Signs Of Loosening Research Articles

Patient-specific instrumentation improved clinical outcome and implant survival but is not superior compared to conventional total knee arthroplasty: Ten years follow-up of a multicenter double-blind randomized controlled trial.

Patient-specific instrumentation (PSI) is a commonly used technique designed to improve mechanical alignment in total knee arthroplasty (TKA) and was therefore believed to lead to better clinical outcome and implant survival rates compared with conventional instruments (CIs). To date, long-term results comparing these two techniques are not available. This study is a 10-year follow-up of a previous double-blind multicenter randomized controlled trial where PSI was compared with CI. Patients with osteoarthritis of the knee who were candidates for TKA were included. Exclusion criteria were metal near the knee-, ankle- or hip joint, patients with contra-indications for a magnetic resonance imaging (MRI) scan and patients who had previous knee surgery (except arthroscopic meniscectomy). Clinical outcomes were assessed using patient-reported outcome measures (PROMs), and the analysis was performed with a general linear mixed model for repeated measurements. Kaplan-Meier curves were used to compare revision rates. X-rays were obtained and examined by two individual reviewers for any signs of loosening of the components. At a mean follow-up of 10.1 (SD 0.1) years, 129 patients (loss to follow-up 23%) were analysed in this trial. No statistically significant difference between the two groups were found for any of the PROMs and revision rates were comparable, six in the PSI group and three in the CI group (p = 0.29). Two X-rays in the PSI group showed a radiolucent line of the femoral component. At 10-year follow-up, PSI does not lead to better clinical outcome or survival of the prosthesis compared with CI.

Long term follow-up of a completely metal free total knee endoprosthesis in comparison to an identical metal counterpart

Aseptic loosening is a feared and not yet fully-understood complication of total knee arthroplasty (TKA). Hypersensitivity reactions may be the underlying cause within some susceptible patients. Metal-free implants have been developed as a possible solution. The aim of this prospective, observational long-term study was the assessment of a completely metal-free ceramic knee replacement system compared to its identical metal counterpart 8 years after implantation, conducted as a follow-up of a previous report. A total of 88 patients (mean age 69 years) were enrolled in this prospective, observational long-term 8-year follow-up study. The “ceramic group” with a completely metal-free total knee replacement system was compared to the “conventional group” with an identical metal TKA system at the final follow-up. Clinical assessment included Knee Society Score (KSS), Oxford Knee Score (OKS), European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-L), European Quality of Life 5 Dimension Visual Analogue Scale (EQ-VAS) and High Activity Arthroplasty Score (HAAS) as well as perioperative or postoperative complications and need for revision. The tibial/femoral positioning, signs of periprosthetic fissures/fractures or radiolucent lines were documented radiographically. All postoperative clinical scores in the ceramic group primarily improved from baseline to 4-year follow-up, but then decreased at the final 8-year follow-up. At the final follow-up, statistically non-significant differences were found in comparison of both groups for the KSS (ceramic: 166 ± 31, conventional: 162 ± 29; p > 0.05), OKS (ceramic: 37, conventional: 39; p > 0.05), EQ-VAS (ceramic: 77 ± 17, conventional: 72 ± 18; p > 0.05), and HAAS (ceramic: 8.29 ± 3.32, conventional: 9.28 ± 4.44; p > 0.05). A significant difference was found for EQ-5D-L (ceramic: 0.819 ± 0.284, conventional: 0.932 ± 0.126; p ≤ 0.05). Progressive radiolucent lines have been found around the uncemented tibial stem (0.8 mm at initial diagnosis (mean 19 months); 1.3 mm at 4-year follow-up; 1.6 mm at 8-year follow-up) without any clinical signs of loosening. One revision surgery was performed after a traumatic polyethylene inlay-breakage. No allergic reactions could be detected. The used ceramic TKA system meets the functional performance standards of an established identical metal TKA system after an 8-year follow-up period, offering a safe option for patients with prior hypersensitivity reactions to metallic materials. Full cementation of ceramic components is recommended.

PRIMARY TOTAL HIP ARTHROPLASTY USING CUSTOM-MADE ACETABULAR IMPLANTS IN PATIENTS WITH CROWE IV DEVELOPMENTAL DYSPLASIA OF THE HIP

Literature data show varying rates of aseptic loosening of standard hemispherical cups after primary total hip arthroplasty (THA) in patients with Crowe IV developmental dysplasia of the hip (DDH). In order to improve the results regarding the frequency of aseptic loosening of the acetabular component, we decided to use custom-made acetabular implants (CMAI) in this category of patients. The aim of our study was to report outcomes after primary THA using CMAI in patients with Crowe IV DDH.We retrospectively analyzed the results of primary THA using the CMAI in 58 hips. The mean follow-up period was 5.2 years (range 4.2 – 6.3).Patients demonstrated improved functional outcomes according to the Oxford Hip Score: preoperatively 16.9 and postoperatively 38.5 (P < 0.05). Revisions were performed in 2 cases due to dislocations, in 1 case due to nonunion of the greater trochanter and in 1 case due to chronic pain syndrome caused by contact of the CMAI flange with the iliopsoas muscle. In a patient with chronic pain syndrome, during the revision, the pubic flange of the CMAI, which was in contact with the iliopsoas muscle, was removed. There were no radiological signs of loosening of the CMAI.The use of CMAI shows good results in patients with DDH. Extended capability for supplementary screw fixation is an excellent feature of such implants, allowing them to obtain reliable primary fixation. Further observation is required to assess CMAI in the long-term follow-up.

The Use of Dual-Mobility Implants Through a Direct Anterior Approach as a Safe and Effective Technique for Revision Hip Arthroplasty: The Two-Year Follow-Up of a Case Series.

Background Dislocation is one of the most prominent and challenging complications following the revision of total hip arthroplasty (THA). Dual-mobility cups are an option to address this problem. There is, however, little data on the outcomes of modern modular dual-mobility (MDM) cups in the revision of THA. In this study, the clinical and radiological outcomes following the revision of THA with an MDM cup using the direct anterior approach (DAA) were evaluated. Methodology We retrospectively reviewed patients who underwent a revision of THA between March 2017 and July 2019. The inclusion criteria were a revision of THA using an MDM cup through the DAA. A uniform acetabular implant was used in each revision. Outcome measures were assessed radiographically and clinically. The clinical outcome measures consisted of dislocation, infection, and re-revision. Functional assessment was performed using the Harris Hip Score preoperatively and at the last clinical examination in our department. Results This study retrospectively identified a cohort of 26 patients who underwent a revision of THA. Two patients were excluded due to incomplete follow-up because they died. Finally, 24 patients were included. A total of 17 isolated acetabular revisions and seven complete revisions were performed with a mean follow-up of 39 months (range = 29-59). No dislocations or deep infections were observed in our population to date. Except for one case of early aseptic loosening of the acetabular component, we observed no other signs of loosening, osteolysis, migration, or intraprosthetic dislocation. Conclusions THA revision through the DAA using an MDM cup is a safe and effective procedure. We observed no dislocation in a high-risk population undergoing THA revision surgery during a minimal follow-up of two years.

Excellent Results of Large-Diameter Ceramic-On-Ceramic Bearings in Total Hip Arthroplasty at Minimum Ten-Year Follow-Up

BackgroundThis study reports the minimum 10 years results of total hip arthroplasty (THA) performed using a monoblock acetabular component with a large-diameter head ceramic-on-ceramic bearing. MethodsOf the 276 THAs included in this study, there were eleven deaths and 27 patients lost to follow up (11%) during the follow-up, leaving 237 (85%) hips available for review at a mean of 10.5 years (range, 10 to 12) postoperatively. Reoperations, implant revisions, adverse events, clinical outcomes, radiographic evaluation, and whole blood metal ion levels were assessed at the last follow-up. ResultsAfter a minimum of 10 years, implant survivorship was 98.7%. There were 3 revisions (1.3%): one for insufficient acetabular cup primary fixation, one traumatic periprosthetic acetabular fracture, and one probable deep chronic infection. No dislocation or ceramic implant fracture was observed. The mean University of California at Los Angeles activity score, Western Ontario and McMaster Universities Osteoarthritis Index score, and Forgotten Joint Score were 5.6 (2 to 10), 90.1 (9 to 100), and 79.2 (4 to 100), respectively. All patients (100%) were satisfied or very satisfied. Since implantation, 43% of patients reported hearing a squeaking noise from the prosthesis. But all patients who reported squeaking were satisfied with the surgery. The mean titanium level was 2.2 μg/L (1.1 to 5.6). No progressive radiolucent lines, osteolysis, or implant loosening signs were observed at the last radiographic evaluation. ConclusionsA large-diameter head ceramic-on-ceramic THA provides outstanding long-term (minimum 10 years) implant survivorship with unrestricted activity while avoiding implant impingement, liner fracture, and hip instability. Functional outcomes, satisfaction, and joint perception were excellent. Although the incidence of squeaking was high, it did not affect patient satisfaction or function. The systemic titanium levels were low, related to unavoidable passive corrosion of implant surfaces, and did not reveal any indirect signs of trunnionosis.

Ankle joint replacement for necrosis of the talus, crusarthrosis, equinovarus and adducted foot

Introduction Surgical treatment of patients with avascular osteonecrosis of the talus and post-traumatic hindfoot deformity is associated with high morbidity, difficulty of early disease detection, the discrepancy between patient expectations and orthopaedic requirements for surgical outcomes due to traditional methods. The use of customized ankle joint replacement may be a potential solution to this problem.The objective was to evaluate the results of treatment of a patient with avascular osteonecrosis of the talus, crusarthrosis and hindfoot deformity using an original replacement method for the ankle joint and the talus.Material and methods A 30-year-old patient with post-traumatic avascular osteonecrosis of the talus, crusarthrosis, equinovarus and adducted foot underwent replacement of the ankle joint and talus using the method developed by the authors. Radiographic and tomographic methods were used for diagnosis. The VAS scale, AOFAS, FFI, EFAS questionnaires and pedobarography were used to assess clinical and functional results.Results The results of treatment evaluated at 12 months showed maintained foot deformity correction, stability of a tailored construct with no signs of loosening and osteolysis. The clinical and functional result showed a 81/2 VAS decrease in pain, functional status improved by 4.3 times with functional foot index (FFI) improved by 2.2 times according to the AOFAS scale at 12 months.Discussion Orthopaedic surgeons are conducting research aimed at preserving ankle motion in the treatment of avascular osteonecrosis of the talus. A serious problem is associated with concomitant deformities of the hindfoot and available implants fail to solve this problem.Conclusion The surgical method offered for the patient provided good clinical and functional results with the hindfoot deformity corrected within one stage reducing the treatment time.

Non-invasive quantitative assessment of induced component displacement can safely and accurately diagnose tibial component loosening in patients: A prospective diagnostic study.

Aseptic loosening often requires major, expensiveand invasive revision surgery. Current diagnostic modalities merely show indirect signs of loosening. A recent proof of concept study proposed a non-invasive technique for the quantitative and visual assessment of implant movement as a diagnostic aid for tibial component loosening. The primary research question addressed is whether this novel diagnostic modality can safely and effectively aid the diagnosis of aseptic loosening. This clinical study included patients suspected of aseptic total knee arthroplasty (TKA) loosening listed for revision surgery and asymptomatic patients. Safety was evaluated using a numerical rating scale (NRS) for discomfort and by registration of adverse events. Feasibility was assessed by recording the duration and ease of the procedure. Intra- and interrater reliability were evaluated. In symptomatic patients, diagnostic accuracy metrics were evaluated with intra-operative assessment as a reference test. In total, 34 symptomatic and 38 asymptomatic knees with a TKA were analysed. The medianNRSfor discomfort during loading was 6 (interquartile range [IQR]: 3.75-7.00) in symptomatic patients and 2 (IQR: 1.00-3.00) in asymptomatic patients. No adverse events were reported. The majority of users found the use of the loading device easy. The median time spent in the computed tomography roomwas 9 min(IQR: 8.00-11.00). Excellent to good intra- and interrater reliabilities were achieved. Diagnostic accuracy analysis resulted in a sensitivity of 0.91 (95% confidence interval [CI]: 0.72-0.97) and a specificity of 0.72 (95% CI: 0.43-0.90). The proposed diagnostic method is safe, feasible, reliableand accurate in aiding the diagnosis of aseptic tibial component loosening. Level II.

Shape-memory sawtooth-arm embracing clamp used in complex femoral revision hip arthroplasty for stem stability: average 9-year follow-up study

BackgroundNickel-Titanium shape-memory sawtooth-arm embracing clamps (SSECs) have been used in revision total hip arthroplasties (rTHAs) to protect stem stability. This study was to introduce this technique and report its mid to long-term clinical and radiographic outcomes.MethodsWe retrospectively reviewed all patients implanted with SSECs in our department from January 2008 to December 2015. 41 patients (41 hips) were finally included. Radiographs and Harris hip scores (HHS) were collected. Radiographs were blindly analyzed for evidence of loosening, subsidence and stress shielding. HHS were compared to previous records by student’s t tests. The average follow-up period was 9.3 years.ResultsAll stems were stably fixed with no signs of loosening. The mean stem subsidence was 0.9 mm (range, 0 to 3 mm). Only one patient (2.4%) demonstrated the fourth degree of stress shielding, with the others none or minor bone resorption. The mean HHS at the final follow-up was 84.2 (range, 81 to 91), which was improved from 17.4 (range, 0 to 37) before surgery. No implant failures or re-revisions occurred. Dislocation occurred in 1 case during the follow-up period.ConclusionsThe SSEC protected stem fixation and achieved favorable clinical and radiographic outcomes in this 9-year follow-up study. It offered an additional extramedullary fixation option for surgeons to choose from in treating complex femoral revision arthroplasties.

Functional survival of cementless trapeziometacarpal total joint arthroplasty after upper extremity trauma

IntroductionOur purpose with this publication is to document the survival of uncemented and unconstrained total trapeziometacarpal arthroplasty after energy trauma to the upper extremity. Material and MethodsFrom 1999 to the present, ten patients carrying total TMC arthroplasty suffered major traumatic injuries on the hand. Eight patients had fractures of the distal radius, one patient had scapho-lunate dissociation and one patient had a dorsal pullout of the triquetrum. A clinical and radiological examination of the patients after the trauma was carried out and compared with the pre-traumatic prosthesis status. ResultsThree patients required surgical intervention for the associated traumatic injury. The postraumatic clinical and functional follow-up of the patients was good, and no differences were documented with respect to mobility, strength and pain at the level of the thumb with respect to the prior to the trauma. No signs of loosening, instability or alteration in the alignment of the components of the protheses were observed in the radiological examinations following the trauma. ConclusionsThere is a high survival rate of uncemented total trapeziometacarpal arthroplasty in the long term, even in the face of energy trauma. It is then a safe implant. Despite of being non-constrained, a good alignment of the prosthetic components is the key to avoid dislocation of the prosthesis.

Common inflammatory markers in the screening of knee arthroprosthesis infections

<p><strong>Aim<br /></strong> To evaluate the sensitivity and specificity of serum C-reactive protein (CRP) in early and late total knee arthroplasty (TKA)<br />infections.<br /><strong>Methods<br /></strong> Blood tests to determine CRP levels (cut-off 10 mg/L) were conducted before surgery, at 1st day, 7th day and 15th day after surgery and at 1, 3, 6,12, 24 and 36 months. Patients had routine follow-up visits and radiological evaluations at 14 days and at 1, 3, 6, 12, 24 and 36 months. Infections were recorded and classified according to Widmer classification. The χ2 test or Fisher (in subgroups smaller than 10 patients) exact test was used to compare categorical variables. The statistical significance was set at p < 0.05.<br /><strong>Results<br /></strong> A total of 19 infections were diagnosed during the followup. According to Widmer, five were classified as early post-operative and 14 as late chronic. All patients with early infections had suspected symptoms such as fever, swelling and pain. During the first month, 59 patients who had high CRP level but negative microbiological culture were considered as false positive representing a CRP sensitivity of 80% and a specificity of 67.6%. Fourteen patients had late chronic infection.<br /><strong>Conclusion<br /></strong> This study suggests that a synovial fluid aspiration should be performed in patients with persistent inflammation<br />symptoms with or without radiographic signs of loosening. Moreover, it recommends the use of different serum and synovial tests for periprosthetic joint infection (PJI) diagnosis.</p>

Nexus Evaluation Primary Trident II UNcemented shEll (NEPTUNE).

The primary aim of this study is to assess the survival of the uncemented hydroxyapatite (HA) coated Trident II acetabular component as part of a hybrid total hip arthroplasty (THA) using a cemented Exeter stem. The secondary aims are to assess the complications, joint-specific function, health-related quality of life, and radiological signs of loosening of the acetabular component. A single-centre, prospective cohort study of 125 implants will be undertaken. Patients undergoing hybrid THA at the study centre will be recruited. Inclusion criteria are patients suitable for the use of the uncemented acetabular component, aged 18 to 75 years, willing and able to comply with the study protocol, and provide informed consent. Exclusion criteria includes patients not meeting study inclusion criteria, inadequate bone stock to support fixation of the prosthesis, a BMI > 40 kg/m2, or THA performed for pain relief in those with severely restricted mobility. Implant survival, complications, functional outcomes and radiological assessment up to ten years following index THA (one, two, five, seven, and ten years) will be performed. Functional assessment will include the Oxford Hip Score, Forgotten Joint Score, 12-Item Short Form Health Survey, EuroQol five-dimension health questionnaire, and pain and patient satisfaction. Radiological assessment with assess for acetabula lucent lines, lysis, and loosening according to DeLee and Charnley zones. This study is part of a stepwise introduction of a new device to orthopaedic practice, and careful monitoring of implants should be carried out as part of the Beyond Compliance principles. The results of this study will provide functional, radiological, and survival data to either support the ongoing use of the HA acetabulum or highlight potential limitations of this new implant before wide adoption.

Excellent mid- to long-term survival of tantalum metal cones in a case series of revision knee arthroplasty with severe bony defects

PurposeSevere metaphyseal bone defects remain a challenge and represent a growing problem in revision total knee arthroplasty (RTKA). The purpose of this study was to examine the survival of first-generation tantalum metal cones (TMC) and to assess clinical and radiographic data obtained from mid- to long-term follow-ups (FU) after RTKA with severe bony defects.MethodsThis retrospective case series included 100 consecutive patients of the same centre, who underwent RTKA surgery with TMC for tibia and/or femur bone defects between January 2011 and December 2015. Fourteen patients had died and six were lost for FU, leaving a total of eighty patients (one hundred and twelve TMC) for final evaluation. Clinical parameters including the Knee Society Score (KSS), visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and range of motion (ROM) were determined preoperatively based on the patients’ medical charts, and assessed again during the final FU after an average of 6.1 (5–9) years postoperative. Standardised postoperative X-rays were analysed during the final FU visit for osseointegration of the cones, and any signs of implant loosening were assessed with the modified Knee Society Radiographic review criteria. Perioperative and postoperative complications, reoperations, as well as implant and cone re-revisions were analysed. Survivorship analysis was performed with (a) cone-related revision for any reason and (b) implant component revision for any reason.ResultsPrevious RTKA had to be performed due to 64 (80%) aseptic and 16 (20%) septic failures. At the final FU, 75 (94%) tibia and 76 (95%) femur TMCs and implants were clinically stable. One patient experienced loosening of cones and implants at the femur and tibia but denied re-revision surgery. There were eight (10%) reoperations including two early wound healing problems, two inlay changes, two periprosthetic fractures, one debridement, antibiotics and implant retention (DAIR), and one secondary patella replacement. The six (7.5%) re-revisions included two aseptic loosening’s of the opposite implant without TMC, one arthrodesis for recurrent instability, and three deep infections managed by two two-stage exchanges, and one amputation for persistent infection. At re-revision, all TMC cones were osteointegrated without signs of loosening. The determined clinical parameters showed significant (p < 0.001) postoperative improvement, and objective KSS was rated as excellent in 51%, and as good in 22% of patients at the final FU. The estimated 8-year Kaplan–Meier survival was 95% for TMC and 92.5% for implant components.ConclusionTantalum metal cones (TMC) demonstrate a secure fixation for treatment of severe femoral and tibial metaphyseal bone defects during RTKA. This fixation concept showed excellent mid- to long-term clinical and radiographic outcomes with promising 8-year survival rates for cones and implant components.Level of evidenceRetrospective cohort study, Level IV.

Effectiveness of one-stage total knee arthroplasty in treatment of advanced active knee tuberculosis

To investigate the effectiveness of one-stage total knee arthroplasty (TKA) in the treatment of advanced active knee tuberculosis. The clinical data of 38 patients with advanced active knee tuberculosis who received one-stage TKA between January 2011 and December 2020 were retrospectively analyzed. There were 20 males and 18 females. The age ranged from 20 to 84 years, with an average of 52.8 years. The body mass index ranged from 17 to 36 kg/m 2, with an average of 23.05 kg/m 2. The preoperative C reactive protein (CRP) was (23.49±4.72) mg/L, erythrocyte sedimentation rate (ESR) was (45.95±8.82) mm/1 h. The Hospital for Special Surgery (HSS) score was 48.8±9.1. During the operation, the infected lesions of the knee joint were completely removed, and the operative area was repeatedly soaked with 3% hydrogen peroxide solution and 0.5% povidone iodine solution. The intraoperative pathological examination confirmed the tuberculosis of the knee joint, and systemic anti-tuberculosis treatment was performed. The operation time, postoperative hospitalization stay, postoperative anti-tuberculosis chemotherapy time, and complications were recorded. CRP and ESR were recorded and compared before and after operation. Anteroposterior and lateral X-ray films of the knee joint were taken to evaluate whether the prosthesis had signs of loosening and sinking, and to determine whether there was recurrence of tuberculosis. The knee joint function was evaluated by HSS score. With treatment failure due to any reason as the end event, the survival time of prosthesis was analyzed by Kaplan-Meier survival curve. All operations were successfully completed without fracture, vascular and nerve injury, deep vein thrombosis, and other complications. All incisions healed by first intention after operation. The operation time ranged from 80 to 135 minutes, with an average of 102.76 minutes; postoperative hospitalization stay was 5-16 days, with an average of 9.7 days; the duration of postoperative anti-tuberculosis chemotherapy ranged from 1 to 18 months, and the median duration was 12 months. All 38 cases were followed up 3-133 months (mean, 63.7 months). At last follow-up, CRP was (4.88±1.24) mg/L and ESR was (13.00±2.97) mm/1 h, both of which were significantly lower than those before operation ( t=20.647, P<0.001; t=20.886, P<0.001). During the follow-up, 3 patients (7.89%) had tuberculosis recurrence. Two patients had tuberculosis recurrence due to withdrawal of anti-tuberculosis chemotherapy at 1 and 2 months after operation, respectively. One patient was cured after debridement, preservation of prosthesis and anti-tuberculosis chemotherapy for 12 months, and 1 patient was cured after oral administration of anti-tuberculosis drugs for 12 months. Another 1 patient had recurrent tuberculosis and mixed infection ( Corynebacterium gehreni) at 2 months after operation, and the infection was not controlled after debridement, and finally the thigh was amputated. Except for the patients with recurrent infection, no complications such as prosthesis loosening, periprosthetic fracture, and periprosthetic infection were found. At last follow-up, the HSS score of the knee joint was 86.8±4.8, and the knee joint function significantly improved when compared with that before operation ( t=-31.198, P<0.001). Prosthesis survival time was (122.57±5.77) months [95% CI (111.25, 133.88) months], and the 10-year survival rate was 92.1%. One-stage TKA combined with postoperative antituberculous chemotherapy in the treatment of advanced active knee tuberculosis can achieve satisfactory infection control and joint function.

Is there still a place for anatomic hemiarthroplasty in patients with high functional demands in primary, nonreconstructable proximal humeral fractures? A clinical and radiographic assessment.

Vitality-threatening proximal humerus fractures often provide an indication for prosthetic treatment. We investigated the issue of how anatomic hemiprostheses perform in younger, functionally challenging patients with the use of a specific fracture stem and systematic tuberosity management in medium-term follow-up. Thirteen skeletally mature patients with a mean age of 64±9years and a minimum follow-up of 1year after primary open-stem hemiarthroplasty for 3- and 4-part proximal humeral fractures were included. All patients were followed up regarding their clinical course. Radiologic follow-up included fracture classification, healing of tuberosities, proximal migration of the humeral head, evidence of stem loosening, and glenoid erosion. Functional follow-up included range of motion, pain, objective and subjective performance scores, complications, and return to sports rates. We statistically compared treatment success based on the Constant score between the cohort with proximal migration and the cohort with regular acromiohumeral distance by means of the Mann-Whitney U test. After an average follow-up period of 4.8years, satisfactory results were obtained. The absolute Constant-Murley score was 73.2±12.4 points. The disabilities of the arm, shoulder, and hand score was 13.2±13.0 points. Patients reported their mean subjective shoulder value as 86.6%±8.5%. Pain was reported as 1.1±1.3 points on a visual analog scale. Flexion, abduction, and external rotation values were 138±31°, 134±34°, and 32±17°, respectively. 84.6% of the referred tuberosities healed successfully. Proximal migration was observed in 38.5% of cases and was associated with worse Constant score results (P=.065). No patient showed signs of loosening. Mild glenoid erosion was apparent in 4 patients (30.8%). All patients who were interviewed and participated in sports before surgery were able to return to their primary sport after surgery and continued to do so during the final follow-up. With narrow indications, use of a specific fracture stem and adequate tuberosity management, successful radiographic and functional results are presented after a mean follow-up of 4.8years after hemiarthroplasty for primary nonreconstructable humeral head fractures. Accordingly, open-stem hemiarthroplasty appears to remain a possible alternative to reverse shoulder arthroplasty in younger, functionally challenging patients with primary 3- or 4-part proximal humeral fractures.

Revision of total knee arthroplasty with press-fit condylar SIGMA TC3-mobile bearing system and porous metaphyseal sleeves in type AORI type II and III bone defects. A long-term follow-up study.

Revision total knee arthroplasty(rTKA) is a challenging and expensive treatment for orthopedic surgeons who have to deal with poor bone quality and bone loss. This study aims to retrospectively evaluate the clinical and radiological results of patients undergoing rTKA and porous metaphyseal sleeves in AORI type II and III bone defects. We conducted a retrospective series of continuous patients treated for mechanical failure of TKA. All patients with aseptic loosening of TKR underwent revision arthroplasty. We included only patients with AORI type IIa/b and III bone defects. The Septic revision or other grades of bone defect or patients lost at follow-up or with less than 2 years follow-up were excluded. We evaluated knee function with Oxford Knee Score (OKS) pain with Visual Analogue Scale (VAS) and range of motion (flex-ext), while radiological evaluation was performed to evaluate any sign of loosening. The mean preoperative OKS was 13.85 +/- 5.39 (range 5 -22), and it improved to 33.89 +/- 3.98 (range 20 - 40) (p<0.00001). The mean preoperative VAS was 7.77 +/- 1.33 (range 5 - 9), and it improved to 1.89 +/- 0.92 (range 0 - 4) (p<0.00001). ROM improved from 62.23° +/- 13.71° (range 40° - 90°) to 100.53° +/- 6.93° (range 90° - 120°) (p<0.00001). No signs of loosening or implant migration were reported. Metaphyseal sleeves made knee revision in large bone defects reliable and effective with good results. Good implant stability was reached in all the cases treated with metaphyseal sleeves.

The semiconstrained DRUJ prosthesis: blessing or curse?

There are numerous operative procedures to treat osteoarthritic changes or a significant instability of the distal radioulnar joint (DRUJ). The key problem of most methods is the destabilization of the forearm leading to secondary painful impingement between the radius and ulna, as well as a significant limitation of forearm rotation. The Aptis-Prosthesis designed by Scheker represents a complete substitute for the DRUJ. It is mostly used after the failure of various treatment options to solve the primary problems (arthritis, instability). We have used this type of prosthesis mostly after multiple operative treatments for more than 25years. In the following retrospective study, we analyzed the data of patients that received an Aptis-prosthesis between 2016 and 2021. We have implanted this prosthesis in 13 cases (11 female, 2 male). Routinely, we document the clinical outcome concerning range of motion (ROM), grip strength, and pain according to numeric rate scaling (NRS) after more than 12months (month 12-24). In addition, complications, osseous changes, and the rate of loosening of the prosthesis were registered. Furthermore, DASH-Score and patients ' satisfaction were evaluated. Also-as with other implants-follow-up x-rays were performed. Removal or significant revision of any of the prostheses was not needed. The ROM was 68.1° ± 19.7° for pronation and 72.3° ± 20.9° for supination, grip strength amounted to 27.7kg ± 11.0kg equaling 83% of the contralateral side. NRS was 0 at rest and 1.2 (0-2) under weight-bearing. A lysis margin of the radial tap was noted in the radiological examination in 2 patients but without any signs of loosening. The DASH-Score added up to 31.8 ± 13.8 (13-55). All patients were satisfied or very satisfied having this implant. The semiconstrained Aptis-prosthesis is a safe and efficient treatment option after failed DRUJ surgeries. It is striking that of the 20 implanted prostheses no significant revision or explantations were necessary over a period of 25years.

IS A TYPE 2B SHORT STEM ADEQUATE IN PATIENTS WITH PROXIMAL FEMORAL DEFORMITIES?

We sought to determine the short to medium-term clinical and radiographic outcomes using a short stem in young adults with a proximal femoral deformity (PFD).We prospectively studied 31 patients (35 hips) with PFDs treated with an uncemented primary THA using a short stem with cervicometaphyseal fixation between 2011–2018. There were 19 male (23 hips) and 12 female (12 hips) patients, with a mean BMI of 26.7±4.1 kg/m2. Twelve cases had a previous surgical procedure, and six of them were failed childhood osteotomies. Mean age of the series was 44±12 years, mean follow-up was 81±27 months and no patients were lost to follow-up. PFDs were categorized according to a modified Berry´s classification. Average preoperative leg-length discrepancy (LLD) was −16.3 mm (−50 to 2).At a mean time of 81 months of follow-up, survival rate was 97% taking revision of the stem for any reason and 100% for aseptic loosening as endpoints. No additional femoral osteotomy was required in any case. Average surgical time was 66 minutes (45 to 100). There was a significant improvement in the mHHS score when comparing preoperative and postoperative values (47.3±10.6 vs. 92.3±3.7, p=0.0001). Postoperative LLD was in average 1 mm (−9 to 18) (p=0.0001). According to Engh's criteria, all stems were classified as stable without signs of loosening. Postoperative complications included 1 pulmonary embolism, 1 neurogenic sciatic pain, 1 transient sciatic nerve palsy that recovered completely after six months, and 2 acute periprosthetic joint infections. One patient suffered a Vancouver B2 periprosthetic femoral fracture 45 days after surgery and was revised with a modular distally fixed uncemented fluted stem.A type 2B short stem evidenced promising outcomes at short to medium-term follow up in young adult patients with PFDs, avoiding the need for corrective osteotomies and a revision stem.

THE ZWEYMULLER PRIMARY STEM IS A RELIABLE, EFFECTIVE, AND LESS INVASIVE IMPLANT IN REVISION ARTHROPLASTY

Stem loosening can be associated with a wide spectrum of bone loss and deformity that represent key factors for choosing the most appropriate revision implant. The aim of this study was to evaluate the clinical outcomes and the survivorship of a consecutive series of THA revisions using a taper rectangular cementless stem for primary implants (Alloclassic® Zweymuller®, Zimmer Warsaw US) at medium-term follow-up.We retrospectively evaluated 113 patients (115 revisions) who underwent femoral revision with Zweymuller stem with a preoperative Paprosky I (86) or II (29) defects from January 2011 to December 2020. The mean follow up was 6 years (2–10). The median age at time of surgery was 71(41–93) with 60 males and 53 females. Osteolysis/radiolucency were observed in the following Gruen zones: I (91), II (3), III (2), VII (15), V (3), VI (1). Clinical assessment was performed by means of Harris Hip Score (HHS) and Visual Analogic Scale (VAS), whereas for the radiological analysis we used conventional x-rays of the hips. The statistical analysis was performed using Graphpad Prism v5.0 and data distribution was assessed by Shapiro-Wilk test, and Wilcoxon matched paired test was used to test the differences between preoperative and postoperative score.9 patients were lost to fu (deceased or not available), 104 (106 hips) were evaluated. The mean HHS and VAS significantly improved at final follow-up, going from 33,84 and 5,78 preoperatively to 66,42 and 2,05 postoperatively, respectively. 28 patients (25%) showed unprogressive radiolucent lines in Gruen zones 1 and 7 with no other radiological nor clinical signs of loosening. One patient suffered from recurrence of the infection. The survivorship with stem revision as endpoint was 100%.Alloclassic Zweymüller primary stem showed good medium-term results and survival rate in revision THA for aseptic loosening and second stages of two stage revisions.

Mid-Term Follow-Up Results After Hemiarthroplasty Using Long Femoral Stem Prosthesis (Peerless-160) for Intertrochanteric Fractures in Octogenarians.

To analyze the clinical effect and imaging data of cementless bipolar hemiarthroplasty employing a long femoral stem (peerless-160) and 2 reconstructed femoral titanium wires to repair intertrochanteric fractures among the octogenarians. Between June 2014 and August 2016, 58 octogenarians with femoral intertrochanteric fractures underwent the long femoral stem (peerless-160) cementless bipolar hemiarthroplasty by the same surgeon. We assessed clinical and radiological outcomes such as operative time, bleeding volume, blood transfusion volume, length of hospital stay, full weight-bearing walking time, walking ability calculated by Koval classification and Harris Hip Score (HHS), including fracture healing and greater trochanter fragments subsidence. The surgery was successfully performed in all patients. The average operation time was 72.8 ± 13.2min, the average blood loss during surgery was 225.0 ± 91.4mL, 200mL of blood was transfused, the mean duration of hospitalization was 11.9 ± 4.0days, the mean time of full weight bearing was 12.5 ± 3.8days. Patients were followed up for 24-68months, averagely 49.4 ± 10.3months. During follow-up, 4 (6.9%) patients died, and 1 (1.7%) was completely lost to ask about the recent situation. The average Harris Hip Score at the last follow-up was 87.8 ± 6.1, most of the patients recovered walking ability, under radiological examination, the prosthesis showed no signs of loosening. All trochanteric fractures gradually healed, the clinical and radiographic signs of healing occurred at average of 4.0 ± 1.1months postoperatively. For osteoporotic unstable intertrochanteric fractures in octogenarians, this study confirmed that the Cementless Bipolar Hemiarthroplasty Using a Long Femoral stem (peerless-160) with double cross binding technique is a satisfactory and safe choice for the octogenarians.

How Does a Novel In Situ Fixed-bearing Implant Design Perform in Revision Ankle Arthroplasty in the Short Term? A Survival, Clinical, and Radiologic Analysis.

Given the growing number of primary total ankle replacements (TAR), an increase in the number of patients undergoing subsequent revisions might be expected. Achieving a stable and balanced ankle while preserving the remaining bone stock as much as possible is crucial for success in revision TAR. Most reported techniques rely on bulky implants with extended fixation features. Since 2018, we have used a novel, three-component ankle prosthesis for revision that is converted in situ to a fixed-bearing, two-component ankle prosthesis once the components have found their position according to an individual's anatomy. The results of this novel concept (fixation, revision, pain, or function) have not, to our knowledge, been reported. What are the short-term results with this new revision TAR design, in terms of (1) repeat revision surgery, (2) patient-reported outcomes on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, (3) pain according to the VAS, and (4) radiographic signs of fixation? Between February 2018 and February 2020, we performed 230 TAR surgeries (in 206 patients) for any indication in our clinic. The novel semiconstrained, uncemented Hintermann Series H2 © implant was used in 96% (220 of 230) of procedures (201 patients). Fifty-four percent (119 of 220) of these were converted from an existing TAR to H2, which was the focus of the present study. However, only 45% (54 of 119) of these conversions to H2 were eligible for analysis. These patients had a mean age of 63 ± 12 years, and 43% (23 of 54) were women. The median (range) follow-up time was 3.2 years (2.0 to 4.3). The H2 design allows in situ conversion to a fixed-bearing system, with minimal bone resection. It achieves translational and rotational stability while preserving function and supporting the periarticular soft tissues. We defined repeat revision as exchange of one or both metal components, ankle fusion, or amputation and assessed it using a cumulative incidence survivorship estimator. Factors potentially associated with revision were assessed using Cox regression analyses. Clinical and radiologic outcomes were assessed preoperatively and at the most recent follow-up interval. Clinical outcomes included pain on the VAS (average pain during normal daily activity during the past seven days) and AOFAS score. Radiologic outcomes were the tibial articular surface angle, tibiotalar surface angle, talar tilt angle in the coronal plane, and AP offset ratio in the sagittal plane, as well as radiolucent lines and radiographic signs of loosening, defined as change in position greater than 2° of the flat base of the tibia component in relation to the long axis of the tibia, subsidence of the talar component into the talus greater than 5 mm, or change in position greater than 5° relative to a line drawn from the top of the talonavicular joint to the tuberosity of the calcaneus, as seen on plain weightbearing radiographs. The cumulative incidence of repeat revision after 1 and 2 years was 5.6% (95% CI 0% to 11%) and 7.4% (95% CI 0% to 14%), respectively. With the numbers available, no clinical factors we analyzed were associated with the risk of repeat revision. The median values of all assessed clinical outcomes improved; however, not all patients improved by clinically important margins. The median (range) AOFAS ankle-hindfoot score increased (from 50 [16 to 94] to 78 [19 to 100], difference of medians 28; p < 0.01), and the median pain on the VAS decreased (from 5 [0 to 9] to 2 [0 to 9], difference of medians 3; p < 0.01) from before surgery to follow-up at a minimum of 2 years. Radiographically, lucency was seen in 12% (6 of 49 patients) and loosening was seen in 8% (4 of 49). One of these patients showed symptomatic loosening and was among the four patients overall who underwent revision. We could not assess risk factors for repeat revision because of the low number of events (four). The investigated new in situ fixed-bearing ankle design achieved overall better short-term results than those reported in previous research. Destabilization of the ankle joint complex, soft tissue insufficiency, and possible changes of the joint configuration need an optimal solution in revision arthroplasty. The studied implant might be the answer to this complex issue and help surgeons in the perioperative decision-making process. However, a relatively high percentage of patients did not achieve a clinically important difference. Observational studies are needed to understand long-term implant behavior and possibly to identify ankles benefiting the most from revision. Level IV, therapeutic study.