Revision Of Acetabular Component Research Articles

Periprocedural clinical outcomes of revision hip arthroplasty: a multi-centric comparison of current strategies based on the NSQIP.

Recent projections suggest a substantial rise in demand for revision total hip arthroplasties, emphasizing the need for optimized perioperative care. Various revision techniques, such as isolated acetabular or femoral component revisions and total replacements, have garnered attention. Further research is needed to establish the most effective strategies for improving clinical outcomes. This retrospective analysis utilized data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use File from 2016 to 2021. The study aimed to compare clinical characteristics and 30-day outcomes among patients undergoing combined acetabular and femoral (A + F) revision, acetabulum-only (A) revision, and femoral side-only (F) revision surgeries. The analysis of 18,888 patients revealed crucial differences in preoperative and postoperative outcomes among various revision strategies. Specifically, there were notable variations in patient demographics, comorbidities, and emergency procedures. Postoperative data showed distinct rates of mortality, complications, and readmissions across the groups. Notably, femoral component revisions were associated with increased risks of mortality, transfusion, and urinary tract infections, underscoring the need for careful evaluation and consideration when opting for this revision approach. The study's significance lies in its extensive patient cohort and multifaceted evaluation of revision strategies. Although consensus is lacking on single-component revisions, targeting the acetabulum component appears relatively safer. Continued research and individualized evaluations are crucial for refining revision strategies and optimizing outcomes in THA revisions.

Arthroscopic Fractional Lengthening After Total Hip Arthroplasty Results in Improved Patient-Reported Outcomes and Low Rates of Revision Total Hip Arthroplasty

PurposeTo report the clinical outcomes and reoperation rates of arthro- and endo-scopic iliopsoas release at short-term follow-up following ipsilateral total hip arthroplasty from two separate medical institutions, and to evaluate whether demographic and radiographic parameters are associated with postoperative patient reported outcomes. MethodsPatients with iliopsoas tendinitis in the setting of prior THA that underwent arthroscopic iliopsoas fractional lengthening from 1988 – 2023 at two academic institutions were reviewed. Patients were included if they had 12 months of follow-up and evaluated for preoperative anterior acetabular component overhang, surgery satisfaction, postoperative subjective hip flexion strength and anterior groin pain improvement, modified Harris Hip Score (mHHS), Single Assessment Numeric Evaluation (SANE) score, Tegner activity scale, visual analog scale (VAS), and revision hip arthroplasty. ResultsSixty hips in 58 patients (19 males, 39 females) were followed for a mean of 39.3 (12.0-105.9) months postoperatively. 77% of patients reported feeling “much” or “slightly better”, 75% reported improved anterior groin pain, and 60% reported improved subjective hip flexion strength. Surgery satisfaction was 7.2 ± 3.3 (scale of 0 to 10). Mean postoperative mHHS, VAS pain at rest, VAS pain with use, and SANE scores were 73.9 ± 19.4, 1.3 ± 2.4, 3.8 ± 2.9, and 71.9 ± 21.9 respectively. Preoperative anterior acetabular component overhang was 3.3 ± 6.5 mm and didn’t significantly correlate with postoperative PROs (p ≥ 0.45). Tegner score improved to 2.9 ± 1.4 from 2.5 ± 1.7 preoperatively (p = 0.0253). Three patients underwent revision arthroplasty at a mean of 25.3 (11.6 – 40.4) months postoperatively, with an acetabular component revision rate of 3.3%. ConclusionsSatisfactory outcomes and low revision arthroplasty rates were observed in patients undergoing arthroscopic iliopsoas lengthening following THA. There was no statistically significant relationship between anterior acetabular component overhang and final PROs.

Aseptic Acetabular Revisions ≤90 Days, 91 Days to 2 Years, and >2 Years After Total Hip Arthroplasty: Comparing Etiologies, Complications, and Postoperative Outcomes

BackgroundIsolated acetabular component revision is an effective treatment for revision total hip arthroplasty patients who have well-fixed femoral implants. We aimed to evaluate the modes of acetabular failure following primary total hip arthroplasty and to identify factors associated with increased morbidities and postoperative outcomes. MethodsWe conducted a retrospective analysis and identified 318 isolated aseptic acetabular revisions. We separated patients by ≤90 days, 91 days to 2 years, and >2 years for acetabular revisions and compared demographics, reasons for revision, 90-day readmissions, rerevisions, and postrevision infections. Revisions ≤90 days, 91 days to 2 years, and >2 years accounted for 10.7, 19.2, and 70.1% of revisions, respectively. Revisions ≤90 days, 91 days to 2 years, and >2 years had their primary total hip arthroplasty at a mean age of 66, 63, and 55 years (P < .001), respectively. ResultsRevisions within 90 days were mainly indicated for dislocation/instability (58.8%) or periprosthetic fracture (23.5%) while revisions over 2 years were indicated for polyethylene wear/osteolysis (37.2%). Patients with revisions past 90 days were more likely to require rerevision compared to patients with revisions within 90 days (P < .001). There were no differences in readmissions (P = .28) or infection rates (P = .37). ConclusionsAcetabular revisions within 90 days were more commonly indicated for instability and periprosthetic fracture, while those over 2 years were indicated for polyethylene wear. Revisions past 90 days were more likely to require subsequent rerevisions without increased 90-day readmissions or infections. Level III EvidenceRetrospective cohort study.

Mid-Term Outcomes of Modular Dual Mobility Bearings in Total Hip Arthroplasty

AbstractModular dual mobility (MDM) prostheses in which a cobalt–chromium liner is inserted into a titanium acetabular shell have the potential for corrosion. This has raised concern. While these constructs have been shown to effectively reduce the risk of dislocation in revision and high-risk primary total hip arthroplasty (THA), previous studies have been limited by the length of follow-up. The purpose of the study is to review the mid-term clinical outcomes of MDM implants with a minimum of 5-year follow-up. A retrospective, observational study was conducted on all consecutive patients who underwent THA with a MDM implant from June 2011 and March 2017 at an urban, tertiary academic medical center. Descriptive statistics were used to describe baseline patient characteristics. Primary endpoints included revision rates, dislocations rates, and implant component survivorship. Implant survival was analyzed using the Kaplan–Meier method. A total of 92 cases (61 primary, 31 revision) underwent THA with a MDM implant at an average follow-up of 6.90 ± 1.48 years (range: 5.01–10.53 years). The mean patient age at the time of surgery was 58.20 ± 11.85 years. Six patients were revised (6.5%, 6/92), two for periprosthetic joint infection (2.2%, 2/92), one due to aseptic loosening (1.1%, 1/92), one due to periprosthetic fracture (1.1%, 1/92), and the remaining two for metallosis (2.2%, 2/92). Kaplan–Meier survivorship analysis showed a 93.5% survival rate for all-cause revisions and 98.9% survival for acetabular component revision. MDM components reliably decrease the risk of dislocation after THA. However, the occurrence of two revisions due to metallosis demonstrates the necessity for continued surveillance in this cohort. Larger trials with long-term follow-up may be required to further elucidate the long-term outcomes and performance of these bearings.

Does Acetabular Bone Loss Severity Associate With Patient-Reported Outcome Measures and Reoperation Rate in Revision Total Hip Arthroplasty?

BackgroundAcetabular bone loss is a challenging clinical problem when performing revision total hip arthroplasty (rTHA). This study aimed to evaluate how acetabular bone loss severity influences (1) clinical outcomes and (2) patient-reported outcome measures (PROMs) in rTHA patients. MethodsPatients who underwent rTHA with acetabular component revision from January 2016 to February 2022 were included. Treating surgeons determined Paprosky acetabular bone loss classification intraoperatively. Patients were grouped based on numeric classification (PI, PII, or PIII) to categorize severity. Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR.) and Lower Extremity Activity Scale (LEAS) score were collected preoperatively and 1 year postoperatively. There were 197 patients included. Paprosky classification was PI for 47 patients (23.9%), PII for 113 patients (57.4%), and PIII for 37 patients (18.8%). Mean clinical follow-up was 29 months (range, 1 to 69). ResultsReoperation rate was 0% (0 patients), 6.2% (7 patients), and 10.8% (4 patients) for PI, PII and PIII groups respectively (P = .052). Mean preoperative HOOS, JR. and LEAS for PI, PII and PIII groups were significantly different, but 1-year postoperative HOOS, JR. and LEAS did not differ significantly. Rates of HOOS, JR. minimal clinically important difference achievement differed significantly between bone loss groups. ConclusionIn this study of rTHA patients, greater acetabular bone loss severity was associated with worse preoperative PROMs and trended toward higher reoperation rate. Postoperative PROMs for bone loss severity groups were statistically similar. Patients who had worse acetabular bone loss were more likely to achieve HOOS, JR. minimal clinically important difference postoperatively. Level of EvidenceIII.

Endoscopic iliopsoas lengthening for treatment of recalcitrant iliopsoas tendinitis after total hip arthroplasty.

Iliopsoas (IP) tendinitis from impingement upon the acetabular component after total hip arthroplasty (THA) has been treated with open and endoscopic IP tenotomy or acetabular component revision. This study describes the results of a consecutive series of patients treated with endoscopic IP tenotomy as a less invasive alternative. Twenty-eight patients with IP impingement after THA underwent endoscopic IP lengthening from 2012 to 2021 at a single-center academic institution. The follow-up of 24 of these patients was achieved with a mean follow-up of 7.6 months (range 1-28). Outcomes included the modified Harris Hip Score (mHHS), visual analog pain scale (VAS), satisfaction, component positioning and complications. Seventy-one percent of patients were satisfied or very satisfied after their operation. The median mHHS preoperatively was 57 (Interquartile range [IQR] 43-60) and postoperatively was 75 (IQR 66-92, P < 0.001). Clinically meaningful improvements in mHHS were seen in patients with VAS pain scores <5, cup prominence >8 mm, body mass index >30, and less than 2 years from their index THA. Two patients developed a deep infection 7 and 10 months postoperatively (neither related to the release), and one patient underwent open psoas release for persistent impingement. Endoscopic IP tenotomy is a safe and effective treatment for impingement after THA. Patients with cup prominence >8 mm, body mass index >30 and less than 2 years since their index THA may have more clinically meaningful improvements in pain and function.

Forte ceramic-on-delta ceramic cementless total hip arthroplasty: an 8- to 15-year follow-up study.

Forte ceramic head on delta ceramic liner articulation showed satisfactory midterm results without ceramic-related complication. We aimed to investigate the clinical and radiological outcomes of cementless total hip arthroplasty (THA) with forte ceramic head on delta ceramic liner articulation. Overall, 107 patients (57 men, 50 women; 138 hips) who underwent cementless THA with forte ceramic head on delta ceramic liner articulation were enrolled. The mean follow-up duration was 11.6years. For the clinical assessments, Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), presence of thigh pain, and presence of squeaking were evaluated. Radiographs were assessed to search for osteolysis, stem subsidence, loosening of implants. Kaplan-Meier survival curves were evaluated. The mean HHS and WOMAC improved from 57.1 and 28.1 preoperatively to 81.4 and 13.1 at the final follow-up, respectively. Nine revisions (6.5%) were performed; 5 hips for stem loosening, 1 hip for ceramic liner fracture, 2 hips for periprosthetic fracture, and 1 hip for progressive osteolysis around cup and stem. Thirty-two patients (37 hips) complained squeaking, in which 4 cases (2.9%) were identified as ceramic-related noises. After a mean follow-up period of 11.6years, 91% (95% CI 87.8-94.2) were free from revision of both femoral and acetabular components due to any reason. Cementless THA with forte ceramic-on-delta ceramic articulation showed acceptable clinical and radiological results. Serial surveillance of these patients should be performed due to the possibility of cerami- related complications such as squeaking, osteolysis, and ceramic liner fracture.

Pseudotumor as adverse local tissue reaction due to implant corrosion

Introduction. The term adverse local tissue reactions (ALTRs) is used to describe pathologic tissue conditions appearing after total joint replacement, and it includes osteolysis, bone necrosis, muscle necrosis, cystic lesions, excessive fluid collections, soft tissue masses, pseudotumors, metal sensitivity, metallosis, and chronic inflammatory lesions. ALTRs are rarely described in the literature after the breakage of the ceramic components of the hip prosthesis. Case report. We present a case of a patient with massive fluid collections filled with metallic and tissue detritus, along with signs of systemic cobalt (Co) and chromium (Cr) intoxication. Symptoms developed after revision of the acetabular component with the application of a metal-on-polyethylene coupling. Previously, several revisions were made due to breakage of the ceramic components of the endoprosthesis and instability of the hip. After removal of pseudotumor masses and revision of all components of the endoprosthesis with implantation of a coupling between the ceramic head and the polyethylene insert, there was a significant drop in the serum values of Co and Cr. Conclusion. Trunnion damage should be assessed during revision procedures, and if present, both prosthetic components should be replaced to prevent disastrous effects of metallic corrosion, ALTRs, and systemic metallic ions intoxication. Measurement of serum levels of Co and Cr in patients after joint replacement could identify patients at risk for the development of ALTRs and metallosis.

Minimum 30-Year Results of Bilaterally Implanted Cemented and Cementless Total Hip Arthroplasty in Patients Younger Than 50 Years

BackgroundThe rate of failure of cemented and cementless total hip arthroplasty (THA) in younger patients is higher than that in elderly patients. The purpose of this study is to document the long-term clinical results of THA with the so-called third-generation cementing and the results of second-generation cementless THA in patients <50 years of age. MethodsThis study included 106 patients who had had bilateral THA with a cemented stem in one hip and a cementless stem in the other. There were 78 men and 28 women. Their mean age was 47 years (range, 21-49). The average follow-up duration was 31 years (range, 30-32.5). ResultsThere were similar mean Harris Hip Scores (90 versus 91 points) between the groups at the final follow-up. Forty-six acetabular components (43%) in the cemented group and 48 acetabular components (45%) in the cementless group were revised. Five femoral components (5%) in the cemented group and 4 femoral components (4%) in the cementless group were revised. Survivorship of the acetabular component at 30.8 years was similar in both groups (57% in the cemented group versus 55% in the cementless group). Survivorship of the femoral component at 30.8 years was also similar in both groups (95% in the cemented group versus 96% in the cementless group). ConclusionLong-term fixation of the cemented or cementless femoral stem was outstanding. There was a high rate of the acetabular component revision due to conventional polyethylene wear and periacetabular osteolysis in both hybrid and fully cementless THA groups.

HOW MUCH STABILITY DO WE NEED IN THE 1 MM PRESS-FIT IMPLANTATION OF A POROUS-COATED ACETABULAR COMPONENT WITHOUT SCREWS DURING SURGERY?

Background: Press-fit implantation of a porous-coated acetabular component without screws can be used for total hip arthroplasty (THA). The purpose of this report is to determine adequate initial stability of the acetabular component by applying a novel method would allow us to avoid screw use and to evaluate the outcomes of an oversized hemispherical cup using the 1 mm press-fit technique. Methods: We retrospectively evaluated 119 consecutive patients who underwent THA from February 2011 to June 2015. The intra-operative stability of fixation was checked by trying to pull the metal shell out of the acetabulum using the shell holder (pull-out test). We confirmed these tests using a digital hand scale. When we reached 9 to 10 kg (1 kg = 9.81 N), we showed that the acetabular shell achieved good stability. Kaplan-Meier survivorship analysis was performed to calculate the survival rate of the acetabular component. Results: The mean follow-up was 6.9 years (5–10 years). No component was revised because of loosening, and all implants were radiologically stable within the observation period. One socket had been revised because of failure of dislocation, which had [Formula: see text] acetabular inclination. There was an acetabular fracture in one hip, which was operated on prior to THA. Conclusions: We used a new method to assess the initial stability gained using the press-fit technique, which may allow the surgeon to determine whether adequate initial stability is achieved. Cup position has a significant impact on the risk of revision of press-fit cementless acetabular component. The risk for early failure can be decreased by optimal cup positioning during primary implantation. In addition, while a stable bone-implant connection is desirable, fracture of the acetabulum can be avoided using the 1 mm press-fit technique.

Outcomes of isolated head-liner exchange versus full acetabular component revision in aseptic revision total hip arthroplasty.

Isolated head and liner exchange in aseptic revision total hip arthroplasty (rTHA) is an appealing option rather than full acetabular component revision; however, early outcome reports suggest high rates of complications requiring re-revision. This study seeks to compare the outcomes of these procedures. This retrospective study assessed 124 head and liner exchanges and 59 full acetabular cup revisions conducted at a single center between 2011 and 2019 with at least 2 years of follow-up. Baseline demographics did not vary by group. Mean follow-up was 3.7 (range 2.0-8.6) years. In the head and liner exchange group, re-revision-free survivorship at 2 years was 79% for all-causes and 84% for aseptic reasons. In the full acetabular revision group, it was 80% for all causes (p > 0.99) and 83% for aseptic reasons (p > 0.99). The 2-year survivorship of head and liner exchange was non-inferior to that of full acetabular revision, correcting for surgical indication and history of prior revision (adj-OR 0.1.39, 95% CI, 0.62-3.28, p = 0.99). A best-fit multivariable model found that revision for instability (adj-OR=3.03, 95% CI 1.40-6.66, p = 0.005), prior revision (adj-OR 2.15; 95% CI, 0.87-5.32; p = 0.10), current smoking (adj-OR 2.07; 95% CI, 0.94-4.57; p = 0.07), and obesity (adj-OR 0.58; 95% CI, 0.24-1.36; p = 0.22) were associated with failure within 2 years. In this analysis, 2-year outcomes for isolated head and liner exchange were non-inferior to full acetabular component revision. A future randomised prospective study should be conducted to better assess the optimal approach to revision in an aseptic failed hip arthroplasty.

A Retrospective Review of Reimbursement in Revision Total Hip Arthroplasty: A Disparity Between Case Complexity and RVU Compensation

BackgroundRevision total hip arthroplasties (THA) are time-consuming, expensive, and technically challenging. Today’s Current Procedural Terminology (CPT) codes and relative value units (RVU) may in fact disincentivize surgeons to perform revision THAs. Our study reviewed labor and time investments for each component-specific revision THA and analyzed the gap between procedural value billed and final reimbursement. MethodsA retrospective review of 165 primary and revision THAs were validated using operative notes and billing records. We stratified revision THAs by standard CPT coding (with modifiers) as single acetabular component, single femoral component, femoral head plus polyethylene liner (head/liner) exchange, all-components, and spacer placement for infection. Operative time, RVUs, total charges, deductions, and final reimbursement data was collected. Mann-Whitney U tests studied final reimbursement per minute vs per RVU in revision and primary THAs. ResultsOur cohort consisted of 27 primary THAs, 26 acetabular component revisions, 32 head/liner exchanges, 26 femoral component revisions, 27 all-component revisions, and 27 spacer placements. Compared to primary THAs, every revision subgroup except for head/liner exchanges were found to reimburse less per minute and all revision subgroups reimbursed less per RVU (P < .05). ConclusionPhysicians face less reimbursement per minute and per RVU for revision THAs. With cuts in reimbursement set forth by Centers for Medicare and Medicaid Services (CMS) and insurers, revisions may be financially unfavorable. This ultimately will lead to an impending access to care problem in the future. Our study supports the need to re-examine the RVU allocation amongst revision THAs and evaluate changes to the Current Procedural Terminology (CPT) coding system.

Fast-track revision hip arthroplasty: a multicenter cohort study on 1,345 elective aseptic major component revision hip arthroplasties.

Background and purposeData on application of fast-track/enhanced recovery protocols in revision hip arthroplasty (R-THA) surgery is scarce. We report length of stay (LOS), risk of LOS > 5 days, and readmission ≤ 90 days after revision hip arthroplasty in centers with a well-established fast-track protocol in both primary and revision procedures.Patients and methodsThis is an observational cohort study from the Centre for Fast-track Hip and Knee Replacement and the Danish Hip Arthroplasty Register. Consecutive elective aseptic major component revision hip arthroplasties from 6 dedicated fast-track centers from 2010 to 2018 were included.Results1,345 R-THAs were analyzed, including 23% total revisions, 52% acetabular component revisions, and 25% femoral component revisions. Mean age was 70 years (SD 12) and 61% were female. Median LOS was 3 days (interquartile range [IQR] 2–6), decreasing from median 6 (IQR 3–10) days in 2010 to 2 (IQR 1–4) days in 2018. The 90-day readmission rate was 20%, but showed a fluctuating and increasing trend from 13% in 2010 to 28% in 2018. Risk factors for LOS > 5 days and readmission were use of walking aid, preoperative hemoglobin ≤ 13 g/dL, pharmacological treated psychiatric disorder, age ≥ 80 years, age 70–79 years (only LOS > 5 days), cardiac disease (only LOS > 5 days), pulmonary disease (only readmission), BMI ≥ 35 (only LOS > 5 days) and ≥ 1 previous revision (only LOS > 5 days).InterpretationLOS decreased to median 2 days at the end of the study period, but the 90 days readmission risk remained high (> 20%). Several risk factors for postoperative complications were identified, suggesting that at-risk patients should be treated using an extended fast-track/enhanced recovery protocol focusing on preoperative optimization and postoperative monitoring as well as surgical techniques to reduce hip dislocations.

Radiolucent lines do not affect the longevity of highly cross-linked polyethylene cemented components in total hip arthroplasty.

We aimed to evaluate the long-term outcome of highly cross-linked polyethylene (HXLPE) cemented acetabular components and assess whether any radiolucent lines (RLLs) which arose were progressive. We retrospectively reviewed 170 patients who underwent 187 total hip arthroplasties at two hospitals with a minimum follow-up of ten years. All interventions were performed using the same combination of HXLPE cemented acetabular components with femoral stems made of titanium alloy. Kaplan-Meier survival analysis was performed for the primary endpoint of acetabular component revision surgery for any reason and secondary endpoint of the appearance of RLLs. RLLs that had appeared once were observed over time. We statistically assessed potential relationships between RLLs and a number of factors, including the technique of femoral head autografting and the Japanese Orthopaedic Association score. The mean follow-up period was 13.0 years (10.0 to 16.3). Femoral head autografting was performed on 135 hips (72.2%). One acetabular component was retrieved because of deep infection. No revision was performed for the aseptic acetabular loosening. The Kaplan-Meier survival curve for the primary and secondary endpoints were 98.2% (95% confidence interval (CI) 88.6% to 99.8%) and 79.3% (95% CI 72.8% to 84.6%), respectively. RLLs were detected in 38 hips (21.2%), at a mean of 1.7 years (1 month to 6 years) postoperatively. None of the RLLs were progressive, and the presence of RLLs did not show a significant association with the survival and clinical score. RLLs were more frequently observed in hips without femoral head autografts than in those with autografts. The use of HXLPE cemented acetabular components in total hip arthroplasty demonstrated excellent clinical outcomes after ten years, and no RLLs were progressive, and their presence did not affect the outcome. Femoral head autografting did not negatively impact the acetabular component survival or the appearance of RLLs. Cite this article: Bone Joint J2021;103-B(10):1604-1610.

Inflation-Adjusted Medicare Reimbursement for Revision Hip Arthroplasty

Background: Investigations into reimbursement trends for primary and revision arthroplasty procedures have demonstrated a steady decline over the past several years. Revision total hip arthroplasty (rTHA) due to infection (rTHA-I) has been associated with higher resource utilization and complexity, but long-term inflation-adjusted data have yet to be compared between rTHA-I and rTHA due to aseptic complications (rTHA-A). The present study was performed to analyze temporal reimbursement trends regarding rTHA-I procedures compared with those for rTHA-A procedures. Methods: The Centers for Medicare &amp; Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool was used to extract Medicare reimbursements associated with 1-stage and 2-stage rTHA-I as well as 1-stage rTHA-A procedures from 2002 to 2019. Current Procedural Terminology (CPT) codes for rTHA were grouped according to the American Academy of Orthopaedic Surgeons coding reference guide. Monetary values were adjusted for inflation using the consumer price index (U.S. Bureau of Labor Statistics; reported as 2019 U.S. dollars) and used to calculate the cumulative and average annual percent changes in reimbursement. Results: Following inflation adjustment, the physician fee reimbursement for rTHA-A decreased by a mean [and standard deviation] of 27.26% ± 3.57% (from $2,209.11 in 2002 to $1,603.20 in 2019) for femoral component revision, 27.41% ± 3.57% (from $2,130.55 to $1,542.91) for acetabular component revision, and 27.50% ± 2.56% (from $2,775.53 to $2,007.61) for both-component revision. Similarly, for a 2-stage rTHA-I, the mean reimbursement declined by 18.74% ± 3.87% (from $2,063.36 in 2002 to $1,673.36 in 2019) and 24.45% ± 3.69% (from $2,328.79 to $1,755.45) for the explantation and reimplantation stages, respectively. The total decline in physician fee reimbursement for rTHA-I ($1,020.64 ± $233.72) was significantly greater than that for rTHA-A ($580.72 ± $107.22; p &lt; 0.00001). Conclusions: Our study demonstrated a consistent devaluation of both rTHA-I and rTHA-A procedures from 2002 to 2019, with a larger deficit seen for rTHA-I. A continuation of this trend could create substantial disincentives for physicians to perform such procedures and limit access to care at the population level. Level of Evidence: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Total Femur Antibiotic Spacers: Effective Salvage for Complex Periprosthetic Joint Infections

BackgroundA simultaneous periprosthetic joint infection (PJI) of an ipsilateral hip and knee arthroplasty is a challenging complication of lower extremity reconstructive surgery. We evaluated the use of total femur antibiotic-impregnated polymethylmethacrylate (PMMA) bone cement spacers in the staged treatment of such limb-threatening PJIs. MethodsThirteen patients were treated with a total femur antibiotic spacer. The mean age at the time of spacer placement was 65 years. Nine patients had polymicrobial PJIs. All spacers incorporated vancomycin (3.0 g/40 g PMMA) and gentamicin (3.6 g/40 g PMMA), while 8 also included amphotericin (150 mg/40 g PMMA). Eleven spacers were biarticular. Twelve spacers were implanted through one longitudinal incision, while 8 of 12 reimplantations occurred through 2 smaller, separate hip and knee incisions. Mean follow-up after reimplantation was 3 years. ResultsTwelve (92%) patients underwent reimplantation of a total femur prosthesis at a mean of 26 weeks. One patient died of medical complications 41 days after spacer placement. At latest follow-up, 3 patients had experienced PJI recurrence managed with irrigation and debridement. One required acetabular component revision for instability. All 12 reimplanted patients retained the total femur prosthesis with no amputations. Eleven (91%) were ambulatory, and 7 (58%) remained on suppressive antibiotics. ConclusionTotal femur antibiotic spacers are a viable, but technically demanding, limb-salvage option for complex PJIs involving the ipsilateral hip and knee. In the largest series to date, there were no amputations and 75% of reimplanted patients remained infection-free. Radical debridement, antimicrobial diversity, prolonged spacer retention, and limiting recurrent soft tissue violation are potential tenets of success. Level of EvidenceIV.

Trabecular Metal Augments for Treatment of Acetabular Defects: A Systematic Review

AbstractSevere acetabular bone defects during revision total hip arthroplasty are often treated with a hemispherical shell and highly porous modular metal augments. Several papers have been already published reporting on the clinical performance of trabecular metal (TM) augments combined with a hemispherical shell for the management of severe acetabular defects. However, no systematic review of the literature has been published to date. The U.S. National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried for publications utilizing keywords pertinent to tantalum augments and TM (Zimmer Biomet, Warsaw, Indiana) augments, revision THA, clinical outcomes, and complications associated with these procedures. Fifteen articles were found to be suitable for inclusion in the present study, which included 769 revision cases where acetabular augments were used. The majority of acetabular bone defects were type 3 according to the Paprosky classification (type 2A in 58 cases, 7.2%; type 2B in 139 cases, 17.2%; type 2C in 72 cases, 8.9%; type 3A in 360 cases, 44.7%; and type 3B in 177 cases, 22.0%). The overall revision rate for the 769 acetabular revisions with augments was 5.7% (46 cases) at mean mid-term follow-up. The most common reasons for revision were dislocation (3.3%), periprosthetic joint infection (2.9%), and aseptic loosening (2.7%). TM augments combined with hemispherical shells were found to be effective in the treatment of moderate-to-severe acetabular bone defects with a 5% acetabular component revision rate at mean mid-term follow-up. The literature did not delineate whether pelvic discontinuity was associated with a higher risk of aseptic loosening after TM augment. Further studies are needed to clarify the impact of additional screw fixation on survival rates, and whether the type of augment (wedge augments, “flying buttress” augments, column augments), the configuration used, and the number of screws influence clinical and radiographic outcomes.

Protection of the Femoral Trunnion During Acetabular Revision Hip Surgery-A Novel Technique.

Revision of a failed acetabular component in the presence of an intact femoral prosthesis comprises approximately 20% of revision total hip replacements performed by the senior author. During this procedure, the femoral trunnion is at risk of damage because of scratching from retractors, reamers, or other instruments. Scratching can result in mechanically assisted crevice corrosion or adverse local-tissue reaction or trunnionosis leading to implant failure. We have used a variety of techniques for protection of the femoral taper over the last 30 years. We describe our current method of taper protection, using a cut segment of #5 silicon laryngeal airway, which is a simple and effective method.

Revision Arthroplasty Through the Direct Anterior Approach Using an Asymmetric Acetabular Component.

Despite increasing numbers of primary hip arthroplasties performed through the direct anterior approach (DAA), there is a lack of literature on DAA revision arthroplasty. The present study was performed in order to evaluate outcomes and revision rates after revision through the DAA using an asymmetric acetabular component with optional intra- and extramedullary fixation. In a retrospective cohort study, we analyzed prospectively collected data of 57 patients (61 hips, 43 female, 18 male) who underwent aseptic acetabular component revision through the DAA with the abovementioned implant system between January 2015 and December 2017. The mean follow-up was 40 months (12–56). Survival rates were estimated using the Kaplan–Meier method. All complications were documented and functional outcomes were assessed pre- and postoperatively. Kaplan–Meier analysis revealed an estimated five-year implant survival of 97% (confidence interval CI 87–99%). The estimated five-year survival with revision for any cause was 93% (CI 83–98%). The overall revision rate was 6.6% (n = 4). Two patients had to undergo revision due to periprosthetic infection (3.3%). In one patient, the acetabular component was revised due to aseptic loosening four months postoperatively. Another patient suffered from postoperative iliopsoas impingement and was treated successfully by arthroscopic iliopsoas tenotomy. Two (3.3%) of the revised hips dislocated postoperatively. The mean Harris Hip Score improved from 35 (2–66) preoperatively to 86 (38–100) postoperatively (p < 0.001). The hip joint’s anatomical center of rotation was restored at a high degree of accuracy. Our findings demonstrate that acetabular revision arthroplasty through the DAA using an asymmetric acetabular component with optional intra- and extramedullary fixation is safe and practicable, resulting in good radiographic and clinical midterm results.

Clinical and radiological survivorship of the Thackray cross plate with rim reinforcement ring for cemented acetabular revision.

Acetabular component revision surgery can be a challenging task due to the encountered bone defects. Both cemented and uncemented techniques are described. We report on the survivorship of the Thackray cross plate with rim reinforcement ring for cemented acetabular revision. This is a retrospective case series of all patients treated with the implant with a minimum follow-up of 2years. Acetabular defects were characterized according to the Paprosky classification. Data on potential risk factors for failure of the construct as well as the Oxford Hip Score (OHS) were collected. Kaplan-Meier survival analysis with radiographic aseptic loosening or revision for aseptic loosening as the end point was performed. From 2000 to 2017, 35 revisions in 18 male and 17 female patients with an average age of 72years were included. Bone allograft was used in 26 cases and additional implants (medial or supero-lateral mesh) in 13. Seven patients have deceased and the fate of all revisions is known. At an average clinical follow-up of 9.7 (2.6 to 19.6) years, there were no further re-revisions for construct failure. Five hips have demonstrated radiological evidence of aseptic loosening. Radiologically loose components were associated with more severe grades of acetabular bone defects (Paprosky Type 3) (60% vs 3%, p = 0.006). Kaplan-Meier survival analysis demonstrates 79.8% overall survivorship at 7years. Survivorship for Type 2 defects was significantly higher compared to Type 3 (90% vs 0% at 7years, Logrank test p = 0.002, Cox proportional hazards p = 0.03). The final median OHS was 38 (12-48) and was not affected by component loosening. This is a cost-effective device that protects the underlying bone graft (81% complete remodeling) and prevents subsidence of the cemented cup (2mm on average). It should be used with caution in high-grade defects and perhaps not advised.