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Background: While the primary objective of joint arthroplasty is to improve patient quality of life, pain, and function, younger active patients often demand a return to higher function that includes sporting activity. Knowledge of rates and predictors of return to sports will help inform expectations in patients anticipating return to sports after joint arthroplasty.Questions/purposes: We measured the rate of sports participation at 1 year using the UCLA activity score and explored 11 variables, including choice of procedure/prosthesis, that might predict return to a high level of sporting activity, when controlling for potential confounding variables.Methods: We retrospectively evaluated 736 patients who underwent primary metal-on-polyethylene THA, metal-on-metal THA, hip resurfacing arthroplasty, revision THA, primary TKA, unicompartmental knee arthroplasty, and revision TKA between May 2005 and June 2007. We obtained UCLA activity scores on all patients; we defined high activity as a UCLA score of 7 or more. We evaluated patient demographics (age, sex, BMI, comorbidity), quality of life (WOMAC score, Oxford Hip Score, SF-12 score), and surgeon- and procedural/implant-specific variables to identify factors associated with postoperative activity score. Minimum followup was 11 months (mean, 12.1 months; range, 11-13 months).Results: Preoperative UCLA activity score, age, male sex, and BMI predicted high activity scores. The type of operation and implant characteristics did not predict return to high activity sports.Conclusions: Our data suggest patient-specific factors predict postoperative activity rather than factors specific to type of surgery, implant, or surgeon factors.Level Of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Intraoperative periprosthetic fractures are becoming more common given the increased prevalence of revision total hip arthroplasty and increased use of cementless fixation. Risk factors for intraoperative periprosthetic fractures include the use of minimally invasive techniques; the use of press-fit cementless stems; revision operations, especially when a long cementless stem is used or when a short stem with impaction allografting is used; female sex; metabolic bone disease; bone diseases leading to altered morphology such as Paget disease; and technical errors at the time of the operation. Appropriate treatment of intraoperative periprosthetic fractures does not compromise the long-term results of total hip arthroplasty unless the bone damage precludes stable fixation of the implant. [ABSTRACT FROM AUTHOR]

In cementless revision total hip arthroplasty (THA), achieving initial implant stability and maximising host bone contact is key to the success of reconstruction. Porous tantalum acetabular shells may represent an improvement from conventional porous coated uncemented cups in revision acetabular reconstruction associated with severe acetabular bone defects. We reviewed the results of 46 acetabular revisions with Paprosky 2 and 3 acetabular bone defects done with a hemispheric, tantalum acetabular shell and multiple supplementary screws. At a mean follow-up of 40 (24-51) months, one acetabular shell had been revised in a patient with a Paprosky 3B defect. Cementless acetabular revision with the tantalum acetabular shell demonstrated excellent early clinical and radiographic results and warrants further evaluation in revision acetabular reconstruction associated with severe acetabular bone defects. [ABSTRACT FROM AUTHOR]

Background: Despite the widespread use of several diagnostic tests, there is still no perfect test for the diagnosis of infection at the site of a total knee arthroplasty. The purpose of this study was to evaluate the diagnostic test characteristics of the erythrocyte sedimentation rate and C-reactive protein level for the assessment of infection in patients presenting for revision total knee arthroplasty.Methods: One hundred and fifty-one knees in 145 patients presenting for revision total knee arthroplasty were evaluated prospectively for the presence of infection with measurement of the erythrocyte sedimentation rate and the C-reactive protein level. The characteristics of these tests were assessed with use of two different techniques: first, receiver-operating-characteristic curve analysis was performed to determine the optimal positivity criterion for the diagnostic test, and, second, previously accepted criteria for establishing positivity of the tests were used.Results: A diagnosis of infection was established for forty-five of the 151 knees that underwent revision total knee arthroplasty. The receiver-operating-characteristic curves indicated that the optimal positivity criterion was 22.5 mm/hr for the erythrocyte sedimentation rate and 13.5 mg/L for the C-reactive protein level. Both the erythrocyte sedimentation rate (sensitivity, 0.93; specificity, 0.83; positive likelihood ratio, 5.81; accuracy, 0.86) and the C-reactive protein level (sensitivity, 0.91; specificity, 0.86; positive likelihood ratio, 6.89; accuracy, 0.88) have excellent diagnostic test performance.Conclusions: The erythrocyte sedimentation rate and the C-reactive protein level provide excellent diagnostic test information for establishing the presence or absence of infection prior to surgical intervention in patients with pain at the site of a knee arthroplasty. [ABSTRACT FROM AUTHOR]

The purpose of this study was to explore patient opinion about asking healthcare professionals to wash their hands before a clinical procedure and to explore if methicillin-resistant Staphylococcus aureus (MRSA) status and access to patient information about infection control would influence the patients' anxiety about asking. A descriptive survey was undertaken using a semi-structured questionnaire. The questionnaire was distributed to a randomized convenience sample of 185 inpatients across all departments of an acute NHS Trust hospital (response rate 58.9%). Spearman's rank order and Kendall Tau-b tests were used to analyse specific correlations. Respondents were more confident than anxious about being involved in a campaign that empowered patients to ask staff to wash their hands. Patients were more anxious to ask if their previous admission episodes were fewer, if their knowledge of MRSA was high and if there was less information about infection control available. Patients who had contracted MRSA in the past were less anxious, as they had a better understanding of the disease. In addition, more patients felt less anxious about asking staff to wash their hands if staff wore a badge saying 'It's OK to ask'. [ABSTRACT FROM AUTHOR]

Periprosthetic fractures are increasing in number and complexity. Appropriate precautions should be taken to prevent these fractures. A systematic approach is needed in the form of detailed assessment of the fracture, stability of the implant and the available bone stock for planning an appropriate treatment. The treatment options described in this article can be used as a framework for making the right surgical decision regarding appropriate method of reconstruction to ensure optimum result. [ABSTRACT FROM AUTHOR]

BACKGROUND: Compression devices have been shown to prevent thromboembolic disease. However, the pressures generated may not be the same as the ones recommended by the manufacturer. The purpose of this study is to investigate a new sequential compression device with feedback to maintain optimal therapy, and to determine whether therapy is improved with this new device. PATIENTS AND METHOD: A series of 50 patients undergoing elective total hip arthroplasty at a major tertiary-care hospital with a special interest in joint replacement were enrolled prospectively. In addition to pharmacological prophylaxis for thromboembolic disease, all patients received compression from a modified device. Maximum pressures generated and the rate of pressure rise in each of the 3 compartments within the device sleeves were measured and the results compared with data from historical controls. RESULTS: We considered therapy to be ideal when in a particular compression cycle all chambers of both right and left sleeves reach within 10% of their target pressures at within 10% of their target pressure rise rates. The average patient received this ideal therapy 88% of the time that the new trial sequential compression device was operating. This represents a dramatic improvement over previous devices. CONCLUSIONS: The new device allows dramatically improved pressures within the device because of a feedback loop that allows dynamic control of each chamber's pressure. Improved consistency of delivery should make it easier to accurately assess the true benefits of mechanical prophylaxis with a sequential compression device. [ABSTRACT FROM AUTHOR]

Background: Two-stage exchange arthroplasty remains the standard treatment of infection at the site of a total knee arthroplasty. The clinical and functional outcomes associated with the use of an articulating antibiotic spacer for two-stage revision for infection are not well established. We conducted a retrospective study to evaluate the outcomes associated with the use of the PROSTALAC articulating spacer between the first and second stages.Methods: Fifty-eight patients underwent two-stage revision total knee arthroplasty for infection between January 1997 and December 1999. Of these, fifty-four were alive at the time of follow-up and forty-seven were available for inclusion in the present retrospective study. In all patients, a prosthesis of antibiotic-loaded acrylic cement (the PROSTALAC system) was implanted during the first stage after débridement. The amount of osteolysis that occurred between the stages and the range of motion of the knee joint were measured. After two years of follow-up, outcomes were assessed with use of the WOMAC, Oxford-12, and SF-12 instruments as well as a satisfaction questionnaire.Results: At a minimum of two years (average, forty-one months) after revision arthroplasty, two patients (4%) had had a recurrence of infection. The amount of bone loss was unchanged between stages, and the range of movement of the knee improved from 78.2 degrees before the first stage to 87.1 degrees at two years. The average normalized WOMAC function and pain scores were 68.9 and 77.1, respectively; the average Oxford-12 score was 67.3; the average SF-12 mental and physical scores were 53.7 and 41.2, respectively; and the average satisfaction score was 71.7.Conclusion: A revision operation for infection at the site of a total knee replacement with use of an articulating spacer was associated with reasonable function and satisfaction scores. These findings may be related to the articulating features of the PROSTALAC system, which permits full active movement of the knee in the early postoperative period. [ABSTRACT FROM AUTHOR]

Background: To date, the literature has not yet revealed superiority of Minimally Invasive (MI) approaches over conventional techniques. We performed a systematic review to determine whether minimally invasive approaches are superior to conventional approaches in total hip arthroplasty for clinical and functional outcomes. We performed a meta-analysis of level 1 evidence to determine whether minimally invasive approaches are superior to conventional approaches for clinical outcomes., Methods: All studies comparing MI approaches to conventional approaches were eligible for analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adhered to throughout this study. Registries were searched using the following MeSH terms: 'minimally invasive', 'muscle-sparing', 'THA', 'THR', 'hip arthroplasty' and 'hip replacement'. Locations searched included PubMed, the Cochrane Library, ClinicalTrials.gov, the European Union (EU) clinical trials register and the International Clinical Trials Registry Platform (World Health Organisation)., Results: Twenty studies were identified. There were 1,282 MI total hip arthroplasty (THAs) and 1,351 conventional THAs performed. There was no difference between MI and conventional approaches for all clinical outcomes of relevance including all-cause revision (P = .959), aseptic revision (P = .894), instability (P = .894), infection (P = .669) and periprosthetic fracture (P = .940). There was also no difference in functional outcome at early or intermediate follow-up between the two groups (P = .38). In level I studies exclusively, random-effects meta-analysis demonstrated no difference in aseptic revision (P = .461) and all other outcomes between both groups., Conclusion: Intermuscular MI approaches are equivalent to conventional THA approaches when considering all-cause revision, aseptic revision, infection, dislocation, fracture rates and functional outcomes. Meta-analysis of level 1 evidence supports this claim., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Hip implants are a successful solution for osteoarthritis; however, some individuals with metal-on-metal (MoM) and metal-on-polyethylene (MoP) prosthetics develop adverse local tissue reactions (ALTRs). While MoM and MoP ALTRs are presumed to be delayed hypersensitivity reactions to corrosion products, MoM- and MoP-associated ALTRs present with different histological characteristics. We compared MoM- and MoP-associated ALTRs histopathology with cobalt and chromium levels in serum and synovial fluid. We analyzed the gene expression levels of leukocyte aggregates and synovial fluid chemokines/cytokines to resolve potential pathophysiologic differences. In addition, we classified ALTRs from 79 patients according to their leukocyte infiltrates as macrophage-dominant, mixed, and lymphocyte-dominant. Immune-related transcript profiles from lymphocyte-dominant MoM- and MoP-associated ALTR patients with perivascular lymphocytic aggregates were similar. Cell signatures indicated predominantly macrophage, Th1 and Th2 lymphocytic infiltrate, with strong exhausted CD8 + signature, and low Th17 and B cell, relative to healthy lymph nodes. Lymphocyte-dominant ALTR-associated synovial fluid contained higher levels of induced protein 10 (IP-10), interleukin-1 receptor antagonist (IL-1RN), IL-8, IL-6, IL-16, macrophage inflammatory protein 1 (MIP-1α), IL-18, MCP-2, and lower cell-attracting chemokine levels, when compared with prosthetic revisions lacking ALTRs. In addition, the higher levels of IP-10, IL-8, IL-6, MIP-1α, and MCP-2 were observed within the synovial fluid of the lymphocyte-dominant ALTRs relative to the macrophage-dominant ALTRs. Not all cytokines/chemokines were detected in the perivascular aggregate transcripts, suggesting the existence of other sources in the affected synovia. Our results support the hypothesis of common hypersensitivity pathogenesis in lymphocyte-dominant MoM and MoP ALTRs. The exhausted lymphocyte signature indicates chronic processes and an impaired immune response, although the cause of the persistent T-cell activation remains unclear. The cytokine/chemokine signature of lymphocyte-dominant-associated ATLRs may be of utility for diagnosing this more aggressive pathogenesis., (© 2021 Orthopaedic Research Society. Published by Wiley Periodicals LLC.)

Background: The early outcomes of large head-metal-on-metal total hip arthroplasty (MoM THA) are compromised by adverse local tissue reaction to metal debris. This study is the mid-term follow-up of a prospective randomised control trial (pRCT) comparing MoM THA to MoM HR. We sought to answer whether there was a difference between MoM THA and MoM HR at mid-term follow-up in the implant survival; patient-reported outcome measures (PROMs); and when performing objective functional tasks?, Methods: A total of 104 patients were studied. Of these 56 had MoM THA (50 male) and 48 had HR (43 male). Mean age at surgery was 52 years in both groups.We reviewed this cohort at mid-term follow-up [minimum 8 years (mean 9 years; range 8-10; SD 0.7)]. PROMs that were completed were OHS, WOMAC, SF-12, and the UCLA. For objective functional task-based outcomes, gait parameters for operated legs were assessed in a subgroup of 17 patients with high UCLA., Results: Revision rate in MoM THA group was 7/56 (12.5%) and in the HR group was 1/48 (2.1%). Overall revision rate at minimum 8-year follow-up was 7.7% (8 of 104 patients). PROMs data comparing MoM THA versus HR showed no difference between the groups. 4 (8.5%) of the non-revised (47) HR patients had WOMAC function or pain score below 70. 3 (6.4%) patients had both pain and function scores <70. In the THA group, 5 (10.2%) of the non-revised (49) patients had WOMAC pain or function scores <70. 3 (6.1%) patients had both pain and function scores <70. The comparison of HA versus THA showed several gait parameters in the HR group to be better but not statistically significant ( p > 0.05 Mann-Whitney U-test)., Conclusions: At mid-term follow-up, the revision rate of MoM articulation for THA is high (7.7%), being higher in large head MoM total hips versus resurfacing. Overall probability of 10-year survival is 92.3% (KM analysis, 95% for MoM THA and 98% for HR). The HR group had better functional parameters on gait-based tasks compared to THA group but this difference did not reach statistical significance.

Adverse local tissue reactions (ALTRs) are a prominent cause of hip implant failure. ALTRs are characterized by aseptic necrosis and leukocyte infiltration of synovial tissue. The prevalence of ALTRs in hips with failing metal implants, with highest rates occurring in patients with metal-on-metal articulations, suggests a role for CoCrMo corrosion in ALTR formation. Although hypersensitivity reactions are the most accepted etiology, the precise cellular mechanism driving ALTR pathogenesis remains enigmatic. Here we show that cobalt ions released by failing hip implants induce mitochondrial stress and cytokine secretion by synovial fibroblasts: the presumptive initiators of ALTR pathogenesis. We found that in-vitro treatment of synovial fibroblasts with cobalt, but not chromium, generated gene expression changes indicative of hypoxia and mitophagy responses also observed in ALTRs biopsies. Inflammatory factors secreted by cobalt-exposed synovial fibroblasts were among those most concentrated in ALTR synovial fluid. Furthermore, both conditioned media from cobalt-exposed synovial fibroblasts, and synovial fluid from ALTRs patients, elicit endothelial activation and monocyte migration. Finally, we identify the IL16/CTACK ratio in synovial fluid as a possible diagnostic marker of ALTRs. Our results provide evidence suggesting that metal ions induce cell stress in synovial fibroblasts that promote an inflammatory response consistent with initiating ALTR formation. STATEMENT OF SIGNIFICANCE: We demonstrate that the cytotoxic effects of cobalt ions on the synovial cells (fibroblast) is sufficient to trigger inflammation on hip joints with metal implants. Cobalt ions affect mitochondrial function, leading to the auto phagocytosis of mitochondria and trigger a hypoxic response. The cell's hypoxic response includes secretion of cytokines that are capable of trigger inflammation by activating blood vessels and enhancing leukocyte migration. Among the secreted cytokines is IL-16, which is highly concentrated in the synovial fluid of the patients with adverse local tissue reactions and could be use as diagnostic marker. In conclusion we define the cells of the hip joint as key players in triggering the adverse reactions to hip implants and providing biomarkers for early diagnosis of adverse reactions to hip implants., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Aims: The practice of overlapping surgery has been increasing in the delivery of orthopaedic surgery, aiming to provide efficient, high-quality care. However, there are concerns about the safety of this practice. The purpose of this study was to examine the safety and efficacy of a model of partially overlapping surgery that we termed 'swing room' in the practice of primary total hip (THA) and knee arthroplasty (TKA)., Methods: A retrospective review of prospectively collected data was carried out on patients who underwent primary THA and TKA between 2006 and 2017 in two academic centres. Cases were stratified as partially overlapping (swing room), in which the surgeon is in one operating room (OR) while the next patient is being prepared in another, or nonoverlapping surgery. The demographic details of the patients which were collected included operating time, length of stay (LOS), postoperative complications within six weeks of the procedure, unplanned hospital readmissions, and unplanned reoperations. Fisher's exact, Wilcoxon rank-sum tests, chi-squared tests, and logistic regression analysis were used for statistical analysis., Results: A total of 12,225 cases performed at our institution were included in the study, of which 10,596 (86.6%) were partially overlapping (swing room) and 1,629 (13.3%) were nonoverlapping. There was no significant difference in the mean age, sex, body mass index (BMI), side, and LOS between the two groups. The mean operating time was significantly shorter in the swing room group (58.2 minutes) compared with the nonoverlapping group (62.8 minutes; p < 0.001). There was no significant difference in the rates of complications, readmission and reoperations (p = 0.801 and p = 0.300, respectively) after adjusting for baseline American Society of Anesthesiologists scores., Conclusion: The new 'swing room' model yields similar short-term outcomes without an increase in complication rates compared with routine single OR surgery in patients undergoing primary THA or TKA. Cite this article: Bone Joint J 2020;102-B(7 Supple B):112-115.

Tourniquets in orthopaedic surgery safely provide blood free surgical fields, but their use is not without risk. Tourniquets can result in temporary or permanent injury to underlying nerves, muscles, blood vessels and soft tissues. Advances in safety, accuracy and reliability of surgical tourniquet systems have reduced nerve-related injuries by reducing pressure levels and pressure gradients, but that may have resulted in reduced awareness of potential injury mechanisms. Short-term use of pre-hospital tourniquets is effective in preventing life-threatening blood loss, but a better understanding of the differences between tourniquets designed for pre-hospital vs surgical use will provide a framework around which to develop guidelines for admitting to hospital individuals with pre-applied tourniquets. Recent evidence supports the application of tourniquets for blood flow restriction (BFR) therapy to reduce muscular atrophy, increase muscle strength, and stimulate bone growth. BFR therapy when appropriately prescribed can augment a surgeon's treatment plan, improving patient outcomes and reducing recovery time. Key risks, hazards, and mechanisms of injury for surgical, BFR therapy, and pre-hospital tourniquet use are identified, and a description is given of how advances in personalized tourniquet systems have reduced tourniquet-related injuries in these broader settings, increasing patient safety and how these advances are improving treatment outcomes., Competing Interests: Competing interestsBM and CD have received research or institutional support from Stryker, DePuy, and Smith and Nephew. JM is president and an indirect shareholder of Western Clinical Engineering Ltd., is a board member and indirect shareholder of Delfi Medical Innovations Inc., and has patents US 9,039,730, US 9,814,467 and US 20170112504 assigned to Western Clinical Engineering Ltd. AE declares that he has no competing interests., (© The Author(s) 2020.)

The demand for revision total hip arthroplasty (THA) is increasing. Information quality on the internet has been extensively analysed in relation to primary THA but no such analysis has ever been performed for revision THA. Our aim was to assess the quality and readability of this information. Three major internet search engines were searched for information on revision THA. All websites were assessed for quality of information using the DISCERN score, the Journal of the American Medical Association benchmark criteria and a novel scoring system specific to revision THA [Vancouver Revision Arthroplasty Information (VRAI) score]. Website readability was assessed, as was presence of the Health On the Net Foundation (HON) seal. The majority of websites (52%) were academic with a post-graduate reading level. Only 6.5% of websites had the HON seal. Twenty-eight percent of websites had a 'good' DISCERN score and only 28% had a 'good' score with the novel VRAI scoring system. Health information websites had significantly higher rates of 'good' VRAI scores ( P = 0.008). Websites with the HON seal had significantly higher DISCERN scores ( P = 0.01). All governmental websites were at a reading level suitable for patient review. Information on the internet relating to revision THA is of low quality, much lower than the quality of information on primary THA. We recommend governmental websites for their readability and health information websites for their quality of information specific to revision THA. Websites with the HON seal provide higher quality information and should be recommended to patients as reading material regarding revision THA., Competing Interests: Conflict-of-interest statement: The authors declare no conflict of interest., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: The treatment for recurrent dislocation of a total hip arthroplasty is surgical using varied techniques and technologies to reduce the chances of re-dislocation and re-revision. The goal of this study is to compare operative techniques to reduce re-dislocation and re-revision in revision hip arthroplasty due to recurrent dislocations., Methods: A retrospective study of revision hip arthroplasties done due to recurrent dislocation prior to 01 January 2014. Electronic physician and provincial health records were used to collect patients' initial and follow-up data. Treatment failure was defined as either aseptic re-revision or re-dislocation without revision. Time to event was considered as the re-revision date or the date of second dislocation when the latter endpoint was used., Results: Of 379 operations, 88 (23.2%) had aseptic repeat revision or recurrent dislocation. Of these: 66 (75.0%) due to dislocation with re-revision; 10 (11.4%) due to dislocation with no re-revision surgery; 5 (5.7%) due to aseptic loosening of components; 3 (3.4%) due to osteolysis; 3 (3.4%) due to pseudotumour; and 1 (1.1%) due to periprosthetic fracture. The following factors increase risk of failure: the use of augmented-liners (lipped, oblique and high-offset liners; HR = 1.68, 95% CI, 1.05-2.69), periprosthetic femur fracture (HR = 2.80, 95% CI, 1.39-8.21) and pelvic discontinuity (HR = 3.69, 95% CI, 1.66-8.21). Femur head sizes 36-40 mm are protective (HR = 0.54, 95% CI, 0.31-0.86). In abductor dysfunction the use of focal constrained liners decreases the risk of failure (HR = 0.13, 95% CI, 0.018-0.973)., Conclusions: Larger head sizes and focal constrained liners (abductors dysfunction) should be used and fully constrained liners and augmented-liners should be avoided in a revision hip arthroplasty due to recurrent dislocations.

Two-stage exchange arthroplasty remains the treatment of choice for chronic periprosthetic joint infections. This retrospective study conducted between 2009 and 2015 examined the diagnostic value of biomarkers for residual infection between stages. The biomarkers evaluated included C-reactive protein prior to reimplantation, preimplantation synovial fluid white blood cell count and percent neutrophils, and the intraoperative histologic synovial white blood cell count per high-power field (×400) on permanent sections. Residual infection was defined as either positive cultures (more than 1) at second stage, any further surgery (eg, amputation, arthrodesis, or another 2-stage revision), or the need for infection suppression with antibiotics. Sensitivity, specificity, positive and negative predictive values, and likelihood ratios were calculated accordingly. A total of 182 two-stage exchange operations that included 109 (59.9%) prosthetic hips and 73 (40.1%) prosthetic knees met the inclusion criteria. Residual infection was present in 38 (20.9%) of the procedures. The area under the curve-receiver operating characteristic values were 0.677 for C-reactive protein (P=.002), 0.506 for aspiration white blood cell count (P=.944), 0.623 for aspiration percent neutrophils (P=.200), and 0.524 for white blood cell count per high-power field (P=.801). Positive and negative predictive values were poor and ranged between 26% and 57% and 78% and 85%, respectively. Analyses using specific combinations of biomarkers did not significantly improve predictive values. This study showed that classic markers perform poorly in identifying residual infection prior to second-stage revision. Further research is necessary to evaluate the diagnostic utility of other, more recently introduced biomarkers to determine whether infection has been eradicated between stages. [Orthopedics. 2019; 42(1):34-40.]., (Copyright 2019, SLACK Incorporated.)

Background: Instability remains one of the main problems after revision hip surgery. The aim of this study was to review the clinical, radiological, and patient-reported outcomes with the use of modular dual-mobility articulation for revision acetabular reconstruction and investigate the risk of fretting corrosion by measuring serum trace metal ion levels., Methods: Sixty consecutive patients with a minimum of 24-month follow-up after the insertion of a modular dual-mobility (Stryker, Mahwah, NJ) cup at the time of revision hip surgery were identified. Follow-up included clinical and radiological patient review and functional outcome measures, and a subset of patients had their metal ion (cobalt and chromium) levels checked., Results: At the most recent follow-up, 5 patients had died, 3 patients have been revised because of ongoing instability, and 3 patients have had revision surgery due to infection. Overall functional outcome (mean Western Ontario and McMaster Universities Osteoarthritis Indexfunction 76, University of California, Los Angeles 5.6, mean Oxford 74.7, Short Form-12 physical 41.6/mental 53.3) and overall pain relief (mean Western Ontario and McMaster Universities Osteoarthritis Index pain score 78.3) scores were good. The mean satisfaction score was 78 of 100. The median serum trace metal chromium and cobalt levels at the most recent follow-up were 0.4 µg/L (range 0.1-6.1 µg/L) and 0.42 µg/L (range 0.21-9.42 µg/L), respectively. The survival with revision as the end point was 90%., Conclusions: Dual-mobility cups with modularity represent an excellent option for the patient having revision hip surgery at high risk of instability. This series presents good patient-reported outcome measures and a low complication and revision rate., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aims: Fretting and corrosion at the modular head/neck junction, known as trunnionosis, in total hip arthroplasty (THA) is a cause of adverse reaction to metal debris (ARMD). We describe the outcome of revision of metal-on-polyethylene (MoP) THA for ARMD due to trunnionosis with emphasis on the risk of major complications., Patients and Methods: A total of 36 patients with a MoP THA who underwent revision for ARMD due to trunnionosis were identified. Three were excluded as their revision had been to another metal head. The remaining 33 were revised to a ceramic head with a titanium sleeve. We describe the presentation, revision findings, and risk of complications in these patients., Results: The patients presented with pain, swelling, stiffness, or instability and an inflammatory mass was confirmed radiologically. Macroscopic material deposition on the trunnion was seen in all patients, associated with ARMD. Following revision, six (18.2%) dislocated, requiring further revision in four. Three (9.1%) developed a deep infection and six (18.2%) had significant persistent pain without an obvious cause. One developed a femoral artery thrombosis after excision of an iliofemoral pseudotumor, requiring a thrombectomy., Conclusion: The risk of serious complications following revision MoP THA for ARMD associated with trunnionosis is high. In the presence of extensive tissue damage, a constrained liner or dual mobility construct is recommended in these patients. Cite this article: Bone Joint J 2018;100-B:720-4.

Background: Once touted as the future of hip arthroplasty, metal-on-metal (MoM) bearing surfaces have fallen sharply from favor with the emergence of a strong body of evidence demonstrating unacceptably high premature implant failure rates. The previously unpredictable development of adverse local tissue reactions (ALTRs) has been a substantive contributor to this. Although the underlying pathophysiology of these so-called "pseudotumors" is now well understood, the fundamental predisposing patient risk factors have remained elusive., Questions/purposes: The aim of this research, as a clinical-genotype correlation analysis, was to identify specific alleles (genes) associated with the development of ALTRs in patients with in situ MoM THAs., Methods: A case-control study of patients who received a large-head, primary MoM THA between 2005 and 2008 was performed with a minimum followup of 5 years. Twenty-six patients who had undergone revision of a primary MoM THA secondary to symptomatic ALTRs were recruited. The mean timeframe from primary MoM THA to symptomatic revision was 5.5 years (range, 1-10 years). Twenty-eight control subjects were randomly selected asymptomatic patients with no evidence of ALTRs on protocol-specific screening. Baseline demographics and high-resolution genotype (human leukocyte antigen [HLA] Class II) were collected for all patients. Cohorts were similar with respect to age at the time of primary MoM THA (mean, 54.8 versus 54.9 years, p = 0.95) and serum cobalt (mean, 5.5 versus 8.5 μg/L, p = 0.09) and chromium concentrations (mean, 2.9 versus 4.2 μg/L, p = 0.27). The association between genotype and revision surgery secondary to ALTRs was determined with gender as a covariate., Results: The prevalence of the risk genotype was 30% (16 of 54) among the entire cohort. Adjusting for sex, the odds of revision were 6.1 times greater among patients with the risk genotype present than among patients without (95% confidence interval [CI], 1.5-25.4; p = 0.01). Among females, the specificity of the risk genotype was 1.0 (95% CIexact, 0.5-1.0; pexact = 0.03), and for males, it was 0.8 (95% CIexact, 0.6-0.9; pexact < 0.01)., Conclusions: The findings of this study suggest that, among patients with a primary MoM THA, allelic variation within the HLA Class II loci may be a strong, independent risk factor associated with the need for subsequent revision surgery secondary to pseudotumor formation., Clinical Relevance: Given the hypothesis-generating nature of this novel undertaking, confirmatory prospective clinical studies are required to further elucidate this correlation and to explore the clinical utility of targeted genetic screening in this specific population. This research may, however, represent a key missing piece in the puzzle that is metal ion-induced pseudotumor formation.

Aims: To present a surgically relevant update of trunnionosis., Materials and Methods: Systematic review performed April 2017., Results: Trunnionosis accounts for approximately 2% of the revision total hip arthroplasty (THA) burden. Thinner (reduced flexural rigidity) and shorter trunnions (reduced contact area at the taper junction) may contribute to mechanically assisted corrosion, exacerbated by high offset implants. The contribution of large heads and mixed metallurgy is discussed., Conclusion: Identifying causative risk factors is challenging due to the multifactorial nature of this problem. Cite this article: Bone Joint J 2018;100-B(1 Supple A):44-9., (©2018 The British Editorial Society of Bone & Joint Surgery.)

Patients with neuromuscular imbalance who require total hip arthroplasty (THA) present particular technical problems due to altered anatomy, abnormal bone stock, muscular imbalance and problems of rehabilitation. In this systematic review, we studied articles dealing with THA in patients with neuromuscular imbalance, published before April 2017. We recorded the demographics of the patients and the type of neuromuscular pathology, the indication for surgery, surgical approach, concomitant soft-tissue releases, the type of implant and bearing, pain and functional outcome as well as complications and survival. Recent advances in THA technology allow for successful outcomes in these patients. Our review suggests excellent benefits for pain relief and good functional outcome might be expected with a modest risk of complication. Cite this article: Bone Joint J 2018;100-B(1 Supple A):17-21., (©2018 The British Editorial Society of Bone & Joint Surgery.)

Introduction: The aim of this study was to review the clinical, radiological and patient-reported outcomes with the use of cup-cage construct for pelvic discontinuity at our institution., Methods: 24 patients were identified at median 6-year (minimum 2 year, maximum 10 years) follow-up. 1 patient was converted to excision arthroplasty for infection. A further 3 patients required revision for instability but the cup-cage construct was not revised., Results: We noted encouraging pain relief (mean WOMAC pain 85.6) and good functional outcome (mean WOMAC function 78.2, mean UCLA 5, mean OHS 78.6). Patient satisfaction with regards pain relief, function and return to recreational activities were noted to be good., Conclusions: The cup-cage construct is a viable method of dealing with complex pelvic discontinuity. However, the failure rate due to loosening (4 cases) in this and other reports does prompt the need for further refinement of the technique and technology in this very challenging group of patients, as well as continued evaluation at the mid- and long-term so as to confirm the ongoing success of this method of reconstruction.

Background: Revision hip arthroplasty for metal-on-metal arthroplasty (MOMA) in the presence of an adverse local tissue reaction (ALTR) has been associated with compromised outcomes. We hypothesized that revision of MOMA for painful micromotion of the cup, in the absence of ALTR, would have a more favorable outcome., Methods: We reviewed our database for Durom acetabular shell revision with minimum 24 months (24 months to 8 years) follow-up. Patients with a diagnosis of painful micromotion in the absence of pseudotumor was identified., Results: At mid-term follow-up, 71 patients had undergone revision of a Durom MOMA. Twenty-seven of these (38%) were for painful micromotion (9 total hip arthroplasty, 18 hip resurfacing) of the cup alone. Following revision surgery, all patients reported resolution of the preoperative pain, as well as satisfactory outcome measures (mean scores: The Western Ontario and McMaster Universities Arthritis Index [WOMAC] 84.6, oxford hip score 84.7, Short Form Health Survey (SF-16) 51, University of California, Los Angeles (UCLA) 7.3). Radiologically, all cases demonstrated osseointegration of the revision shells; 1 case had zone-3 radiolucency that was nonprogressive. One patient had a dislocation treated by closed reduction at 10 weeks., Conclusion: Revision MOMA for painful micromotion of the shell in the absence of ALTR is not similar to revision for ALTR and is associated with predictable improvement in pain and quality of life., (Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.)

Background: The risk of early revision because of pseudotumors in patients who have undergone large-head metal-on-metal (MoM) total hip arthroplasty (THA) is well documented. However, the natural history of asymptomatic pseudotumors or of MoM articulations without pseudotumors is less well understood. The aim of our study was to investigate the natural history of primary MoM THA at mid-term followup., Questions/purposes: The purposes of this study were: (1) Did previously detected pseudotumors persist or worsen in asymptomatic patients at mid-term followup; and if so, did any of them require revision THA? (2) Did new pseudotumors form in asymptomatic patients at mid-term followup? (3) What happened to serum trace metal ions at mid-term followup? (4) Were postoperative patient-reported outcome measures (PROMs) maintained at mid-term followup?, Methods: Seventy-one patients who underwent a MoM THA using a Metasul LDH implant with a Durom acetabular cup and an M/L Taper stem between September 2005 and October 2008 were reviewed. All patients for this study were part of two previously published studies from our early followup. Data from the previous studies were used for comparison only. Two of the 71 patients (2.8%) were lost to followup. The mean age at operation was 56 years (range, 34-68 years). There were 24 female patients. All patients had serum trace metal ions testing, ultrasound imaging, and PROMs at a mean 3.5 years (early followup) after the index operation (range, 3-5 years) and delayed followup at a mean 7 years (range, 6.5-9 years). The indication to undertake revision THA was based on clinical evaluation and not solely on the investigation results., Results: Twenty-three of 71 patients (32%) had a positive ultrasound scan for pseudotumor at early followup. Of these, eight patients underwent revision THA (11% of MoM THA or 35% of patients with an early positive ultrasound scan). The mean time between positive ultrasound scan and revision surgery was 13 months (range, 5-22 months). Of the remaining 15 patients with pseudotumor noted on early ultrasound, 12 had persistent pseudotumor, two resolved, and one was lost to followup. Six patients (13%) with a normal ultrasound scan at early followup showed new ultrasound findings at delayed followup. Of these, four (8%) were conclusively diagnosed as pseudotumor and one was revised. Serum trace metal ion increased at mid-term followup in the seven cases that showed an increase in volume of pseudotumor. Of the five patients in whom the volume of pseudotumor decreased on ultrasound at mid-term followup, three showed a decrease in serum trace ions levels, whereas two showed an increase. New-onset pseudotumors at mid-term followup was associated with an increase in serum trace metal ions at mid-term followup only in two of six cases. PROMs at mid-term followup of patients in this study remain high., Conclusions: At mid-term followup, approximately 35% of patients who develop an early pseudotumor undergo revision arthroplasty, whereas the remaining are asymptomatic. The incidence of new-onset ultrasound findings suggestive of pseudotumors at mid- to long-term followup is approximately 8% and these require continued surveillance., Level of Evidence: Level II, prognostic study.

Background: The ideal femoral component for revision THA is undecided. Cylindrical nonmodular stems have been associated with stress shielding, whereas junctional fractures have been reported with tapered fluted modular titanium stems. We have used a tapered fluted nonmodular titanium femoral component (Wagner Self-locking [SL] femoral stem) to mitigate this risk. This component has been used extensively in Europe by its designer surgeons, but to our knowledge, it has not been studied in North America. Added to this, the design of the component has changed since early reports., Questions/purposes: We asked: (1) Does the Wagner SL stem have low rates of rerevision and other complications at a minimum 2 years after surgery? (2) Is the Wagner SL stem associated with high levels of patient function and pain relief at a minimum 2 years after surgery? (3) Does the Wagner SL stem have low rates of subsidence at a minimum 2 years after surgery? (4) Is the Wagner SL stem associated with proximal femoral bone remodeling at a minimum 2 years after surgery?, Method: Between May 2011 and December 2012, we performed 198 femoral revisions, of which 104 (53%) were performed using the Wagner SL femoral stem; during that period, our institution gradually shifted toward increasing use of these stems for all but the most severe revisions, in which modular fluted stems and proximal femoral replacements still are used on an occasional basis. Median followup in this retrospective study was 32 months (range, 24-46 months), and one patient was lost to followup before the 2-year minimum. The femoral deformities in this series were Paprosky Type I (10 hips), Paprosky Type II (26), Paprosky Type IIIA (52), Paprosky Type IIIB (nine), and Paprosky Type IV (two). Functional assessment was performed using the Oxford Hip Score (OHS), WOMAC, SF-12, and the University of California Los Angeles (UCLA) activity score. All complications and cases of revision were documented. All patients had radiographs performed within 1 year of the latest followup. These were assessed by two surgeons for signs of proximal femoral bone remodeling and subsidence., Results: Complete preoperative scores were available for 98 patients (98 of 104; 94%). The mean OHS preoperatively and at final followup were 39 (SD, 15) and 87 (SD, 19), respectively (p < 0.001; mean difference, 48; 95% CI, 43-53). Average WOMAC scores were 44 (SD, 15) and 87 (SD, 20), respectively (p < 0.001; mean difference, 43; 95% CI, 38-48). At final followup, signs of restoration of proximal femoral bone stock was noted in 45 of 103 hips (44%). Six (six of 104; 6%) patients had subsidence of 10 mm to 15 mm. In the remainder (98 of 104; 94%), the mean subsidence was 2 mm (range, 0-9 mm). One revision was performed for loosening associated with infection., Conclusions: The Wagner SL stem is a viable option for patients with Paprosky Types II and III defects undergoing revision THA. This component provides high levels of patient function with low revision rates and low rates of subsidence during the early postoperative phase. They provide a viable alternative to modular components for treatment of Types II and III defects without the risk of junctional fractures. They can be used for very selected Type IV defects, however this extent of bone loss is most easily addressed with other techniques such as a proximal femoral replacement., Level of Evidence: Level IV, therapeutic study.

Fractures around total knee arthroplasties pose a significant surgical challenge. Most can be managed with osteosynthesis and salvage of the replacement. The techniques of fixation of these fractures and revision surgery have evolved and so has the assessment of outcome. This specialty update summarises the current evidence for the classification, methods of fixation, revision surgery and outcomes of the management of periprosthetic fractures associated with total knee arthroplasty. Cite this article: Bone Joint J 2016;98-B:1489-96., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Background: Splined conical stems offer design features that facilitate their use in the misshapen, dysplastic proximal femur., Methods: This study assessed the survivorship of a conical prosthesis when applied to secondary coxarthrosis because of a range of pathologies. Fifty-one prostheses were implanted in 50 patients with a mean age of 50 (range, 15-80) and a median follow-up of 34 months (range, 24-73 months). Indications for the stem included developmental (36), neuromuscular (7), post-traumatic or surgical (7), and inflammatory conditions (1). Survivorship, functional outcome (WOMAC [Western Ontaria and McMaster University Osteoarthrits Index], Oxford Hip Score, and UCLA [University of California Los Angeles]), health status (short form-12 [SF-12]), satisfaction, and osseointegration were determined., Results: Survivorship for aseptic loosening was 100% at 2 years and 98.04% for septic revision. Eight patients required reoperation, 4 for instability, and 1 each for infection, impingement, adverse reaction to metal debris, and pelvic insufficiency fracture. The mean WOMAC score was 85 (standard deviation [SD], 18), the mean Oxford Hip Score 84 (SD, 18), the mean physical SF-12 score was 48.3 (SD, 8.6), and the mean mental SF-12 was 53.7 (SD, 9.2), the mean satisfaction score was 91.5 (SD, 3.9), and the mean UCLA was 6 (SD, 1.6). All femoral components demonstrated osseointegration., Conclusion: The cone femoral prosthesis demonstrates excellent early survival and osseointegration when applied to the challenging femur. Because of these encouraging results, we recommend this prosthesis be considered for the small, abnormal femur in primary hip arthroplasty., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aims: Reconstruction of the acetabulum after failed total hip arthroplasty (THA) can be a surgical challenge in the presence of severe bone loss. We report the long-term survival of a porous tantalum revision acetabular component, its radiological appearance and quality of life outcomes., Patients and Methods: We reviewed the results of 46 patients who had undergone revision of a failed acetabular component with a Paprosky II or III bone defect and reconstruction with a hemispherical, tantalum acetabular component, supplementary screws and a cemented polyethylene liner., Results: After a minimum follow-up of ten years (ten to 12), the survivorship of the porous tantalum acetabular component was 96%, with further revision of the acetabular component as the end point. The ten-year survivorship, with hip revision for any reason as the end point, was 92%. We noted excellent pain relief (mean Western Ontario and McMaster Universities Arthritis Index (WOMAC) score pain 92.6, (40 to 100)) and good functional outcomes (mean WOMAC function 90.3 (30.9 to 100), mean University of California Los Angeles activity scale 5 (2 to 10)) and generic quality of life measures (mean Short Form-12 (SF-12) physical component 48.3 (18.1 to 56.8), mean SF-12 mental component 56.7 (32.9 to 70.3)). Patient satisfaction with pain relief, function and return to recreational activities were excellent., Take Home Message: Uncemented acetabular reconstruction using a tantalum acetabular component gives excellent clinical and quality of life outcomes at a minimum follow-up of ten years. Cite this article: Bone Joint J 2016;98-B:767-71., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Aims: We present a case series of ten metal-on-polyethylene total hip arthroplasties (MoP THAs) with delayed dislocation associated with unrecognised adverse local tissue reaction due to corrosion at the trunnion and pseudotumour formation., Methods: The diagnosis was not suspected in nine of the ten patients (six female/four male; mean age 66 years), despite treatment in a specialist unit (mean time from index surgery to revision was 58 months, 36 to 84). It was identified at revision surgery and subsequently confirmed by histological examination of resected tissue. Pre-operative assessment and culture results ruled out infection. A variety of treatment strategies were used, including resection of the pseudotumour and efforts to avoid recurrent dislocation., Results: The rate of complications was high and included three deep infections, two patients with recurrent dislocation, and one recurrent pseudotumour., Conclusion: This series (mean follow-up of 76 months following index procedure and 19 months following revision THA) demonstrates that pseudotumour is an infrequent but important contributor to delayed instability following MoP THA. It is easy to overlook in the differential diagnosis, especially if the alignment of the components is less than optimal, leading to an assumption that malalignment is the cause of the dislocation. The instability is likely to be multifactorial and the revision surgery is complex., Take Home Message: Due to the high complication rate associated with revision in this cohort, the diagnosis should be borne in mind when counselling patients regarding the risks of revision surgery., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Periprosthetic joint infection (PJI) complicates between 0.5% and 1.2% primary total hip arthroplasties (THAs) and may have devastating consequences. The traditional assessment of patients suffering from PJI has involved the serological study of inflammatory markers and microbiological analysis of samples obtained from the joint space. Treatment has involved debridement and revision arthroplasty performed in either one or two stages. We present an update on the burden of PJI, strategies for its diagnosis and treatment, the challenge of resistant organisms and the need for definitive evidence to guide the treatment of PJI after THA., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Tapered fluted titanium stems are increasingly used for femoral revision arthroplasty. They are available in modular and non-modular forms. Modularity has advantages when the bone loss is severe, the proximal femur is mis shapen or the surgeon is unfamiliar with the implant, but it introduces the risk of fracture of the stem at the junction between it and the proximal body segment. For that reason, and while awaiting intermediate-term results of more recently introduced designs of this junction, non-modularity has attracted attention, at least for straightforward revision cases. We review the risks and causes of fracture of tapered titanium modular revision stems and present an argument in favour of the more selective use of modular designs., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Background: Antibiotic-impregnated bone cement spacer (ACS) with tobramycin ± vancomycin is commonly used in a 2-stage replacement of infected prosthetic joints. This procedure has been associated with development of acute kidney injury (AKI)., Objective: To determine the incidence and risk factors for AKI after implantation of tobramycin-impregnated ACS., Methods: This prospective, observational study evaluated 50 consecutive patients who received tobramycin ACS for first-stage revision of an infected hip or knee arthroplasty from August 2011 to February 2013. AKI was defined as 50% or greater rise in serum creatinine (SCr) from baseline within the first 7 postoperative days (PODs)., Results: The incidence of AKI was 20%, with median onset occurring at POD 2 (interquartile range [IQR] = 1-3); patients with AKI had a longer median duration of hospital stay (16 days, IQR = 12-17, vs 10 days, IQR = 8-10; P = 0.03). Serum tobramycin concentrations were significantly higher in the AKI group, peaking on POD 1 (median 1.9 vs 0.9 µg/mL, P = 0.01). Risk factors for nephrotoxicity identified by multivariate analysis were use of bone cement premanufactured with gentamicin (OR = 8.2; 95% CI = 1.1-60; P = 0.04), administration of blood transfusions intraoperatively (OR = 32.5; 95% CI = 2.3-454.3; P = 0.01) and nonsteroidal anti-inflammatory drugs postoperatively (OR = 23.0; 95% CI = 1.3-397.7; P = 0.03)., Conclusions: Tobramycin ACS is associated with a high risk of AKI. Measures to minimize AKI risk in the perioperative period include early detection through close monitoring of SCr, avoiding use of premanufactured bone cement containing gentamicin, and avoiding potential nephrotoxins within the first 72 hours postoperatively., (© The Author(s) 2015.)

Purpose: Adverse local soft tissue reactions can occur in response to wear debris or corrosion products released from total hip arthroplasty (THA). Hip arthroscopy is a useful diagnostic adjunct in the investigation of painful THA., Methods: A patient with a painful primary metal-on-highly cross-linked polyethylene THA underwent hip arthroscopy to confirm the diagnosis of trunnion corrosion., Results: The prosthetic implants were well fixed and aligned with no indication of infection. Hip arthroscopy was used to confirm the presence of corrosion on the trunnion of a titanium stem at its junction with a cobalt-chrome head. Due to persistent symptoms, the patient subsequently underwent arthrotomy, which confirmed the diagnosis, and revision hip arthroplasty to a titanium adapter sleeve, ceramic head and liner exchange, with relief of his symptoms., Conclusion: Hip arthroscopy may prove a useful additional diagnostic tool in the investigation of this emerging clinical entity.

Adverse reaction to wear and corrosion debris is a cause for concern in total hip arthroplasty (THA). Modular junctions are a potential source of such wear products and are associated with secondary pseudotumour formation. We present a consecutive series of 17 patients treated at our unit for this complication following metal-on-highly cross-linked polyethylene (MoP) THA. We emphasise the risk of misdiagnosis as infection, and present the aggregate laboratory results and pathological findings in this series. The clinical presentation was pain, swelling or instability. Solid, cystic and mixed soft-tissue lesions were noted on imaging and confirmed intra-operatively. Corrosion at the head-neck junction was noted in all cases. No bacteria were isolated on multiple pre- and intra-operative samples yet the mean erythrocyte sedimentation rate was 49 (9 to 100) and C-reactive protein 32 (0.6 to 106) and stromal polymorphonuclear cell counts were noted in nine cases. Adverse soft-tissue reactions can occur in MoP THA owing to corrosion products released from the head-neck junction. The diagnosis should be carefully considered when investigating pain after THA. This may avoid the misdiagnosis of periprosthetic infection with an unidentified organism and mitigate the unnecessary management of these cases with complete single- or two-stage exchange., (©2015 The British Editorial Society of Bone & Joint Surgery.)

There is currently no consensus on the optimal management of the infected total hip arthroplasty. Multiple management techniques have been described in contemporary literature.This paper focuses on 2-stage revision for the infected total hip arthroplasty. We discuss the rationale and examine the current evidence for the use of this technique.

Background: Reconstruction of large acetabular defects remains a substantial challenge in hip arthroplasty. There remains a paucity of data on the long-term results of acetabular trabecular metal augments., Questions/purposes: The purpose of this study was to assess the survivorship, clinical outcomes, restoration of center of rotation of the hip, and radiological signs of component fixation of trabecular metal augments in the context of reconstruction of acetabular defects., Methods: Between 2002 and 2005, we performed 56 revision (n=53) and primary (n=3) THAs using trabecular metal augments in combination with a trabecular metal acetabular component. Of the 56 patients, 16 (29%) died during followup. Of the 40 surviving patients, 37 (93%) had complete radiological followup, 23 (58%) had complete outcome questionnaire followup, and 17 (42%) provided partial questionnaire responses in the clinic or over the telephone. Median followup was 110 months (range, 88-128 months). During that period, we used these implants when preoperative templating indicated that an augment would be required to achieve acetabular implant stability with restoration of the hip center of rotation. We also chose during surgery to use an augment when we could not achieve a stable acetabular trial component without one. The combination of trabecular metal augments and trabecular metal shells was used in 18% (53 of 292) of our acetabular revisions during that time. Survivorship, functional outcome (WOMAC and Oxford hip score), health status (SF-12), and osseointegration according to the criteria of Moore and presence of radiolucencies were determined., Results: Survivorship of the augments at 10 years was 92% (95% confidence interval, 81%-97%). Four patients underwent cup revision, one for infection and three for loosening. The mean WOMAC global score was 79 (SD 17), the mean Oxford hip score 76 (SD 18), the mean physical component SF-12 score was 39 (SD 11), and the mean mental component SF-12 score was 52 (SD 9). The center of rotation was corrected from more than 35 mm above the inter-teardrop line in 48 of 56 patients preoperatively to only five of 46 postoperatively. One patient had radiographic findings suggestive of loosening, but this patient was asymptomatic., Conclusions: The results of the acetabular trabecular metal augments continue to be encouraging in the medium to long term with low rates of revision or loosening in this complex group of patients. We continue to recommend the use of these augments in the reconstruction of complex acetabular defects., Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

The burden of revision total hip arthroplasty (THA) is rising. As increasingly younger patients are treated with THA procedures, it is likely that this trend will continue. The results of revision THA are greatly influenced by the quantity and the quality of available femoral bone stock available for reconstruction. Modular and nonmodular tapered fluted titanium stems are increasingly used in revision THA. It is helpful to be familiar with the use of these components in revision THA.