscle hypotonia and gait abnormalities. Hip-specific factors include: a high incidence of hip dysplasia, as well as a number of other acetabular, femoral and combined femoroacetabular anatomical variations. Four studies encompassing 42 hips, which reported the clinical outcomes of THR in patients with Down’s syndrome, were identified. All patients were successfully treated with standard acetabular and femoral components. The use of supplementary acetabular screw fixation to enhance component stability was frequently reported. The use of constrained liners to treat intra-operative instability occurred in eight hips. Survival rates of between 81% and 100% at a mean follow-up of 105 months (6 to 292) are encouraging. Overall, while THR in patients with Down’s syndrome does present some unique challenges, the overall clinical results are good, providing these patients with reliable pain relief and good function.Cite this article: Bone Joint J 2013;95-B, Supple A:41–5.

In this retrospective study we evaluated the proficiency of shelf autograft in the restoration of bone stock as part of primary total hip replacement (THR) for hip dysplasia, and in the results of revision arthroplasty after failure of the primary arthroplasty. Of 146 dysplastic hips treated by THR and a shelf graft, 43 were revised at an average of 156 months, 34 of which were suitable for this study (seven hips were excluded because of insufficient bone-stock data and two hips were excluded because allograft was used in the primary THR). The acetabular bone stock of the hips was assessed during revision surgery. The mean implant–bone contact was 58% (50% to 70%) at primary THR and 78% (40% to 100%) at the time of the revision, which was a significant improvement (p < 0.001). At primary THR all hips had had a segmental acetabular defect > 30%, whereas only five (15%) had significant segmental bone defects requiring structural support at the time of revision. In 15 hips (44%) no bone graft or metal augments were used during revision. A total of 30 hips were eligible for the survival study. At a mean follow-up of 103 months (27 to 228), two aseptic and two septic failures had occurred. Kaplan-Meier survival analysis of the revision procedures demonstrated a ten-year survival rate of 93.3% (95% confidence interval (CI) 78 to 107) with clinical or radiological failure as the endpoint. The mean Oxford hip score was 38.7 (26 to 46) for non-revised cases at final follow-up. Our results indicate that the use of shelf autografts during THR for dysplastic hips restores bone stock, contributing to the favourable survival of the revision arthroplasty should the primary procedure fail. Cite this article: Bone Joint J 2013;95-B:777–81.