BACKGROUND:In public hospitals the number of complex urgent and semi-urgent revision joint replacements has increased over time, conversely the number of primary joint replacements has decreased. This study aimed to investigate the effect of this change on service delivery of elective surgery and training in one large metropolitan hospital. METHODS:We retrospectively reviewed changes in staffing, workload and all hip and knee joint replacements performed at the Royal Adelaide Hospital over a 20-year period, between January 2003 to December 2023. RESULTS:The number of primary total hip replacements (THR) and total knee replacements (TKR) performed on elective lists has decreased from 210/year to 140/year. The number of revisions THR and TKR increased from 76/year to 219/year (135 septic). The number of patients awaiting elective surgery has increased from 220 in 1999 (THR 18) to 597 in 2024 (THR 69). CONCLUSIONS:There is an urgent need of decisions by local policy makers to plan for the continual increase in THR and TKR as well as revision joint replacements. The significant change in pathology requires consideration of staffing, training and funding to account for the increased number of complex septic revisions.
PURPOSE:To assess the impact of the intramedullary canal occupying ratio (ICOR) on bone union and the stability of fixation in intertrochanteric fracture treatment using proximal femoral nail anti-rotation (PFNA) surgery. METHODS:A retrospective analysis included 151 patients aged 60 years and above who underwent PFNA for unilateral intertrochanteric fractures between June 2020 and 2022. Patients were categorised into 3 groups based on ICOR percentiles (0.48-0.93). Bone healing was assessed using the Radiographic Union Score for Hip (RUSH) at 2, 6, and 12 weeks postoperatively. Fixation stability was assessed by comparing immediate and 3-month postoperative radiographs. Multivariate regression was used to assess the relationship between ICOR, RUSH scores, and fixation stability. RESULTS:No significant differences in RUSH scores or stability measurements were found among the 3 ICOR-based groups. Multivariate regression showed no clear correlation between ICOR and RUSH scores, except for a statistically significant but not clinically relevant association with changes in neck-shaft angle. In contrast, RUSH scores were significantly associated with fracture severity according to the OTA/AO Classification. CONCLUSION:ICOR was not a significant predictor of fracture healing or fixation stability. In uncertain cases regarding nail size, using a smaller nail was not linked to inferior radiographic or fixation-related outcomes.
BACKGROUND/OBJECTIVES:The acetabular labrum plays a key role in hip biomechanics, reducing contact pressure and peak stress on articular cartilage. In femoroacetabular impingement (FAI), injuries often require surgical intervention. While anatomical repair restores function, irreparable cases necessitate labral reconstruction with grafts. Despite advancements, detailed morphometric studies remain limited. This study analyses labral morphometry, focusing on regional and sex-based differences to optimise graft selection. MATERIALS AND METHODS:18 adult hip specimens were included after screening for normal hip morphometry on fluoroscopy (Wiberg 25-40°, alpha angle <55°, preserved joint space; Tönnis <2) and verification of intact labral and chondral structures after dissection. Morphometric measurements included labrum height (anterior,superior,posterior), acetabular diameter, anterior superior iliac spine (ASIS) distance, and transverse ligament (TAL) width. Specimens were analysed regionally and stratified by sex. Statistical comparisons identified morphometric differences. RESULTS:Labrum height was greatest in the posterior (7.49 ± 0.95 mm), followed by the superior (6.78 ± 0.91 mm) and anterior (5.60 ± 0.71 mm) regions. Statistically significant (p < 0.05) sex-based differences were observed in all measurements. Males exhibited greater labral height in the superior (7.19 ± 1.02 mm vs. 6.29 ± 0.91 mm), posterior (7.38 ± 0.66 mm vs. 6.93 ± 0.70 mm), and anterior (5.49 ± 1.03 mm vs. 5.03 ± 0.71 mm) regions. Additionally, males had larger transverse ligament width (7.04 ± 0.68 mm vs. 6.66 ± 0.63 mm), ASIS distance (285.73 ± 7.12 mm vs. 275.88 ± 9.24 mm), and acetabular diameter(54.35 ± 2.76 mm vs. 50.29 ± 4.97 mm). CONCLUSIONS:The acetabular labrum shows progressive height variation - posterior > superior > anterior - with males exhibiting approximately 1 mm greater dimensions across all regions. These anatomical differences should guide graft selection and surgical planning to optimise patient-specific hip preservation and outcomes.
BACKGROUND:This study aimed to compare: (1) periprosthetic bone mass changes; (2) clinical results; (3) revision rates; and (4) survivorship of total hip arthroplasty (THA) in patients younger than 50 years. METHODS:This was a retrospective study in which 168 patients with conservative metaphyseal-fitting anatomic cementless (CMA) stems (201 hips) were identified, and then a separate group of 181 patients with conventional anatomic cementless (CA) stems (209 hips) were identified. Periprosthetic bone mass change was measured using DEXA. The mean follow-up was 20-22 years (range 20-24 years) in both groups. RESULTS:In the CA group, BMD decreased markedly in both Gruen zones 1 and 7 of the femur. Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and University of California, Los Angeles (UCLA) activity score improved significantly at the final follow-up in both groups. The survival rate was 97.5% (95% CI, 91-100%) in the CMA stem group and 97.1% (95% CI, 91-100%) in the CA group at 20 years of follow-up. CONCLUSIONS:At a mean follow-up of 20-22 years, both CMA and CA stems provided excellent clinical results. However, CA stems had significantly higher stress-shielding-related bone loss.
AIMS:Acetabular fractures in young patients are usually treated with open reduction and internal fixation (ORIF) to preserve the native joint. Despite this, many develop post-traumatic arthritis, needing conversion to total hip arthroplasty (THA). The timing of THA and the long-term survival of these implants remain uncertain. We systematically reviewed the literature to determine the interval from ORIF to THA and to evaluate implant survivorship. METHODS:We searched PubMed, Embase, Scopus, and Web of Science for studies reporting outcomes of patients <60 years who underwent ORIF for acetabular fracture and later THA. Data extracted on patient demographics, fracture type, time to THA, survivorship, and complications. Pooled estimates were calculated using random-effects models, and survivorship summarised using Kaplan-Meier methods. RESULTS:12 studies including, ~450 patients met inclusion criteria. The pooled mean time from ORIF to THA was approximately 5.2 years (95% CI, 3.7-6.6). Between a ¼ and ⅓ of patients required THA at longer follow-up. Implant survivorship was 95% at 5 years and 85-90% at 10 years, declining to 70-80% at 15 years. Outcomes were worse in complex fracture patterns. Cementless fixation and modern porous ingrowth cups achieved survivorship similar to primary THA. Complications were more common than in primary THA, including dislocation (~10%), infection (~7%), and reoperation (~15%). CONCLUSIONS:In patients under 60, ORIF usually delays the need for THA by several years, but conversion is required in a substantial population. Conversion THA restores function and achieves acceptable survivorship, although it remains technically demanding, with higher complication rates than primary THA.
BACKGROUND:The purpose of this study was to identify risk factors associated with wound complications following DAA THA and to evaluate the incidence of these wound issues when negative pressure wound therapy (NPWT) was used as the primary surgical dressing. METHODS:We reviewed 725 patients from five different surgeons at a single institution who underwent THA through a DAA from 2011 to 2023. Medical records were reviewed for demographics, comorbidities, surgical details, and a broad set of criteria denoting wound complications or dehiscence. Univariate and multivariate analyses were performed to identify potential risk factors. Secondary outcomes included periprosthetic joint infection (PJI), 90-day emergency room visits, readmission, and all-cause revision rates. RESULTS:83 (11.4%) patients developed a wound complication based on criteria. Univariate analysis showed that increased body mass index (BMI) (mean 30.4 vs. 27.8, p < 0.001), surgical time (138.0 vs. 108.5 minutes, p < 0.001), hospital length of stay (50.4 vs. 40.6 hours, p = 0.013), DAA surgeon experience of less than 1 year (p = 0.012) and use of NPWT (25.3 vs. 11.6%, p < 0.001) were associated with wound complications. Multivariate analysis further demonstrated BMI (OR 1.06 [1.01-1.11] p = 0.016), longer surgical time (OR 1.01 [1.00-1.01] p = 0.004), and NPWT use (OR 2.1 [1.2-3.9], p = 0.016) as associated with higher rates of wound complications. Patients with wound complications had higher rates of 90-day emergency room visits (10.8 vs. 4.4%, p = 0.018), readmissions (15.7 vs. 3.9%, p < 0.001), all-cause revision (19.3 vs. 2.8%, p < 0.001) and PJIs (13.3 vs. 0.5%, p = 0.005). CONCLUSIONS:Obesity, length-of-stay, longer surgical time, and surgeon DAA experience <1 year were identified as risk factors for wound complications following DAA THA in our series. Prophylactic use of NPWT was not associated with a lower risk of wound complications in our cohort. Patients with wound complications had higher rates of PJI, readmission, and reoperation.
INTRODUCTION:In the event of early or haematogenous periprosthetic joint infection (PJI), the preferred treatment is debridement, antibiotics, and implant retention (DAIR), with reported cure rates ranging from 60% to 80%. Nevertheless, the performance of this surgical strategy and the factors associated with poorer outcomes remain unknown in the Brazilian population. This study aims to evaluate the effectiveness of DAIR in early PJI following total hip arthroplasty (THA) and identify factors linked to unfavourable clinical outcomes. METHODS:This is a retrospective cohort study of patients who underwent primary THA between January 2011 and December 2017, developed early PJI, and were treated with DAIR with a minimum follow-up of 1 year. An unfavourable outcome was defined as infection persistence, recrudescence, recurrence, or the need for revision surgery. RESULTS:A total of 83 hips were included in the study, with a DAIR success rate of 72.3%. Staphylococcus aureus was the most frequently identified pathogen (59.7%), and no pathogen-related factors were associated with outcomes. Patient-related independent risk factors for unfavourable outcome included pre-DAIR haemoglobin ⩽ 10 g/dL (OR [95% CI] = 6.26, 1.63-24.08; p = 0.008) while a lower Charlson Comorbidity Index (CCI), a validated score that quantifies patient comorbidity burden, ⩽1 (OR [95% CI] = 0.04, 0.00-0.32; p = 0.003) and primary osteoarthritis (OR [95% CI] = 0.23, 0.06-0.95; p = 0.042) were protective. A procedure-related factor associated with failure was primary and THA surgical time ⩾180 minutes (OR [95% CI] = 10.15, 2.54-40.56; p = 0.001). CONCLUSIONS:In this population, prognostic factors associated with DAIR outcomes were related to patient characteristics and features of the index procedure rather than to antibiotic therapy or DAIR itself. These findings may help refine patient selection for DAIR and highlight potentially modifiable factors - such as preoperative anaemia, that could reduce the risk of treatment failure following THA.
AIM:The aim of this study was to compare the radiographic accuracy, clinical outcomes, and complications of robotic-assisted total hip arthroplasty (rTHA) and conventional total hip arthroplasty (cTHA) in patients with Crowe type 3-4 developmental dysplasia of the hip (DDH). METHODS:This single-centre retrospective comparative study included 38 patients with Crowe type 3-4 DDH who underwent total hip arthroplasty (THA) between 2016 and 2021 (20 rTHA, 18 cTHA). Clinical outcomes were evaluated using the Harris Hip Score (HHS). Acetabular cup inclination, anteversion, leg-length discrepancy (LLD), operative time, and complications were assessed at a mean follow-up of 32.0 ± 15.7 months in the rTHA group and 35.9 ± 19.0 months in the cTHA group. RESULTS:Acetabular anteversion and inclination were comparable between groups (p = 0.099 and p = 0.231). The proportion of cups within the Lewinnek safe zone was higher in the rTHA group (90% vs. 77%), without statistical significance (p = 0.302). No significant differences were observed in postoperative LLD or HHS. Operative time was significantly longer in the rTHA group (109.7 ± 33.6 vs. 93.5 ± 21.3 minutes, p = 0.042). Complication rates were similar between groups (2 vs. 2 cases). CONCLUSIONS:rTHA and cTHA demonstrated comparable radiographic and clinical outcomes in Crowe type 3-4 DDH at short- to mid-term follow-up. Although rTHA showed a trend toward improved implant positioning, operative time was longer. Larger prospective studies are required to determine potential long-term advantages of rTHA in severe DDH.
Objective: This study aimed to compare the reduction quality and clinical outcomes of locked and unlocked blade variants of the proximal femoral nail antirotation (PFNA) system in the treatment of trochanteric fractures in patients aged >65 years with similar demographic and clinical profiles. Methods: A total of 314 patients treated for trochanteric fractures between 2013 and 2020 were retrospectively analyzed. Patients were grouped according to whether locked ( n = 160) or unlocked ( n = 164) blade PFNA implants were used. Baseline characteristics including age, gender, comorbidities, and fracture type were similar across groups. Surgical parameters, radiological measurements, postoperative complications, and clinical outcomes (Harris Hip Score, Visual Analog Scale) were compared. The use of unlocked blade implants was gradually replaced by locked blade implants after 2017 due to changes in reimbursement regulations. Results: The locked group had significantly longer operation time and greater intraoperative bleeding. No significant difference was found in reduction quality between groups ( p > 0.05). Radiologically, Parker ratio AP was higher in the locked group, whereas type apex distance, calcar-referenced distance, and cervical angle difference were greater in the unlocked group ( p < 0.05). VAS was higher in the locked group at 6 weeks ( p < 0.05). Postoperative complications were more frequent in the locked group, although nonunion rates were not significantly different ( p > 0.05). Long-term clinical scores showed no significant difference ( p > 0.05). The unlocked group had significantly longer follow-up duration ( p < 0.05). Conclusions: While both implant types provided comparable clinical and radiological outcomes, the unlocked PFNA group showed advantages in terms of surgical efficiency and lower complication rates.
INTRODUCTION:Increasing demand for revision hip arthroplasty (rTHA), particularly among patients with longer life expectancy, necessitates durable femoral implants. The Link MP modular fluted tapered stem lacks granular mid- and longer-term outcome data. METHODS:A retrospective review of 125 rTHA procedures using the Link MP stem was conducted at a UK centre from 2011 to 2025. Demographics, operative details, complications, radiographic migration, and clinical outcomes were analysed, and Kaplan-Meier survival analysis assessed implant survivorship. RESULTS:Median follow-up was 57 months, with 100 followed up for at least 2 years. Aseptic loosening was the primary revision indication (n = 85, 68%). Extended trochanteric osteotomy (n = 71, 56.8%) and cortical windowing (n = 35, 28%) were common adjuncts, with 98.1% union rate across the osteotomy cohort. Median stem migration was 3 mm; 36% had >5 mm migration without correlation to reduced mobility (p = 0.273). Overall, 12 cases (9.6%) returned to theatre; stem-related reoperation occurred in 5 cases (4%). Infection was the most common reason for return to theatre (n = 4, 33.3%), with instability, fractures, and device issues also noted. Kaplan-Meier analysis showed 96% stem survival at 166 months (95% confidence interval from 89.1% to 100%, with 4 hips at risk at that period. 96 cases (76.8%) returned to baseline mobility, 7 (5.6%) of cases suffered an intraoperative complication. CONCLUSIONS:The Link MP stem demonstrates excellent survivorship in complex revision scenarios. Early stem migration appears benign. Mechanical complications at the modular junction were rare but clinically important, requiring return to theatre. This study supports the implant's reliability and provides technical insight into its use.
BACKGROUND:A suboptimal radiographic inclination (RI) angle of the cup has been associated with worse short- and long-term outcomes after primary total hip arthroplasty (THA). There are several factors that lead to RI outliers including cup version, pelvic orientation at time of cup impaction and angle of the cup introducer relative to the floor. The primary aim of this study was to analyse if a digital inclinometer helps achieving a target RI of cups in primary THA and what factors increase the risk of having a cup inclination outside the target zone. PATIENTS AND METHODS:In this prospective study, we included 200 consecutive patients undergoing primary THA. Preoperatively, the surgeon determined the target intraoperative inclination (IOI). The IOI was measured with the aid of a digital inclinometer after seating of the acetabular component. Anteroposterior pelvic radiographs were made to measure the RI of the acetabular component. The target zone for inclination was defined as 35-45° of RI. RESULTS:The mean RI was 37.9° SD 4.7. There were 53 outliers (26.5%) for the 35-45° zone. The mean absolute ΔIOIcup-IOItarget was 1.2° SD 1.0. The absolute ΔIOIcup-IOItarget was <1° in 108 patients (54%), <2° in 160 patients (80%) and <3° in 186 patients (93%). The absolute deviation from the mean ΔOImath-IOIcup, which corresponds with pelvic motion, was significantly higher in RI outliers compared with non-outliers for the 35-45° inclination zone (4.7°, SD 2.8 vs. 2.5°, SD 2.0 respectively) (p < 0.0001). CONCLUSIONS:Using a digital inclinometer allowed the surgeons to intraoperatively put the cup within 3° of the IOItarget in 93% of cases. This led to 74% of the acetabular components being placed within an RI target zone of 35°- 45°. The remaining outliers were caused by more of less than average deviation of the pelvic position at time of impaction.
BACKGROUND:Osteonecrosis of the femoral head (ONFH) is a progressive, debilitating condition caused by compromised blood supply, leading to bone cell death and femoral head collapse. Effective early-stage treatments remain limited. AIM:This study compared core decompression (CD) with allograft and autologous bone marrow therapy plus alendronate against classical bone grafting alone in patients with Ficat Grade II-III ONFH, aiming to assess functional outcomes and delay the need for total hip arthroplasty. METHODOLOGY:This randomised, prospective study involved 48 patients with Ficat Grade II-III avascular necrosis of the hip. Group A received CD combined with autologous bone marrow stem cells and allograft plus alendronate, while Group B underwent CD with a classical iliac bone graft and alendronate. Clinical outcomes were assessed at 6, 12, and 24 months using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), Oxford Hip Score (OHS), and magnetic resonance imaging-based necrotic area evaluation. RESULTS:Over a 24-month follow-up, Group A demonstrated superior outcomes across all clinical indices. WOMAC scores improved from 36.9 to 12.2 in Group A, versus 34.7 to 22.4 in Group B. HHS rose from 45.8% to 82.0% in Group A and from 42.6% to 60% in Group B. OHS increased from 12 to 44 in Group A and from 14 to 28 in Group B. Significant (p < 0.0001) reductions in necrotic segment size and fewer poor outcomes were observed in Group A. CONCLUSIONS:Group A's approach yielded greater functional recovery, pain relief, and mobility restoration than classical grafting alone.
BACKGROUND:Hip arthroscopy outcomes for femoroacetabular impingement remain heterogeneous. The Hip Outcome Score (HOS) comprises 2 distinct subscales measuring activities of daily living and sports performance, yet their dissociation after surgery remains poorly characterised. PURPOSE:To identify distinct recovery phenotypes after hip arthroscopy using unsupervised machine learning and determine preoperative predictors of phenotype membership. METHODS:We analysed 326 consecutive patients with complete 1-year HOS-ADL and HOS-Sports data. K-means clustering was performed on 5 outcome variables with Gaussian Mixture Model validation. Multinomial logistic regression identified preoperative predictors. RESULTS:4 phenotypes emerged: Complete Responders (41.7%), ADL-Dominant Responders (27.3%), Slow Progressors (19.0%), and Non-Responders (12.0%). ADL-Dominant phenotype was predicted by age >40 years (OR 3.42, p < 0.001), Tegner <5 (OR 2.87, p = 0.001), and Outerbridge III-IV (OR 2.41, p = 0.005). CONCLUSIONS:4 robust recovery phenotypes exist, with 27% demonstrating ADL-sports dissociation predicted by older age, lower activity, and greater chondral damage. Recognition enables personalised preoperative counselling.
BACKGROUND:Non-traumatic avascular necrosis (AVN) of the femoral head is primarily attributed to vascular compromise; however, the potential role of spinopelvic alignment in its development remains insufficiently defined. This study aimed to evaluate whether sagittal spinopelvic parameters differ between patients with non-traumatic AVN and asymptomatic individuals. METHODS:A retrospective case-control radiographic study was performed including 21 adults with bilateral Ficat-Arlet stage II-III non-traumatic AVN and 100 age- and sex-matched asymptomatic controls. Standardised standing full-length lateral radiographs were analysed to measure pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis (TK), and sagittal vertical axis (SVA). Spinopelvic morphology was classified using the Roussouly and Barrey systems. Interobserver reliability was evaluated using intraclass correlation coefficients (ICC), and statistical significance was set at p < 0.05. RESULTS:Patients with AVN demonstrated significantly lower PI, PT, SS, and LL values compared with controls (all p < 0.01), whereas TK did not differ significantly between groups. Although no statistically significant differences were observed in the distribution of Barrey and Roussouly types, a higher prevalence of Roussouly type 3 morphology was noted in the AVN cohort. Sex-related differences evident in the control group were not observed among AVN patients, and age showed minimal association with sagittal parameters. Inter-observer reliability was excellent for all measurements (ICC > 0.90). CONCLUSIONS:Patients with non-traumatic AVN exhibit a distinct spinopelvic alignment profile characterised by reduced PI-derived sagittal parameters and limited compensatory pelvic orientation. These findings indicate that altered lumbopelvic biomechanics may be associated with increased mechanical stress on the femoral head and may reflect a biomechanical profile linked to AVN susceptibility. Further prospective studies are warranted to clarify the clinical implications of this association.
Hip resurfacing arthroplasty (HRA) has a rich history of innovation. This review documents the changes in HRA, focusing on how the successes and failures of different historical design concepts and bearing materials have shaped current indications and patient selection. We also examine the evolution and development of modern prostheses.
BACKGROUND AND OBJECTIVES:Paediatric femoral neck fractures (PFNFs) are rare but carry a significant risk of avascular necrosis (AVN) of the femoral head. Delbet type II fractures are the most common variant, yet specific predictors of AVN within this subgroup remain unclear. This study aimed to identify risk factors for AVN in Delbet type II PFNFs and evaluate the functional outcomes following management with weight-bearing restriction and bisphosphonate therapy. METHODS:A retrospective case-control study conducted from June 2011 to May 2022 included a total of 15 Delbet type II fractures. 5 patients who developed AVN (cases) were matched in a 1:2 ratio with 10 patients who did not develop AVN (controls). Quality of reduction was quantified using the neck-shaft angle (AP view) and Southwick angle (lateral view). Functional outcomes were evaluated at final follow-up (mean 35.2 months) using the Ratliff criteria and modified Harris Hip Score (mHHS). RESULTS:An increased Southwick angle was significantly associated with AVN (mean 14.8° vs. 5.95°, p = 0.012; OR 1.30, 95% CI, 1.01-1.68). Age >7 years and non-anatomic reduction showed high odds ratios (OR 6.00), but did not achieve statistical significance. Reduction method, type of fixation and injury-surgery interval were not significantly associated with AVN. 4 out of 5 AVN cases achieved good functional outcomes, and 1 achieved a fair outcome following a 12-month regimen of oral bisphosphonates and restricted weight-bearing. CONCLUSIONS:An increased Southwick angle following fracture reduction is a significant predictor of AVN in Delbet type II PFNFs, emphasising the critical importance of achieving anatomical reduction in the sagittal plane. If AVN develops, conservative management with oral bisphosphonates and protected weight-bearing yields favourable functional outcomes.
BACKGROUND:Cemented polished taper-slip (PTS) stems are widely used in total hip arthroplasty but are associated with an increased risk of periprosthetic femoral fracture. Stem centralizers enable surgeons to achieve an even cement mantle and allow for controlled subsidence, which is essential for maintaining fixation, as this relies on the PTS implant's interaction with the surrounding cement mantle (known as a "force-closed" mechanism). However, if subsidence exceeds the centralizer's limit, the implant transitions to a configuration where fixation depends on direct mechanical interlocking with the cement mantle (a "shape-closed" mechanism), potentially increasing stresses within the cement mantle. The aim of this study was to quantify the stress distribution changes within the cement mantle when further subsidence is restricted using finite element analysis (FEA). METHODS:Three commonly used PTS designs: C-Stem AMT (Johnson & Johnson MedTech, Warsaw, IN, USA), Exeter (Stryker, Kalamazoo, MI), and CPT (Zimmer Biomet, Warsaw, IN), were 3D scanned and modelled, incorporating cement mantle and centralizer gaps per manufacturer guidelines. FEA simulated loading conditions mimicking a stumble (6,900 N) with and without a distal gap to assess von Mises stress and deformation. Variations in stem materials (Stainless steel (SS316L) and Co-Cr alloys) and friction coefficient were also evaluated. RESULTS:With subsidence allowance, peak von Mises stresses were concentrated in the medial calcar (Gruen zone 7), with CPT stems showing the highest stress (~45 MPa). When subsidence was restricted, stress shifted to the distal tip (zone 4), increasing by 49-102% depending on stem design and material. Co-Cr stems exhibited higher stress and displacement at the distal tip compared to SS316L stems. CONCLUSIONS:Restricting subsidence in PTS stems significantly increases distal cement mantle stress, which may elevate PPF risk. Stem design, material and implant-cement interface friction influence stress distribution and subsidence behavior, potentially affecting long-term implant stability.
BACKGROUND:Proximal femoral replacement (PFR) is a useful salvage option for reconstruction after massive proximal femoral bone loss. However, functional outcomes in non-oncologic cases remain underreported. The purpose of this study was to evaluate postoperative function, complications, and implant survival after PFR performed for non-oncologic indications. METHODS:We retrospectively reviewed 63 consecutive non-oncologic PFRs performed between 2018 and 2023. After applying exclusion criteria and accounting for duplicates and patients lost to follow-up, 30 participants were available for final evaluation. The primary outcome was the postoperative modified Harris Hip Score (mHHS). Secondary outcomes included postoperative complications, infection-free survival, and revision-free arthroplasty survival. Univariate linear regression analyses were performed to identify factors associated with postoperative mHHS. RESULTS:The study cohort included 30 patients (63.3% female) with a mean age of 64.4 ± 13.6 years and mean follow-up of 31.4 months. The mean postoperative mHHS was 54.0 ± 22.4. Male patients demonstrated higher unadjusted mHHS than females (69.2 ± 18.5 vs. 45.2 ± 19.8; p = 0.003). The Kaplan-Meier estimated infection-free survival was 96.4% (95% CI, 89.8-100%) at 12 months, 91.4% (95% CI, 80.4-100%) at 24 months, and 73.1% (95% CI, 46.3-100%) at 60 months. Revision arthroplasty survival was 85.1% (95% CI, 68%, 100%) at 12 and 24 months, and 49.7% (95% CI, 25.6-96.3%) at 60 months. Overall complications occurred in 15 patients (50%), with periprosthetic joint infection being the most frequent (n = 4, 13.3%). CONCLUSIONS:PFR for non-oncologic indications provides modest limb salvage and functional outcomes, although complications remain common. Functional recovery appears multifactorial and not solely dependent on implant design or fixation method. These findings may support the use of PFR as a salvage option in carefully selected non-oncologic cases, while emphasizing the need for larger prospective studies to improve patient selection and outcomes.
INTRODUCTION:Cement-in-cement (CiC) is a well-established technique in revision hip arthroplasty. It involves cementing a new femoral stem into an existing intact cement mantle. It is less invasive than the conventional technique of removing well-fixed cement. This study evaluates the clinical and radiological outcomes of the C-Stem in CiC revision hip arthroplasty at the design centre. METHODS:A retrospective analysis was conducted using a prospectively maintained database of CiC revision hip arthroplasties performed between July 2015 and 2023. Inclusion criteria included patients undergoing CiC femoral revision with a C-Stem and have a minimum of 1 year follow-up. Patients with a disrupted cement mantle, infection at index surgery, or less than 1 year of follow-up were excluded. Data on indications, complications, radiographs and survivorship were analysed. Kaplan-Meier survival analysis was performed with revision for any cause as the endpoint. RESULTS:There were 102 cases, of which 78 had at least 1 year of clinical and radiological follow-up. The average patient age was 71 years (47-90). The mean follow-up was 41 (25-72) months. The 3 most common reasons for revision surgery were cup loosening (60%), dislocation (16%) and stem loosening (11%). Following revision arthroplasty using the CiC technique, there were a total of 11.8% stem revisions. Kaplan-Meier survival analysis was 86% (95% confidence interval 76-96) at 8 years for all-cause stem revisions. There were no re-revisions of the femoral stem for aseptic loosening. The majority of cases (93%) maintained their preoperative Barrack grading. CONCLUSIONS:This largest single study demonstrates favourable medium-term implant survival with the C-Stem in CiC revision hip arthroplasty. This technique remains viable in carefully selected revision cases since it is associated with a much lower complication and risk profile. Further studies with longer follow-up and functional outcome scores are warranted.
