Revision Total Hip Arthroplasty Research Articles

A Case of Successful Perioperative Rehabilitation in Two-Stage Revision Total Hip Arthroplasty for an Intraoperative Acetabular Fracture: Insights Into Interim-Period Rehabilitation Strategies

A Case of Successful Perioperative Rehabilitation in Two-Stage Revision Total Hip Arthroplasty for an Intraoperative Acetabular Fracture: Insights Into Interim-Period Rehabilitation Strategies

The impact of acetabular revision in revision total hip arthroplasty for a Vancouver B2 fracture requiring a change of femoral component.

The aim of this study was to assess the necessity of revising the acetabular component in revision total hip arthroplasty (THA) in patients with a Vancouver type B2 periprosthetic femoral fracture (PFF) who require revision of the femoral component. The hypothesis was that revision of both the acetabular and femoral components and using a dual-mobility acetabular component would provide a lower postoperative risk of dislocation, without increasing perioperative morbidity and mortality. Data were retrospectively analyzed from a continuously gathered database. We included 150 revisions, performed between January 2015 and December 2022, in 150 patients, with 81 revisions limited to only the femoral component and 69 involving revision of both components. This resulted, after surgery, in 60 patients having a simple-mobility acetabular component and 90 having a dual-mobility component. The mean age of the patients was 79.7 years (SD 10.1), and 98 were female (65.3%). The mean follow-up was 31 months (SD 2.3). There were no significant differences between those in whom only the femoral component was revised and those in whom both components were revised with the use of a dual-mobility acetabular component for the rate of intraoperative complications, postoperative mortality, blood loss, the requirement of a blood transfusion, medical complications, dislocation (11/81 in the femoral component-only group vs 6/69 in the femoral + acetabular component revision group) or the overall need for reoperation at the final follow-up. Patients were at a significantly higher risk for dislocation when a simple-mobility component was retained (18.3% (n = 11) vs 6.7% (n = 6) for dual-mobility implants; p = 0.036). The revision rate prompted by postoperative instability was significantly higher in patients in whom a simple-mobility acetabular component was retained at revision (10% (n = 6) vs 0%; p = 0.002). Based on these results, concurrent revision of the acetabular component was not associated with a higher rate of mortality or increased morbidity and patients in whom a dual-mobility acetabular component was used were significantly less prone to dislocation. We thus recommend routine revision of the acetabular component in favour of a dual-mobility component for patients sustaining a Vancouver B2 PFF requiring revision of the femoral component if their initial THA included a simple-mobility acetabular component.

Surgeon Experience May Predict Failure after Revision Total Hip Arthroplasty for Periprosthetic Fracture.

Periprosthetic fracture often requires revision hip arthroplasty. This study evaluated factors contributing to subsequent revisions and reoperations in patients who underwent revision hip arthroplasty for periprosthetic femur fracture. The authors hypothesized that surgeons who had higher revision volume would have decreased subsequent complications. A retrospective review of 84 revision hip arthroplasties for Vancouver B2 periprosthetic femur fractures performed at a single academic institution was conducted. Surgeons were categorized based on their reoperation volume: experienced (≥ 12 complicated hip reoperations annually) and less experienced (< 12 complicated hip reoperations annually). Univariable and multivariable analyses evaluated risk factors for all-cause revision. Survival analyses were performed using Cox Proportional Hazard modeling. Of the 84 patients, there were 8 (10%) revisions and 15 (18%) reoperations. Survivorship free of all-cause revision was greater for high-volume surgeons [Hazard Ratio [HR] 0.03 (0.00 to 0.43); P = 0.01]. Sub-analysis demonstrated that experienced surgeons had increased 5-year survivorship free of septic revisions [HR 0.03 (0.00 to 0.54); P = 0.02]. The multivariable analysis also demonstrated that extended oral antimicrobial prophylaxis was associated with 5-year septic reoperation-free survival [HR 0.03 (0 to 0.45); P = 0.01]; this only trended toward significance in 5-year septic revision-free survival [HR 0.04 (0.00 to 1.97); P = 0.11). There was no association between aseptic revision and surgeon experience in univariable or multivariable analysis. Experienced arthroplasty surgeons, as well as extended oral antibiotic prophylaxis, may improve patient outcomes when treating patients who have periprosthetic fractures requiring revision arthroplasty. Consideration should be given to call schedules and management of this vulnerable population.

The Use of Highly Porous 3-D-Printed Titanium Acetabular Cups in Revision Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

Background/Objectives: As the rate of revision total hip arthroplasty (THA) has risen, there has been a drive to improve the technology in the manufacturing of the implants used. One recent advance has been 3-D printing of trabecular titanium implants to improve implant stability and osteointegration. The aim of this study was to review the clinical and radiological outcomes of these acetabular implants in revision THA. Methods: A manual search of the databases of the US National Library of medicine (PubMed/MEDLINE), Embase, and the Cochrane library was performed. The following keywords of “revision total hip arthroplasty” AND “acetabulum” AND “titanium” AND “porous” were utilised. Results: In total, 106 abstracts were identified during manual search of databases. In total, 11 studies reporting 4 different implants, with a total of 597 operated joints in 585 patients were included in this review. There were 349 (59.7%) female patients, and the mean age per study ranged from 56.0 to 78.4 years. The all-cause survival rate was 95.52% (95% CI: 92.37–97.96) at a mean follow up of 3.8 years (95% CI: 2.6–5.1). The 40 cases that required re-operation included 17 (2.8%) for infection, 14 (2.3%) instability, 2 (0.3%) for shell migration and 5 (0.8%) for aseptic loosening. The most commonly used patient reported outcome measure was the Harris Hip Score with the mean post-operative score of 86.7 (95% CI: 84.3–89.1). Conclusion: Trabecular titanium acetabular implants, when used in revision THA, resulted in excellent short- to mid-term outcomes with improved hip specific outcomes and a survivorship of 95.52% over the reported follow-up period. Future prospective studies evaluating long term outcomes are needed to make comparisons between more established solutions used in revision THA.

P-70. Outcome of Gram-Negative Periprosthetic Joint Infection after Primary and Revision Total Hip and Knee Arthroplasty

Abstract Background Gram-negative bacteria (GNB) account for 5-23% of all periprosthetic joint infections (PJI), following total knee or hip arthroplasties (TKA, THA). Literature on the management of Gram-negative PJI is limited. This study aimed to describe our experience with the presentation, management, and outcomes of Gram-negative PJI.Table 1:Baseline characteristics (N = 126 cases)Data are N (%) unless otherwise specified. Abbreviations: BMT; Bone-marrow transplant, CCI; Charlson comorbidity index, CPPD; Calcium pyrophosphate crystal deposition, CRP; C-reactive protein, DMARDs; Disease-modifying antirheumatic drugs, ESR; Erythrocyte sedimentation rate, GERD; Gastroesophageal reflux disease, IQR; Inter-quartile range, PJI; prosthetic joint infection, SD; Standard deviation, TNF; Tumor necrotic factor, WBC; white blood cell Methods A retrospective review of our infected institutional total joint registry from 2012-2023 identified 125 patients with 126 GNB PJI (60 THA and 66 TKA) according to MSIS criteria for PJI. Seventy-two cases (57%) of GNB PJI in this series were classified as acute based on the duration of symptoms of less than 4 weeks. Treatment failure was defined as reoperation for any reason, persistent infection, or reinfection post-surgery. Baseline demographics, presenting symptoms, microbiological data, and treatment outcomes were reviewed.Table 2:Therapies (N = 126 joints)Data are N (%) unless otherwise specified. Abbreviations: DAIR; Debridement, antibiotics, and implant retention, IQR; Inter-quartile range Results For baseline demographics, see Table 1. Notably, 10% of patients included in the study were immunosuppressed. Fifty-five cases (43.6%) had a history of revision prior to the diagnosis of PJI, including 44 cases with history of prior PJI. Pseudomonas aeruginosa was the most commonly isolated pathogen (31.7%). Wound drainage was associated with polymicrobial growth (40.8%). Debridement, antibiotics, and implant retention (DAIR) was utilized in 42 cases with 9.8% failure rate. History of revision arthroplasty, chronic PJI and the presence of sinus tract were associated with higher odds of reoperation within 1 year. Eighty-four cases underwent resection arthroplasty (RA), 73 had antimicrobial spacer, of those, 60 patients completed two-stage revision (TSR). At the time of reimplantation, 45/60 (75%) of cases had negative cultures (Table 2). The overall failure rate in resection group failure rate was 45.2%. Wound drainage was associated with higher odds of reoperation in this group (Table 3). The Failure rate in this cohort was 33%. Fluoroquinolones had a 90% susceptibility rate but were used infrequently for chronic suppression (25%).Table 3:Predictor factors with reoperation for any reason within 1 yearData are N (%) unless otherwise specified.Abbreviations: DAIR; Debridement, antibiotics, and implant retention, PJI; Prosthetic joint infection Conclusion Pseudomonas aeruginosa was the predominant pathogen in GNB PJI, with a high failure rate observed in the resection group. History of revision arthroplasty, chronic PJI, sinus tracts and wound drainage were associated with increased risk of reoperation within 1 year.Figure 1:Distribution of failure events across the study Disclosures Nicholas Bedard, MD, Stryker: Advisor/Consultant

Incidence of hypomagnesemia based on ionized and total serum magnesium in patients undergoing revision total hip arthroplasty: A retrospective cohort study

Incidence of hypomagnesemia based on ionized and total serum magnesium in patients undergoing revision total hip arthroplasty: A retrospective cohort study

Preoperative diagnostic efficacy of novel blood markers white blood cell ratio and fibrinogen levels in periprosthetic joint infection

To investigate the clinical utility of novel of new hematological markers in the preoperative diagnosis of periprosthetic joint infection (PJI). A retrospective analysis was conducted on a total of 149 patients who underwent revision of total hip arthroplasty (THA) or total knee arthroplasty (TKA) at a single center between January 2016 and June 2022, including 63 males and 86 females, aged from 47 to 93 years old with an average of (69.5±11.8) years old. Of them, 46 were diagnosed as PJI(PJI group), including 22 males and 24 females. The mean age was (71.3±12.5) years old. The body mass index (BMI) was (26.4±3.1) kg·m-2. And 103 patients were diagnosed as aseptic prosthesis loosening (aseptic group), including 41 males and 62 females. The mean age was (68.7±11.4) years old. The BMI was (25.8±3.5) kg·m-2. Preoperatively analyzed clinical parameters included C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), albumin, globulin, albumin-to-globulin ratio (AGR), plasma D-dimer, and plasma fibrinogen. The receiver operating characteristic curve (ROC), sensitivity, and specificity analysis were employed to compare the diagnostic value of each blood marker in preoperative PJI diagnosis. In the PJI group, the levels of CRP were 16.6 (7.6, 4.5) mg·L-1, ESR was 17.0 (12.8, 35.5) mm·h-1, plasma D-dimer was 1.0 (0.5, 3.1) μg·L-1, and plasma fibrinogen was 4.2 (3.2, 3.1) mg·L-1;all of which were higher compared to the aseptic group with CRP at 4.2 (2.6, 7.8) mg·L-1, ESR at 12.0(8.0, 20.0 )mm·h-l, D-dimer at 0.4(0.2, 0.7)μg·L-1, and fibrinogen at 2.8(2.4, 3.3 ) g·L-1(P<0.05). However, the albumin level of 35.3 (32.3, 37.5) g·L-1 and the WBC ratio of 1.0(0.9, 1.1) in the PJI group were significantly lower compared to the aseptic group with levels of 39.8 (36.1, 41.8) g·L-1 and 1.4 (1.3, 1.5), respectively (P<0.05). Only the area under the curve (AUC) of AGR and plasma fibrinogen were greater than 0.8. The optimal predictive cut-1off, AUC, sensitivity and specificity were 3.4 g·L-1, 0.820, 69.57% and 84.47% for plasma fibrinogen; 1.18, 0.813, 82.61% and 78.64% for AGR, respectively. AGR and plasma fibrinogen are promising blood markers for improving the diagnosis of PJI.

Effect of head size, head material, and radiation dose on the repeatability of CT-RSA measurements of femoral head penetration.

The risk of early revision of total hip arthroplasty (THA) for polyethylene wear is now low, but there remains a need to perform wear measurements in patients for clinical surveillance. The gold standard of wear measurements has been radiostereometric analysis (RSA), which has limited availability. The use of computed tomography (CT) to perform THA wear measurement was described a decade ago and found to have acceptable accuracy and precision, but high radiation dose was a concern. Additionally, the use of larger femoral head sizes and ceramic femoral heads has risen in the past decade. The objectives of the study were to determine the effect of femoral head size, femoral head material, and lowered radiation dose on femoral head penetration measurement repeatability. A cadaveric hip was implanted with a cementless THA implant system. CT scans were acquired at a conventional radiation dose and at a reduced dose and repeated for a 32mm and 36mm cobalt-chromium femoral heads and a 32mm ceramic femoral head. Apparent translation of the femoral head versus the acetabular cup was measured between the repeated scans using a CT-RSA software, where deviations from zero indicated measurement precision. The mean and standard deviation of translations in all planes was <0.200mm. There was no effect for 3D translation of increasing cobalt-chromium head size (p=0.2252). Cobalt-chromium heads had superior repeatability compared to ceramic heads at reduced dose (p=0.022), but not at conventional dose (p=0.1265). Further, superior repeatability was achieved with the reduced dose scan for the cobalt-chromium head (p=0.0058), however there was no difference between doses for the ceramic head (p=0.8148). CT-based wear measurement repeatability is excellent and consistent with prior literature even when implementing a larger femoral head, a ceramic femoral head, or reducing radiation dose to 25% of a conventional clinical scan.

Trends and Epidemiology in Revision Total Hip Arthroplasty: A Large Database Study.

The clinical and financial burden of revision total hip arthroplasty (rTHA) continues to grow. Therefore, further investigation is needed to characterize case volume, reason for failure, and postoperative complications. The purpose of this study was to characterize contemporary indications for and complications following rTHA. Patients undergoing rTHA between 2010 and 2021 were identified within the PearlDiver database. Adjusted rTHA incidence was calculated by dividing the annual rTHA volume by the annual primary THA and multiplying by 100,000. Mann-Kendall trend tests were utilized to trend revision volume, etiology, and 90-day postoperative complications. A total of 225,958 rTHAs were identified. The annual volume of rTHA did not change over the study period (18,871 to 15,994; P=0.064). However, the adjusted incidence of rTHA significantly decreased (20,169.3 to 13,061.2 per 100,000 THAs; P<0.001). The most common causes of revision THA were aseptic implant loosening (21.5%), instability (19.8%), and infection (19.1%). The adjusted incidences of revision due to infection (4,659.9 to 2,596.1 per 100,000 THAs; P<0.001) and aseptic implant loosening (4,651.4 to 2,493.2 per 100,00 THAs; P<0.001) decreased over time. The adjusted rate of instability (3,149.8 to 3,245.3 per 100,000 THAs; P=0.304) did not change. Rates of post-revision deep vein thrombosis, hematoma, surgical site infection, and transfusion significantly decreased over the study period (p<0.05) while rates of emergency department visits and readmission did not change. In addition to a decreased adjusted incidence of rTHA, our analysis demonstrated a decreased incidence of infection, aseptic loosening, and various post-operative complications. However, no difference in the adjusted incidence of instability and periprosthetic fracture were seen over our study period. Continued study is necessary to further decrease the need for revision THA with focus on the etiologies and complications that have remained unchanged.

Intraoperative Femoral Fractures During Primary Total Hip Arthroplasty Are Associated With Increased Revision and Complication Rates.

Intraoperative femoral fractures are a rare, but serious complication of primary total hip arthroplasty (THA), and little is known about the rates of complications and reoperations in these patients. The objective of this investigation was to describe the two-year outcomes and revision rates in patients who sustain an intraoperative femoral fracture during THA. A large administrative claims database was queried for patients who sustained an intraoperative femoral fracture during primary and elective THA from 2015 to 2022. Patients requiring THA for tumors or fractures were excluded. Patients who sustained an intraoperative fracture were matched 1:1 based on age, sex, and comorbidity burden. The incidence of medical and surgical complications was compared between cohorts. Kaplan-Meier and multivariate analyses were used to compare two-year outcomes between groups. Among matched cohorts of 2,795 patients, those who sustained an intraoperative femoral fracture experienced higher rates of periprosthetic joint infection (PJI) (odds ratio [OR]: 2.0, P < 0.001), instability (OR: 1.6, P= 0.013), revision THA (OR: 2.7, P < 0.001), deep vein thrombosis (OR: 3.0, P < 0.001), and transfusion (OR: 2.8, P < 0.001) at 90 days and demonstrated significantly longer length of stay (5.7 ± 6.3 versus 3.6 ± 4.5 days, P < 0.001). At a 2-year follow-up, patients who had an intraoperative femoral fracture were more likely to develop a PJI (OR: 2.1, P < 0.001), periprosthetic fracture (OR: 1.6, P= 0.030), aseptic loosening (OR: 3.0, P < 0.001), and instability (OR: 1.7, P= 0.001) and undergo all-cause revision (OR: 2.3, P < 0.001). Patients who sustained an intraoperative femoral fracture during primary THA were significantly more likely to develop PJI, periprosthetic fracture, aseptic loosening, instability, undergo revision THA, and experience medical complications. Strategies to mitigate intraoperative fracture during THA are necessary to improve outcomes in these high-risk patients.

Biomechanical analysis of a short femoral stem used in revision total hip replacement of a standard femoral stem

Short-stem total hip arthroplasty (SHA) has become popular because it preserves femoral bone stock and enables the use of short femoral stems in revision total hip arthroplasty (THA). However, no study has evaluated whether a short stem in revision THA, replacing a standard stem, can provide adequate primary stability to facilitate osseous integration. In this biomechanical study, a metaphyseal anchoring SHA (Tri-Lock BPS) stem and a standard THA (Corail) stem were implanted into ten composite femurs and loaded dynamically from 300 to 1700 N with 1 Hz. Primary stability was estimated using three-dimensional (3D) micromotions at five points around the bone–implant interface. A revision scenario was then established by removing the standard stem and implanting the same Tri-Lock BPS stem, with subsequent measurements of 3D micromotions. In the primary scenario, no significant differences in 3D micromotions were noted between the short and standard stems at most of the test points. Compared with the Corail group, the Tri-Lock BPS group presented significantly greater 3D micromotions only at the lateral point of the distal femur (P5: Tri-Lock BPS 32.9 ± 7.54 μm vs. Corail 25.1 ± 4.32 μm; p = 0.011). In the revision scenario, no significant differences in the 3D micromotions were noted between the primary and revision Tri-Lock BPS stems at all test points. Our results show that the SHA (Tri-Lock BPS) offers good primary stability, which is similar to that of the standard THA (Corail). The Tri-Lock BPS stem obtained comparable stability in this revision scenario as in the primary scenario; therefore, it can be assumed that the Corail standard stem can safely be revised with a Tri-Lock BPS short stem.

Cost Effectiveness of Fixation Versus Total Hip Arthroplasty in Vancouver B2 Periprosthetic Femur Fractures: A Predictive Markov Analysis.

Although Vancouver B2 periprosthetic fractures (PPFs) have been historically managed with revision total hip arthroplasty (rTHA), open reduction and internal fixation (ORIF) has been proposed as an alternative option for reasons including lower cost and surgical time. The purpose of this study was to, therefore, create a Markov model to assess the cost effectiveness of ORIF versus rTHA for Vancouver B2 periprosthetic femur fractures and evaluate various inflection points for varying costs and outcome measures. A Markov model was built using discrete and mutually exclusive health states of the hypothetical patient with Vancouver B2 PPF. A decision tree was created on possible outcomes for each health state, using probabilities defined in the recent PPF literature. Direct costs and quality-adjusted life-years for each surgery and complication state were also collected. One-way and two-way deterministic sensitivity analyses were conducted to better understand the effect of 1 to 2 variables on the incremental cost-effectiveness ratio. The hypothetical patient with a Vancouver B2 PPF that was treated with rTHA incurred a cost of $52,559.64 with an effectiveness of 0.71. When treated with ORIF, the cost was $47,371.97 with an effectiveness of 0.38. The incremental cost and effectiveness of rTHA over ORIF were found to be $5,187.67 and 0.33, respectively. The cost of rTHA, the cost of ORIF, and the effectiveness of ORIF were the most influential variables in the model. On two-way sensitivity analysis, rTHA was more cost effective than ORIF within realistic healthcare parameters. From the payer perspective, we estimate that rTHA is more cost effective than ORIF for the treatment of Vancouver B2 PPFs within certain cost and quality-of-life parameters.

Custom-Made 3D-Printed Augments and Cages: An Effective Solution for Managing Severe Acetabular Bone Loss.

Total hip arthroplasty (THA) is recognized as one of the most effective surgical procedures for the treatment of end-stage hip arthritis. However, the increasing number of primary THA cases has led to a corresponding rise in the frequency of revision surgeries, which are often more complex and challenging due to severe acetabular bone loss. In such cases, managing Paprosky type 3A and 3B defects requires precise implant design and advanced surgical techniques. Standard acetabular augments and anti-protrusio cages are commonly used, but they often fail to provide the necessary stability, leading to re-revision rates as high as 36% within 10 years. This case series explores the efficacy of custom-made 3D-printed acetabular augments and cages in managing severe acetabular bone loss during revision THA. This retrospective case series includes seven patients who underwent revision THA for Paprosky grade 3 acetabular bone loss between January 2023 and April 2024 at two high-volume tertiary care centers. The mean age of the patients was 45 years, with three males and four females included in the study. Pre-operative planning involved advanced imaging techniques, including 3D-computed tomography scans and custom virtual modeling, to design the acetabular components tailored to each patient's specific anatomical requirements.During the surgeries, custom-made 3D-printed titanium augments and cages were used. These implants were fabricated using in-house software, and the turnaround time from the decision to surgery was approximately 10 days. Post-operatively, the planned 3D model was superimposed on post-operative radiographs to assess implant placement accuracy. The Harris hip score at the final follow-up averaged 69.16, with no signs of implant loosening observed. Custom-made 3D-printed acetabular augments and cages offer a reliable and cost-effective solution for managing severe acetabular bone loss in revision THA. Despite the small sample size and short follow-up period, the results demonstrate the potential of these custom implants to improve outcomes in complex acetabular reconstructions. Further studies with larger sample sizes and longer follow-up periods are needed to confirm these findings and establish long-term efficacy.

Cup-Cage Reconstruction for Pelvic Discontinuity: Encouraging Long-Term Survival.

Pelvic discontinuity (PD) poses a difficult challenge in revision total hip arthroplasty (rTHA). There is a paucity of evidence assessing five- to ten-year outcomes of cup cages for PD. This study aimed to review the survivorship and outcomes of cup-cage constructs for PD. Cases without PD or with < 2-year follow-up were excluded. There were 48 cup-cage revisions identified with a mean follow-up of 7.2 years (range, two to 20). The mean age was 77 years, and 71% were women. Kaplan-Meier analysis was used to determine survival with all-cause and aseptic loosening re-revision as endpoints. Secondary outcomes included radiological failures and patient-reported outcomes (PROMs). All-cause re-revision survival was 80% (95% CI [confidence interval] 0.70 to 0.93) at five years and 68% (95% CI 0.54 to 0.85) at 10 years. Re-revision survival for aseptic loosening of the cup-cage construct was 95% (95% CI 0.89 to 1.00) at five years and 85% (95% CI 0.74 to 0.98) at 10 years. There were 13 (27%) patients who underwent re-revision at a mean of 45 months post rTHA (range, one to 112). Aseptic loosening prompted re-revision in five of 48 (10%) cases at a mean of 68 months (range, 29 to 98). Of these, three required cup revisions for loosening, and two required isolated cage/liner revisions with well-fixed cups. There were three patients who had resection arthroplasty for chronic infection. There were three patients revised for instability with liner exchange or femoral revision only, as the cup-cage constructs had not failed. Patient-reported pain (mean Western Ontario and McMaster Universities Arthritis Index (WOMAC), 83.5) and function (mean WOMAC function 75.4, Oxford Hip Score (OHS), 71.2) were acceptable. Cup-cage reconstruction is a good solution for PD with encouraging five- to ten-year results and acceptable survivorship and PROMs.

Modular dual-mobility constructs outperformed large femoral heads in 299 revision total hip arthroplasties at mid-term follow-up.

The purpose of this study was to directly compare the Modular Dual Mobility (MDM) Mobile Bearing Hip System (Stryker, USA) and large femoral heads (LFHs) in revision total hip arthroplasties (THAs) at mid-term follow-up, with specific emphasis on survival free of re-revision for dislocation, any re-revision, dislocation, and the risk of metal-related complications. We identified 299 revision THAs performed at a single tertiary care academic institution from March 2011 to July 2014. Aseptic loosening of the acetabular component (n = 65), dislocation (n = 58), and reimplantation as part of a two-stage exchange protocol (n = 57) were the most common reasons for index revision. MDM constructs were used in 123 cases, and LFHs were used in 176 cases. Mean age was 66 years (28 to 93), mean BMI was 31 kg/m2 (18 to 55), and 45% (n = 136) were female. Mean follow-up was seven years (2 to 12). The ten-year survival free of re-revision for dislocation was 99% (95% CI 95 to 100) in the MDM cohort and 91% (95% CI 84 to 96) in the LFH cohort, with a significantly increased risk of re-revision for dislocation in the LFH cohort (HR 7.1 (95% CI 1.3 to 40.8); p = 0.023). The ten-year survival free of any re-revision was 92% (95% CI 82 to 99%) in the MDM cohort and 84% (95% CI 74 to 90) in the LFH cohort with a significantly increased risk of any re-revision in the LFH cohort (HR 2.6 (95% CI 1.1 to 5.9); p = 0.024). The ten-year survival free of any dislocation was 95% (95% CI 85 to 99) in the MDM cohort and 87% (95% CI 78 to 92) in the LFH cohort with a significantly increased risk of any dislocation in the LFH cohort (HR 2.7 (95% CI 1.1 to 6.3); p = 0.028). There were no re-revisions or reoperations for metallosis or corrosion in the MDM cohort. In this head-to-head comparison, revision THAs with a MDM construct safely and effectively lowered the risk of re-revision for dislocation, any re-revision, and any dislocation compared to LFH at mid-term follow-up. There were no re-revisions or reoperations for metallosis or corrosion in the MDM cohort.

The Visual Assessment of Cup Position on Anteroposterior Pelvis Radiographs Before Revision Total Hip Arthroplasty for Instability Is Highly Deceiving.

Is "eyeballing" enough to determine cup malposition on anteroposterior (AP) pelvis radiographs before revision total hip arthroplasty (rTHA) for instability? We aimed to determine the following: (1) the reliability of eyeballing cup inclination/anteversion on AP pelvis radiographs vs geometrical measurements and (2) whether visual assessments are affected by surgeon experience. Fifteen de-identified standing AP pelvis radiographs obtained before rTHA for instability were evaluated by one orthopedic surgeon who measured inclination/anteversion of the cups (n=15) using a new simplified method based on basic geometry. Subsequently, 4 orthopedic surgeons and 4 fellows (postgraduate year 6) assessed inclination/anteversion by eyeballing. A modified Lewinnek safe zone range was employed to categorize each value (in degrees) by geometrical measurements or by raters' eyeballing as within or outside the safe zones. Cohen's kappa (κ) statistics were performed. Mean κ values of attending surgeons and fellows were compared. According to geometrical measurements, 8 and 12 cups were in malposition (for inclination and anteversion, respectively). By just eyeballing, no attending surgeon or fellow attained an excellent (κ>0.8) level of agreement when compared with geometrical measurements. Only 1 attending surgeon attained a substantial (κ=0.6-0.8) level of agreement (κ=0.737, for inclination, P=.003). Mean κ values of attending surgeons and fellows were 0.476 and 0.187, respectively, for inclination (P=.2) and 0.416 and 0.428, respectively, for anteversion (P=.9). Eyeballing cup position on AP pelvis radiographs before rTHA for instability is extremely misleading, regardless of surgeon experience. It is imperative to always measure the inclination and anteversion of the cup. [Orthopedics. 2025;48(1):e22-e26.].

Dual-Mobility Articulations in Revision Total Hip Arthroplasty: A Comparison with Metal or Ceramic on Highly Cross-Linked Polyethylene and Constrained Articulations.

The increased availability of dual-mobility acetabular constructs (DMCs) provides surgeons with a newer option to increase the effective femoral head size in revision total hip arthroplasty (rTHA). We sought to evaluate risks of re-revision and prosthetic dislocation following rTHA involving a DMC compared with other articulations. A cohort study was conducted using data from a U.S. integrated health-care system's Total Joint Replacement Registry. Adult patients who underwent primary THA and went on to undergo an aseptic rTHA in 2002 to 2022 were identified. Patients who received a DMC, a constrained liner, or a metal or ceramic unipolar femoral head on highly cross-linked polyethylene (XLPE) at the time of rTHA were the treatment groups. Subsequent aseptic re-revision and dislocation were the outcomes of interest. Multivariable Cox proportional-hazards regression was used to evaluate the risks of the outcomes, with adjustment for patient, operative, and surgeon confounders. The analyzed rTHAs comprised 375 with a DMC, 268 with a constrained liner, 995 with a <36-mm head on XLPE, and 2,087 with a ≥36-mm head on XLPE. DMC utilization increased from 1.0% of rTHAs in 2011 to 21.6% in 2022. In adjusted analyses, a higher re-revision risk was observed for the constrained liner (hazard ratio [HR] = 2.43, 95% confidence interval [CI] = 1.29 to 4.59), <36 mm on XLPE (HR = 2.05, 95% CI = 1.13 to 3.75), and ≥36 mm on XLPE (HR = 2.03, 95% CI = 1.19 to 3.48) groups compared with the DMC group. A higher dislocation risk was observed in both XLPE groups (<36 mm: HR = 2.04, 95% CI = 1.33 to 3.14; ≥36 mm: HR = 2.46, 95% CI = 1.69 to 3.57) compared with the DMC group; a nonsignificant trend toward a higher dislocation rate in the group with a constrained liner than in the DMC group was also observed. In a large U.S.-based cohort, rTHAs using DMCs had the lowest re-revision risk and dislocation risk. Both outcomes were significantly lower than those using a unipolar femoral head on XLPE, re-revision risk was significantly lower than using a constrained liner, and dislocation risk trended toward a lower risk than using a constrained liner. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

A systematic review on revision total hip arthroplasty employing the direct anterior approach.

The increased use of the direct anterior approach (DAA) for primary total hip arthroplasty (THA) has extended to revision THA. This systematic review evaluated studies reporting both the utility and clinical outcomes of revision THA using DAA, focusing on studies comparing revision approaches. A review of the Cochrane Library, EMBASE, and MEDLINE databases identified 577 publications. 538 were excluded after abstract screening. Full-text review identified 21 studies with 1627 patients. All studies were retrospective, level IV evidence. MINORS criteria rated 14 as poor and seven as moderate. Five studies compared DAA to alternative approaches. Meta-analysis was not performed due to significant heterogeneity and lack of comparative studies. The most common indications for revision were aseptic loosening (n = 929) and polyethylene wear (n = 158). The majority of the studies (n = 11/21) performed primarily acetabular revision or head-liner exchanges. Half the revisions (50.6%; n = 823/1627) included femoral revisions (35.2%; n = 573/1627) or combined femoral-acetabular revisions (15.4%; n = 250/1627). However, 80.6% (n = 462/573) of femoral revisions were from two non-comparative studies. Among the five comparative studies, two included femoral or combined revisions with significantly more performed using the posterior approach. Three of the five comparative studies did not find the DAA protective against postoperative dislocation. The overall complication rate was 14.0%; periprosthetic femoral fracture (n = 106), dislocation (n = 80), and infection (n = 36) were most common. Fourteen studies reported patient-reported outcome measures, demonstrating consistent improvements following revision THA. Current data on revision DAA THA are limited due to their retrospective nature. They demonstrate the ability to safely perform acetabular and head-liner revisions in carefully selected patients. Comparative studies lack femoral revisions, show a propensity for femoral fractures, and exhibit selection bias. Higher-quality, comparative prospective studies are needed. PROSPERO: CRD4202236457.

Dual-Mobility Articulations in Revision Hip Arthroplasty: Commentary on an article by Monti Khatod, MD, et al.: "Dual-Mobility Articulations in Revision Total Hip Arthroplasty. A Comparison with Metal or Ceramic on Highly Cross-Linked Polyethylene and Constrained Articulations".

Dual-Mobility Articulations in Revision Hip Arthroplasty: Commentary on an article by Monti Khatod, MD, et al.: "Dual-Mobility Articulations in Revision Total Hip Arthroplasty. A Comparison with Metal or Ceramic on Highly Cross-Linked Polyethylene and Constrained Articulations".

Identifying 10-year cumulative incidence and risk of revision following total hip arthroplasty in patients with and without a diagnosis of human immunodeficiency virus.

Prior studies have shown human immunodeficiency virus (HIV) may be a risk factor for early revision following THA, but little data exists looking at long-term implant survivorship. Therefore, the purpose of this study was to compare the 10-year cumulative incidence rate for revision following THA in patients with and without HIV. A retrospective cohort analysis of patients with HIV undergoing elective THA was conducted using a national database. Patients were stratified into asymptomatic HIV (AHIV) and acquired immune deficiency syndrome (AIDS) cohorts. These patients were propensity-score matched to a group of elective THA patients without HIV based on age, gender, and Charlson Comorbidity Index (CCI) at a 1:2 ratio. Kaplan-Meier and Cox Proportional Hazards Regression Analyses were used to assess cumulative incidence and risk of revisions within 10-years of the index procedure. In total, 678 patients were at-risk at the 10-year mark. There were no differences in 10-year risk of revision THA, amongst patients with HIV when compared to matched and unmatched controls (p > 0.05 for all). Patients with HIV did have an increased risk of periprosthetic joint infection (PJI) following THA when compared to the unmatched control (p = 0.001). Surgeons and patients can be reassured of comparable 10-year revision rates in patients with and without HIV. However, as these patients are at increased risk for PJI and PPF, especially those with AIDS, when compared to the general population, surgeons should consider PJI prophylactic modalities in this patient population.