Stem Revision Research Articles

Primary Cementless Femoral Stems in Conversion Hip Arthroplasty After Failed Fixation of Intertrochanteric Fractures.

Salvage conversion hip arthroplasty is a viable solution to restore function and reduce pain after failed intertrochanteric hip fracture fixation. Our primary objective was to assess early outcomes achieved with primary cementless metaphyseal-engaging femoral stems for conversion hip arthroplasty compared with revision diaphyseal-engaging stems. This was a retrospective review of 70 patients with failed intertrochanteric hip fractures subsequently managed with conversion total hip arthroplasty or hemiarthroplasty. Thirty-five patients who underwent conversion using a primary cementless stem were compared with 35 patients who underwent conversion using a revision stem. The groups were similar regarding sex, body mass index, American Society of Anesthesiologists classification, preoperative diagnosis, and implants removed. Clinical and radiographic outcomes and complications were compared over a mean follow-up of 6 years. The primary stem cohort had a shorter mean hospital stay (3.03 vs 4.34 days, P=.028). There were no significant differences between the primary and revision cohorts regarding mean time to conversion (2.26 vs 1.75 years, P=.671), operative time (127 vs 131 minutes, P=.611), incidence of discharge to home (54.3% vs 37.1%, P=.23), postoperative complications (5.71% vs 5.71%, P=1.0), reoperations (5.71% vs 11.4%, P=.669), leg length discrepancy (5.33 vs 7.38 mm, P=.210), subsidence (20.0% vs 23.3%, P=.981), and Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (78.6 vs 81.9, P=.723). We report comparable outcomes of conversion hip arthroplasty with the use of primary cementless and revision stems. Current primary cementless femoral stems may be considered for conversion hip arthroplasty for failed intertrochanteric fracture fixation. [Orthopedics. 2024;47(1):e6-e12.].

Revision total hip arthroplasty using a fluted, tapered, modular stem follow-up method for a mean of three years: A preliminary study.

Objective: This study aimed to evaluate the results and complications related to revision total hip arthroplasty within a short-to-medium follow up period. Methods: From January 2016 to January 2020, we reviewed 31 prosthetic hip arthroplasty stem revisions using a fluted, tapered modular stem with distal fixation. The median age of the patients was 74.55-79years. The survival rate was 100%, and there were no re-revisions. The Harris hip score improved from an average of 36.5 ± 7.8 before surgery to 81.8 ± 6.2 at the final follow-up. Results: The average final follow-up was 36 (24-60)months. During this time, there was no periprosthetic infection, no prosthesis loosening or breakage, and no sciatic nerve injury. Complications included four (12.9%) intraoperative fractures and eight (25.8%) dislocations that had no stem fractures. The postoperative limb was lengthened by 17.8 ± 9.8mm. In most cases, bone regeneration was an early and important finding. Three cases underwent extended trochanteric osteotomy, and bone healing was achieved by the final follow-up. Conclusion: The modular tapered stem reviewed in this study was very versatile, could be used in most femoral revision cases, and allowed for rapid bone reconstruction. However, a long-term follow-up study is needed to confirm these results.

Outcome of Irrigation and Debridement with Topical Antibiotic Delivery Using Antibiotic-Impregnated Calcium Hydroxyapatite for the Management of Periprosthetic Hip Joint Infection.

We assessed the clinical results of irrigation and debridement (I&D) with antibiotic-impregnated calcium hydroxyapatite (CHA) as a novel antibiotic delivery system for the treatment of prosthetic-joint-associated infection (PJI) after total hip arthroplasty (THA). Thirteen patients (14 hips) treated with I&D for PJI after THA at our institution between 1997 and 2017 were retrospectively evaluated. The study group included four men (five hips) and nine women, with an average age of 66.3 years. Four patients (five hips) had symptoms of infection within less than 3 weeks; however, nine patients had symptoms of infection over 3 weeks. All patients received I&D with antibiotic-impregnated CHA in the surrounding bone. In two hips (two cups and one stem), cup and/or stem revision were performed with re-implantation because of implant loosening. In ten patients (11 hips), vancomycin hydrochloride was impregnated in the CHA. The average duration of follow-up was 8.1 years. Four patients included in this study died of other causes, with an average follow-up of 6.7 years. Eleven of thirteen patients (12 of 14 hips) were successfully treated, and no signs of infection were observed at the latest follow-up. In two patients (two hips) for whom treatment failed, infection was successfully treated with two-stage re-implantation. Both patients had diabetes mellitus and symptoms of infection over 3 weeks. Eighty-six percent of patients were successfully treated. No complications were observed with this antibiotic-impregnated CHA. I&D treatment with antibiotic-impregnated CHA produced a higher rate of success in patients with PJI after THA.

Survival of the Exeter V40 short revision (44/00/125) stem when used in primary total hip arthroplasty

The Exeter V40 femoral stem is the most implanted stem in the National Joint Registry (NJR) for primary total hip arthroplasty (THA). In 2004, the 44/00/125 stem was released for use in 'cement-in-cement' revision cases. It has, however, been used 'off-label' as a primary stem when patient anatomy requires a smaller stem with a 44 mm offset. We aimed to investigate survival of this implant in comparison to others in the range when used in primary THAs recorded in the NJR. We analyzed 328,737 primary THAs using the Exeter V40 stem, comprising 34.3% of the 958,869 from the start of the NJR to December 2018. Our exposure was the stem, and the outcome was all-cause construct revision. We stratified analyses into four groups: constructs using the 44/00/125 stem, those using the 44/0/150 stem, those including a 35.5/125 stem, and constructs using any other Exeter V40 stem. In all 328,737 THAs using an Exeter V40 stem, the revision estimate was 2.8% (95% confidence interval (CI) 2.7 to 2.8). The 44/00/125 stem was implanted in 2,158 primary THAs, and the ten-year revision estimate was 4.9% (95% CI 3.6 to 6.8). Controlling for age, sex, year of operation, indication, and American Society of Anesthesiologists grade demonstrated an increased overall hazard of revision for constructs using the 44/00/125 stem compared to constructs using other Exeter V40 femoral stems (hazard ratio 1.8 (95% CI 1.4 to 2.3)). Although the revision estimate is within the National Institute for Health and Care Excellence ten-year benchmark, survivorship of constructs using the 44/00/125 stem appears to be lower than the rest of the range. Adjusted analyses will not take into account 'confounding by indication', e.g. patients with complex anatomy who may have a higher risk of revision. Surgeons and patients should be reassured but be aware of the observed increased revision estimate, and only use this stem when other implants are not suitable.

What is the Role of Stem Size and Offset in the Risk of Nonseptic Revision of the Exeter® 150-mm Stem? A Study From the Swedish Arthroplasty Register.

The Exeter® stem is used worldwide, often in older patients, and it is the second most commonly used cemented stem design in Sweden. Previous studies have shown that for cemented stems with a composite beam, the smallest sizes result in an increased risk of revision for mechanical failure. However, little is known about whether the survivorship of the polished Exeter stem, which generally has been shown to be good, might be associated with design parameters such as stem dimensions or offset at extreme implant sizes. Are differences in (1) stem size or (2) offset of the standard Exeter V40 150-mm stem associated with differences in the risk of stem revision for aseptic loosening? Between 2001 and 2020, 47,161 Exeter stems were reported to the Swedish Arthroplasty Register, with very high coverage and completeness documented during the period studied. In this cohort, we included patients with primary osteoarthritis who underwent surgery with a standard Exeter stem length of 150 mm and V40 cone with any type of cemented cups that had had at least 1000 reported insertions. This selection resulted in a study cohort representing 79% (37,619 of 47,161) of the total number of Exeter stems in the registry during that time. The primary study outcome was stem revision for aseptic indications such as loosening, periprosthetic fracture, dislocation, and implant fracture. A Cox regression was performed, with adjustment for age, gender, surgical approach, year of surgery, use of highly crosslinked polyethylene cups, and femoral head size and length dictated by the shape of the head trunnion. Adjusted hazard ratios are presented with 95% confidence intervals. Two separate analyses were performed. The first analysis excluded stems with the highest offsets (50 mm and 56 mm, which were not available for stem size 0). The second analysis excluded stem size 0 to include all offsets. Because stem survival was not proportional over time, we divided the analyses into two insertion periods, 0 to 8 years and beyond 8 years. Stem size 0 (compared to size 1) was associated with an increased risk of revision up to 8 years when all stem sizes were included (first analysis 0 to 8 years, HR 1.7 [95% CI 1.2 to 2.3]; p = 0.002). Forty-four percent (63 of 144) of revisions of size 0 stems were for periprosthetic fracture. There was no consistent association between stem size and risk of aseptic stem revision when size 0 was excluded in the second analysis beyond 8 years. The most common offset (44 mm) was associated with an increased risk of revision (compared with 37.5 mm) up to 8 years when all sizes were included (first analysis, HR 1.6 [95% CI 1.1 to 2.1]; p = 0.01). In the second analysis (beyond 8 years, all offsets included), offset of 44 mm was compared with offset of 37.5 mm; compared with the first period, this offset was associated with a reduced risk (HR 0.6 [95% CI 0.4 to 0.9]; p = 0.005). We found overall high survival of the Exeter stem, with generally little or no influence of stem variations on the risk of aseptic revision. However, stem size 0 was associated with an increased risk of revision mainly for periprosthetic fractures. If the femoral anatomy offers a choice between sizes 0 and 1 in patients with poor bone quality who are at risk of periprosthetic fracture, our data speak in favor of choosing the larger stem if the surgeon believes it is safe to insert the larger size, or, if available, another stem design that has a documented lower risk of this complication. For patients with good cortical bone quality but very narrow canals, a cementless stem may also be a good alternative. Level III, therapeutic study.

Intermediate-Term Survivorship of Total Hip Arthroplasty With a Proximally Coated Tapered-Wedge Femoral Stem: A Retrospective, Multi-Center Registry Review.

Short tapered-wedge stems have been used frequently over the past decade, but long-term follow-up data are not readily available in the literature. A retrospective outcomes review was conducted to assess survivorship and clinical outcomes for the TRI-LOCK® Bone Preservation Stem (TRI-LOCK BPS; DePuy Synthes, Warsaw, IN, USA), a proximally coated, tapered-wedge femoral stem. In a cohort of 2,040 hips, Kaplan-Meier survivorship estimates (95% CI {confidence interval}; N with further follow-up, where N is the number of hips remaining at each post-operative interval), with survivorship defined as no revision of any component for any reason were 96.6% (92.8%,98.4%; 45) at eight years under the clinical assumption and 98.6% (97.9%,99.1%; 90) at 14 years under the registry assumption. With survivorship defined as stem revision for any reason, estimates were 97.7% (93.7%,99.2%; 45) at eight years under the clinical assumption and 99.2% (98.6%,99.5%; 90) under the registry assumption. Mean Harris Hip Scores and WOMAC scores were 90.08 and 21.98, respectively, at 10 years postoperatively. Our evaluation demonstrates excellent construct and stem survivorship and clinical outcomes at intermediate-term postoperative follow-up.

Clinical outcome of Bioball universal adapter in revision hip arthroplasty

BackgroundRemoval of a well-fixed uncemented femoral component in revision hip arthroplasty is challenging. A modular head–neck adapter provides an option to optimise the femoral offset and anteversion, avoiding the need for femoral stem revision. AimTo present the clinical results following revision arthroplasty with the Bioball head-neck adapter in the elderly American Society of Anaesthesiologists (ASA) Grade II, III & IV patients. Materials and methodsA retrospective review of our database was performed, and all patients classed as ASA grades II, III, & IV treated with the Bioball Universal Adapter (BUA) for 10 years were included. The indication for revision, stem retention, type of adapter, and head size were identified. Patients were contacted by a research nurse to assess the Forgotten Joint Score (FJS), the Oxford Hip Score (OHS), and any symptoms of instability at a minimum of one year post revision surgery. ResultsOur study included 47 patients. 5 (10.6%) were ASA II, 19 (40.4%) were ASA III and 23 (49%) were ASA IV. The mean age was 74 years. The mean follow up was 52 months ± 28.4 SD. The median FJS was 86 ± 11.6 SD. The median OHS was 43 ± 6.2 SD. One patient (2.1%) developed recurrent dislocation following lumbar spinal fusion. None of the other patients experienced instability. The survival rate for the adapter was 98%. ConclusionThe BUA gives good clinical outcomes with very low post revision instability. It is a valuable option for the elderly because it avoids the morbidity and risks associated with the removal of a well-fixed femoral stem. Level of EvidenceLevel IV

2-Year Radiostereometric Analysis Evaluation of a Short, Proximally Coated, Triple-Taper Blade Femoral Stem Versus a Quadrangular-Taper Stem With Reinforced Proximal Body: A Randomized Controlled Trial

BackgroundCementless stem designs with proximal metaphyseal fixation aim to achieve better load distribution, reduce stress shielding, and improve primary stability. The purpose of this prospective, randomized controlled trial was to evaluate the 2-year migration and clinical outcomes of two cementless femoral stems. MethodsA total of 60 participants undergoing primary total hip arthroplasty for any cause were randomly allocated to receiving either a proximally coated, short blade stem or a quadrangular-taper stem with a reinforced proximal body. Radiostereometric analysis radiographs were performed postoperatively and at 6 weeks, 6 months, 1 year and 2 years. The Harris Hip Score, Oxford Hip Score and the EuroQol five-dimension were also collected. ResultsAt two years, the median subsidence of the short-blade stem was 0.097 millimeters (mm) [Interquartile range (IQR) −0.67 to 0.08)] versus 0.086 mm(IQR, −0.29 to 0.005, P = .683); medial translation 0.023 mm (IQR 0.08 to 0.12) versus 0.029 mm(IQR −0.07 to 0.10, P = .907); anterior translation 0.035 mm (IQR −0.23 to 0.33) versus 0.07 mm (IQR −0.13 to 0.08, P = .268). At 24 months postoperatively, there were no stem revisions and Patient-Reported Outcome Measures (PROMs) were comparable between groups. ConclusionBoth cementless stems exhibited a predictable migration pattern and achieved initial stability. There was no difference in migration across the three Cartesian axes at any time point. Clinical outcomes and PROMs were also comparable. Biological fixation of both implants evidenced by the radiostereometric analysis and excellent PROMs are likely to translate to longer-term stability, which would need to be corroborated by longer-term outcome studies.

Minimum 25-Year Results of a Tapered Titanium Porous Plasma Spray Coated Femoral Component

BackgroundPrevious studies have reported excellent results with tapered, titanium, porous plasma-sprayed components in patients undergoing uncemented primary total hip arthroplasty (THA). The purpose of this study was to examine survival and clinical results at a minimum 25-year follow-up. MethodsWe reviewed all patients who underwent primary THA at our center through 1995 with a specific femoral component that was essentially unchanged since its 1984 introduction, except porous coating was continued circumferentially in 1987, a hydroxyapatite-coated option was offered in 1988, and an offset option was added in 1999. There were 332 patients (396 THA) who had a minimum 25-year follow-up (range, 25 to 37). Mean age at surgery was 48 years (range, 21 to 70 years). Mean follow-up in nonfailed patients was 29 years (range, 25 to 37 years). ResultsThere were 31 femoral revisions (7.8%): 9 infections, 3 failures of ingrowth, 5 aseptic loosening, 8 osteolysis well-fixed, 2 periprosthetic fractures, 2 polyethylene wear with trochanteric avulsion, 1 component breakage, and 1 malalignment well-fixed. Kaplan-Meier survival with the endpoint of all-cause stem revision was 94.8% (95% confidence interval: ±0.9%) at 37 years, and with the endpoint of aseptic loosening/failure of ingrowth was 98.7% (95% confidence interval: ±0.5) at 37 years. Harris hip scores improved significantly from 43 preoperatively to 76 most recently. ConclusionThis tapered, titanium, porous plasma spray-coated femoral component continues to demonstrate high long-term survival with a low rate of femoral component revision for any reason or aseptic loosening/failure of ingrowth.

Extensively Porous-Coated Stems Demonstrate Excellent Long-Term Survivorship in Revision Total Hip Arthroplasty

BackgroundExtensively porous-coated cylindrical stems have demonstrated excellent results in revision total hip arthroplasties (THAs). However, most studies are midterm follow-ups and of modest cohort size. This study aimed to evaluate long-term outcomes of a large series of extensively porous-coated stems. MethodsFrom 1992 to 2003, 925 extensively porous-coated stems were utilized in revision THAs at a single institution. The mean age was 65 years, and 57% of patients were males. Harris hip scores were calculated, and clinical outcomes were assessed. Radiographic assessment for stem fixation was categorized as either in-grown, fibrous stable, or loose according to Engh criteria. Risk analysis used Cox proportional hazard method. The mean follow-up was 13 years. ResultsMean Harris hip scores improved from 56 to 80 at the last follow-up (P < .001). Fifty-three femoral stems (5%) were rerevised: 26 for aseptic loosening, 11 for stem fractures, 8 for infection, 5 for periprosthetic femoral fractures, and 3 for dislocation. Cumulative incidence of aseptic femoral loosening and femoral rerevision for any reason were 3% and 6.4% at 20 years, respectively. Nine of eleven stem fractures occurred with 10.5-13.5 mm diameters (mean 6 years). Radiographic review of unrevized stems demonstrated 94% bone-ingrown. Demographics, femoral bone loss, stem diameter, and length were not predictors of femoral rerevision. ConclusionIn this large series of revision THAs using a single extensively porous-coated stem design, the cumulative incidence of rerevision for aseptic femoral loosening was 3% at 20 years. These data confirm the durability of this stem in femoral revision, providing a long-term benchmark for newer uncemented revision stems. Level of EvidenceLevel IV, retrospective study.

Breakage of Tapered Junctions of Modular Stems in Revision Total Hip Arthroplasty—High Incidence in a Consecutive Series of a Single Institution

Modularity in revision THA (RTHA) has become accepted during the last three decades. Nevertheless, specific risks of modularity of current revision devices such as breakage of taper junctions occur during follow-up. Data reporting failure rates are predominantly given by the manufacturers but independent data acquisition is missing so far. 1. What time-related risk of breakage of taper junction between neck and body of an established modular revision device can be expected in a consecutive single institutional series and a mid-term follow-up? 2. Are there specific factors influencing breakage in this cohort? A retrospective analysis was performed of a consecutive series of 89 cases after femoral revision using a tapered modular revision stem. Mean follow-up period was 7.1 (range: 3.0-13.7) years. Breakage of stem as failure criteria of the implant was investigated with a Kaplan-Meier analysis. Breakage of taper junctions occurred in four patients during follow-up showing a time-depending implant survival of 94.2 (95% CI: 88.6-100%) after 13.7 years. Implant survival of stems with lateralized necks of 87.4 (95% CI: 75.6-100%) after 13.7 years was significantly lower compared to the standard offset variant with 100% after 13.5 years (log rank test p = 0.0283). Chi square test also revealed a significantly higher risk of breakage of lateralized necks compared to standard offset pieces (p = 0.0141). Three of four patients were obese with a mean BMI of 37.9 kg/m2. Grade of obesity (grade 1 or higher) had significant influence on risk of breakage. Survival of the implant was significantly lower in obese patients with at least grade 1 obesity compared to patients with a BMI < 30 kg/m2 (82.9 (95% CI: 64.9-100%) after 11.6 years vs. 98.4 (95% CI: 95.3-100%) after 13.7 years; log-rank p = 0.0327). Cumulative risk for failure of taper junctions was high in this consecutive single institutional cohort and may further increase during follow-up. As independent data acquisition in registries is missing, failure rate may be higher than reported data of the manufacturers. The use of lateralized offset necks in obese patients of at least grade 1 obesity showed a significantly higher risk of breakage. The use of monobloc revision devices may be an option, but randomized control trials are currently missing to establish standardized treatment protocols considering individual risks for both monobloc and/or modular implants.

The use of a standard-length conical tapered stem in hip revision arthroplasty to address Paprosky type I–II femoral defects: a prospective study of 87 patients

IntroductionLow-grade femoral defects in revision total hip arthroplasty (rTHA) might be preferably treated with a primary implant. Almost no previous study reported the use of standard-length conical tapered (SLCT) stems in these cases. We analyzed a series of cases using a SLCT stem in rTHA with Paprosky type I–II femoral defects. The purpose of the study was to determine clinical and radiographic outcomes in this series of rTHA.Materials and methodsWe prospectively followed 87 patients undergoing a femoral component rTHA: 53 Paprosky type I and 34 type II femoral defects. Patient-reported measures (Oxford Hip Score, EQ-5D, VAS pain during rest and activity) were administered at baseline, 1 and 2 years post-operatively. Radiographic subsidence overtime was scored. Kaplan–Meier curves were used to evaluate the subsidence over time, the complication-free survival, and the implant survivorship with reoperation and stem revision as endpoints.ResultsThe mean follow-up was 72.5 (SD ± 23.9) months. All PROMs significatively improved over time. The average subsidence was 2.8 (SD ± 3.2), 3.6 (SD ± 4.4), and 4.0 (SD ± 4.9) mm at 4, 12, and 24 months respectively. 6 stems had subsidence > 10 mm. The survival without complication was 0.85 (95% CI 0.94–0.77), while the implant survival without reoperation was 0.83 (95% CI 0.95–0.72). The overall stem survival rate was 93.7% (95% CI 0.91–0.97) at 2 years.ConclusionThe use of a SLCT stem in rTHA with Paprosky type I–II femoral defects demonstrated good survival with low subsidence rates during the first 2 years after surgery. Surgeons should consider the use of this primary prosthesis as a potential treatment during stem revision in cases with limited femoral bone loss.

Partial retention of the acetabular cement mantle in aseptic revision hip arthroplasty: is it a viable option?

Choosing the most appropriate reconstruction method when addressing a cemented cup at hip revision surgery can be a difficult decision. The aim of this study is to look into the practice and results of retaining a well-fixed medial acetabular cement mantle while removing loose superolateral cement. This practice goes against a preconceived principle that if some of the cement is loose it must all be removed. So far, no significant series looking at this is available in the literature. We assessed a cohort of 27 patients in our institution where this practice was carried out and assessed their outcomes clinically and radiographically. Of the 27 patients, 24 had follow-up ⩾2 years (2.9-17.8, mean 9.3 years). There was 1 subsequent revision for aseptic loosening at 11.9 years, 1 first-stage revision of both stem and cup for infection at 1 month, and 2 patients died without a 2-year review. 2 patients did not have radiographs available for review. 2 of the 22 patients with radiographs available had changes in lucent lines, which were not clinically significant. Based on these results we conclude that retaining well-fixed medial cement during socket revision is a viable reconstruction option in carefully selected cases.

Mid-term outcomes of revision hip arthroplasty due to titanium modular neck failure.

The current strategy for modular neck failures in total hip arthroplasty (THA) is calibrated on CrCo neck failures. Stem revision is usually required, but the procedure is challenging and achieves modest outcomes (up to 20% of re-revisions at short-term). No study reports revision strategies and outcomes after Ti neck failures. Aims of the study were to evaluate: (1) demographic and implant features of the cohort to be revised, (2) intra-operative findings and surgical revision strategies and (3) clinical and radiological post-revision outcomes. Hospital database was enquired about revisions due to Ti neck failures in primary THAs. Sixty-five revisions were enrolled (all with the same modular system). Neck exchange was attempted as the first-line treatment. Patients were clinically and radiographically evaluated after revision. The revision cohort encompassed fatigue neck fractures occurred 4.4 ± 2.6years after THA: patients < 65years and/or > 80kg (98.5%) were predominant. Fifty-three neck exchanges were performed (81.5%). Eleven failures required stem revisions (16.9%), generally due to demanding neck extraction. Six complications occurred after neck exchange (11.3%), among them 2 acute infections requiring surgery (3.8%). Among stem revisions, one aseptic loosening and one neck re-fracture (18.5%) required re-revisions. At a mean follow-up of 7.1 ± 4years, the neck exchange cohort achieved a mean HHS of 89.1 ± 6.3 (stem revisions: 84.1 ± 10.9). Revisions for Ti neck failures were predominantly performed due to fatigue fractures. In case of failures, neck exchange is a feasible procedure in most of the cases, with good outcomesat 7 years. Level IV, retrospective case series.

Custom Triflange Acetabular Components For Catastrophic Bone Loss: Minimum 5-Year Results

IntroductionCustom acetabular components are an increasingly utilized reconstructive option in total hip arthroplasty for catastrophic bone loss and acetabular failure. The purpose of this study was to determine the survivorship of such components for reconstruction due to catastrophic bone loss at a minimum 5-year follow-up. MethodsFrom August 2003 to July 2016, 64 patients (66 hips) underwent acetabular reconstruction with custom triflange components. All hips were classified as Paprosky 3B or 3C. Harris hip scores were analyzed. Overall survivorship was determined by survival analysis. ResultsSeventeen patients (18 hips) died prior to returning for 5-year follow-up. One presumed living patient was lost to contact, yielding a cohort of 46 patients (47 hips) who had minimum 5-year follow-up. The mean age was 65 years (range, 46 to 85), mean body mass index was 29.4 (range, 18 to 45), and 72% were women. Mean follow-up was 8 years (range, 5 to 16). There were 3 revisions of the triflange device (6.4%) due to infection. Survivorship to end point of triflange removal for any reason was 94.1% (95% confidence interval: ±3.4%) at a mean of 16 years. In the overall series (n = 66), there were 9 (13.6%) additional reoperations as follows: 5 incision and debridements, one open reduction internal fixation, two stem revisions for periprosthetic femoral fracture, and one head revision. Harris hip scores improved significantly from a mean of 41 points preoperatively to 64 points postoperatively. ConclusionsCustom acetabular triflange components represent a highly effective tool in a surgeon’s armamentarium. These devices are extremely helpful in managing catastrophic bone loss and have a good mean 16-year survival.

Revision of anatomic shoulder arthroplasty

With the increasing number of primary arthroplasties, revisions of anatomical prostheses are becoming increasingly important. The most common reasons for revision are glenoid loosening, including protrusion, rotator cuff insufficiency, including instability, and early/late infection. The reconstruction of glenoid defects can be done with an autograft or allograft. Depending on the size and situation, it is carried out in one or two stages. The stemless humeral head replacement and the short-stem prostheses that have been used more frequently in recent years have significantly simplified humeral revision. Platform systems take adifferent approach with the option of conversion without major interventions on the glenoid or revision stem. Intraoperative complications mainly occur on the humeral side. Postoperative complications include dislocation, component loosening, and infection. Revision of anatomical to reverse arthroplasty shows better clinical outcomes and lower complication rates than anatomical revision.

No significant differences in 60-day postoperative complication rates between conventional and shortened stems

PurposeTo compare 60-day complication rates, radiographic outcomes, and clinical outcomes following primary THA with conventional versus shortened stems, in a large cohort study.MethodsThe authors reviewed a consecutive series of 800 primary THAs, of which 781 met the inclusion/exclusion criteria: 395 received a conventional stem and 386 received a shortened stem. Intraoperative and postoperative complications were noted. Radiographic and clinical assessments were performed preoperatively and 60 days after surgery.ResultsCompared to conventional stems, shortened stems had significantly less intraoperative complications (2.8% vs 0.3%, p = 0.006), but no significant differences in complications that did not require reoperation (1.0% vs 1.3%, p = 0.620), complications that required reoperation without stem revision (2.0% vs 1.0%, p = 0.384), and complications that required stem revision (0.5% vs 0.5%, p = 1.000). Four hips (two from each group) required stem revision and were thus excluded from 60-day assessment. There were no significant differences between groups in subsidence ≥ 3 mm (1.0% vs 0.5%, p = 0.686), alignment (90.3%vs 86.7%, p = 0.192), net change in offset (within 3 mm, 32.3% vs 30.5%, p = 0.097), and limb length discrepancy (3.0 ± 2.6 mm vs 2.9 ± 2.4 mm, p = 0.695). Compared to conventional stems, shortened stems had significantly better preoperative mHHS (56.5 ± 18.5 vs 64.5 ± 13.5, p < 0.001), and significantly lower net improvement in mHHS (29.9 ± 17.1 vs 24.4 ± 15.0, p < 0.001), but no significant differences in postoperative mHHS (87.3 ± 11.9 vs 89.4 ± 9.6, p = 0.109).ConclusionsThere were no significant differences between conventional and shortened stems in terms of postoperative complication rates, radiographic outcomes, and postoperative mHHS. However, patients implanted with shortened stems had less intraoperative complications, but lower net improvement in mHHS.Level of EvidenceLevel IV, Retrospective comparative cohort study

Open reduction and polyaxial plating for stemmed knee periprosthetic fractures: A case series

Introduction: Stemmed total knee arthroplasty (STKA) periprosthetic fractures (PPFs) are an emerging problem affecting frail patients. Their surgical fixation is challenging, due to intramedullary involvement and poor bone stock. Polyaxial locking plating has yielded good results in implant-related femur fractures. We hypothesized that this treatment would provide similar results for STKA PPFs. Methods: Retrospective analysis of consecutive patients with a femoral PPF or inter-implant fracture around a knee revision stem who had undergone open reduction and periprosthetic-specific polyaxial plate fixation. Results: We found 14 cases of mean age 85.4 years. Cerclages were used in 80% of cases. Fixation of a mean 8.6 cortices around the revision stem was achieved, with an overall screw density of 1:2 or 1:3. Four patients lost their ability to walk, while four experienced postoperative local complications. Bone healing was achieved in all except one who died during hospitalization. The 13 remaining survived the first year of follow-up. Conclusion: STKA PPFs are an emerging and challenging problem affecting frail patients. Treatment using polyaxial locking plates provides stable fixation allowing early mobilization despite high complication rates.

Post-valuation quality check of multiple-choice questions

Background: Multiple choice questions find important place in assessment in medical curriculum. Each MCQ is called item. Item analysis is quality check of MCQs after valuation of response sheets. This serves to recognize flaws in MCQs so that the given questions can be preserved in question bank, modified or deleted. Methods: 140 medical students of second MBBS were assessed pharmacology through 20 single best response type MCQ. Post exam validation of MCQs was done by item analysis. Each item was analyzed for level of difficulty, ability of the question to discriminate between poor and good performing students and distracter effectiveness.Results: Score ‘1’ was given for correct and ‘0’ for incorrect or no response. The mean score of the test was found to be 10.58±2.48, with a range 5-18. The whole test had an acceptable difficulty level with 43.25±17.81 mean difficulty index. The discrimination index of the whole test was found to be 0.123±0.184 mean PBI correlation coefficient, which is not satisfactory. Out of 60 distractors, 51 were found to be functional, hence distractor efficiency of the given test was 85%±19.96% which is acceptable.Conclusions: 60% questions were found to be ideal and 25% were acceptable with revision of stem or options. One question was easy with poor discrimination which needs major modification in construct or subject to be placed in question bank while another one question was difficult but had negative biserial index which needs to be deleted from the question bank.

Risk of simultaneous and delayed breakage of total hip replacement ceramic implants in patients with trauma induced periprosthetic fracture and acetabular shell loosening

BackgroundCeramic implant breakage (CIB) in total hip replacement (THR) is a rare incident. A confusion exists between the fragile mechanical behaviour of ceramic materials (brittleness) and fragility in the common sense (easy to break), leading to the misconception that trauma is to blame for these breakages. Trauma has been reported as a cause of breakage by several authors and it is debated whether the burst force can be reached in one single trauma in-vivo. We did a retrospective investigation aiming to determine the risk of CIB associated with a major trauma defined as a periprosthetic femoral fracture (PPFF) or a traumatic loosening of the acetabular shell (TLAS) in ceramic-on-ceramic (CoC) THR. HypothesisThe impact forces responsible of PPFF and TLAS, which are probably the most important impact forces sustained by patients, are not sufficient to induce immediate or delayed CIB. Material and methodsWe conducted a retrospective study on 31 patients (62 ceramic implants, 31 acetabular liners and 31 femoral heads) with a PPFF or TLAS between January 2010 and January 2022. We reviewed the records and X-rays at the time of the major trauma and at the last follow-up. We searched for simultaneous CIB, and those occurring on the non-explanted ceramic implants at last follow up (delayed CIB). These major traumas occurred in 9 men and 22 women. Median age was 75 years old [20–97years old]. There were 28 PPFF and 3 TLAS. Mean time from THR to trauma was 91.2±67months [2.4–240months]. ResultsOn X-rays and after intraoperative confirmation, we do not report any simultaneous CIB on the 62 ceramic implants. Treatment consisted of internal fixation for 20 patients with preservation of both ceramic implants for Vancouver A, B1 and C fractures, 8 stem revisions with preservation of acetabular liner for Vancouver B2 and B3 fractures and 3 acetabular shell revisions to dual mobility and ceramic head change for TLAS. Thus, a total of 48 ceramic implants remained implanted (28 acetabular liners and 20 femoral heads). At last follow-up after the index revision (median=36 months [6–100months]), no patient had a delayed CIB. DiscussionMajor trauma resulting in a PPFF or TLAS in patient withs a CoC THR did not result in simultaneous CIB. The impact forces during these traumas are not sufficient to induce immediate breakage of the ceramic implants. At a median 3years follow-up we found no delayed CIB. Because CIB is a rare event, longer follow up and larger cohort study is needed to determine if a single high impact trauma can initiate and favour the spread of a crack in the ceramic material leading to a breakage. Considering the high mechanical resistance of the ceramic implants and the absence of CIB during or after a major trauma in our study, patients with CoC bearings should not be restricted in their daily activity to prevent CIB. Level of evidenceIV, retrospective cohort study.