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Background S-ROM hip is a well-established and versatile prosthesis that offers extensive metaphyseal and diaphyseal geometries providing solutions for a variety of surgical scenarios. The aim of this study is to report on long-term survivorship and radiographic outcomes of complex primary total hip arthroplasty (THA) using a modular cementless stem (S-ROM). Methods Retrospective consecutive study was conducted of 167 patients (167 hips): 97 males and 70 females with average age at the time of surgery of 55 years (range 22-76). All patients underwent complex THA by the senior author from 1987 to 1999. Patients were identified using a prospective database. Demographic, clinical, and surgical data were collected from health records. All patients received a cementless acetabular component with a standard polyethylene liner. The primary outcome measure was survivorship beyond 15 years using stem revision for any cause as an end point. Secondary outcome measure was rate of radiographic loosening using Engh classification. Results Only 3 patients required stem revision for aseptic loosening and 1 for periprosthetic fracture. Isolated acetabular revision was undertaken in 23 of 167 patients (13.8%) due to polythene wear, osteolysis, and aseptic loosening. Proximal femoral stress shielding (zone 1, 7) was noted in 34 of 167 hips (20.4%). Stable bony ingrowth was noted in 144 hips (86.2%) and the remaining 23 hips had stable fibrous ingrowth (13.8%). Using stem “any-cause revision” as an endpoint, the mean stem survivorship was 31.5 years (95% confidence interval 31.007-31.985) with 30-year estimated survivorship of 97.6%. Conclusion In a single designer surgeon series, S-ROM stem has stood the test of time with long-term, 30-year survivorship of 97.6% and continues to play an important role in modern hip surgery providing longevity and versatility. However, further comparative long-term studies from independent centers are needed for a definitive conclusion. Level of Evidence IV.

Failure of the extensor mechanism is a debilitating complication with significant limitation on patients’ function and quality of life. Allograft reconstruction in selected patients restores function with good outcomes. This chapter discusses the challenges of managing extensor mechanism failure in revision knee surgery and we describe our surgical technique in allograft extensor mechanism reconstruction with case demonstrations.

The principles and concepts of managing periprosthetic joint infection rTKA are well-established. Early intervention in acute infections with thorough debridement and modular exchange is preferred. Patient selection, meticulous surgical debridement, and targeted antibiotic treatment in conjunction with a specialist microbiologist are the most important factors to ensure success in managing chronic PJI in either a single- or two-stage strategy. This chapter focuses on the practical aspects of managing infection in revision knee surgery and present our recent tertiary experience.

Chronic patella dislocation after primary or revision TKA is a major challenge in revision surgery. This chapter describes a surgical technique which had been developed based on the biomechanical principles of changing the vector force to centralise the patella and further reinforced by a viable dynamic vastus medialis obliquus (VMO) stabiliser to ensure durability and a sustained outcome with practical tips and case demonstration.

Periprosthetic distal femoral fractures are the most common around the knee and are expected to increase with the exponential growth of TKA. For acute comminuted fractures, the use of distal femoral replacements leads to satisfactory clinical outcomes with an acceptable complication rate for this challenging group of patients. Meticulous preoperative planning is crucial with appropriate surgical skills in using endoprostheses. This strategy offers patients immediate mobilisation with the ability to fully weight-bear which helps to reduce perioperative medical complications. This chapter discusses the management of periprosthetic knee fractures from an arthroplasty perspective using massive endoprostheses.

Primary total knee arthroplasty is an effective and successful operation that has helped millions of patients worldwide. Over the last few decades, significant advances in our understanding of knee kinematics, implant designs and manufacturing processes have helped to ensure improved outcomes and longevity of knee arthroplasty. Despite its proven success, a significant proportion of patients remain dissatisfied with their knees. In this chapter, we will discuss our surgical philosophy in primary TKA, reverting to first principles and discussing some contentious contemporary variations in practice.

One of the main pillars of a durable revision knee construct is implant fixation. Stemmed components are used in most revision cases. Adjunctive fixation is also needed in cases of bone loss and a compromised epiphysis where surface cementation is not enough to support the implants. In this chapter, we focus on the philosophies of different fixation techniques and our preferred approach to not only achieve durable fixation but also to help in joint reconstruction by the use of tibial metaphyseal sleeves to reliably establish a stable tibial platform with the frame principle.

The common indications for rotating-hinge implants in revision knee practice are soft tissue failure; posterior capsule, MCL and significant complex bone loss. They are also part of segmental bone replacing prostheses, either as a distal femoral replacement or using massive augments to fill in major bone defects. They also play a role in complex primary cases. Contemporary hinge implants have seen improved outcomes and survivorship since the introduction of the rotating-hinge mechanism. However, common complications with hinges remain high with early loosening and patellofemoral issues. This chapter focuses on the practical aspects of hinge implants and their kinematics to avoid common hinge-related complications.

Despite its success and durability, about 20% of patients report unfavourable outcomes following their TKA. This is multifactorial with ongoing knee pain, limited function, and failure to meet preoperative expectations being the issues most likely to result in dissatisfaction. A systematic approach to evaluating problematic knees is essential to ascertain whether a revision surgery, a major undertaking, would solve the patient’s problems. In this chapter, we try to shed light on some practical aspects of evaluating patients presenting to revision knee clinics.

Revision knee arthroplasty is a major undertaking for most patients, particularly septic revisions which carry a high morbidity and mortality. In a large cohort of rTKA cases at our tertiary centre, the 10-year survivorship of septic revisions was 68.7 and 80.2% for aseptic revisions. These findings have important practical implications as these outcomes are comparable to those that we see in some cancer patients; the risk of mortality following septic rTKA is higher than that of some of the most common cancers. This reality should be highlighted in candid discussions when counselling patients not only at time of revision surgery, when patients have little choice when infection has already developed, but more importantly at time of primary TKA, particularly for those patients who are at higher risk for developing periprosthetic joint infection. This chapter focuses on long-term mortality in revision knee patients, particularly focusing on septic versus aseptic revisions.

Orthoplastic rTKA cases are challenging and should be managed closely with plastic reconstructive surgeons within a multidisciplinary team approach. Infrapatellar soft tissue defects are the most commonly encountered ones in rTKA practice. These defects are amenable to a pedicled medial gastrocnemius flap. This is commonly done by transposing the flap, as a muscle-only flap, necessitating a combined split-thickness skin graft. This chapter focuses on managing soft tissue defects in rTKA practice particularly in the presence of infection.

Complex primary total knee arthroplasty includes a variety of clinical scenarios with either compromised surrounding soft tissues, deformity, or lack of suitable bone for fixation. In this chapter, we will provide some tips and lessons that we have learnt over years of practice dealing with complex and unusual cases with some common themes and basic principles that would apply to most complex cases including deformities, previous fractures, previous patellectomy, revising unicompartmental knees and the use of patient-specific instrumentation and primary hinge implants, among others.

There are varying indications to revise a poorly performing TKA. Understanding why a knee is not functioning well and being able to fix the problem is an essential prerequisite before embarking on revision surgery. This chapter focuses on some of the contemporary indications for revision providing a summary of our practical experience and views on the current challenges in rTKA.

The aim of revision surgery is to deliver near-normal knee kinematics in the presence of a compromised bone stock and a compromised soft tissue envelope as a result of the original failure or repeated operations. Constrained implants are often used to provide the stability needed. In this chapter focuses on the practical implications of constraint in rTKA in the context of instability, particularly the kinematics of condylar revision implants, the role of varus valgus constraint and its impact on fixation interfaces as we as the role of mobile bearings.

The demand for salvage surgery is increasing, with more and more patients coming to their third or fourth revision in a situation with increasing bone loss. Traditionally, salvage options rely on allograft-prosthetic composite techniques, the use of massive endoprostheses which are currently the most commonly used option, implant-arthrodesis techniques and amputation. This chapter focuses on the practical aspects of salvage revision surgery, particularly the use of massive endoprostheses, and presents our tertiary experience with case demonstrations.

In revision knee surgery, adequate exposure to the knee joint is crucial for the safe removal of components, scar tissue, protecting important structures, and minimising iatrogenic complications of bone loss or extensor mechanism injury. In this chapter, we describe our approach to surgical exposure in revision knees particularly focusing on our technique of getting extensile exposure through a tibial crest osteotomy.

The principles of joint reconstruction in condylar revision knee arthroplasty are similar to that of a primary arthroplasty, with a balanced approach relying on a stable tibial platform and intact collaterals with the frame principle. In this chapter, we discuss the principles of surgical reconstruction and discuss the use of a balanced approach for an efficient and reproducible workflow in revision knee practice.

The safe removal of implants with minimal bone loss is a crucial step in revision knee surgery and it paves the way for an efficient and successful reconstruction. While most revised primary knees are cemented implants that require certain techniques for removal, cementless knees, revision components and metaphyseal sleeves or cones for adjunctive fixation are used more commonly and certain techniques are needed to extract those implants safely. In this chapter we describe our practical approach and tips to successful implant removals in revision surgery with the overarching principle that patience is indeed a virtue.

I did my first knee replacement, a Gunston knee, at the Wellesley hospital in Toronto when I was an assistant resident in 1972. In 1975 I spent a year with Mike Freeman in the Royal London Hospital in London, England learning how to do a knee replacement, which actually worked. I was working at Toronto General when I developed my first knee design, the Tricon, with Richards, now Smith and Nephew, in the late 70 s. I have done in excess of 5,000 total knee replacements. As part of the Travelling Road Show, which I wrote about in my book, Have Knife Will Travel ( Cameron, H.U., Have Knife Will Travel. 2019; 1–152. Xlibris US. ISBN: 9,781,796,053,418. 2019: Xlibris US. 1–152.), I taught hip and knee replacement surgery all over the world for 30 years. The motto for the young surgeon should be “festina lente”, hasten slowly. I will attempt to lay out my experience and philosophy of knee revision surgery in this chapter, which it is my honour to write.

Case We report a 67-year-old gentleman who presented with a painful unstable knee. He had undergone a successful total knee arthroplasty 12 years earlier and was highly functional. He presented with a 10-month history of mild pain, instability, and gait alteration. During revision surgery, there was a loss of bony support, and a fractured femoral component was identified. He required constrained revision components for reconstruction and made an uneventful recovery. Conclusions Fractured femoral components are rare complications of modern primary total knee arthroplasty. Loss of bony support in critical areas of high loading will inevitably lead to catastrophic component failure.

Persistent post-surgical pain (PPSP) remains a problem after knee replacement. "Pain" is not likely to be monolithic or a single entity. It can broadly be divided into mechanical pain that is not continuous and is influenced by movement and non-mechanical pain, which is continuous and is marginally affected by activity. If the cause of mechanical pain can be identified, corrective surgery may help. Non-mechanical pain can be subdivided into three groups as follows: sepsis, neuropathic, and perceived pain. The first two groups can be treated to some extent, but the perceived pain group that is very heterogeneous, remains a significant problem.

Background The aim of this study is to provide an overview of randomized controlled trials (RCTs) in primary total knee arthroplasty summarizing the available high-quality evidence. Methods Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2019, Issue 3), Ovid MEDLINE, and Embase. We excluded nonrandomized trials, trials on unicompartmental knee arthroplasty or revision surgery, systematic reviews, and meta-analyses. Trials that met our inclusion criteria were assessed using a binary outcome measure of whether they reported statistically significant findings. These were then classified according to the intervention groups (surgical approach, tourniquet use, design, etc.). Results Four hundred and three RCTs met the inclusion criteria and were included. The total number of patients in those 403 RCTs was 47,675. Only 33 RCTs (8.2%) reported significant differences between the intervention and the control groups. The trials were grouped into surgical approach 34, tourniquet 31, minimally invasive surgery 13, patient specific instrumentation 30, knee design 37, fixation 27, mobile bearing 47, navigation 50, polyethylene 19, technique 27, patella resurfacing 26, drain 19, closure 16, and others 27 RCTs. Conclusion For the vast majority of patients, a standard conventional total knee arthroplasty with a surgical approach familiar to the surgeon using standard well-established components, with or without tourniquet, without surgical drain leads to satisfactory long-term clinical outcomes.

The length of time to return to work after Total Knee Replacement is often treated as a monolithic entity. Figures produced under such an assumption are interesting but have little practical value in individual cases.Numerous factors most of which are not under medical control are involved. What is clear however is that the timing of surgery is of considerable importance in a job specific situation and this is under medical control.

This is a retrospective review of two series of using the same stem and modular neck design (R-120™) with the exception that the second series had an improved modular neck construct. Model I, 145 stems implanted between 2002 and 2005. Taper neck problems consisted of two neck trunion fractures at the neck stem junction and one modular neck disassociation at the modular junction. Stem was withdrawn from the market and redesigned to a more robust structure.Model II, 188 stems were implanted between 2007 and 2011 by the senior author utilizing the same surgical technique. There have been no modular neck taper problems.This paper will demonstrate that once a modular junction problem has been identified corrective action can be taken to resolve the problem. We advocate that there is a benefit to a modular neck cemented stem design and all modular junctions are not equal in design or function.

In this study we present our experience with four generations of uncemented total knee arthroplasty (TKA) from SmithNephew: Tricon M, Tricon LS, Tricon II and Profix, focusing on the failure rates correlating with each design change. Beginning in 1984, 380 Tricon M, 435 Tricon LS, 305 Tricon 2 and 588 Profix were implanted by the senior author. The rate of revision for loosening was 1.1% for the Tricon M, 1.1% for the Tricon LS, 0.5% for the Tricon 2 with a HA coated tibial component, and 1.3% for the Profix TKA. No loosening of the femoral component was seen with the Tricon M, Tricon LS or Tricon 2, with no loosening seen of the tibial component with the Profix TKA. Regarding revision for wear, the incidence was 13.1% for the Tricon M, 6.6% for the Tricon LS, 2.3% for the Tricon 2, and 0% for the Profix. These results demonstrate that improvements in the design of uncemented components, including increased polyethylene thickness, improved polyethylene quality, and the introduction of hydroxyapatite coating, has improved the outcomes of uncemented TKA over time.

A moderator and panel of five experts led an interactive session in discussing five challenging and interesting patient case presentations involving surgery of the hip. The hip pathologies reviewed included failed open reduction internal fixation of subcapital femoral neck fracture, bilateral hip disease, evaluation of pain after metal-on-metal hip arthroplasty, avascular necrosis, aseptic loosening secondary to osteolysis and polyethylene wear, and management of ceramic femoral head fracture.

Cemented stems are sometimes used as a last resort, i.e., if stability cannot be achieved with a cementless stem, a cemented stem is used as a last resort. As canal preparation for cementless and cemented stems is completely different, this is misuse of cement and invites a poor outcome. The purpose of this report is to show that when used properly, i.e., electively, the longevity of a variety of cemented stems is excellent. The report also shows that cementless fixation can almost always be achieved no matter the quality of the bone, if an appropriate implant is chosen. Cement should not be used as a last resort for failure of cementless fixation.

A review of the results of 964 cemented stems has been performed with a 24-year follow-up. Three different stems were used, two being cobalt chrome and one a titanium alloy. The current stem has a modular neck to allow version change after cementation. The cementing technique is to ream lightly and trial with a stem large enough to give rotational resistance without cement. When cement is introduced, this large stem pressurizes the cement to completely fill the canal. Six cases only (0.6%) were revised for aseptic loosening. It is concluded that with this cement technique and with appropriate patient selection cement is still a reasonable option in the elderly with wide canals.

Hydroxyapatite (HA) is commonly used on femoral stems to assist in osseous integration but there is limited evidence of the benefit it provides. We report a prospective comparison of 117 and 102 patients receiving either porous or HA coated sleeves respectively. Patients were evaluated at mean of 12.5 years in the porous and 13.7 years in the HA groups. The mean Harris Hip Score was 94.7 and 94.5 in the porous and HA groups respectively. One porous and 2 HA stems required revision. This study demonstrates that there is no long-term advantage to using an HA coating on the sleeve of this modular stem and confirms excellent long-term results for the SROM stem in a primary arthroplasty setting. Level of evidence: II (prospective cohort study).

The panel reviewed cases involving both revision and primary total hip arthroplasties. The panelists are Hugh Cameron and Allan Gross from Toronto, Charles Engh from Arlington, Aaron Rosenberg from Chicago, and Bernard Stulberg from Cleveland. The cases discussed brought up some controversial issues.

A review of 241 consecutive total knee revisions has been carried out. Other than loosening, wear, and stiffness, at present, a commoner reason is an unsatisfactory result due to minor errors of tibial and femoral placement. Currently, about 16% of femoral components required derotation during revision.

The results of treatment of 116 intraoperative femoral fractures were reviewed. Excluding calcar and greater trochanter fractures, there were 14 Type I cases (Vancouver classification). All healed with cerclage wiring. Three cases of vertical fractures of the proximal segment following a subtrochanteric osteotomy did not heal and required revision. There were 8 Type II fractures, most being minor splits or limited, nondisplaced, vertical fractures. Control was lost in 2 wired cases, suggesting that Type II fractures should be converted to Type I by the use of a long stem, or, if impractical, by supplementary fixation. In 7 septic cases, a comminuted fracture occurred during implant removal. An intramedullary nail and cerclage wires were used, and the patients were left with a Girdlestone. The infections were overcome, the fractures healed, and subsequent revision was straightforward, because an open channel existed in the femur.

This case discussion features knee arthroplasty cases presented to a panel of surgeons. The cases were chosen to represent common clinical problems encountered in everyday practice.

Total hip arthroplasty in patients requiring very small femoral stems is a challenge because frequently deformity and inadequate bone stock, especially of the acetabulum, are also present. An analysis of 34 consecutive cases managed with a 9-mm distal diameter noncemented stem was performed. The mean patient age was 42.6 years and mean follow-up time was 7.8 years. Two patients were lost to follow-up at 4 and 6 years, and 1 patient had a fracture below the stem immediately after surgery, necessitating revision. These patients were excluded from analysis. Of the remaining 31 patients, 1 underwent revision for distal osteolysis leading to fracture. The Harris hip ratings for these patients were 58.1% excellent, 22.6% good, 16.1% fair, and 3.2% poor. Complications experienced included 1 femoral component that fractured but remains asymptomatic. Polyethylene wear of the very small acetabular components in 31% of cases is a cause for concern; 2 of these patients have required revision for this reason. The acetabular component was subsequently modified to allow thicker polyethylene.

Recognized long-term problems associated with hip fusion include lower back pain, ipsilateral knee instability, contralateral patellofemoral pain, and contralateral hip pain. However, one of the major concerns in converting a hip arthrodesis to total hip arthroplasty (THA) is residual limp, due to insufficient abductor muscle strength. A series of patients who had undergone conversion of a hip fusion to THA were assessed postoperatively, in regards the Harris hip score (HHS), and the degree of limp (absent, mild, or severe/Trendelenburg positive). Patients were asked to evaluate their overall satisfaction with the procedure. The cohort included 24 patients and 25 hips. Mean age of the patients was 50.5 years (27-72), with a mean length of time from initial fusion of 19 years (5-40). The average follow-up of the patient was 8.6 years (2-17). Intraoperative complications included 2 calcar splits, and 3 femoral shaft fractures requiring an intraoperative switch to a long-stem implant. At latest follow-up, limp was absent in 20%, mild in 12%, and severe in 68%. Postoperative HHS was excellent in 28%, good in 32%, fair in 16%, and poor in 24%. Four patients required a cane to walk. All patients indicated they were overall satisfied with the procedure, and would consent to undergoing the procedure again. Although patient satisfaction rates are high after conversion of a hip fusion to THA, the incidence of postoperative limp is also high (80%), and only 60% have good or excellent postoperative HHSs.

A prospective study was carried out on the use of a proximally modular, proximal ingrowth noncemented stem in hip revision surgery. There were 109 short stems and 211 long stems. The mean follow-up was 7 years (range, 2-12 years). No revisions were required in the short-stem group for aseptic loosening; 3 (1.4%) revisions were required in the long-stem group. Lucency was absent in 91.7% of short-stem cases, was low grade in 7.2%, and was high grade in 1.1%. In the long-stem group, lucency was absent in 72.9% of cases, was low grade in 24.5%, and was high grade in 2.6%. No measurable subsidence occurred in the short-stem group, and 5 mm of subsidence occurred early in 2 of the long-stem group. This subsidence stabilized subsequently. Osteolysis distal to the sleeve was not observed. A proximal ingrowth, proximally modular stem can be used in revision hip surgery.

Few studies have examined the relationship between the severity of congenital dysplasia of the hip (CDH) and the clinical outcome of total hip arthroplasty. The authors have used a prospective design to study this question, using the Crowe grade to assess the severity of CDH. There were 71 patients with CDH operated on using the S-ROM total hip (Joint Medical Products, Stamford, CT); the control group was composed of 22 patients without CDH operated on using the same implant during the same period as the CDH patients. The patients with mild CDH did not have a different outcome from the patients without CDH with respect to Harris hip score or limp. The higher the Crowe grade, the more complications occurred. It was also found that the patients in whom the true acetabulum was not used had a significantly higher incidence of limp.

If distal fixation is a goal in revision hip surgery, then modularity may not be necessary. If, however, proximal fixation is desired, both proximal and distal fit and fill are necessary to achieve initial stability. This can only be done in the revision situation by using a modular stem. Long-term follow up of 320 revision cases treated using a proximally modular proximal ingrowth stem shows a re-revision rate for late aseptic loosening of 0.93% at a mean time of 7 years, indicating that such a stem is a reasonable option. © 2003 Elsevier Inc. All rights reserved.

Acquired patella baja may result in decreased range of motion of the knee, extensor lag, and anterior knee pain. The aim of the study was to evaluate the efficacy of tibial tubercle osteotomy with proximal displacement.Between 1998 and 2011, a proximalization of the tibial tuberosity was performed in 15 patients (15 knees) with patella baja diagnosed using the Blackburne-Peel ratio. Clinical outcomes included the Tegner Lysholm knee scoring scales, the WOMAC questionnaire, the short form-12 (SF-12), and a visual analogue score (VAS) pain scale.Fifteen proximalizations of the tibial tuberosity were performed, with a mean follow-up period of 64 months (5-160). The mean patient age was 59 years (41-86 years). The mean preoperative Blackburne-Peel ratio of 0.4 (0.1-0.6) was improved to a mean of 1.0 (0.8-1.2) post-operatively, which was associated with significant improvements in the Lysholm knee scoring scale from 13.3 ± 13.0 to 86.7 ± 10.4 points (p0.0001). Quality of life, as measured using the SF-12 outcome, also improved significantly (p0.0001), as did all WOMAC questionnaire score subscales (p0.0001). The VAS preoperative status for pain improved from 8.3 ± 2.0 to 1.5 ± 1.8. No patient had delayed or non-union of the osteotomy site.A series of patients with patella baja, treated with proximalization of the tibial tuberosity, achieved satisfactory outcomes in terms of pain relief and improved function, without major complication.

Knee revision using constrained implants is associated with greater stresses on the implant and interface surfaces. The present report describes a case of failure of the screw coupling between the stem and the femoral component. The cause of the failure is surmised with outline of the treatment in this case with extensive femoral bone loss. Revision implant stability was augmented with the use of a cemented femoral stem, screw fixation and the metaphyseal sleeve of an S-ROM modular hip system (DePuy international Ltd).