Aims The aim of this study was to conduct a cross-sectional, observational cohort study of patients presenting for revision of a total hip, or total or unicompartmental knee arthroplasty, to understand current routes to revision surgery and explore differences in symptoms, healthcare use, reason for revision, and the revision surgery (surgical time, components, length of stay) between patients having regular follow-up and those without. Methods Data were collected from participants and medical records for the 12 months prior to revision. Patients with previous revision, metal-on-metal articulations, or hip hemiarthroplasty were excluded. Participants were retrospectively classified as ‘Planned’ or ‘Unplanned’ revision. Multilevel regression and propensity score matching were used to compare the two groups. Results Data were analyzed from 568 patients, recruited in 38 UK secondary care sites between October 2017 and October 2018 (43.5% male; mean (SD) age 71.86 years (9.93); 305 hips, 263 knees). No significant inclusion differences were identified between the two groups. For hip revision, time to revision > ten years (odds ratio (OR) 3.804, 95% confidence interval (CI) (1.353 to 10.694), p = 0.011), periprosthetic fracture (OR 20.309, 95% CI (4.574 to 90.179), p < 0.001), and dislocation (OR 12.953, 95% CI (4.014 to 41.794), p < 0.001), were associated with unplanned revision. For knee, there were no associations with route to revision. Revision after ten years was more likely for those who were younger at primary surgery, regardless of route to revision. No significant differences in cost outcomes, length of surgery time, and access to a health professional in the year prior to revision were found between the two groups. When periprosthetic fractures, dislocations, and infections were excluded, healthcare use was significantly higher in the unplanned revision group. Conclusion Differences between characteristics for patients presenting for planned and unplanned revision are minimal. Although there was greater healthcare use in those having unplanned revision, it appears unlikely that routine orthopaedic review would have detected many of these issues. It may be safe to disinvest in standard follow-up provided there is rapid access to orthopaedic review. Cite this article: Bone Joint J 2022;104-B(1):59–67.

AIMS:This study aimed to develop a virtual clinic for the purpose of reducing face-to-face orthopaedic consultations. PATIENTS AND METHODS:Anonymized experts (hip and knee arthroplasty patients, surgeons, physiotherapists, radiologists, and arthroplasty practitioners) gave feedback via a Delphi Consensus Technique. This consisted of an iterative sequence of online surveys, during which virtual documents, made up of a patient-reported questionnaire, standardized radiology report, and decision-guiding algorithm, were modified until consensus was achieved. We tested the patient-reported questionnaire on seven patients in orthopaedic clinics using a 'think-aloud' process to capture difficulties with its completion. RESULTS:A patient-reported 13-item questionnaire was developed covering pain, mobility, and activity. The radiology report included up to ten items (e.g. progressive periprosthetic bone loss) depending on the type of arthroplasty. The algorithm concludes in one of three outcomes: review at surgeon's discretion (three to 12 months); see at next available clinic; or long-term follow-up/discharge. CONCLUSION:The virtual clinic approach with attendant documents achieved consensus by orthopaedic experts, radiologists, and patients. The robust development and testing of this standardized virtual clinic provided a sound platform for organizations in the United Kingdom to adopt a virtual clinic approach for follow-up of hip and knee arthroplasty patients. Cite this article: Bone Joint J 2019;101-B:951-959.

In vivo fluoroscopic studies of patients with total knee replacements (TKRs) have shown lift-off of the femoral condyles from the tibial insert. This study investigated the influence of femoral condylar lift-off on the ultra-high molecular weight polyethylene (UHMWPE) wear of fixed bearing (FB) and rotating platform mobile bearing (RP MB) total knee replacements, using a physiological knee joint simulator. In the absence of lift-off, the RP MB knees exhibited a lower wear rate of 5.2;;2.2 mm3 per million cycles (mm3/MC) compared with 8.8;;4.8 mm3/MC for the FB knees. The presence of femoral condylar lift-off was found to accelerate the wear of the FB and RP MB knees tested in this study to 16.4;;2.9 and 16.9;;2.9 mm3/MC respectively. For the RP MB knees the increase in wear rate was more marked, resulting in a similar wear rate for both designs of knee under lift-off conditions. In both cases the medial condyle displayed more wear damage. This study has shown that a small amount of abduction/adduction lift-off and medial-lateral shift increases wear and that the increase in wear is design dependent. In this simulator test, lift-off was simulated on every cycle, whereas the amount of wear and effect of lift-off clinically would depend on the frequency of occurrence of lift-off in vivo.

AIMS:Increasing demand for total hip and knee arthroplasty (THA/TKA) and associated follow-up has placed huge demands on orthopaedic services. Feasible follow-up mechanisms are therefore essential.METHODS:We conducted an audit of clinical follow-up decision-making for THA/TKA based on questionnaire/radiograph review compared with local practice of Arthroplasty Care Practitioner (ACP)-led outpatient follow-up. In all 599 patients attending an ACP-led THA/TKA follow-up clinic had a pelvic/knee radiograph, completed a pain/function questionnaire and were reviewed by an ACP. An experienced orthopaedic surgeon reviewed the same radiographs and questionnaires, without patient contact or knowledge of the ACP's decision. Each pathway classified patients into: urgent review, annual monitoring, routine follow-up or discharge.RESULTS:In total, 401 hip and 198 knee patients were included. There was substantial agreement between the ACP and surgeon for both hip (kappa = 0.69, 95% confidence interval (CI) 0.62 to 0.76) and knee (kappa = 0.81, 95% CI 0.74 to 0.88). Positive agreement was very high for discharge and routine follow-up; however the ACP was more likely to select annual monitoring and the surgeon urgent review.DISCUSSION:Review of the questionnaire/radiograph together identified all patients in need of increased surveillance, with good agreement for on-going patient management. However, review of the radiograph or questionnaire alone missed some patients with potential problems. A radiograph in conjunction with a questionnaire as a review may represent a cost effective THA/TKA follow-up mechanism.TAKE HOME MESSAGE:A questionnaire and radiograph-based remote review may represent a cost-effective total joint arthroplasty follow-up mechanism; thereby reducing the considerable burden that follow-up currently places on the NHS.

Background Magnetic Resonance (MR) offers the potential to identify early loosening and assess peri-articular soft tissue structures in patients with metal joint prostheses. Unfortunately, conventional MR is currently incapable of assessing the prosthesis-bone interface in patients with joint replacements because of field inhomogeneity resulting from metal related paramagnetic and ferromagnetic effects. New Slice-Encoding Metal Artefact Correction (SEMAC) techniques have been developed that may allow visualisation of the bone and soft tissues close to metal work. Objectives In order to explore the clinical utility of the technique, we conducted a retrospective audit of conventional MR and the newer metal suppression techniques. Methods Patients who had previously received hip prostheses and were undergoing clinical review were imaged using both conventional and metal suppression MR techniques using a Siemens Avanto 1.5T MR scanner as part of their routine clinical care. T1 TSE and STIR coronal and T1 and STIR SEMAC sequences were assessed. The femoral and acetebaular components were consensus scored by two experienced musculoskeletal radiologists for diagnostic quality. Each prosthesis zone was scored using a five point scale: (0) definitely non-diagnostic; (1) probably non-diagnostic; (2) possibly diagnostic; (3) probably diagnostic; (4) definitely diagnostic. Abnormalities were assessed on both radiographs and MRI using a four point scale: (0) none; (1) mild; (2) moderate; (3) severe. Effusion and bone-cement interface were assessed by prosthesis zone. These abnormalities were defined as increased signal on STIR sequences with intermediate signal on T1 scans. Results Images were reviewed from 19 patients (mean age = 64; SD = 12 years) with a variety of hip prostheses (Charnley = 4, Corail = 7, Furlong = 1, Metal-on-Metal = 7). SEMAC increased the number of diagnostically useful images (defined as ≥2) in all Gruen zones for both STIR and T1 images (Table 1). Importantly, this also translated into to an increased ability to identify abnormalities: Use of SEMAC enabled identification of more abnormalities in all Gruen zones and doubled the number of effusions visible (Table 2). Conclusions The use of SEMAC sequences substantially improved image quality and enabled identification of more peri-prosthetic complications in patients with metallic joint prostheses. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1494

The results of hip and knee replacement surgery are generally regarded as positive for patients. Nonetheless, they are both major operations and have recognised complications. We present a review of relevant claims made to the National Health Service Litigation Authority. Between 1995 and 2010 there were 1004 claims to a value of £41.5 million following hip replacement surgery and 523 claims to a value of £21 million for knee replacement. The most common complaint after hip surgery was related to residual neurological deficit, whereas after knee replacement it was related to infection. Vascular complications resulted in the highest costs per case in each group.Although there has been a large increase in the number of operations performed, there has not been a corresponding relative increase in litigation. The reasons for litigation have remained largely unchanged over time after hip replacement. In the case of knee replacement, although there has been a reduction in claims for infection, there has been an increase in claims for technical errors. There has also been a rise in claims for non-specified dissatisfaction. This information is of value to surgeons and can be used to minimise the potential mismatch between patient expectation, informed consent and outcome.

Nanometre-sized particles of ultra-high molecular weight polyethylene have been identified in the lubricants retrieved from hip simulators. Tissue samples were taken from seven failed Charnley total hip replacements, digested using strong alkali and analysed using high-resolution field emission gun-scanning electron microscopy to determine whether nanometre-sized particles of polyethylene debris were generated in vivo. A randomised method of analysis was used to quantify and characterise all the polyethylene particles isolated. We isolated nanometre-sized particles from the retrieved tissue samples. The smallest identified was 30 nm and the majority were in the 0.1 microm to 0.99 microm size range. Particles in the 1.0 microm to 9.99 microm size range represented the highest proportion of the wear volume of the tissue samples, with 35% to 98% of the total wear volume comprised of particles of this size. The number of nanometre-sized particles isolated from the tissues accounted for only a small proportion of the total wear volume. Further work is required to assess the biological response to nanometre-sized polyethylene particles.

Quantification of the wear rate in vitro is now considered an essential step in the development of a new joint replacement prior to clinical trials. However, little research exists around in vitro simulation of wear in the patellofemoral joint (PFJ) despite over 200,000 being implanted annually within the European Union. A method to simulate wear in the laboratory using four input degrees of freedom within the PFJ of total knee replacement (TKR) has been developed. Wear simulation was validated through comparison of functional kinematics and patellar surface damage modes produced in vitro to clinical outcomes. The technique has been shown to replicate the prescribed in vivo kinematics in a reproducible and repeatable manner. The wear scar areas were similar to those found in vivo. However, geometrical measurements of wear were not reliable due to creep and geometry changes. As has been found previously with tibial inserts, geometrical determination of wear volume was not found to be an effective method of comparing wear from simulators and retrievals. Change in volume calculated gravimetrically was seen to be the most repeatable measure of patellar wear in vitro.

Crosslinked ultra-high molecular weight polyethylene (UHMWPE) has been developed and introduced into clinical practice in order to reduce wear in the hip. Zero wear of highly crosslinked UHMWPE in vitro has been reported by some groups using lubricants with high concentrations of serum proteins in hip simulators. In contrast, some clinical studies have reported finite wear rates. The aim of this study was to compare the wear rates, wear surfaces, and wear debris produced by UHMWPE with different levels of crosslinking in a hip joint simulator, with lower, more physiologically relevant concentrations of protein in the lubricant. The UHMWPEs were tested in the Leeds ProSim hip joint simulator against cobalt-chromium (CoCr) femoral heads. The wear particles were isolated and imaged using a field emission gun scanning electron microscope (FEGSEM) at high resolution. The highly crosslinked UHMWPEs had significantly lower wear volumes than the non-crosslinked UHMWPEs. No significant difference was found in the percentage number and percentage volume of the particles in different size ranges from any of the materials. They had similar values of specific biological activity. The functional biological activity (FBA), which takes into account the wear volume and specific biological activity, showed that the highly crosslinked UHMWPEs had lower FBAs due to their lower wear volume.

There is currently considerable interest in the wear debris and osteolytic potential of different types of bearings used in total joint replacements. The biological activity of the wear debris is dependent on the size and volume of the particles produced. Wear volume also plays an important role in the functional biological activity of a joint replacement. In vitro studies have shown that crosslinking of ultra high molecular weight polyethylene (UHMWPE) acetabular cups and tibial trays produces a reduction in wear volume, and crosslinking has now been introduced clinically for both types of prostheses. Previous studies have identified both micron and submicron-sized polyethylene wear particles. The aim of this study was to characterize the wear and wear particles generated from moderately crosslinked GUR 1,020 GVF UHMWPE acetabular cups and tibial trays in hip and knee joint wear simulators down to 10 nanometers in size. The wear rates of the two prosthesis types were very similar at 25.6 +/- 5.3 mm(3) per million cycles for the hip prostheses and 22.75 +/- 5.95 mm(3) per million cycles for the knee prostheses. Nanometer-sized wear particles were isolated and characterized from both hip and knee simulator lubricants for the first time. Significantly higher numbers (p < 0.05) of particles in the nanometer (<0.1 microm) size range were produced by the hip prostheses compared to the knee prostheses. The knee prostheses produced larger particles, with the mode of particle size in the 0.1-1.0 microm size range, compared to <0.1 microm size range for the hip prostheses. In addition, the knee prostheses produced a greater volumetric concentration of wear particles in the 1.0-10 microm size range, and consequently lower specific biological activity and functional biological activity indices. These results indicated that the knee prostheses had a lower osteolytic potential compared to the hip prostheses.

Debris-induced osteolysis due to surface wear of ultra high molecular weight polyethylene (UHMWPE) bearings is a potential long-term failure mechanism of total knee replacements (TKR). This study investigated the effect of prosthesis design, kinematics and bearing material on the wear of UHMWPE bearings using a physiological knee simulator. The use of a curved fixed bearing design with stabilised polyethylene bearings reduced wear in comparison to more flat-on-flat components which were sterilised by gamma irradiation in air. Medium levels of crosslinking further improved the wear resistance of fixed bearing TKR due to resistance to strain softening when subjected to multidirectional motion at the femoral-insert articulating interface. Backside motion was shown to be a contributing factor to the overall rate of UHMWPE wear in fixed bearing components. Wear of fixed bearing prostheses was reduced significantly when anterior-posterior displacement and internal-external rotation kinematics were reduced due to decreased cross shear on the articulating surface and a reduction in AP displacement. Rotating platform mobile bearing prostheses exhibited reduced wear rates in comparison to fixed bearing components in these simulator studies due to redistribution of knee motion to two articulating interfaces with more linear motions at each interface. This was observed in two rotating platform designs with different UHMWPE bearing materials. In knee simulator studies, wear of TKR bearings was dependent on kinematics at the articulating surfaces and the prosthesis design, as well as the type of material.

Simple configuration pin-on-plate tests were conducted in order to compare the wear of ultrahigh-molecular-weight polyethylene (UHMWPE) when sliding against titanium-nitride (TiN)-coated wrought cobalt-chromium (Co-Cr) plates obtained by arc evaporative physical vapour deposition (AEPVD) with that which occurs when sliding against uncoated wrought and cast Co-Cr plates. UHMWPE wear was determined for plates in their undamaged form and following simulated third-body damage to produce scratches similar to those observed on retrieved implants. In their undamaged form, the coatings produced a similar wear rate of UHMWPE to that with the uncoated Co-Cr plates. However, in their damaged form, TiN-coated plates showed significantly lower polyethylene wear than uncoated wrought Co-Cr plates (analysis of variance; α = 0.05). The TiN-coated plates prevented the generation of high scratch lips due to their higher hardness, producing much smaller R p values (0.19 μ) than the scratched uncoated Co-Cr plates (0.92-1.15 μ). This is a probable explanation for the lower wear rate on the scratched TiN-coated plates than on the scratched uncoated wrought plates. The results of this study have illustrated the possibility of using AEPVD TiN coatings in total knee joint replacements in order to reduce polyethylene wear.

Metal-on-metal hip arthroplasties have demonstrated low wear rates. However, the ion release and toxicity of the metal wear particles remains a concern. Modifying the surface of metal bearings with thick chromium nitride (CrN) coatings has the potential to further reduce wear and ion release, and improve the biocompatibility of wear particles produced. The aim of this study was to investigate the application of surface engineering technology to modify metal-on-metal (MOM) bearings to reduce wear and improve the functional biocompatibility of metal-on-metal prostheses. CrN-on-CrN bearings had lower wear rates in comparison to metal-on-metal bearings, particularly under adverse loading conditions. CrN-on-CrN bearings produced similar nanometer-sized particles to metal-on-metal bearings, however, CrN wear particles were less cytotoxic when cocultured with macrophage and fibroblast cells.

There is currently much discussion about the most clinically relevant testing methods for evaluating total hip replacements. This study examined the effect of different swing phase loads, including microseparation, on the wear, friction, and wear particles of metal-on-metal (MOM) hip replacements. MOM hip replacements were tested for 5 million cycles with the use of a hip simulator; prostheses were tested with a low (100-N) and ISO (280-N) swing phase load, and under microseparation conditions. Increasing the swing phase load from 100 to 280 N in the same hip simulator increased the wear of the MOM hip replacements by over tenfold. Introducing microseparation into the gait cycle increased wear further, and stripe wear was observed on the femoral heads, accompanied by corresponding rim damage on the acetabular cups. No significant difference in wear particle size was observed between wear particles produced by low load and microseparation hip simulator conditions. Introducing microseparation into the hip simulator gait cycle increased the wear of MOM prostheses. Joint laxity and separation may lead to increased wear rates of MOM prostheses in vivo. Additionally elevated positive swing phase loads may also increase wear. Variable swing phase load conditions in vivo may contribute to variations in clinical wear rates.

Cross-linked polyethylene currently is being introduced in knee prostheses. The wear rates, wear debris, and biologic reactivity of non cross-linked, moderately cross-linked, and highly cross-linked polyethylene have been compared in multidirectional wear tests and knee simulators. Multidirectional pin-on-plate wear studies of noncross-linked, moderately cross-linked (5 Mrad), and highly cross-linked (10 Mrad) polyethylene showed a 75% reduction in wear with the highly cross-linked material under kinematics found in the hip, but only a 33% reduction under wear in kinematics representative of the knee. In knee simulator studies, with the fixed-bearing press-fit, condylar Sigma cruciate-retaining knee under high kinematic input conditions, the wear of 5 Mrad moderately cross-linked polyethylene was 13 ± 4 mm3 per 1 million cycles, which was lower (p < 0.05) than the wear of clinically used, gamma vacuum foil GUR 1020 polyethylene (23 ± 6 mm3/1 million cycles). For the low-contact stress mobile-bearing knee, the wear of moderately cross-linked polyethylene was 2 ± 1 mm3 per 1 million cycles, which was lower (p < 0.05) than GVF GUR 1020 polyethylene (5 ± 2 mm3/1 million cycles). The wear debris isolated from the fixed-bearing knees showed the moderately cross-linked material had a larger percentage volume of particles smaller than 1 μm in size, compared with GVF GUR 1020 polyethylene. Direct cell culture studies of wear debris generated in sterile wear simulators using multidirectional motion showed a increase (p < 0.05) in tumor necrosis factor-alpha levels and reactivity for GUR 1050 cross-linked polyethylene debris compared with an equivalent volume of noncross-linked GUR 1050 polyethylene. The use of cross-linked polyethylene in the knee reduces the volumetric wear rate. However, the clinical significance of reduced fracture toughness, elevated wear in abrasive conditions, and the elevated tumor necrosis factor-alpha release from smaller more reactive particles warrant further investigation.

Over the last 10 years there has been increasing concern over wear of polyethylene and osteolytic potential in the knee. During this period there have been considerable developments in both the design, materials and sterilisation techniques used for polyethylene in the knee. This paper reviews wear performance of polyethylene sterilised by different techniques, under a range of kinematics conditions in a single knee joint simulator system. Reducations in polyethylene wear were found with both stabilised polyethylene and cross-linked polyethylene, and with rotating platform mobile bearing designs.