The Thompson hemiarthroplasty is a common treatment option for acute neck of femur fractures in the elderly population. Our department noted a significant number of patients returning with thigh pain, radiographic loosening and femoral osteolysis following cemented implantation of the titanium alloy version of the Thompson hemiarthroplasty. We are not aware of any previous reports documenting complications specific to the titanium Thompson implant and a retrospective cohort study was therefore initiated following clinical governance approval. 366 titanium alloy Thompson prostheses were implanted for hip fracture treatment between 2017 and 2020. As of February 2023, 6 of these have been revised at our hospital. 5 were revised for symptomatic femoral osteolysis and 1 presented with an acute periprosthetic fracture. All revised cases were determined to be aseptic. 32 living patients were excluded from recall on compassionate grounds due to permanent nursing home residence. 47 living patients were identified of which 33 attended for xray. 28 deceased and/or nursing home resident patients who had pelvis x-rays in the previous 12 months were also included in the analysis. Including the 6 index hips already revised, a total of 61 hip xrays were analysed, of which 19 hips (31.1%) showed radiographic evidence of femoral osteolysis or loosening. We conclude that there is a concerning incidence of femoral osteolysis and implant loosening associated with the titanium Thompson implant. We have discontinued use of the implant and reported our experience to the MHRA. We encourage other Scottish Health-Boards who use this implant to consider enhanced follow-up

The Low Contact Stress (LCS) mobile-bearing total knee replacement (TKR) was designed to minimize polyethylene wear, aseptic loosening and osteolysis. However, registry data suggests there is a significantly greater revision rate associated with the LCS TKR. The primary aim of this study was to assess long-term survivorship of the LCS implant. Secondary aims were to assess survival according to mechanism of failure and identify predictors of revision. We retrospectively identified 1091 LCS TKRs that were performed between 1993 and 2006. There was incomplete data available 33 who were excluded. The mean age of the cohort was 69 (SD 9.2) years and there were 577 TKRs performed in females and 481 in males. Mean follow up was 14 years (SD 4.3). There were 59 revisions during the study period: 14 for infection, 18 for instability, and 27 for polyethylene wear. 392 patients died during follow up. All cause survival at 10-year was 95% (95%CI 91.7–98.3) and at 15-year was 93% (95%CI 88.6–97.8). Survival at 10-years according to mechanism of failure was: infection 99% (95%CI 94–100%), instability 98% (95%CI 94–100%), and polyethylene wear 98% (95%CI92–100). Of the 27 with polyethylene wear only 19 had associated osteolysis requiring component revision, the other 8 had simple polyethylene exchanges. Cox regression analysis, adjusting for confounding variables, identified younger age was the only predictor of revision (hazard ratio 0.96, 95%CI 0.94–0.99, p=0.003). The LCS TKR demonstrates excellent long-term survivorship with a low rate of revision for osteolysis, however the risk is increased in younger patients

Aims

For displaced femoral neck fractures (FNFs) in geriatric patients, there remains uncertainty regarding the effect of total hip arthroplasty (THA) compared with hemiarthroplasty (HA) in the guidelines. We aimed to compare 90-day surgical readmission, in-hospital complications, and charges between THA and HA in these patients.

Introduction. Large wear rate reductions have been shown for crosslinked PE in simulators and short- to mid-term clinical wear studies. However, concerns persist about long-term in-vivo oxidation (especially with annealed PE), late accelerating wear and the possibly higher osteolytic potential of crosslinked PE particle debris. This is the first long-term study comparing conventional to crosslinked PE investigating whether the wear reduction is maintained in the long-term and if reduced osteolysis becomes evident. Materials & Methods. In a prospective study 48 primary THA patients (Stryker ABG-II, 28mm CoCr heads) were randomized to either receive a first generation crosslinked PE (Stryker Duration: 3MRad gamma irradiation in N2, annealed) or then conventional, now “historic” PE (3MRad gamma irradiation in air). Both groups were statistically non-different (p>0.1) regarding age (63.9 years), gender, BMI, stem and cup size, cup inclination, liner thickness or pre- and post-op HHS leaving the insert material as the only variable. Patients were followed-up annually using the Harris Hip score, AP and lateral radiographs and digital wear measurements using Roman V1.70 [1, 2]. Wear and radiographic signs of osteolysis were analysed at a mean follow-up of 12.9 years (12.0–13.3). Groups were compared using the t-test (means) or the Fisher Exact test (proportions). Results. Thirty-one patients (18 conventional, 13 Duration) were left for analysis (8 deaths, 9 lost to FU). At 13yrs the total linear head penetration was sign. lower with Duration (0.70 ±0.36mm, range: 0.3–1.2mm) than conventional PE (1.56 ±0.83, range: 0.4–3.3mm, p=0.015). Also the annual wear rate was sign. lower (p=0.005) for Duration (0.063 ±0.027mm/yr) than conventional PE (0.122 ±0.065mm/yr). This reduction (−48%) compared well to the original simulator prediction (−45%) and even increased with time (−30% at 5yrs, −38% at 8yrs, −42% at 10yrs). In the Duration group only 1 patient had a wear rate >0.1mm/yr (osteolysis threshold) compared to 10 in the Conventional group (p=0.007). Patients with radiographic signs of acetabular osteolysis (cysts) on the AP x-ray were less frequent in the Duration (4/13=31%) than in conventional group (13/18=72%, p=0.023). This difference became even more pronounced when also the lateral view was evaluated and the affected DeLee-Charnley zones were counted (7 vs 22, p=0.017). Only in the conventional group a revision was performed (cup for wear). Discussion & Conclusions. At long-term FU the absolute wear rate of Duration crosslinked PE did not increase but decrease and the wear relative reduction did not deteriorate but increased. The incidence of osteolysis was sign. less. Thus No clinical evidence of degradation or elevated osteolytic potential for this annealed first generation crosslinked PE debris was found

The use of a total hip arthroplasty with alumina on alumina bearing couple should limit the risk of wear and secondary osteolysis. From June 1999 to December 2002, we have realised a continuous series of 265 ABGII cementless THA with Alumina bearing. The average age was 58 years (22–78 years). The main causes were osteoarthritis (81%) and osteonecrosis (13%). The operation was performed through a posterior standard approach. In all cases, an anatomic cementless ABG II stem and an acetabular cementless ABG II cup were implanted. The bearing couple was always Alumina Biolox Forte with a 28 mm femoral head in 99% of cases. To date, 12 patients died and 17 patients were lost to follow up (6.4%). 224 patients (232 hips) had a regular clinical and radiological follow-up. The mean follow up was 8.5 years (5–11 years). 9 patients were revised for septic loosening (4cases), femoral fracture (4 cases) and inveterate dislocation (1 case). There was no aseptic loosening. The overall survival rate at more than 10 years is 96.6%. We deplore 2 cases of postoperative dislocation. In this series, we did not observe any breakage of ceramic implant. The clinical and functional outcome is good and stable over time with an average PMA score at 17.6 and an average Harris score at 97.3. 16 patients reported at least one or more episode of abnormal noise “Squeaking” type (6%). It is most often a mild noise and it occurs in a static bending position. This noise disappeared with time in 10 cases. It never necessitated a prosthetic revision. The radiological control does not show any wear. There is no evidence of acetabular or femoral osteolysis. The radiological implant fixation according to the Engh and ARA criteria was good and stable in all cases. This series demonstrate that the implantation of an anatomic cementless HA arthroplasty with an alumina bearing in a young and active patient prevents the risk of wear and osteolysis and improves durability over time. The use of a 28 mm head does not increase the risk of instability and we did not observe failure of the ceramic implants

INTRODUCTION. The lifetime of UHMWPE implants may be limited by wear and oxidative degeneration. Wear produced particles are in general biologically active, and may induce osteolysis. As threshold of PE wear rate below which osteolysis is rarely observed is postulated to be less tahn 0.1 mm per year. Moreover, PE delamination and breakage are consequences of the embrittlement of the PE due to oxidation. Both demonstrate, that improving the clinical behaviour of UHMWPE means reduction of wear particles. The first can be achieved by cross-linking the second by the anti-oxidative stabiliser vitamin E. The highly cross-linked PE vitamys ® used for the isoelastic monobloc cup RM Pressfit (Mathys AG Bettlach, Bettlach, Switzerland) is mixed with 0.1% of synthetic vitamin E and is the first and only highly cross-linked PE used in total hip replacement that meets all requirements for the best grade UHMWPE in yield strength, ultimate tensile strength and elongation at break. METHODS AND MATERIAL. With the first implantation of RM Pressfit vitamys® a prospective multicentre study was started. So far 256 cases in 7 clinics from Europe and New Zealand are included. This report presents the first clinical experiences of one Swiss clinic from the multicentre study. Prospective data collection includes Harris Hip score (HHS), patient satisfaction and radiographic analysis. Clinical and radiographic follow-up is done after 6 weeks, 6, 12 and 24 months, and thereafter for long-term results. Standardized documentation of surgery and postoperative course is performed. RESULTS. 81 patients were included in the study. Mean age at implantation is 69 years. The indication was primary OA in 57% and secondary OA in 36%, the others were treated either for necrosis, fracture or hip dysplasia. 68% of the patients received a 36mm femoral head, 31% a 32mm and 1% a 28mm. Intraoperatively two minor complications occurred, one femur and one trochanter fissure. No complications occurred during implantation of the cup. Most of the cups (59%) were implanted with an inclination of 40°-50°, 30% with 35°-40°. There were no signs of early loosening and a good Harris Hip Score was achieved. DISCUSSION. The principals of this monobloc cup with its isoelastic property and the thin titanium coating is a proven concept. Ihle et al. (JBJS 2008) reported 91% survival rate with revision for aseptic loosening as endpoint after 20 years. They found an increase of cup revisions after 14 to 16 years after implantation due to osteolysis probably due to PE wear. At short term, we haven't encountered any problems related to the implantation of this cup. So far one patient in the entire multicentre study needed a stem revision after periprosthetic femur fracture. To prove the durability of this novel material a follow-up of 14 years and more will be required

We present our results of cementless total hip arthroplasty with a tapered, rectangular stem made of titanium-aluminum-niobium alloy. This implant is used since 1979 with only minor modifications. The design of the femoral component achieves primary stability through precision rasping and press-fit implantation. Between October 1986 and November 1987, two hundred consecutive patients (208 hips) underwent total hip arthroplasty with this tapered, rectangular stem. In all cases the acetabular component was a threaded cup made of titanium. At a minimum follow-up of twenty years eighty-seven patients were still alive. Sixty-seven patients (69 hips) were available for clinical and radiographic follow-up. The probability of survival of the stem was 0.96 (95% confidence interval, 0.91 to 0.98) and that of the cup was 0.72 (0.62 to 0.80). The probability of survival of both the stem and the acetabular component with revision for any reason as the end point was 0.71 (0.61 to 0.78). Two stems have been revised due to aseptic loosening. We found various degrees of osteolysis around the acetabular and femoral component (61,7%). At the time of the 20-year follow-up no stem was deemed at risk for loosening. The key findings of our twenty-year follow-up are the very low rate of revisions of the femoral component and the low rate of distal femoral osteolysis associated with this stem. Our data show that femoral fixation of the stem continues to be secure at a follow-up of twenty years

Osteoporosis following ovariectomy has been suggested to modulate bone response to polyethylene wear debris. In this work, we evaluate the influence of estrogen deficiency on experimental particle-induced osteolysis. Polyethylene (PE) particles were implanted onto the calvaria of wild-type (WT), sham-ovariectomized (OVX), OVX mice and OVX mice supplemented with estrogen (OVX+E2) (12 mice per group). Sham-implanted mice served as internal controls. After 14 days, seven skulls per group were analyzed with a high-resolution micro-computed tomography (CT) and by histomorphometry, and for tartrate-specific alkaline phosphatase. Five calvariae per group were cultured for the assay of IL-1, IL-6, TNF- and RANKL secretion using quantitative ELISA. The expression of RANKL and OPG mRNA were evaluated using real-time PCR. As assessed by CT and by histomorphometry, PE particles induced an extensive bone resorption and an intense inflammatory reaction in WT, sham-OVX and OVX+E2 mice. In OVX mice group, these features appeared considerably attenuated. In WT, sham-OVX and OVX+E2 mice, PE particles induced an increase in serum IL-6, in TNF-and RANKL local concentrations, and resulted in a two-fold increase in RANKL/OPG mRNA ratio. Conversely, these parameters remained unchanged in OVX mice after PE implantation. The combination of two well-known bone resorptive mechanisms ultimately attenuated osteolytic response, suggesting a protective effect of estrogen deficiency on particle-induced osteolysis. This paradoxical phenomenon was associated with a downregulation of pro-resorptive cytokines. It is hypothesized that excessive inflammatory response was controlled, illustrated by the absence of increase of serum IL-6 in OVX mice after PE implantation

Introduction. Acromioclavicular dislocation (ACD) is frequent, at 8% of all shoulder traumas. Management in grade III lesions remains controversial. The present study assessed objective and subjective results at medium-term follow-up (mean, 60 months; range, 12—120 mo) in 27 patients managed by Ligastic® ligament reconstruction for acute dislocation. Patients and Methods. This is a multicenter, multi-surgeon retrospective study. Between 1998 and 2006, 59 patients were operated on for grade III or IV ACD, in one teaching hospital (Lille, France) and one general hospital (Tourcoing, France). Follow-up was performed by an indepen- dent (non-operator) observer. The 27 acute cases followed up underwent comparative bilateral radioclinical shoulder examination. Initial X-ray assessment found 14 grade-III (52%) and 13 grade-IV (48%) dislocations using Patte's classification. Results. Mean Constant score was significantly lower on the operated side (82.44 vs 90.04; p < 0.05). Specific strength analysis, on the other hand, showed no significant difference with the contralateral shoulder. Coracoclavicular distance was significantly greater on the operated side (p < 0.05), with and without traction. Periprosthetic osteolysis was found in 24% of cases, and seemed to worsen over follow-up. There were no cases of fracture on osteolysis. There were no cases of sepsis or of implant intolerance. Four patients, however, required surgical revision. Conclusion. In light of literature findings and our own experience, surgery is not to be recom- mended in grade-III ACD, and the authors have given up use of this device in this group due to the rate of associated osteolysis. Level of evidence. Level IV

Introduction. Cobalt chrome on polyethylene remains a widely used bearing combination in total joint replacement. However wear induced osteolysis, bulk material property degradation of highly cross-linked polyethylene (HXLPE) [1], and oxidation after implantation (thought to be as a result of lipid absorption or cyclic loading [2]) remains a concern. ECIMA is a cold-irradiated, mechanically annealed, vitamin E blended next generation HXLPE developed to maintain mechanical properties, minimise wear and to improve the oxidation resistance in the long-term. The aim of this study was to compare the in-vitro wear rate and mechanical properties of three different acetabular liners; conventional UHMWPE, HXLPE and ECIMA. Methods. Twelve liners (Corin, UK) underwent a 3 million cycle (mc) hip simulation. Three conventional UHMWPE liners (GUR1050, Ø32 mm, 30 kGy sterilised in Nitrogen), three HXLPE liners (GUR1020, Ø40 mm, 75 kGy cross-linking and EtO sterilised) and six ECIMA liners (0.1 wt% vitamin E GUR1020, Ø40 mm, 120 kGy cross-linking, mechanically deformed and annealed, and EtO sterilised) articulated against CoCrMo alloy femoral heads to ASTM F75 (Corin, UK). Wear testing was performed in accordance with ISO 14242 parts 1 and 2, with a maximum force of 3.0 kN and at a frequency of 1 Hz. The test lubricant used was calf serum with a protein content of 30 g/l and 1% (v/v) patricin added as an antibacterial agent. Volumetric wear rate was determined gravimetrically after the first 0.5 mc and every 1 mc thereafter. ASTM D638 type V specimens (3.2 mm thick) were machined from ECIMA material for uniaxial tension testing to ASTM D638. Ultimate tensile strength (UTS), yield strength and elongation values were measured. These values were compared to mechanical data available for the other material types. Results. There was a 94% and a 68% reduction in the wear rate for the ECIMA liners compared to the conventional UHMWPE and HXLPE liners respectively. There was an increase in UTS, yield strength and elongation of 11%, 11% and 15% respectively, for ECIMA compared to HXLPE. Discussion. The wear results reported in this study indicate that ECIMA is a very low wearing material which has the potential to reduce wear related osteolysis in-vivo. Importantly, the mechanical properties were generally maintained unlike the degradation found in many modified polyethylene materials and were more comparable to conventional UHMWPE than HXLPE. The reduced wear rate during in-vitro hip simulation of ECIMA compared to conventional UHMWPE, coupled with improved mechanical properties in comparison to HXLPE, makes ECIMA a promising next generation, advanced bearing material

Introduction. A recent review of the literature on metal-on-metal total hip arthroplasties (THA) revealed the lack of comparative clinical studies with a sufficient sample size and the inclusion of patient-reported outcomes as well as patient activity levels. Methods. We conducted a prospective cohort study including all metal-on-metal and conventional polyethylene (PE)-ceramic THAs with an uncemented cup (Morscher press-fit cup), a 28mm head and operated upon via a lateral approach at our University hospital between 1/1999 and 12/2008. Only THAs for primary osteoarthritis were included. The study population is part of the Geneva Hip Arthroplasty Registry, a prospective cohort followed since 1996. The following outcomes were compared between the two groups (metal-on-metal=group 1 vs. PE-ceramic bearing=group 2): (1) Complication rates with respect to infection, dislocation and revision, (2) Radiographic outcomes (presence of linear or focal femoral osteolysis, loosening), and (3) Clinical outcomes (Harris Hip score increase, SF-12, activity and patient satisfaction evaluation, presence of groin pain). Patients operated between 1/1999 and 12/2004 were evaluated five years postoperatively by an independent assessor. Cox regression analysis was used to compare incidence rates while adjusting for differences in baseline characteristics. Results. 1988 THAs were included, 544 with a metal-on-metal and 1444 with a PE-ceramic bearing. The two groups differed significantly with respect to gender distribution (men 56% vs. 41%), mean age (66 vs. 73 years), co-morbidities and type of stem (uncemented 16% vs. 2%). Crude incidence rates for complications were: 0.16 vs. 0.11 cases/100 person-years for infection; 0.37 vs. 0.35 cases/100 person-years for dislocation; and 0.29 vs. 0.16 cases/100 person-years for all-cause revision (incidence rate ratio 1.8, 95% CI 0.7; 4.6). After adjusting for baseline differences the slightly higher risks for infection and revision in group 1 were attenuated. Osteolytic lesions were found in 3.7% of metal-on-metal vs. 4.7% of PE-ceramic THAs. After adjustment for age, gender and activity the OR was 0.6 (95% CI 0.2;2.1). Five years postoperative, 176 THAs of group 1 and 695 THAs of group 2 were seen at follow-up. Clinical outcomes were similar among the two groups with a mean Harris Hip score increase of 39.2 vs. 40.9 points. SF-12 mental and physical health, patient satisfaction (9.3 vs. 8.9 on visual analogue scale) as well as the incidence of groin pain (1.7% vs. 1.2%) was also similar among the two groups. The activity level was significantly higher in group 1 (6.4 vs. 5.4, p<0.001). Conclusion. Mid-term results with respect to complications, revision rates, presence of osteolysis and clinical outcomes were similar among patients with metal-on-metal and PE-ceramic total hip arthroplasties

We reviewed 13 patients with a complex fracture-dislocation of the proximal interphalangeal joint of a finger and one patient with a complex fracture-dislocation of the interphalangeal joint of thumb. We had treated these injuries using a pins and rubbers traction system which had been modified to avoid friction of the pins against the bone during mobilisation of the joint in order to minimise the risk of osteolysis. A Michigan hand outcome questionnaire was used for subjective assessment. The active range of movement (AROM) of the proximal and distal interphalangeal joints and the grip strength were used for objective assessment. The mean follow-up was 34 months (12 to 49). The mean normalised Michigan hand outcome score was 84. The mean AROM of the proximal interphalangeal joint was 85° and that of the distal interphalangeal joint 48°. The mean grip strength was 92% of the uninvolved hand. Twelve patients have returned to their original occupations. There has been no radiological osteolysis or clinical osteomyelitis. This modified traction system has given acceptable results with a low rate of complications. It is light, cheap, effective and easy to apply

In biomaterial engineering the surface of an implant can influence cell differentiation, adhesion and affinity towards the implant. Increased bone marrow derived mesenchymal stromal cell (BMSC) differentiation towards bone forming osteoblasts, on contact with an implant, can improve osteointegration. The process of micropatterning has been shown to improve osteointegration in polymers, but there are few reports surrounding ceramics. The purpose of this study was to establish a co-culture of BMSCs with osteoclast progenitor cells and to observe the response to micropatterned zirconia toughened alumina (ZTA) ceramics with 30 µm diameter pits. The aim was to establish if the pits were specifically bioactive towards osteogenesis or were generally bioactive and would also stimulate osteoclastogenesis that could potentially lead to osteolysis. We demonstrate specific bioactivity of micropits towards osteogenesis with more nodule formation and less osteoclastogenesis. This may have a role when designing ceramic orthopaedic implants

Introduction. Alternative bearings – metal-on-metal and ceramic-on-ceramic bearings have been introduced in the last decade with the aim to diminish wear and, subsequently, aseptic loosening and osteolysis. These bearings were aimed for younger, more active patients. Clinical results which would compare the performance of various alternative and traditional bearings are scarce. Methods. Between January 2000 and December 2002, we performed 487 total hip replacements in 474 patients using three types of bearings: metal-on-metal (MOM), metal-on-polyethylene (MOP), and ceramic-on-ceramic (COC). All patients received the same type of acetabular cup (Bicon-Plus, Plus Orthopedics) and same type of femoral component (SL-Plus, Plus Orthopedics). We used the hospital computer database for the evaluation of patient data and data on revision operations. Results. At a mean follow-up of 8.5 years (range, 6.8 to 9.9 years), eighteen hips were revised. Seventeen revisions were aseptic, and one was septic. The percentage of revision in the whole group was 3.7%. The percentage of revisions for individual groups of bearings varied and ranged from 1.5% in the MOP group, 4.1% in the COC group to 8.7% in the MOM group. Reasons for revisions were analyzed in details. We noticed that the percentage of aseptic loosening differed among the groups, with the MOM group having the highest percentage of revisions due to aseptic loosening. Conclusions. The results obtained for this large series of THRs with the same type of acetabular and femoral components, and differing only in the type of bearing, indicate that the combination of material of acetabular cup and femoral head affect the performance of the hip prosthesis

Between July 2000 and December 2002, 263 consecutive patients across 5 surgical centers underwent to a revision surgery of a failed acetabular component in which TM acetabular components were used. There were 150 women and 113 men with a mean age of 69.5 years. The indication for acetabular revision was aseptic loosening in 186 cases (70.7%). Clinical evaluations were performed using the Harris hip score, the WOMAC and UCLA activity scale. Implant and screw position, polyethylene wear, radiolucent lines, gaps, and osteolysis were assessed. Preoperatively, acetabular bone deficiency was categorized using the classification of Paprosky et al. Statistical analysis was performed using nonparametric correlations. Standard life table was constructed, and the survival rate was calculated by means of Kaplan-Meier method. The overall mean follow-up was 73.6 months (range, 60–84 months), and no patient was lost to follow-up. The preoperative HHS rating improved from a mean of 43.6 ± 11.4 before revision, to a mean of 82.1 ± 10.7. None of the patients was re-revised for loosening. The cumulative prosthesis survival was 99.2% at 5 years. There was no correlation found between the various degrees of acetabular bony defect and the magnitude of clinical results (independent of pre-revision Paprosky grade). The use of component augments allowed us to minimize the volume of morsellized allograft used for defect repair. TM acetabular component demonstrates promising midterm results similar to those reported by other authors

Background. An increased incidence of periprosthetic osteolysis, resulting in loss of biologic fixation, has been recently reported in contemporary THAs with low-carbide metal-on-metal compared to metal-on-polyethylene couple bearings. A hypersensitivity reaction due to Co and Cr debris is reported as a potential cause for failure of THAs with high-carbide bearings, but there are no evidence-based data for this reaction in low-carbide metal-on-metal bearings. Questions/purposes. We investigated whether there were differences in immunologic hypersensitivity reactions in retrievals from revised THAs with COP versus MOM bearing couples. Patients and Methods. We compared newly formed capsule and periprosthetic interface membranes retrieved from revision surgery due to aseptic failure in 20 patients with low-carbide bearings and 13 patients with ceramic-on-polyethylene bearings. For control tissue we obtained samples from the hip capsule during the primary THA implantation in 13 patients with low-carbide bearings and seven with ceramic-on-polyethylene. We examined the tissues with conventional histologic and immunohistochemical methods. Results. Compared to the controls and the tissue from patients with ceramic-on-polyethylene bearings, the tissues from patients with low-carbide metal-on-metal bearings were associated with (1) extensive necrosis and fibrin exudation in the newly formed hip capsule and (2) diffuse and perivascular lymphocytic infiltration of a higher degree than in the ceramic-on-polyethylene hips in conventional histologic examination and (3) more T than B cells. Conclusions. The conventional histologic and immunohistochemical findings in tissues retrieved from failed THAs with low-carbide metal-on-metal bearings are consistent with a link between hypersensitivity and osteolysis with low-carbide bearing couple THA

Introduction. Dislocation following total hip arthroplasty THA is a major short term complication not infrequently resulting in revision arthroplasty. Malposition of the acetabular component in THA results in a higher rate of dislocation as well as increased wear and osteolysis. The aim of this study was to assess the effect of mode of fixation on positioning of the acetabular component. Patients, materials and methods. For all THAs performed at our hospital in 2008, angle of acetabular inclination was measured using PACS by two independent observers. Interobserver and intraobserver reliability were assessed (Pearson's correlation coefficient, r). We determined whether the number of acetabular components outside the target angle range (eg:45±5°) was significantly different between cemented and cementless THA (chi squared test). An enquiry was made to the National Joint Registry (NJR) in respect to incidence of revision for dislocation of THA using cemented and cementless acetabular components, 2004–2009. Results. During 2008 126 THA were performed, 80 cemented and 46 cementless. There was good reliability of angle measurement (interobserver: r=0.89; intraobserver: r=0.87 and 0.97). More cemented acetabular components were within target angle range compared to cementless (cemented 32/80, cementless 29/46; chi squared=6.39, p<0.05). Using data from NJR comparing the number of primary hip replacement operations with number of revisions due to dislocation found a higher rate for cementless THA, 0.381% (266/69,822) than for cemented, 0.282% (262/92,928) (Odds ratio: 1.35 (95% CI 1.14–1.60; P<0.05). Conclusion. Positioning of the acetabular component is more difficult when using cementless systems as implant position is determined by orientation of reaming whereas with cement there is potential for fine implant position adjustment on insertion. The choice of a cementless acetabular component significantly increases the incidence of dislocation post THA. Acetabular component malposition is likely to be a factor in this increased incidence

Introduction. The prosthetic impingement occurs if the range of motion of the hip exceeds implant mobility or in case of component malorientation. This retrieval study was designed to assess the frequency and the risk factors of this phenomenon. Material and Methods. The frequency and the severity of the impingement were calculated from a continuous series of 311 cups retrievals collected between 1989 and 2004 by a single surgeon. The reason for retrieval was loosening (131 cases), infection (43 cases), instability (56 cases), osteolysis (28 cases), unexplained pain (48 cases) and prosthetic impingent (5 cases all with hard bearings). The notching at the cup rim was assessed twice by two examiners with optic magnification. The risk factors were analyzed from clinical charts by univariate and cox multihazard. Results. Among the 311 cups explants, the frequency of impingement was 59.2% (it was severe in 11%, the notching exceeding 3 millimeters). The impingement was the reason for removal in only 1.6%, meaning that it was mainly unexpected (98.4 percent). The impingement was more frequent when revisions were performed because of instability (notching 80%), when the sum of hip motion exceeded 200 degrees (sum of motion in the 6 degrees of freedom of the hip) (notching 66%). The other risk factors were: use of heads with skirts, liner with an elevated rim, and head-neck ratio below 2, younger age at surgery. The multivariate analysis identified only two independent factors: 1) the use of skirted heads (Odd ratio 3.2 (1.2–15.3)), 2) and revision because of instability (Odd ratio 4.2 (1.1–16.2)). In contrast different classical factors were not correlated with impingement on retrieval: cup inclination, the duration before retrieval, the indication for primary prosthetic replacement. Discussion and Conclusion. This study underlines the impingement is common when assessing cup retrievals (over 50 percent). One should be aware of impingement when performing hip replacement in patients having a high range of motion. This situation may require prostheses with a high head-neck ratio, as well as use of computer-assisted surgery. One should avoid liners with elevated rim as well as heads with skirts to prevent dislocation, particularly when other risk factors are detected

Introduction. The advantages of metal on metal (MOM) hip replacement are decreased wear rate, preservation of bone stock, anatomical restoration and enhanced stability. Large amounts of metal wear particles and metal ions are released which may induce adverse reactions including local soft tissue toxicity, hypersensitivity reactions, bone loss and risk of carcinogenesis. Aseptic loosening can be the result of a peri prosthetic osteolysis generated as a result of a biological response to particulate wear debris. Our aim in this study was to determine whether a steeply inclined acetabular component would give rise to a higher concentration of metal ions. Patients and methods. Between April 2003 and June 2006, 22 patients had MOM hip replacement for osteoarthritis by a single Surgeon. There were 12 male and 10 female patients. The average age at the time of surgery was 56 years (Range: 44–69 years). We divided the 22 patients into 2 groups, one group (A) of 11 patients with the acetabular inclination angle more than 50 degrees and the other group (B) of 11 patients with the angle less than 50 degrees. The inclination of the acetabular cup was measured using a standard AP radiograph of the pelvis. The patients had metal ion levels (blood chromium and serum cobalt) measured at an average follow up of 3.2 years (Range 2.4 to 5 years). Results. Mean blood chromium level in the group A (146 nM/L) was significantly higher (p=0.005) than in Group B (92 nM/L). Mean serum cobalt level in the group A (245 nM/L) was significantly higher (p=0.002) than in Group B (110 nM/L). Discussion. The early to mid term published results of MOM hip replacements have been encouraging. There are, however, a number of concerns about the MOM bearing. Although its wear rate is low, it still releases metal ions into the body particularly cobalt and chromium since most metal on metal bearings are made of a cobalt chromium alloy. The long-term consequences of increased levels of these ions in the body are not known. High concentrations of Co and Cr are toxic and are known to interfere with a number of biological functions. There also have been recent reports of soft tissue reactions with MOM hip replacement. In the light of these concerns, it is important to examine factors which may influence the release of metal ions after MOM hip replacement. It has been reported in the recent literature that the position of the acetabular component will influence the bearing wear inturn leading to the release of metal ions after MOM hip replacement. Our findings indicate that steeply inclined acetabular components with an inclination angle greater than 50 degrees gives rise to higher concentration of metal ions

INTRODUCTION. The advantages of large diameter metal on metal total hip arthroplasty (MoM THA) and hip resurfacing arthroplasty are decreased wear rate, preservation of bone stock, anatomical restoration and enhanced stability. Large amounts of metal wear particles and metal ions are released which may induce adverse reactions including local soft tissue toxicity, hypersensitivity reactions, bone loss and risk of carcinogenesis. Aseptic loosening can be the result of a peri-prosthetic osteolysis generated as a result of a biological response to particulate wear debris. No reports in the literature exist as to whether circulating levels of Chromium (Cr) and Cobalt (Co) decrease upon removal of a symptomatic large diameter MoM implant or whether levels remain high due to the effect of metal ions debris left behind in the soft tissues after revision surgery. PATIENTS AND METHODS. Between June 2006 and June 2009 we undertook 44 revision surgeries of both large head MoM THAs (femoral head diameter 38mm) and metal-on-metal hip resurfacings for suspected metallosis. Mean time from original implant to revision was 4 years, 8 months (1yr 4mo–7yr 9mo). The mean follow up evaluation was 2 years and 2 months (1yr 2mo–4 years). Blood samples were taken for whole blood Cr and serum Co according to a recognised protocol and compared with reference levels indicated by the Medicines and Healthcare Regulatory Agency recommendation of less than 7ppb for Cr (130nM/L) and Co (119nM/L). RESULTS. 42 patients were found to have histological evidence of either metal allergy, metal toxicity or foreign body reaction. 2 patients had evidence of infection with no features of metal reaction. 3 patients suffered early dislocation requiring closed reduction. 1 patient had infective complications necessitating Girdlestones. 11 patients were lost to follow up, 8 patients were diagnosed pre operatively on Co and Cr levels in urine or synovial fluid aspirate alone. 23 patients had pre revision blood or serum metal ion level results available for direct comparison. Median serum Co level pre revision was 176.6nM/L, falling post revision to 5.1nM/L (p=<0.001∗). The median whole blood Cr level pre revision was 117nM/L and 19nm/L post revision (p=<0.001∗). Mean Oxford Hip Score was 23.7. DISCUSSION. This study demonstrates that at greater than one year post removal of a large diameter MoM hip implant for the indication of symptomatic metallosis or metal hypersensitivity, metal ion levels fall to almost normal levels and that outcome of revision surgery in terms of patient satisfaction is not adversely affected