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CCJR - an enduring learning continuum

I would like to take this opportunity to wel- advocatcd solution, ¿rs rvell as facuJty discr-rs-
come the readership of The Bone ü Joint Jour- sions of papers presented at recent interna-
nal (BJJ) to this fifth annual supplement which tional meetings. This supplement contains 11
contains hip and knee reconstruction contribu- paper selections from these formats. It is hoped
tions from the 32nd Annual Current Concepts that this st1'1ised approach r,vill assist in the
in Joint Replacement (CCJR) §Tinter meeting appreciation of a still very much evolving dis-
held in Orlando, Florida in 2015. cipline.
CCJR's unique educational meeting format No undertaking of this magnitucle occurs in
has contributed to the hip and knee arthro- a vaculrm or reflects the effort of a single per-
plasty education of thousands of orthopaedic son. It is s,ithout doubt that this supplement
surgeons around the world over the last 33 owes its creation to the dedication exhibited b,v
years. These supplements serve as enduring Christine S. Heirn and Karen L. Lizanich of
written extensions of this continuing activity in CCIR, as w'ell as the timely revie'nvs of the B.lJ
medical education. Its intent is to make aspects and CCJR Editorial Aclvisory Boards. Both
of the meetings' commentaries available to the Fares Haddad, Editor-ir-r-Chief, and Peter
journal's global readership. Richardson, lvlanaging Director, of the BJJ are
A1l papers have been peer reviewed by both thanked f<¡r their continued support.
- S Greenwald, members of the BJJ and CCJR Editorial Advi- Lastl-r,,, it is my hope that you, the reader, will
i rri (Oxon), Course Director
--ent Concepts in Joint sory Boards. In this fifth supplement you will gain from the clinical and surgical erperiences
::r acement, Cleveland Ohio,
18 find commentaries related to topical practice of the authors r,vhose ongoing dedication to
issues of our day encompassing primary and continuing orthopaedic education is reflected
: -'espondence should be sent
:: S Greenwald;e-mai :
revision hip and knee arthroplasty outcomes as on these pages and sets a tone for enduring
:::_ g cclr com well as implant selection, fixation options, learning in our discipline.
--7 The British Editorial
bone deficienc¡ joint instabilit¡ trauma, and
::: :ty of Bone & Joint patrent management.
: 'aetY
r -0 1302/030'l-620X 9981 The meeting itself employs learning method- A. Seth Greenrvald, D.Phil.(Oron)
:-30s200 ologies inclusive of clinical papers, debates, Course Director
: : '¿ Joint J surgical techniques and discussions focusing Current Concepts in Joint Replacement@
- - I 99-B(1 Supple A):1 on challenging cases where arthroplasty is an Cleveland, Ohio, United States
31

50

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Joint registries
§rHAT CAN §TE LEARN IN 2016?
:¿

D. J. Berry Aim'¡s
To demonstrate, with concrete examples, the value of in-depth exploration and comparison
From Mayo Clinic, of data published in National Joint AÉhroplasty registry repofts.
Rochester,
\Iinnesota, United Fatients and Metirods
\tates The author reviewed published current reports of National Joint Arthroplasty registries for
findings of current significance to current orthopaedic practice.
Results
A total of six observations that demonstrate actionable or unexpected findings from joint
registries are described. These include; one third to one half of all arthroplasty failures in the
first decade occur in the first one to two years; infection rates after arthroplasty have not
declined in the last three decades; infection after TKA is more common in men than women;
outcomes of TKA are more variable in young compared with older patients; new
technologies (uncemented implants and crosslinked polyethylene) have improved'results of
THA and a real-time shift in use of ceramic femoral heads is occurring in THA.
Gonclusior'¡
These six observations may be used to better understand current practice. stimulate
practice improvements or suggest topics for further study.
Cite this article: Bone Joint J 2017;99-8,(1 Supple A):3-7

The value of National Joint Registries is well steep earlv slope in the first one to two years,
understood. The,v can provide real-time feed- follor'ved by a lower slope for the rest of the first
back to stakeholclers about the rates of success decade after surgery (F'ig. 1).1 The steep early
and failure of procedures and specific portiorl means that one third to one half of all
irrplants. Thel' can provide information on arthroplasty failures in the first decade occur in
n¡rtion¿rl patterns of prirctice, and they can the first few years. These early failures are par-
serve as a 'trip u,ire' to identify problems and ticularly important for two reasons. First, the,v
trigger improvements in practice. The goal of represent a disproportionate number of lifetime
this paper is not to erpound upon those bene- failures of the arthroplasty because a1l patients
fits; rather it is to demonstrate the i,alue of are at risk irnmediately after surgery; whereas
cirrefully exploring the data av¿rilable in after ten years, onl1, about half the number of
national registries. The author has chosen sir patients who have undergone an arthroplasty
observations from current Natior-ral Joint Reg- are sti1l alive and at risk; and secondly', becaltse
'I J Berry, MD, L.Z. Gund
*sor of Orthopedic istr,v data that demonstrate actional¡1e or unex- early failures are particularly disappointing for
>'gery
U¿rc Clin¡c. 200 First Street pected findings that may be used to understand patients and surgeons. Importantl¡,, registlres
Sdr. Rocñester, MN 55905, cLlrrent practice, stimulate improvements in tell us what causes these failures: for TH-\ thel'
-S\ practice, or suggest topics for further: study. are mainly infection, loosening, disloc¡rtion and
i;.epondence should be sent periprosthetic fracture (Fig. 2ar ¡rrd for TKA
r f- J. Bery; email:
edu *hs*rveti*¡: ? they are mainly infection :rnd loosening (Fig.
-:y.daniel@mayo
- --: Brltlsh Editorial Tíming a¡.¡rl *cr¡rc* +f one tÉ'¡ird t* *ne l"ra!{ of ail 2b).1 Many of these earh t.rilures would be
: :'3one and Joint j*ir:t artÉ:rcpiastis* fa!!¡":¡'es ir: first te¡'': y*ar=. The avoidable with optim..r1 .urgical technique, dif-
shape of cumulative failure curves of arthro- ferent choice of rn-r¡.1.1¡¡ rearly aseptic loosen-
:12 0301-620X 9981
: :.,3a3Fl$200 plasties of the hip (THA) a¡d knee (TKA) from ing, dislocation lnd periprosthetic fracture) and
all r:egistries in the i,vorld follow a remarkirbly by der cl,,l'rrrl :rore effcc¡ii e meirsures to pre-
::': I SuppeA):3-7 consistent p"tte.n,l'2 which is characterised by a vent rniectron.

99 B, No. 1, JANUARY 2017


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Fig, 1a Fig, 1b

Graphs showing from the cumulat¡ve cases of revision after pr¡mary total hip (a) and knee (b) arthroplasty. Note the steep early slope of both
curves. Reproduced with permission from the Australian Orthopaedic Association National Joint Replacement Registry. Annual Report. AOA:
Adelaide; 201 5.

) 4 5 6 1 3 9 1011 1l
Ye¿E S¡.e Prm¿ry P@edure

Fig 2a Fig 2b

Graphs showing cumulative rates of revision aftertotal knee arthroplasty (a) and cumulat¡ve rates
of revision after total hip arthroplasty (b) according to failure mode. Reproduced with permission
from the Australian Orthopaedic Association National Joint Beplacement Reg¡stry. Annual Report
AOA: Adelaide;2015.

**s*rwati** 7 cRR f/, )

án Le*s*lve.i pr*r>1*r* * infe*tis*. Infection is currently or-re


19Gr965O D= 2,75
of the main re¿sons for earl,v failure. It also represents one 19S,1995c ñ=16,1ü
:9,5D
195-¡05 c ñ
Graph showing cumulative
of tl-re most comrrorl indications for revrsion during the life- 2OGa11 € n =6!,ñ
curves of revision for infection
rime of an arthroplastr. Registry data show that we have after total knee arthroplasty
(TKA). Modified with permis-
made little progress in prei'enting this problem during the sion from the Swedish Knee
last three decades. Ercellent information on this subject Arthroplasty Registry. Annual
Report 2013 Elvins Grafiska
comes from rhe Ssedish r:egistr¡3 which has some of the AB: Helsingborg; 2014.
best long-terr.n d¡rra. Cumulative curves of failure due to
infection irorn e ach of the last t!-rree decades.are able to be 1012(161620
virtuallv sr.rpenmposed 1Fig. 3).3 One might have expected
Fig 3
that better adl.rerence ro peri-operative antibiotic protocols,
as ."vell as more eiiicienr sllrger\-, u'ould have reduced the
rates of infection s'irh rhe p¿ss.rge of time, but this has not
been the case. Perhaps the ¿ctions to date simpl,v have not *bservatl*st 3
been successful, or perhaps ther hale been counterbalanced ,Am unexpl*iered sbseriJ¿¡tioÉ: rnen l-rave a higher rate *f
by other factors such as the fact that more arthroplasties ls:fectÉon after TKA than wor":len. Infection is not usually
are unclertaken in patients with serious comorbidities and considered to be a complication that has a strong ¿ssocia-
higher body mass index (BMI).4 Houerer, these data shoiv tion with gender. Several national registries have published
that this area could benefit greatly from transformatjve and curves sh«¡wing the cLlmulative risk of revision for infection
innovative approaches and technologies. after THA and TKA, and retlarkabll', each shows that

CC]R SLTPPLENIENT TO THI BONE & ]OINT ]OURNA t


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Fig 4

Graphs showing cumulat¡ve rate of revis¡on after TKA. Note for ¡nfec-
tion men (a) have much higher rate than women (b). Reproduced with
permission from the Australian Orthopaedic Association National Joint
Replacement Registry. Annual Report. AOA: Adelaide; 2015.
Fis,6a

e riHi!6Éq,s46,

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Fig.5 Fig 6b
Graph showing cumulative rate of rev¡sion of total knee Graphs showing cumulative rate of revision for any reason after
arthroplasty (TKA) for infection Modified with permis- total hip (a) and knee (b) arthroplasty stratified by age Repro-
sion from the Swedish Knee Arthroplasty Registry, duced with permission from the Australian Orthopaedic Associ-
Annual Report 2013 Elvins Grafiska AB: Helsingborg; ation National Joint Replacement Registry, Annual Report
20'14 AOA: Adelaide; 20'15

. rsion for infection after TKA is almost twice as common further \\,ith the passage of time. Not only are the rates of
¡en as women (Figs 4 and -5).1'3 Whi, should this be? It revision higher in young patients, but also, data from the
.::::s unlikely to be a spuriolls observation, bec¡use it is so United Kingdom National Joint Registrv shou, that patier.rt
. .istent in registries that publish this information. lnter- reported outcomes (PROMs) of TKA are more variable in
- :rgl\-, recent data from the Ner,v Zealand Joint Registrl. younger compared rvith older pxtienrs (I'ig. z¡.: An impor-
-- rhe Kaiser Joint Registry show similar findings.i'6 This tant caveat to these findings is that the collection of
:-:rr¿rtion has previouslv attracted little attention. lt can PROt,Is b,v registries is in its infancy and the validity and
- r ils fertile area for the generation and testing of value r'vithout cornplex risk adjr-rstment is yet to be deter-
r,)theses with more detailed research, and n,ill hopefully mined. Nevertheless, taken together, these observations
-i ro interventions that reduce the risk. suggest an irnportant role for shared decision n-raking u.ith
yoLlng patients that incorporates discr-ission of these con-
l ¡s*ra=Éí** 4 cerns, and also sr-rggests a role for continued improvement
- -ae *etz*nt* hávs rnore v*ri*bie a!'¡d y*,orsÉ &uÉco?r.,e§ of the technology of TKA, nr alternative surgical strategies
.-.:r Í{-É+ Él'ca* older pat;Énts" A comparison of cun'es of to meet rhe llecdr of v9x¡gs¡ petienrs.
, :..lative rates of revision show' modest differences
- ien voung and o1d patients after modern THA for the ****rz¡ati*r¡ E
- .lecade after surgery,. Thereafter the cnrves diverge, ItJew i*ci'¡n*E+*V eiir: have **i{}r *e*.-:ri:;z*i *ffest $n il'?e
=
f : \'oung patients requiring more revisiofls than older **lcafl1* *f art\r*plaety As THA ancl TKA have become
Y .rrs. pr:obably due to increased activitv (Fig. 6a).1 The more m¿rture, rates of success har-e lncreased, thr-rs making
, - :s of cumulative failure after TKA follow a dramati- further dramatic improvements nlore difficult. Some recenr
I , liiferent pattern (Fig. 6b).1 For both men and \Á¡omen, papers shorved little implovenrent in outcome dr-rring the
1 -:er patients have much higher: rates of revision after last decade with neu' implants.''8 Ho.nvever, the specitic
t : . er en in the first decade, and the curves diverge qrlestions asked and t1-re periods of time rvhich u-ere srudieJ

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Fig 7 Fig 8a

Graph showing outcome scores after total knee arthroplasty. Note the
more variable post-operative results in younger pat¡ents Modified with Figure HT13 Cum! aDve per.,nt Rdisron ór pnm¿ryTolat aoNenrion¿r Hrp Repa.eménr,ór pa¡sú yeetr
5; &
permissíon from the National Joint Reg¡stry. Nation Joint Registry 12t, by FEt o. iPr máry Di4no*OA) ^qñ
Annual Report, 2015. Pad Creative Ltd: Hertforclshi , United kingdom,
2415

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in slrch p:rpers aftect the reslrlts. Innovation tends to occur


in :r step.,r,ise rather than linear manner, and stud),irg a
short timc interv¿rl may fail to captrlre á step\\.ise K'iR,@!ÑlE

inrl-.re1'sr-1.., in outcome. Two technologies rvhich have 0Y. th !h -_ 7yE tuh


257tAO1Mr1fi4-m
i:crn clereloped or refined dr-rrir-rg the last two decades are 4w s1@ 29D6 @! lw n@
1@ p64 97t3 5U1
:\.imples of technology provicling major improvernents in '1$
ún

,.r:.onlcs. Data lrom the Australi¿rl Registry shorv that


- r-.inl.nrecl THA, refired in the 1¿rst 20 vears, now olltper-
-.r) .errented and hybrid THA ir younger parients (Fig. Fis 8b
\ Dat¿.r from this registrv also shor,v that crosslinked pol- Graphs showing cumulative risk of revision after total h¡p arthroplasty
- ¡¡hrLer-re. stratified by fixation type in patients less than 55 (a) and patients age 56
'"vhich was introduced abor_rt 15 years ego, is to 64 years (b). Reproduced with perm¡ss¡on from the Australian Oitho-
i:,r.1rr-rg to a dr¿lmatic redr:ction in rates of revision in the paedic Association National Joint Replacement Registry. Annual
Report. AOA: Adelaide; 2015.
.¡;oncl decacle after THA, presumably due to less tvear and
¡.sociatecl osteolysis (Fig. 9).r These observations shorv the
_ Non Cf6s r ñbd
leirl value to patients oi continued innor.ation in arthro-
plastv surgerl; just as data from registries also dernonstrate
the need for thc careful and responsible introduction of ner,v
techrrolog,ies i nro practice.
:l

*&:s*rvaticm 5
Éz *ai-tizt.* ohseruatic¡.r *f a *hange *l praeti*,e in ar]nhr*-
rylastz¡ **rgery Rcal-timc observation of changes of prac- Fig. 9
tice can inform surgeons about hou, their colleaglles are Graphs showing cumulative risk of revision after total hip
respor.rding to the larest informatior.r. Data from tl-re Amer- arthroplasty accord¡ng to polyethylene type: conventional
versus crosslinked Beproduced with permiss¡on from the
icar-r Joint Replacement Registrl,, u,hich is not matllre Australian Orthopaedic Assoc¡ation National Joint Replace_
enough to have rnuch longrrudinal data, shorv a change in ment Registry Annual Report. AOA: Adelaicle; 201S.
contelnporary operati\ e pracrlce. For the larst ferv years,
surgeons have used a hrgher propolrion oi cer¿rnlic femoral
heads in THA, and importanrlr. ther are graduallv using tí rE-: it*t í * * s *f f',É *t i * n a á J *i,ztt ** gi*tri *s
this type of femoral head more in older parienrs (Fig. 10).e Registries of all ti,pes have many limitations, of u.hich read-
Presumably this change is mainly dnr en I¡r recent concerns ers should be ar,vare and understand rvhen interpreting the
about taper corrosion r,vith modular cobek-chromium alloy data. The most imporrant limitation is that registrv data are
heads, and uncertainry about this problen-r's ¿leriologv and observational and can on11' pr:or.ide information aLrour
predisposing factors. associations beñ,veen variables, and that these associations

(-(]IR 5T,])PLE-\II \T TO TIIE BONE & JOIN T JOURNAL


JOI\T RECISTRIES

*-;;. These data also allorv Lls to ask "rvhere are our currelrr srlc-
: cesses?" allor,ving us to capitalise on and adopr rhem.
: ,.'

Z-"
¡"*
arthroplasty surgeons and their patients.
Author contribut¡ons:
D J Berry: Writing the paper, Content development, Data acquisition and anal-
Fig 10 ysrs

Graph showing ceramic femoral head use in different The author or one or more ofthe authors have received or will receive benefits
patient age groups by year. Reproduced with permission for personal or professional use from a commercial party related directly or
from the American Joint Replacement Beg¡stry American indirectly to the subject of this article
Joint Replacement Registry Annual Beport 2014 Ameri-
can Joint Replacement Registry: Fosemont, lllinois, 2015 This article was primary edited by J Scott
This paper is based on a study which was presented at the 32nd annual Winter
20T 5 Current Concepts in Joint Rep acement meeting held in Oriando, Florida,
gth to 12th December
,)r lack thereof) lnay or mav not arise from causalitv. Man\r
-,
pes of bias can affect such associations inch-rding selection 7=*l*r*z-,***
'.res, performance bias, ancl in some cases, reporting bias. 1. No authors listed. Austra lan 0rth0paed c Assoc ation National Joint Fep acement
Begistry Annual Beport 2015 https://aoanjrrsahmri com/annua reports 2015 (date
.:rreractions arnong variables ma,v be difficult to tease ast accessed I 4 Ju y 201 5)
The stratification of risk has often ror been per-
,--'-r:lrt. 2.No authors listed Nationa Jont Fegistry l2t Annua Bep0rt,20T5 httpr/
t rrmed or ma)¡ be rudimentarr'. Finalll', registrics tvpicall,v wwr",v njrcentre org uk/njrcentre/Feports,Pub rcationsand[i] nutes/Annua reportsi
tabid/86/Default aspx {date ast accessed 'l 4 Ju y 201 6)
-.:c revision as en elrdpoint ancl other outconre measLlres 3. Sundberg M, Lidgren L, W-Dahl A, Robensson 0. Swed sl¡ Knee Artrrop astl
:.r.h as pain relief and function xre equall,v or poss¡bl)' Reg stry Anrual Report 2013 http//myknee se/pdf/SKAB2013 Eng pdf ldate ast
accessed 14Ju y20T6)
rrore lmportant to nlan\. patlents.
4. Wagner ER, Kamath AF, Fruth KM, Harmsen WS, Berry DJ. Effect of body mass
The six examples cited aboi.e onh' represent ¿r fer,v obser- irdex on complicat ofs and reoperatl0ns after total rip arthroplasty J Bone Jot¡t
-lrions that calr be made bt'carcfLll revie\\,of current dat¿r Surq [Am]2016',98 A:l 69 1 79

:orn joint registries. As the baseball sage and pundit Yogi 5. Namba RS, lnacio MC, Paxton EW. Bisk f actors associated w th deep surg ca s.te
i¡fectionsafterprmarytota k¡eearthropasty.ananaysisof56,2l6knees JBu.ns
lcrra apparently saic'l: ",vou can reallv observe quite a Jot, Joint Surg [Ant]2A13,95 A.115 182
-rst b¡ looking". In depth cvaluation of pub1ic1,v available 6. Tayton EB, Frampton C, Hooper GJ, Young SW. The mpact of pat ent and surg cal
-:qrstr,v data, cross referencing of thc data benveen factors on the rate of infectio¡ after pflmary total knee arthrop asty an analysis of
64,566 joints from the Nerry Zea and Joint Reg slry Bane Jotnt J2A1 6;98 B.334 340
-gistries for validation, and the thoughtfr-rl co¡sideratiolr
7. Anand B, Graves SE, de Steiger RN, et al. What is the be¡ef t of introducing nerrr
1rotcntial erplanations and rarnific¿rtion of findings, can hip ard knee prosthesesT J Bone Jotnt Surg [Ar¡l20T 1;93 A.51-54

:.1c1 to improvements in practice and thc gcneration of 8. Nieuwenhuijse MJ, Nelissen RG, Schoones JW, Sedrakyan A. Appra sal of
evlde rce base for ntroductlon of new implants in h p and knee rep acement. a sys-
\ potheses for furthcr study. These c1¿rta allou, orthopaedic
tematjc revlew of five wide y used dev ce technologies BMJ 201 4;349.5 I 33
:-rrgeons to ask ",uvhere are the current unsolrred prob- 9. No authors listed. Amer ca¡ Joint Bep acement Registry Annua Beport 201 4 http:/
.nrs?", so that \\¡e can attack them and try to fir them. /wlvw alrr net/ mages/annual reports/AJRF_201 4-Annual Beport fina T 1 -1 T -
1 5 pdf (date ast accessed T 4 July 201 6)

iL 99 B, No l, JANLIARY 201;
ñ Aá\Jtr§GT,&T§&Ed

&
O Mobile pump deep vein thrombosis
ÉJ I= prophylaxis
JUST SAY NO TO DRUGS

J. Haynes, Aims
R. L. Barrack, The purpose of this article was to review the current literature pertaining to the use of
D. Nam mobile compression devices (MCDs) for venous thromboembolism (VTEI following total
loint arthroplasty (TJAl, and to discuss the results of data from our institution.
From.Washington
Fatients and Methods
Uniuersity
Previous studies have illustrated higher rates of post-operat¡ve wound complications, re-
Orthopedics,
operation and re-admission with the use of more aggressive anticoagulation regimens, such
Missouri, United
as warfarin and factor Xa inhibitors. This highlights the importance of the safety, as well as
States
efficacy, of the chemoprophylactic regimen.
Results
Studies have shown a symptomatic VTE rate of 0.92% with use of MCDs for prophylaxis,
which is comparable with rates seen with more aggressive anticoagulation protocols. A
prior prospective study found that use of a pre-operative risk stratification protocol based
on personal history of deep vein thrombosis, family history of WE, active cance[ or a
hypercoaguable state allowed for the avoidance of aggressive prophylactic anticoagulation
in over 70o/o of patients while maintaining a low incidence of symptomatic VTE.
Conclursion
Further investigation is needed ¡nto the role of aspirin in VTE prophylaxis as well as the
efficacy of MCDs as stand-alone prophylactic treatment.
Cite this aÉicle: Bone Joint J 2017;99-8(1 Supple Al:8-13.
Venous thromboen.rbolic events (VTE), con- Chest Physicians (ACCP).8 AAOS guidelines
sisting of deep vein thrombosis (DVT) and pu1- focused on the prevention of symptomatic
monary embolus (PE), are one of the most VTE events while minimising the incidence of
common c¿ruses of r¡orbiditr- and mortality haematoma, infection and re-operation.8,e In
following total joint arthroplastr, (TJA), and the orthopaedic community, there has been the
thns ¿rre of sigr-rificant concern to the arthro- concern that patients at 'low risk' of VTE may
plasty sr-rrgeon. l'l Prior studies ha',,e shorvn the receive excessive anticoagulation and risk fur-
incidence of VTE follor,ving TJA to be as high ther peri-operative morbidity. Thus, AAOS
as 20iA lvhen no prophr,laxis is used.3 More guidelines sought the optimal balance between
J Haynes, MD, Resident
Physic a n specificalll', rates of sl,mptomatic VTE follorv- safety and efficacy. In contrast, ACCP guide-
F L Barrack, ¡.¡D, Professor ing total hip arthroplastl' and tot¿ri knee
D Nam, l\4D, MSc, Assistant
lines classically emphasise d efficacy, with the
Professo r arthroplastv range fron-r 0.83%, to 15% and primary outcome measure being prevention of
Wash ngton University
2oA to 107o, respectively.47 Based on these a venographic DVI regardless of the presence
Ofthopedics, Barnes Je\.,lsh
Hospita ,660 S Euc d Avenue, d¿1ta! solre form of VTE prophylaxis is indi- of symptoms. However, in 201,2, the updated
Campus Box 8233, St Lou s
cated follou,ing TJA. The purpose of this arti- ACCP guidelines more closely reflected those
MO, 63110. USA
cle is to provide a revierrn, of the current put forward by the AAOS, with both now
Correspondence shou d be se¡:
to D Nam; email: literature pertaining to the use of mobile corr- focused on the reduction of fatal and sympto-
namd@wudosis wustl edu pression devices (MCDs) for VTE follor.ving matic VTE events.10,11 This was an important
O2017 The British Editorial TJ-\. and discuss the results of data from our philosophical shift, as both guidelines now rec-
Society of Bone & Joint r nstltL1t1On. ognise the importance of tailoring the prophy-
Su rgery
doi:10 1302/0301-620X 9981 Historicallr'. there rvas a difference in the laxis regimen to the patient based on both their
BJJ-2016-0165 R1 $2 00 philosophl- in gLridelines for VTE prophl,laxis safety and eÍfícacy.
Bone Jo¡nt J betr.veen the Americ¿rn Acaden-rv of Ort}ropedic The safety profile of VTE prophylaxis regi-
2017;93 B(1 Supple A):8-'13 Surgeons (AAOS) and the American College of mens are important following TJA, especially

8 CC'TR SUPPLF-I\,II,NT TO THE BONE & ]OI\T JOL]RN-\L


llOtslLL PU\lP Dl-EP !El\ fHROr\lIlOSl5 PROPHYL-\\IS

- rhe current climate in rvhich penalties and rewards are devices for VTE prophylaris follou,ing TJA u-ith rl.re use of
r,r\ecl on complic¿ition and re-admission rates. Thns, the a slnchronised NICD der.ice. The first, a multi-centre. pro-
:umal VTE prophylaxis regimen is simple, effective, easy spective, randomised controlled trial, compared the use oi
, monitoq and has a high degree of patient compliance. MCDs ."vith lorv molecular rveight heparir-r in ¡r¡¡1s¡¡5
.':rriarin, an inhibitor of Vitamin K-dependent clottir-rg fac- ur-rdergoing priman', elective total hip arthroplasty (THA).
,:s. has historicalll,been used for VTE prophl,laris follorv- All patients received their prophvlactic regimen for a period
-,1 TJA.2 However, rvarfarin is notoriouslv difficult to dose of ten da,vs post-operatively., and 6I'A of patients in the
.s pharmacokinetics va¡1' rvidell' betrveen patients based on MCD cohort also received 81 mg of aspirin based on the
:.netics, body mass index (BMI), drug interactions and surgeon's discretion. Efficac,v was determined based on the
,- e r.'! One recent investigation for-rnd that over a for-rr r'r.,eek results of a screening lor,ver extremity ultrasound con-
::riod, patients maintained a therapeutic international nor- ducted at ten to 12 days post-operativel.v of bilateral lorver
:r¿Lised ratio (INR) onl¡, 50%, of the time f osr- ertremities. The stud.v found no significant difference in the
:eratively.l2 Additionallv, the use of lvarfarin peri- rates of VTE betrveen the MCD (5%; ten ctf 197 THAs) or
,'-¡eretively has been shor.vn to increase the rate of lvound L\,I§IH groups (5%; ten of 192 THAs; p = 0.9). Hou,ever,
,-:ainage, infection, re-operation and revision surgerl, fol- the rate of major bleeding events were higher in the LM§lH
,,,r ing TJA.13 Lor.v molecular rveight heparin (LNI\IH), an (6"4) uersus NICD (0%; p = 0.0004) cohorts. Furthermore,
:r.eversible inhibitor of clotting factor Xa, has also been there was good compliance ."vith NICD use in the studv
..ed for VTE prophylaxis and is simple to dose and does population, with a mean use of 20 hours per da1..20 Ur-rfor-
ot require monitoring. Holvever, its use has ¿rlso been tunatell., this studr- i,vas limited b,v the fact that 61% of the
.'sc¡ciated with increased operative site bleeding and higher MCD group also received aspirin and that the studl' rvas
-.rtes of transfusion following TfA.8 powered to assess differences in bleeding rates, not s),mpto-
matic VTE. The second investigation b,v Colwell et a121
l'Í, **iÉ* ** rft presÉ;** dÉqr;cÉg \\¡as! a multi-centre revierv of the joint replacemenr regis-
:rtermittent pneumatic compression l-ras been shown to tries fron'r tel institutions. They included 1551 primarr
rcrease the velocity of venous l¡lood flow in the lorver total knee arthroplasties (TKA) and 1559 primarv THAs.
:'\tremities and increase local and systemic fibrinoll,sis, and found the incidence of s1'mptomatic VTE to be 0.92o,¡
i.rus decreasing the incidence of s,vmptomatic VTE ir.rpatients receiving a VTE prophylaxis regimen of MCDs
:rentS.14 Prior limitations to their use included their large for a period of ten days post-operatively ivith or u,ithout
.rze and lack of portabilityi but now rnultiple companies the use of aspirin.zl This rate is comparable to VTE rates
:.ranufacture MCDs i,vhich are lightr,veight, portable, and seen previously reported u,ith the use of factor Xa inhibi-
- ln be worn during ambu]ation. Pierce et all'in a s\srem- tors, u,arfarin and LM\X/H. Additionally, 46.4'A of VTEs
.ric review of lorver extremity compression devices, found rvere in patients rvho rvere taking aspirin, .uvhile 53.6o/,,
lat l¡elow-knee intermittent compressive clevices that rl,ere in patients u,ho were not on aspirin, but the associa-
,,rk by synchronising culti eontr¿ction to respir.rtorr- tion ben'veen aspirin and the occurrence of VTE events
¡lated venous phasic flor,l, signal, had the highest level of could not be assessed.2l Currentll', there is a lack of evi-
.r idence to srlpport use in VTE prophylaxis, as .,vell as the dence supporting the duration of MCD use. The ACCP
:ighest levels of patient compliance, ease of use, and com- guidelines recor.nmend using some type of mechanical com-
:Liance with the AAOS, ACCP and Sr-rrgical Care Improve- pression for ten to 14 days, and a minimum of 18 hours per
'.rent Project (SCIP) guidelines. Furthermore, ma jor day.' Other str-rdies examining the efficacy of MCDs have
,.1\'antages of MCDs include that there is no increased used a protocoi of ten days of MCD use, though tc orlr
:leeding risk and patient compliance w,ith use can be mon- knolvledge, there are no comparison studies examining the
:ored on the device. impact of duration of \,ICD use on the incidence of
Studies have shown the benefits of pneumatrc compres- vTF.2r,2r
.ion for mitigating VTE risk following TJA. A total of four
.¡.rall studies from roughly 25 ,vears ago fourd an overall ?n*áítuti**aE experí*n*e
:isk reduction of 56%, for post-TJA VTE with the r-rse of Thus, a VTE prophylaris regime that is safe, effective, easr
--.neumatic boots, hor,",ever these were small studies ivith a to monitor and achieves high patient compliance is ideal
:,.rmulative study population of roughly 110 patients.l6 le follorvrng TJA. In the past, the AAOS h¿rs recr¡rnmended
Furthermore, the compressiol devices used in these inr-esti- "risk stratification" for VTE events and/or bleeding, but
:.rtions did not h¡ve rhe cepacirl' to monitor respiretorl- the abilitl, to effectivel), do so is limited l¡. .r lack of evi-
-elated venous phasic florv, and thus generate compression dence elucidating the specific risk f¿lcto¡s rhat elevate VTE
r.L svnchronisation with this flou,. Synchronisation of com- risk.la Previously, r,varfarin was usecl in rhe vast majority of
'-.ression rvith respiratory-related venous phasic flolv has patients undergoing TJA at our insritution. Ho.nvever, due
..een shown to increase the peak venous velocitl, b.¡ 66t/".ts to concerns or.er complic¿rtir¡ns associated with excess anti-
L Cohvell et al20 have recently published tr,vo, multi-centre coagulation including haematoma, wound dehiscence, and
I .tudies evaluating the effectiveness of mobile compression infections, our institLr¡ior.r implemented a risk stratification

I 'l oqB.\,, l.T\NI \R\ l0t-


r
J. HAYNES. R. L, BARRACK. D \\\1

Table l. Rates of venous thromboembolism and bleeding complications in the routine and high rlsk cohotls during the initial study period

Phase 1 Routine risk (n = 858) High risk (n = 644) p-value

(+) DVT or PE within 6 wks 5 of 756 (0 6',0 1 to 1.2) T of548(02;00to05) 021


(+) DVT or PE w¡thin 6 mths 5 of 803 (0 6:0.1 fo 1 2) 3of600(05; 00to1'l ) >09
(+) Major bleeding complications within 6 wks 1 of'155 (0.1: 0 0 to 0 4) '1'l of 549 12.0:ABtrc32) < 0.001
(+) Wound problems within 2 wks 0 ol ll1
l0 to 0,0)
0; 0 0 7 of 570 i1 2; a 3b 2.1) 0 002
Days of drainage < 3 days 631 of771 181.8;79 1 to 84 6) 442 of 568 \77,8: 74 4 1o 81 2\ 0 009

Data are presented as the absolute number and the percentage of respondents in parentheses, along with the 95"; confidence interval
Percentages are calculated from the number of patients available for each outcome measuTe
DVI deep vein thrombosis; PE, pulmonary embolism

protocol in patients Lrndergoing TJA in which those deenred (betrveen April 2010 and r\1¿rr 2012.), ¿1 rnid-term analvsis
"routine" risk for VTE received lvlCDs in conjur.rction \\¡ith was performed to deten¡ine the effectiveness of our risk
aspirin, where¿rs those patients deemed "high" risk received stratification protocol and to assess if inclusion criteria for
warfarin for thromboproph.vlaxis. Patients \''er:e enrolled the high risk cohort could be narro\\'ed. It was determined
prospectively rvith the prim¿lrl purpose to determine the that there rvas ¿r lor'v incidence of \¡TE in both the routine
efficacy arlcl safet,v of our risk stratific¿rtion protocol.25 The and high risk cohorts. Furthermore, there',vas a significant
hypothesis was that, after risk stratification, the use of increase in rnajor bleec'ling,'nvouncl problems, and incisional
MCDs r'vith aspirin would be non-inferior to warfarir in clrainage in the high risk cohort. Given our encoureging
the prevention of VTE follorving T.lA. The clesign, reslrlts pr:eliminarl. results and the knou'n difficLrlt,v in warfarin
and methods of the studl' are summarised belou'. dosing ¿nd monitoring, criteria for inclusion in the high
risk cohort ivere modificcl to see if prophl'laxis r'vith rvarfa-
7 ati *¡=?* a'rz # í".* *ttz r: * rin cor-rld be s¿rfely avoided in more patients. Age, multiple
="
Patients undergoing primary or revisiorr TKA, unicompart- medic:rl comorbidities and BNII were no longer used as
mental knee arthroplastl', primary or revisiort THA, and inclusion criteria for stratification to the high risk cohort.
slrrface replacelnent arthroplast]- at a single ílcaclemic med- The primarv oLltcome measure was the incidence of DVT
ical centre were approached for enrolment in the studt. or VTE in both cohorts. Patients were contacted at two
Inclusion criteria were: patients aged 18 yeilrs or older, u,eeks and underr'vent clinical er,¿rluation in the office at sir
ur-rdergoing an elective, unilateral joint replacernent proce- wecks post-operertively. Lower extremit,v dupJex ultr:rsound
dure. Patients were excluded if thev currently had a DVT and spiral chest computed tomograph.v (CT) r'vere used to
detected on prc-operative ultrasound (obtainecl in all assess for the presence of a thrombus rrn'hen the clinical
patients ."vith a personal histor,v of DVT), or were undergo- s)¡l1lptoms were concerning for a DVT or VTE, respectivel\,'.
ing treatment for a DVT, had a personal history of PE (as Secondar.v outcome measures consisted oi the incidence c¡f
on warfarin and lou. molecular
the,v r'r''ould be placed major bleeding events, the number of davs of "drainage"
weight heparin post-operatively), were scheduled to from the \\roulld, re-admission i'vithin six months of sur-
undergo multiple (three or greater) surgeries r'vithin a three- gerl', all-car-rse patient deaths and patient satisfaction with
month period, or were on immlrnosuppressive medication their prophl'lactic regimen. Patient satisfaction i'vith their
for a solid organ transplant. Patients were not erclr-rded for thromboprophvlaris protocol \\¡as assessed at t\\ro and six
a personal histor,v of DVT, with a negative pre-operatiYc weeks post-operati\¡el). using the follor,ving scoring s\-stem:
ultrasound. Patients were then stratified as "rolttine" or 1 = very satisfiecl,2 = satisfied,3 = neutral,4 = dissatisfied,
"high" risk for post-operative VTE using our institutional 5 = r,er-v dissatisfied.
clinical protocol. Venous thromboembolism pr:ophylaxis
for the rolrtine risk population consisted of MCDs worn for ***'¿1t=
ten dilr s. :rnd aspirin 325 mg, trvice daily for six weeks. For In phase one of the studri 6,{4 (12.9%) of the 1502 patients
the l-righ-risk cohort. sir weeks of lvarfarin (with target INR enrolled were assigned to the high risk cohort. There r,vas
of 1.8 ro 2.r r. uith \'lCD Llse during hospitalisrti,)n, was no statistical difference in the VTE rate between the routine
used. and high risk cohorts at six §'eeks or six months fo11or'ving
There were rri.o phlscs to this prospective investigation. TJA (Tabie l). The cumulative rate of VTE events rvas 0.67o
ln the first phase, patierrts \\-ere stratified to the high risk in the routine risk cohorr uerslts 0.2'A in the high risk
cohort if they met an\- one oi the foilorving criteria: age > 70 cohort u,irhin six weeks post-operatively (p = 0.21), and
years, personal historl oi a D\¡T with a negatiYc pre- 0.6'% in the routine risk and 0.-5% in the high risk cohort
operative ultrasound, active cerlcer. hvpercoagulable states, rvithin six months post-operati\.el), (p - 0.9). Additionalll',
morbid obesitr. (BMI > 40 kg/mr). familr' historl'of DVT or the rates of major bleeding episodes, prolonged wound
PE, prolor-rged immobilit,v at the surgeon's discretion, or drainage (greater than three davs) and r,vound problems
two of tl¡e three follor'r,ing conditions: diabetes, lung dis- lvithin tu'o weeks of TJA w'ere significantl,v highel in the
ease, or heart disease. After tlvo r-eárs of patient enrolment high risk cohort. There lvere trvo re-admissions in the rou-

CCTR St]I)PLETIE\T IO THF- BO\I 3( JOINTJOLIRNAL


\IOBIt F PL]NIP t)I]I]P vET\ IHROJ\tBOSIS PROPHYL ]XIS

Table ll. Rates of venous thromboembolism events and bleeding complications in the routine and high risk cohons during the second
::udy period
Routine risk (n = 1364) High risk ln =277]. p-va lu e
Phase 2
8 of 1240 \0 6; 0 2 ¡o 1.1) 3 of 237 11.3;0.0 to 2 7) 03
- DVT or PE within 6 wks
8 of 1254 \0 6;0 2Io 1 1) 6 o'i 248 12.4',0.5 to 4 3) 002
- DVT or PE with¡n 6 mths
wks 6 of 1236 (0 5 0,1 to 0 9) 5 of 23a 12.1;0 3 to 3.9) 004
- Major bleeding complications within 6
5of 1317 10.4;005fo071 4 of 265 ( 7.5; 0.04 to 3.0) 0,048
- Wound problems within 2 wks
)ays of drainage < 3 days 1174 of 1313to 91 1 )
189 4;88 8 224 of 263 (85.2; 80.9 to 89.5)
0.02

Jata are presented as the absolute number and the percentage of respondents in parentheses, along with the 95% confidence interval
rercentaqes are calculated from the number of patients available for each outcome measure
IVI deep vein thrombosis; PE, pulmonary embolism

>ls
:SK
Table lll. Bates of VTE events and bleeding complications in the routine and high risk cohorls during the overall study
period
OI
-.id Routine risk ln = 22221 High risk (n = 921) p-value
Phaseland2Combined
ne +t DVT or PE within 6 wks 13 of 1996 (0.2 0.3 to 1.0) 4of 921 10.5;0.01 to l0) 067
13 of 2057\0 6; 0.3 to 1.0) 9 of 848 ( 7.7; 0.4 to 1.8) 0,23
lrlt -) DVT or PE within 6 mths
<0001
wks 7 of 1991 (0 4; 0 1 to 0 6) 16 of787 (2.0; 1 0 to 3.0)
:i .r1 -) Major bleeding complications within 6
5 of 2088 (0.2; 0 03 to 0.4) of 835 11 3; O.5 to 2 1l
'11 <0001
-) Wound problems within 2 wks
rg 1805 of 2084 (86 6; 85.2 to 88.1 666 of 831 180 1;77.4to 82.9) <0001
Days of drainage < 3 days )

:L1l
Data are presented as the absolute number and the percentage of respondents ¡n parentheses, along with the 95% confidence interval
:lh Percentages are calculated from the number of patients available for each outcome measure
IVI deep vein thrombosis; PE, pulmonary embolism

rle
¿S
' :rc cohort (2.9%\ related io anticoagulation therapv and for the routine risk cohort, r,vith 84.5% of patients rvearing
\T ' c re-admissior-rs in the high-risk cohort (4.9'1"; p = 0.8). the device for greater than 18 hours per day, according to
-,\'o Lr the second phase of the stud\', after modification of the the MCD readings. Onli' 1.5% of patients \\¡ore the N{CDs
.l
:l\ .k stratification criteria, 277 16.9%l of the 641 patients for less than 12 hours per da1'.
rrd .: r'olled were assigned to the high risk group. Again, there
:to .rs no significant difference in the incidence of VTE 7u7z;r'* 4ir**|i*rz*
iJal -::\\'een the routine risk (0.6%) and high risk (1.3%) As arthroplast) surgeons continue to seek the optimal VTE
- ,horts at six weeks follolving sLlrgerv (p = 0.3) (Table II). proph,vlactic regime that minimises the risk of rvound com-
J rrrever, at six months follor.ving sllrger)¡, the cumulative plicirtions, re-admission and re-opcration,',vhi1e providing
-.idence of VTE was st¿ltistica11v higher in the high risk the m¿rrimal efficac,v, ¿ fs11, questions remain. First, are
l,-{'l'i,) cohort compared with the routine risk (0.6%) MCDs sr-rfficient as stand-alone VTE prophl'laxis for stand-
, ,hort (p = 0.02). The r¿rte of mejor bleeding episodes, pro- ard risk patients? \ülhilc previotts studies have shou''u thc
,rqed §'ound drainage (more than three davs), ancl wolrnd effectiveness of N{CDs for reducing the incidence of svmp-
-roblems \\¡ere again lorver in the routine risk cohort. There tomatic VTE, no studv to date has been adequateh'pow-
':re t\\,o re-admissions in the routine cohort (1.2%) ered to detect a difference in VTE rate with N1CD treatment
.l¡ted to the effects of anticoagulation therapy ¿rnd three alone ¿,ers¡rs other proph\''lactic regimens.20'21 Secondll',
.-.rdmissions in the high-risk cohort (6.8'l/o; P = 0.1). what is the optimal duration of N'ICD use? \lhile the ACCP
\\¡hen analysing the entire cohort, the rirte of VT-h, i'vas Guidelines have recommended use of \{CDs for a mini-
, -rite lor,r,', with 16 events (0.6%) and 22 events (0.87") doc- mum of l8 hor-rrs per dav and ten to l4 da,vs post-opera-
:rented within sir lveek and sir molrths, respectivel)', fol- tivel,l', there have been no randolnised studies exiilnining
,rrrng primary TJA, and there \\¡as no statisticalll' the effect of \{CD use on the incidence of VTE. The role of
. gnificant difference in the rates of VTE betu'een the high aspirin in VTE proph,vlaxis is another ¿rea in need of con-
-.k and routine risk cohorts. During the initi¿rl six months tinued study. The Pulmonary Embolism Prevention (PEP)
r )st-operatively,2t2- patients in the routine risk cohort Trial shor,",ed a modest clecrease in the inciderlce of DVT
L1).3%) and 139 patients in the high risk cohort (16.4"Á; u,ith the dilil.v use of 160 mg of aspirirl in patients under-
r < 0.001) were re-admitted to the hospital, ',vith several going hip fracture sLlrger)', u,hen comp¿rred r'vith placebo
r,ltients h¿lt,ing multiple re-admissions (Table III). Or-re lim- treatment.26 Hort,ever, this difference \\'¿1s not seen in the
,.ltion of the studf is that the cohort of petients who were population unciergoing elective TJA. Another recent stlldY
, ,nsidered routine risk under the new stratificetion ploto- evaluating the efficac.v of VTE prophvlaxis, Llsed ¿ dose of
,,r1. br-rt were consiclered high risk under the rtlder protocol 150 mg of aspirin clail¡ anc1 ior-rnd a cumulative inciclerlce
he . ¡re not independently examined to determine if thel' h¿d of PE to be 0.6% ancl 1.'17?;, following THA ¿rncl TK-\.
Ll- : ei ¿rte d rates of VTE. Compliance u'ith lvlCDs lvas high resllectivel\'.1 Hos'evet, this rate inclucled multiple \-TE

rL 99 B. No l. TANL]Aj{Y 201;
J H.{YNES,R L.BARR\CK

prophylactic regimens, including warfarin and low molecu- 4 Salvati EA, Pellegrini VD Jr, Sharrock NE, et al. Becent adv¿nces n venous

lar weight heparin, which inhibits the ability to draw defin- thromb¡:-b: : ¡'::-
ar s d¡t ng and after tota h p replacement J Bone Jornt Surg
1,4rrl 2000,t¿-- :a:-:;!
itive results about the efficacy of the used aspirin dosing.
5. Leclerc, JR, Gent M, Hirsh J, Geerts WH, Ginsberg JS. The ircidence of symp- §
Huang et al28 showed that aspirin doses of 81 mg or 325 tomatic \i eno-s r":'-a,- -:i
sr a;ter enoxaparin prophy ax s l ower extremlty l
mg, taken twice dail¡ were significantly more effective than arthrop asty ¿ c:-¡- r.-.r :''
:81 pat ents Canad an Co aborative Group thes¡
warfarin in the prevention of VTE, with rates of 0.2'A and 1998,114:1155 ll8;c

0.6'A ínthe low risk and high risk groups, respectively. Mul- 6. Colwell CW Jr, Collis DK, Paulson R, et al Comparison of enoxaparln and war-

tiple additional studies from the Rothman Institute have f arin for the prevent 0 ¡', É-0.r. ; r'tr''r¡¡embo lc disease atter tota hip arthrop asty
Evauatondurnghospializat! ¿-.-trr:emonthsafterdlschargeJBoneJotntSurg
investigated the use of aspirin and have postulated that aspi- 1999;8'l 4 932 940
1,4mJ
rin is an adequate VTE chemoprophylaxis in routine risk T.WhiteRH,HendersonMC.Fskfacor¡for';enousthromboembolismaftertota hlp
patients following primary TJA, citing their findings of and knee rep acement surqeTV Curr Ct,ri Pttirn Med2A02,8.365-311
decreased incidence of wound infection (0.5%" uersus 1,.4Y") 8. Lieberman JB, Pensak MJ, Preve¡t on ¡f ven¡us thromboemb0 c d sease after
with use of aspirin compared with warfarin, and the fact total rip and knee arthrop asty J Erre J0if ¡,St rg [Am] ?A13',95 A.T B0T 1 8l 1
that aspirin was an independent predictor of decreased cost 9. Barrack RL. Current guide ines for total ioint VTE prophylaxis: dawn of a new day J

of index hospitalisation, and total episode of care charges, Bone Joint Surg [Br]2012,94 8.3 I
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American Co ege of Crest Physicians Evidence-Based C in ca Practlce Guide nes
,iorr.2e-31 Further investigation into the dosing regimen,
(8th Edit on) Chesr2008 133381S 453S
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11. Lieberman JR Amer can Col ege of Chest Physic ans ev dence based guide nes for
tive effects of aspirin during the peri-operative period is venous thromboembo c prophy ax s. tre guide lne wars are ouer J Am Acad Arthop
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In conclusion, at this point in 2016 MCDs have been 12 Nam D, Sadhu A, Hirsh J, et al. The use of wafarin for DVT prophy axis following

shown to be effective in reducing the incidence of sympto- rip and knee arthr0pasty h0w often are patierts within theirtarget 1NB range? J

matic VTE following primary TJA. However, data are still A nh ra p Ia sty 2A1 5,30:3 I 5-3 1 I
lacking on the adequate duration of MCD use and whether 13 Simpson PM, Brew CJ, Whitehouse SL, Crawford RW, Donnelly BJ Compli-
catons0fperoperativewarfarirtrerapyLntota kreearthropasty JArthraplasty
MCDs alone are adequate or concomitant chemoprophy- ?014,29'.324-324
laxis is required. Additionall¡ avoiding aggressive anticoag- 14. Jacobs DG, Piotrowski JJ, Hoppensteadt DA, Salvator AE, Fareed J. Hemody'
ulation when possible allows for the minimisation of wound namjc and frbr nolytic consequences 0f intermittent pneumatic comp,ession: pre mi
complications, re-operation and re-admission. The imple- nary resu ts J Trauma1996,4A.11a 116

mentation of appropriate risk stratification protocols will 15. Pierce TP, Cherian JJ, Jauregui JJ, et al A Current Beview of \4echanica Com-
pression and ts B0 e in Venous Thromboembolic Prophylax s ln Tota Knee and Tota
allow for the safest and most efficacious VTE prophylaxis
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protocols to be used for patients undergoing primary TJA.
i

16. McKenna R, Galante J, Bachmann F, et al. Prevention of venous thromboembo


lisrn after total kree rep acerrent by I gh-dose aspir n 0r ntermltteft ca f and thigh
compress on Br Med J 1980,284.514-511

17. Haas SB, lnsall JN, Scuderi GR, Windsor RE, Ghelman B. Pneumatrc sequen
tlal-compress on boots cornpared with aspir n prophy ax s of deep-ve n thrombosis
TJA, and their inclusion should be strongly considered when designing a
after tota kree arthroplasty J Bone Jotnt Surg [Am]199A,12 A.?1 31
prophylactic protocol.
18. Hull B, Delmore TJ, Hirsh J, et al. Effectiveness of intermittent pu satile e astic
Author contributions: stock rgs for the prevention of ca f and thigh vein thrombosis in patients undergoing
J Haynes: Manuscript prepdration e ective knee surgery Thromb Bes T 979;1 6:37-45
R L Barrack: Study design, Manuscript preparation
19. Kaempffe tA, Lifeso BM, Meinking C. lntermittent oneumatic compression versus
D Nam: Data analysis, Manuscript preparation
coumad r Prevent on of deep veln thrombosis in ower extremity total j0 nt arthr0-
Although none of the authors has received or will receive benefits for personal plasty C/in 0tthap Belat Res 1991 ,269:89 97
or professional use from a commercial parry related directly or indirectly to the
subject ofthis article, benefits have been or will be received but will be directed 20. Colwell CW Jr, Froimson Ml, Mont MA, et al. Thrombosis prevention after tota
solely to a research fund, foundation, educational institution, or other non h p arthroplasty: a prospective, randomlzed tr al comparing a mobi e compression
profit organization with which one or more of the authors are associated dev ce witr ow-mo ecu ar we ght hepar n J Bone Jotnt Surg [Am]?A10,92-4.521-
This article was primary edited by AD Liddle 535

This paper is based on a study which was presented at the 32nd annual Winter 21. Colwell CW Jr, Froimson Ml, Anseth SD, et al. A mob e compression devlce for
2015 Current Concepts in Joint Replacement meeting held in Orlando, Florida, thrombosis prevent 0n in h p and knee arthrop asty J Bone Jotnt Surg [An]2A14,96
gth to 12th December A:177 183

22. McAsey CJ, Gargiulo JM, Parks NL, Hamilton WG. Patient satistactlon wlth
fteferc¡:ccs mob e
compression devices fo ow ng total hip arthr0plasty 0nhopedtcs
1, Shimoyama Y, Sawai T, Tatsumi S, et al. Perloperative risk factors for deep vein 2014,31'.613-611
thromb0s s after tota hip arth'cp ¿st, 0r tota k|ee arthroplasty J Clin Anesth
23. Nam D, Nunley RM, Johnson SR, Keeney JA, Barrack RL. Mobile compress on
2012,24.531 536
dev ces and aspirin for VTE prophy axis fo ow ng s mu taneous bi atera total knee
2 Sheth NP, Lieberman JR, Della Valle CJ. DVT prophylaxis in total j0int recon
arthrop asty J Arthra pl asty ?A15;30:447-450
struction rr¡hop CIi n No rth An ?010,41.21 3-?84
24 Johanson NA, Lachiewicz PF, Lieberman JR, et al. American academy of ortho
3.WarwickD,FriedmanRJ,AgnelliG,etal, rsufflclentdurationofvenousthrom
boembo ism prophy axis after tota hlp or knee rep acement when c0mpared w th the paed c surgeons clinica pract ce guideltne on Preventlon of symptomat c pulmonary
time course of thromboembo c events f ndings from the G oba 0rthopaedic Beg stry embo sm in patients undergoing total h p or knee arthroplasty J Bane Jornt Surg
J Bone Joint Surg [Br]2001.,89 8 799-807 [Am]2009,9 A 1756 1757

crcrlr{ SIIPPLEN{ENT TO THF BONE & JOINT IOURNAI


##E*TECH[UOLOGIES

a
Not all cementless femoral stems are created
t;) equal but the resu[ts ma),be comparable

S. W. Carlson, Airns
S. S. Liu, The aim of this study was to compare the survivorship and radiographic outcomes at ten-
J. J. Callaghan year follow-up of three prospective consecutive se¡ies of patients each of which received a
different design of cementless femora! components for total hip arthroplasty (THA).
From Uniuersity of
Fatie¡'lts and Methods
Iowa College of ln Cohort f , 91 consecutive patients (100 hips) underwent THA with a cementless porous-
Medicine, lowa,
coated anatomic femoral stem (PCA) between October 1983 and January 1986. ln Cohort 2,
United States
80 consecutive patients (100 hips) underwent THA with an extensively porous-coated
cementless femoral stem (Prodigy) between June 1994 and October 1997. ln Cohort 3, 88
consecutive patients (100 hipsl underwent THA with a proximally porous-coated triple-
tapered cementless stem (Summit) between April 2OO2 and October 2003. All three groups
underwent prospective clinical and radiographic evaluation.
Results
Kaplan-Meier survivorship analysis of Cohort 1 was 91% (95% confidence interval (Cl) 88 to 9al
with an endpoint of revision for any reason and9TYo (95% CI 95 to 99) with aseptic loosening
as the endpoint. Survivorship of Cohort 2was88o/o (95% Cl 79 to 97) for revision for any reason
and 100% for aseptic loosening. Survivorship of Cohoft 3 was 95% (95% Cl 91 to 99) for
revision for any reason and 100% with aseptic loosening as the endpoint.
Gonclusion
With revision for aseptic loosening of the femoral component as the endpoint, the three
femoral components with different design philosophies demonstrated excellent
survivorship, ranging from 97Yo to 100% at ten years.
Cite this article: Bone Joint J 2O17;99-Bl1 Supple Al:1L17.
In the United States, cementless fem«¡ral com- nents, it is important to contlnrle rnvestigating
ponents have become the preferred stand¿rrcl the comparative outcomes of these designs in
for fernoral fixation in total hi¡r arthroplasty order to marimise the benefit to patients.
S W Carlson, BA, Medica (THA). Cementless femoral components have The purpose of this st¡:dr rv¡rs to compare
Student, Depaftment of
Onhopaedic Surgery demonstrated excellent dLrrabilit¡, and survi- the snrvivor-ship, radrographic and clinical
S S Liu, N4D, Associate vorship at ten- to 2O-vear follow-r-rp.r As a results at ten-vear iollos'-up of three prospec-
Research Scientist, Department
of Onhopaedic Surgery
resr-rlt of this success, 60oA to 90% of rhe tive consecutlle series oi perients prcviously
J J Cal aghan, MD, approximatell, 200 000 THAs performed revielvecl 1¡r our in.¡irurior-i u-ho each received
Professor, Department of
Odho paed lc S u rgery,
yearly in the United States use cementless fem- different desigr.r. i¡i ce ¡ncn¡less femoral compo-
University of owa, University oral components.2 F1cr.u.,ever, despite the over- nent, all oi u r;¡-r \\.rú irlplented by. a single
of lowa Co lege of Mediclne,
01073 JPP, 200 Hawkins Drive, all success of this THA constrllct. there is sLrrqeorl .[]C i ,r :'1, 1, :r'rldics and D. Goetz f«tr
lowa City, 1452242, USA substantial r.ariation in stem design. tl-re ():l-:- --. i. -.-
-..:.r sed br- independent
Correspondence should be sent
to J J Callaghan; email: john-
\fhile the majori¡,of
stem designs continue to '1.. --.'\ '.,ll,
demonstrate ercellent outcomes, joint repl.rce-
ca laghana@uiowa edu
ment registry data trom the Australi¿rn Orrho-
4.12017 The British Editorial
paedic Association National Joint Replacei::r: ip. stress shielding and clinical
Societv of Bone & Joint
S u rgery Regi5rr)'repol.tsl.eri.ionrll[C.I..,ll.::..
.l
compared in three cohorts
doi 10'1302/0301-620X 9981
BJJ-2016 0269 R1 52 00
2.9o4 to ..-r-.:-.:::
07o ¿rt ten \-e¿us irlnong '--^j rct ieued b1 c,ur insritu-
_-

femoral con.lp-,,onents.i Due tc, ¡lr; r .-. , patients were prospectively


Bone Joint J
stenr design. ¡nd rlrc .l'-j. .'.-. ,r::,-)ir1g THA performed by a
rtttTc..c.l :llTl()lll- -r --. 't .. -

_ ,-r 1HE BONE & JOINT JOT.ITNAL


NOT \LL CEXIENTLESS FE\IORAL STFN/IS A RE CITEATED EQUAL BUT THE RESL]I TS ÑIAY tsT CO \ II \R \BL: T.'

Cohort I consisted of 9'l cor-rsecutive patients (surgery modular Articul/eze (DePuy) femoral he:rd. The femoral
carried out by JJC) (100 hips) who underu,ent THA with a component was mated .'vith the Pinnacle Sector ' acet¿rl.lt-
poroLls-coated anatomic total hip prosthesis (PCA; Horv- 1ar corlponent (DePuv) in all hips. The liners used u ere
medica, Rutherford, Ner.v Jersey) betr'veen October 1983 moderatel¡, crosslinked polyethylene (Marathon; DePur I in
and January 1986. This colnponent is a chromium-cobalt 60 hips, galnln¿ vacuum foil (GVF) polyethylene in 1-3 hips,
stem that is po«rus-coated over the prorimerl third and used and cobalt-chromium-molybdenum (CoCrMo) metal liners
u,ith ¿r .32 mm diameter modular femoral head. The femoral in 27 hips (Ultamet; DePuy-). An anterc¡lateral approach
component is collarless rvith a posterior bow to confonn to was used in all cases. The mean age at thc tin.re of incler sur-
the anatomical configuratior.r of the proximal femur. The ger)' was 61.6 years (25.1 to 90.2). There \\''ere 51 women
femoral and acetabular colnponents of this prosthesis are :rnd l- nlen. The revision stíltus Jt a minimunl of ten lears
cornposed of chron.rium-col¡alt allov (Vitallium) r'vith a after index THA was known for all 66 living patients (74
double layer of sintered Vitallium beads on the back <¡f the hips) trnd att 20 of the deceased patients (24 hips). Mini-
acetabular componert ancl circumferentixll)' on the proxi- rnum ten-year follow-up radiographs wele available for 61
m¿rl one-third of the femoral stem. The acetabular compo- oÍ the 74 hips (82 9'" ) in 54 of the 66 living patients (82%).
nent has two peripheral pegs for rotational stability. A For radiological evaluation correction for magnification
direct lateral approacl-r rvas used for the first 66 arthroplas- r'vas completed by star-rdardising all nreasurenrents to the
ties, r'vhi1e the remaining 34 u,ere performed with a poster- kno."vn size of the femoral head. Femoral components were
olateral approach. The mean age at the time of inder evaluated for bone ingrol'vth, stable fibrous fixation, or
surgery r'vas -¡8 vears (22 to 81). There.nvere 62 men and29 unstable fibrous fixation according to the criteria of Engh.
women. At minimum ten-),ear follolv-up, 71 patients (77 Massin and Suthers.' Femoral cornponent subsidence lvas
hips) u,ere living and 20 patients (23 hips) were dece¿lsed. determined by the relationship of the top of the lesser tro-
All 71 Iiving patients (77 hips)u,ere evaluated c1inicail1, and chanter to the medial aspect of the stem collar, defined as a
radiographicall,v. The mean clinic¿,r1 ar-rd rac'liogr:aphic decrease of at least -5 mm between the initial post-operitiye
fo11ow-up 11.6 ,vears (10 to 13). Revisior-r status was radiograph and thr¡se from final fo11ow-up.t Osteolysis ivas
"vas
known for all livir-rg 77 htps at minimum ren-\'err follow-up defined as any non-linear radioiucency at the bone-
and for the 23 hips of patients lvho died prior to ten-1,s¡¡ prosthesis interface that was at least 5 mmZ accorcling to
fo11ow-up. the seven femoral zones defined by Gruen, McNeice ar-rd
Cohort 2 consisted of 86 consecutive patients (100 hips) Amstutz.e Femoral component stress shielding rvas defir-red
lvho underwent THA lvith an extensively porous-coated ursing a modification of the criteria defined by Engh and
cementless stem (Prodigy; DePul', '§farsaw, Indiana ) Bobyn.r0 !(¡e defined mild stress shielding to he limited to
bet.nveen Jtrne 1994 and October 1997. This component the upper third of the implant, moderate stress shielding
u,as rnade of chromium-cobalt and r,vas a fully coated fer-n- ertended to the middle third, and severe stress shielding
oral stem r'vith a 22 mm or 26 mm modular femoral head. extended below the middle third of the stem. The acetabu-
The stem rvas mated rvith a Harris-G¿rl¿nte I acetabular lar components were evaluated for bone-prostl-resis radiolu-
component (68 hips) (Zirnmer, lülarsaw, lndiana) or with a cencies and acetabr-rlar component migration according to
Duraloc Sector acetabular conrponent (32 hips) (DePuy). the criteria of Massin, Schmidt and Engh.tl The definition
The polyethylene liner used in this series consisted of either of acetabular osteolysis \\ras the same as that for femoral
ganrma-irradiated in air polyethylene (for the 68 HG-I ace- osteolysis.
tabular components) or non-crosslinked poll.ethylene (for §taiistieal *naiy*i*. In all cohorts, Kaplan-l,Ieier surr-ivor'-
the 32 Duraloc acetabular components). All surgerv rvas ship analysis was performed with 95%, conficlence intervals
performed b,v :r single surgeon (JJC). A posterolateral (CI) for the endpoints of revision for any reas()n, revision
approach .,vas used in all cases. The mean age at the time of for loosenir-rg and radiographic evidence of femoral compo-
index surgerv was 17 .7 y ears to 72) .'f hele were 5 8 men
(1 8 nent loosening.1z
and 28 women. At ten to 12,vears follor.ving the index
THA,69 patients (82 hips) were alive, 14 patier-rts (15 hips) ffiesuEts
.1
rvere deceasecl, and three patients (thr:ee hips) were lost to In Cohort 1 (PCA), there r,vere 1 re-operations at ten-\ eilr
follow-up. The mearr clinical follow-up was 11.4 years (10 follow-up. In sir hips, onll' the acetabular componel-it \\'as
to 12). Among the 69 living patients (82 hips), 63 patients revised, in one hip onl1, the femoral component u-as rer-ised,
(76 hips) (91%) had a minimum ten-year follolv-up radio- and ir.r four hips both the acetabular and the femoral com-
graph. ponents were revised. Of the five fen-roral rerisions, tivo
Cohort 3 cr¡nsisted of 88 consecutive patients (100 hips) rvere performed bec¿ruse of femoral component loosening
rvho underwent THA ivith a proximallv llorous-coated and three rvere ¡rerformed because oi ertensive osteolysis.
triplc-tapcred cemcntless stem (Summit; DePuy) between Femoral loosening was defined as rerision of the femoral
April 2002 ancl October 2003 by a single surgeon (D. component because of sr mptomatic aseptic loosening
Goetz¡. This component is a titanium stem that is porous- or subsidence of the fen-roral component ¿ls seen
coated over the prorimal third a 28 mrr, 32 mm, or 36 mm radiographicallr-. Bv these criteria, five femoral componcrlts

YOL 99 P,,No. l..JANUAJlY20L


5. \\. C,\RLSON, S. S. LIU, J J CALL-\C;HAN

Table l. Kaplan-Meier survivorship analysis at ten years with 95% conf¡dence intervals of the three
cohorts with endpoints of revision for any reason and femoral component loosening Cohort 1:77
hips at risk; Cohorl 2: 82 hips at risk; Cohort 3: 74 hips at risk

Survivorship Cohort 1 (PCA) Cohort 2 (Prodigy) Cohort 3 (Summit)


Bevision for any reason (%) 97 (88 to 94) 88 \79 to 9l) 95 (91 to 99)
Femoral component loosening (%) 97 (95 to 99) 100 100

were radiographicalh loose, accounting for t\Á,,o of the rcvi- ascptic loosening or radiographic loosening as the end-
sions. In all, 7-t of the rcnrainingT2 \92%) fenroral compo- point. Radiographic evahration of the 6l hips (54 patients)
nents clerxor-rstr¿rted bone ingrowth fixtrtion, while one (82%,) r,vith minimum ten-year radiographic follor,v-up
demonstratecl stable fibrous fixation (1%). The nrean timc demonstrated no stress shielding in four hips (7%), nrild in
to revision \\,as 9.4 ,vears (-5 to l3). I(aplan-Meier sur\-ivor- -50 hips (82%), moderate in sir hips (10'%), and severe in
ship analvsis of the 71 patients (77 hips) at risk, demon- one hip (1%). All femoral components had bone ingrorvth
strated a sur\¡ival rate at ten,vears oÍ 9'l'A (95%, CI 88 to and there was no evidence of radiographic loosening. At
941 for re\¡ision for anv re¿1son, 95% (95'% CI 93 to 97\ for latest revier'v one patient (1.-t%,) complained of thigh pain.
revision of tl.re femoral component ard 97 oA (95 %, Cl 95 to
99) f<¡r revision of the fernoral component becanse of asep- *a*r:u**i*ra
tic Jooser-rir-rg. L-r terns of clinical reslrlts, nine paticnts of the Each cohort included a r-rnique cernentiess sten-r design, r,vith
71 patients (12%) compJained of thigh pain at final follor.v- an anatomical stem in Cohort 1, a straight stem in Cohort
L1p. Furthermore, 17 patients (23%), con-rplained of a mod- 2 and a t¿lpered stem in Cohort 3. These represent thr:ee
erate or severe limp. b¿sic cementless femoral component clesigns. Anatomical
In Cohort 2 (Prodigr.), there rvere 14 re-operations at designs are stems that are intended to match the posterior
ten-year fo1low-up. No femoral cornponents r,vere revised inner-trochanteric borv of the femur, straight stem designs
for aseptic loosening or infection. A total of ten hips (ten involve preparing ir-rternal femoral geometry to accept a
patients) underwent liner erchangcs dLle to \vear end disso- straight stem, and tapered stems are stems that obtain fix-
ciation of the line¡ tu,o patients (nvo hips) h:rd re- ation in the metaphyseal-diaphyseal junction. At the time of
olrerations for periprosthetic femoral fractures with rcten- the development of each of these stems, each construct rep-
tion of the femor¿rl co[rponents, and the rem:rining ts.cr rcscnted a nerv phiiosophl, in THA regarding the best r,vav
hips undenvent re-operations for recurrent dislocation ¿rnd to obtain sLrccessflrl fi-x¿rtion ar-rd clinical oLltcomes.
r'vith fen-roral head exchange and acetabr-rlar liner erchange Despite these differences in design philosophl,, each stem
to constrained liners at 0.6 ve¿rrs ancl 4.6 vears after the ini- obtainecl good fixation and clinical results. \rVith revision
tial slrrgerv. The mean time to revision \\-as se\-en -vears (0.2 for any reason as an endpoint, there was sllLlstantial vari¿r-
to 12.3). Survivorship analvsis of the 69 patienrs (82 hips) tion in snrvivorsirip between the three cohorts (Table I).
at risk demonstrated a survival rate at ten ye¿trs of 88% Horveveq r'r,ith revision for aseptic looser.ring of the femoral
(9-t% CI 79 to 97 ) for revisic¡r-r for an1' reason. Survir.orship component as the endpoint, fhe tluee femor¿rl cornponents
rvas 1007o for the endpoir.rt of femoral component reten- den-ronstrated ercellent survivorship. ranging irom 97%, to
tion ¿rnd radiographic looserring. Of the 63 patients (76 100% at ten )¡ears (Table I). The r ari¿rtron in survivorship
hips) rvith minimum ten-,vear radiographs, all of the femo- r'vith the endpoint of revision for'¡r.r,'1'ü.1\,rn can Jargely be
ra1 corrponents demonstr¿1ted Lrone ir-rgrowth. Femoral attribr-rted to issues related to thc .rcc-r¿L¡ular component.
stress shielding was n-rild in 54'% (41 hips), moderate in There was a differencc bcts-een rhe sr¡ess shielding in
l6uu (20 hips) and severe in 1'lo (one hip). Lr all, tlvcr Cohort 2 and Cohort 3, rvith Cohorr ' ienronstr¿ting more
pirtients {29'i,)reported some thigh pain at last follo,,v-up. moderate stress shielding il6o, c,r l::¡-i cornpared r,vith
In Col-rort -3 tSumn-rit), there r,r.ere fonr re-operarions Cohort 3 (10% of hips). This drti-r-r--. 1r srress shielding is
(four patier-its) i1t ten-vear follou,-np. No femoral compo- likel,v to be the resulr of the nr.:-.,: ri>..11-diephyseal fix-
nents were rer ise d ior aseptic loosening or infection. A total ation of the prorimallr l!r:L,.s-., ,:.:i.1 triple-tapered
of three hips u'er:e rer ised for recurlent dislocation and all cementless stem compared ri i:h :. : ,::.rr seal fixation of
were treated r,vith a iemoral he¿rd erchange to a constrained the extensivelv porous-.o.1!i: :: :-
=: :1e ss stem. §lith
liner rvith retention oi tLte prirnary femoral component. Just fixatior.r obtained more cir,\ r , ., ihe n-retaphyseal-
one hip was revised for a periprosthetic fracture that diaphyseal junction. rh.r. - :i: - r::: tr:rnsfer from the
required a femoral componenr rer isir¡n. The mean time to bone to the stern collra.:.--. . .. I i ;:- th¡rt obtains fixa-
levision was 2.4 )'ears (0 to 5.91. Survir-orship ar-ral1,sis of tion u,ithin the cl:rphr .:.
the 66 patients (74 hips) at risk demonstrated a survival shielding.
rate of 9 5% (95% Cl 91 to 99) ivith an endpoint of revision This study has several frerrghs. including prospective
for anv reason. Survivorship was 100%, rvith rer.,ision for evaluation in all cohons. pade rts \sere followed at regular

T TO TFrE BONE & JOrNT JOURNAL


\OTALLCEIIENTLESSFE\IOR.\t STI]\tSALI.T]CREATEDEQUALBUITHF, ITISI]LIS,\I\\BE'-'\í,:..'...

intervals with slrrgerv perfonred b,v a single surgeon in The author or one or more of the authors have Tec€ !s3 a',', -::: : ::-:' rs
for personal or professional use from a commerc a p¿ñ', '-:--:: :-::: a-
each cohort, and minimal loss tc'r follorv up ilr each cohort indirectly to the subject of this article
tCohort 1: none; Cohort 2: three patients (three hips); This article was primary edited by G Scott
Cr¡hort 3: turo patients (two hips)). Furthermore, one
This paper is based on a study which was presented at the 32nd annua 1, ! r::'
¿iuthor was involved in the analr,sis and radiographic 201 5 Current Concepts in Joint Replacement meeting held in Orlando, F or c¿
gth to 1 2th December
interpretation of each cohort. The limitatior.rs of this com-
pirrison include the same lin-ritations present in all raclio-
graphic an¿lh.ses includir-rg inter- and intr¿r-observer **É*,r*rz***
variabilit,v of radiographic measurements. In adclition, the 1. Lombardi AV Jr, Berend KR, Mallory TH, Skeels MD, Adams JB. Survivorsh ¡;
of 2000 tapered titar um p0rous plasma-sprayed fem0raL components C/rn O¡¡hc!
mean ¿1ge as rvell as gender distribution varied betu'een Eela¡Fes2009,467 146 T54
series. Finally, one surgeon perfornred the surgeries in trvo 2. Khanuja HS, Vakil JJ, Goddard MS, Mont MA. Cement ess femoral fixat or .
cohorts and another slrrgeon performed the sr-rrgery in the tota hip arthr0plasl\ J B1ne Jaint Surg I,4ml201 T;93-A:500 509

third cohort. Despite these limitations, femoral fixation 3 No authors listed. Australian 0rthopaed c Assoc ation National Jo nt Rep aceme .

Begistry Annual Feport Adeaide. A0A; 2015 https://aoa¡jrrsahmr comll'ore


was extremelv durable at rlinilnurl ten-)err foilo"v-u¡-r (date last accessed 27 Ju y 201 6)

lvith all three cerrentless femoral stem designs. This present 4. Xenos JS, Callaghan JJ, Heekin RD, et al Tre porous-coated anatomlc tota' !
comparison is srn-ri1ar to other str-rdies in the iiterirture, prosthesis nserted \,vithout cer¡ent A prospective study with a minlmum of te:r
years of fo aw tp J Eone Jotnt Surg [Arn]1999,81 4.14 82
r.vhich demonstrate excellent firation u'ith multiple femoral y
5. Hennessy DW, Callaghan JJ, Liu SS Second-generation extens ve porous
stem designs.2'3 Toda¡, durable results of femoral fixatior-r coated THA sterns at minirnum 10year followup Clin anhop Belat Fes
2AA9,461.229A 2?96
should be obt¿rin¿.rble rvith most of the cementless fetroral
6 Carlson SW, Goetz DD, Liu SS, Greiner JJ, Callaghan JJ. [/ nlmum ten year fo
stems available to the surgeon. In conclusion, use of ow-up of ce rent ess total hip arthroplasty using a contemporary trip e tapered i ia
cenrentless femoral components of multiple designs can nium stem J Arthraplasty2016;S0883 540330143-7

provide durable firation at ten or rnore ),eers of fo11ow-up. 7. Engh CA, Massin P, Suthers KE. B0e¡tgenograph c assessment 0f the bro cg c'ir
at on of porous surfaced femoral comp0rents Clin 0rthop Relat Bes l990,257:1 07
l ro

S. Loudon JB, Charnley J. Subs dence of the fem0rai prosthes s n tota h p repiace
mentinreati0rtothedesigr0f thestem J6úreJ0li?tSurg[Br]1980,62 8.450-453
9. Gruen TA, McNeice GM, Amstutz HC. "Modes of fa ure" of cemented stem't\,'pe
femora components: a radiograph c ana .¡s s of loosen ng Clin )rthop Relai Bes
1919,141 11 21
Author contr¡but¡ons:
10. Engh CA, Bobyn JD. The nf uence of stem slze and extent of porous coating on fem
S W Carlson: Wrote the paper, Helped analyse the data
ora bone resorpti0n after prirnary cementless hlp arthroplasty Clin Arthzp Belat Res
S S Liu: lmplementation and data analysis of two of the cohorts, Heiped with
ana ysis of paper
1988;231 7 28

JJ Callaghan: Design, writing and analysis for three of the cohorts, Helped 11. Massin P, Schmidt L, Engh CA. Evaluation of cementless acetabu ar c0mp0neirt
with analysis and writing of paper migration An experimenta sfidy J Arthroplasty l 9S9;4 245 251
We would like to acknowledge D Goetz for carrying out the surgery in one out 12. Kaplan EL, Meier P. Nonparametric estimation from incomp ete observations J¿1m
of the three cohorts S¡ar,Assoc 1 958,81.66

:>¡

VOL.99-B, No. 1. TANUARY 2017


E I{IP TECFII\IOLOGIES
?*
iI
Dislocarion followirg totalhip arrhroplasry
ru
.L
using dual mobili ty acetabulai componenrs
A SYSTEMATIC REVIE§T

I. De Martino, Aims
R. D'Apolito, The aim of th¡s systematic review was to repoÉ
the rate of dislocation following the use of
V. G. Soranoglou, dual mobilitv (DM) acetabular components in primary
and revision total hip arfhroplasty
L. A. Poultsides, (THA).
P. K. Sculco,
T. P. Sculco Materials a¡rd Methods
A systematic review of the literature according
to the preferred Reporting ltems for
Systematic Reviews and Meta_analyses gu
From Hospital for h
of Pubmed/Medline, Cochrane LlOráry aia
Special Swrgery, New
afticles between January 1g74 and March 20
York, United States
"dual mobility'l',dual-mobility,í ,,tripolar,,,
"socket'i The foltowing data were extract
:,
e
demographics, whether the operation was a primary
or revision THA, rength of foilow_up,
the design of the components, diameter of t ¡e femorar
head, and type of fixation of the
acetabular component.
I De l\rladino, MD. Clinicat Results
Fellow, Department of
Orthopaedic Surgery, Complex ln all' 59 articles met our inclusion criteria. These
Joint Beconstruct¡on CEnter, included a total of 17 g0g rHAs which were
Adult Reconstruction and Joint divided into two groups: studies dealing with
Replacement Division
DM components in primary THA and those
V G Soranoglou, MD, dealing with these components in revision THA.
The mean rate of dislocation was 0.9% in
Fesearch Fellow, Depañment of the primary THA group, and 3.0% in the revision
Ofthopaedic Surqerv, Aduit THA group. The mean rate of
BeconstructÍon and Joint intraprosthetic disrocation was 0.7% in primary
Replaceme¡t D¡vis¡on and r.3% in revision THAs.
L A Poultsides, t\.4D. Ctinicat
Fellow, Department of Conclusio¡l
Orthopaedic Su.gery, Adult Based on the current data, the use of DM
Reconstruction ancl Joint acetabular components are effective in minimising
Replacement Div¡sion the risk of instability after both primary and revision
P K Sculco, l\¡D, Assistant THA. This benefit must be balanced
Attending Orthopaedic Suroeon aga¡nst continuing concerns about the additionat
and Orthopaedic Surgeon, modularity, and the new mode of failure of
Depanment of Oñhopaedic intraprosthetic dislocation. Longer term studies
Surge.y, Adult Reco.struction
are needed to assess the function of these
and Joint Replacement Division
newer materials compared with previous generations.
T P Scu co, l\,4D, professor of
Orthopaedic Surgery and Cite this article: Bone Joint J 2O17;(l Supple
Aftend ng Orthopaecjic Suroeon A):1g_24.
Depadment of Ofthopaedi;
Surgery, Aduit Reconstruction
a¡d Joint Replacement Division
Hospita for Special Surge.y, 53S
asry (THA s carrl' considerable economic burden as the
East 70th Street, New york, Ny, mmon and
10021 USA
R D Apolito l\¡D O(hop¿edi.
It reduces s
Besident DecdÍmeni ñf ty of life.2
Geriatr cs, Neurosc ences and uous rmprovement of healthcare and increas_
Orthopaedics, Orthopaedtc
Su rgery Divisio n ing life expect¿1nc)/, the demand for THA r,r,ill
Cathoiic Univers tV oíihe S¿cre.l
Heart, Agostino Gemelii gro\\. to re flect the more acrive, aging popula_
Universlty Hospital, Larqo tion,
Agostino Gemelli 8, Rome, tion. The number of THAs p.rfo.-.á in tl-,.
inclu
00168, ltaly
ULrite d States is projected to increase
bv mobi
L_+ in l0 i0year.3
Correspondence should be sent
to I De l\4artino; email:
comparerl u.irh 20U5. rcachirrg nents
demaftinoi@hss edu 572 000 pe. primary THA from about 5% to about 1o%..t
iO2017 The
lnsta[¡ilin continues to be a tronb]esome Howeveq there rem¿rirr patients r,vho are at a
B.itish Edltorial
Society of Bo¡e & Joint Surgery complic:rtion after THA ancl has been high risk of dislocation, such as those with
doi:10.1302,0301 62OX.99Bl
BJJ 2016-0398 R1 S2 oO reported to be the main indication for revision
neuromuscular diseases, cognitive dysfunc_
in the United Srates, accoulrting for 22.5'A
Bone Jo¡nt J ot tion. an Amerie¡n Socierr ,.,f Anesrheriolo_
2017;99-B(1 Suppte A)j.j8_24 revisions. I Re-rdm i.rlon ¡nd rJulri,-rn ,rrrger:1 gists score6 of more than three, those aged
18
C(-.,R SLIPPLT.\f I \T To I T]T Bo1\.8 & JoINT IOURNAI
I)ISI,OCI\TIONFOLLOV'INCi TOT\LHIPARTHROPL\STYLTSINC;Dt]ALN1OBIL]TYAC,}ÍABLI.\RCT)\i ', :
":''

[._]
lol
l.=l
l6l Records identified through
lol
database searching
l'.=l
l3l ln =720\

tr_]
L.l
cl
Records after duplicates
removed
cl (n = 471).
ol
ol

fl
LI
ol

Records screened Records excluded


(n = 471\ (n = 398)

t=-l
l=l
lsl
l."l
lul Full-text articles assessed

L] for eligibility
(n = 73)
Ful l-text a rticles excl uded
(n = 1a)

tJ
lEl
lrl Studies included
lol

tl
lcl (n = 59)

Fig, 1

Preferred Reporting ltems for Systematic Reviews and Meta-Analyses flow diagram outlining the systematic
revtew process,

> 75 r,ears and those r'vith a l-ristory of previous surger-,v to years! it onl.v became available in the United States in 2009.
the hip, in rvhom the rate of dislocation is stiil high, rang- Recentll', horvever, concerns have been raised about the pos-
ing from 4.8% to 13%, despite improvements in the sur- sibilitv of ¿rccelerated PE -uvear, osteolysis and aseptic loosen-
gical techniques.' In additior-r, the rate of dislocation is higher ing follor'ving the use of these cc,-po,-rerts,21 in addition to ¿r
in revision surger)', ranging from7.4'% to l4.r+7o.8-l(l ne.nvmode of failure, intraprosthetic dislocation.' This sys-
The use of the duaI mobilit.v (DM) acetabular components tematic revier,v summarises the outcomes of the use of DM
has been shorvn to increase stability after THA.' The concept components in primary and revision THA and specifically
of dual articulatic¡n .nvas introduced in France in 1974 by evaluirtes its efficacy in redlrcing the rate of dislocation.
Gilles Bousquet and André Rambertlr'll and cornbined
Charnlev's low friction principlel3 r,vith the Mckee-Farrar l* at* rZ*á* *re* 7.& e€h * ds
concept of using larger diametcr femoral headsrr to enhance \le performed a systematic review of the literature in order
stabilit,l'. The tirst design rvas a cylindrical/spherical unce- to identify articles reporting the rate of dislocation follorv-
mented stainless steel componcnt with a poror-rs plasma ing the use of DM components in THA.
spra,ved alurnina coating ancl an inner polished surface; an Pul¡mediMedline, Cochrane Library and Embase data-
external anchor clip for a 4.5 mm 5s¡s¡r, and two Morse bases r'r,ere searched for articles published r-rp to March
taper pegs provided additional initial fixation.tj The mobile 2016 using the following search terms: 1) dual mobilitl' OR
liner rvas made from Lrltra-high molecul¿rr weight polyethyl- dual-mobility OR tripolar OR double-mobility OR double
ene (UHMWPE), gamt'ra sterilised in air ancl articulated mobility and 2) hip OR cup OR socket. No iimi¡ \\-as ser
with n.retal femoral head rvith a diameter of 22.2 mm. §lhile '"r,ith regard to the year of publication. Inclusiun cnteria
the polvethl,elene (PE) line r and the introduction of ceramic were original articles investigatir-rg DM in ¡rnnan and revi-
fen.roral heads have improved the overall tribology., the sion THA with an adequate fo11ou,-up (minimum sir
underlying concept of the "unconstrained tripolar" r6 THA is months). Erclusion criteria consisted oi case reports or
still the san.re. The purpose of this kind of comp,,nent is ro series with < 20 patients, revierr, articles, experr opinions,
provide increased range of movement (RO\rI)1- ¿ntl head- letters to editors, bion-rechaliical reports, instructional
neck ratio,lE a larger effective head sizete ar-rd a grearer jLrmp course lectures, studies inrolrrng animals or cadavers, or
distance,20 all of r,vhich lead to increased stabilitv. \lhile the in uitro investigations, book chapters, abstracts from scien-
DM articulation has been r-rsed in Europe for more than 25 tific meetings, irnd unpublished reports.
\()l .,.,8. \,, l. J\\f \R\ .',,1-
I' DE MARTINO, R. D'APOLITO, v G. soRANoclou, L. A. PouLTSiDEs. P. K sclraco. T. p. sculco

3;¿;t- i*::ts2¿,;. Figure 1 sho.nvs an outline of the rer iciv pro_ *lt4 **t-.;***nts r¡ iirnia¡\,iHÁ. -\ total of 12 84zt hips
¡¡ss. The initial search yielded 720 citatior-rs. After screening u,ith a me¿-Ln .lqc ¿r r¡e rr-l.lc oi sLrrgery of 68.8 years (sl 9.7)
ior dLrplicate publications, 249 tyere ercluded, leaving 471. r.vere included. The r¡.re¡r :olloii'-lrp rvas 6.8 years (Sn 5.1).
\irer revieu,'ing the absrracts of these, 73 rvere screened for The mean rare oi dislc¡¡.r:ior.l u'¿rs 0.97o (sD 1.9) and the
cLigibility and 59 rvere idcntified for- inclusion./.1-1,r6.21 76 mean rate of intr:rprostherc disloc¿.rtion w.¿s 0.7o% (SD 1.4).
Trvo independenr revielr,,ers (IDr\I and VGS) separately The details ancl demoqr¿phic dara are shown in the supple-
conducred the search b,v title and abstract. If the title arrd rnentary n'rateri¿r1.
abstract <¡f each srudy containcd insufficient information ¿:::*l-,t¿*. Í-rl, -\ total of 5064 hips rvith
*?.,4 **ttzp<srz*rz1*
to deterr¡ine its appropriatencss for inclusion, the fr_rU a mean age at the tir¡re of surser\ oi 69.3 years (SO 4.6)
manuscript r,vas revierved. A cross-reference search of the rvere included. The rnean iollou -up s-as .1.4
¡,ears (so 2.4).
selected articles rvas also performed to obtain other rele- The mean rare of c|sloc¿rtiorr ri¿s.1.09/o (SD 3.0) and the
vant articles. The fLrll texts of the chosen papers were mean rate of intraprostheric dislocatron rvas I.3% (so 2.2 .
obtained to decide rvhether tl-rel. were suitable for thc pur- The details and demographrc data a¡e sho,"vn in the supple-
pose of the str-rd1.. If there w,as disagreement between the mentary material.
tlvo revie-uvers, a tl-rird (RD) rvas consulted and consensus *.**,ÉÉf.y&3****/1=*-c. The rnean ,\II\ORS score r,vas 12.6
r,vas reached. Tl-re 27-item Prcfer.red Reporting Items for points (9 to 21), shor,.ing rh¿rr rhe clualitl.of the str_rdies rvas
Sl,stematic Review,s and Meta-Anah..ses checklist lvas lo.uv. A meta-anal1-srs \\'as nc)r undertaken due to the general
used.tT The origir-ral two reviervers ifDM and VS) ir.rdepen- poor qualit.v of the studies.
dentlv extr.rcted the data inchrding the title, vear of publi-
cation, aLlthors, study design, numbeq age and *i**z;**\*;=.
distribution of patients l¡y gencler, rvl.rether the procedure Our main finding \r-as rhar D-\I-THA is a successful proce-
rvas primarv or levisior-r, length of folJor,v-r_rp, implant dure rvith lor,v rares of dislocation borh in primary and revi-
de sign, diameter of the fer¡oral head, and tvpe of fixation sion THA. Several aspects shor_rld, however, be consic.lered
of the acetabular corlpouent. The primar,v oLltcome \\¡¿ts further.
the rate of dislocation and the secondar_v olltcome was the Dislocation is one of the most common complications of
rate of intraprosthetic dislocation. THA and its incidence increases with the passage of time.sl
Ás=e+sme¡:Í t*l ?:ia* The level of evidence of each article Data about the inciclence :rnd prevalence are biased br. the
,nl,as recorded.is In
order to assess the qualitv of tl-re studies, fact that mosr articles on rhis subject are from high-volume
the MethodoJogicaJ Index for Non-Randomised Str_rdies centres, restricting their generalisation for lolv-volume cen_
(MINORS)-e lvas used. This validated instrumenr was tres and community practices.22 According to the Austral-
developed to detern-rine the qr-ralitv of observ¿.rtional and ian Orthopaedic Association National Joint Replacement
non-randomised studies. Two investigators (IDr\I and RD) Registry (2015), the most common indications for revision
independentlv assessed the quality of each ¿.rrticle. Ther. of a convenrional primary THA are loosening/osteolysis
rvere scored on ir l2 item scale: aim of the stud1,, inclusion (28.0%,), dislocation (21.2"A), fracure (18.2%) and infec-
of cor-rsecutive patienrs, prospecrivc collection of data, tion (17.3%,) .,r,hereas dislocatiorr follou,ing a first revision
appropriateness of the endpoints, ur-rbiased assessment of is the most common reason for a further revision THA
the endpoint, appropriateness of length of follorv-r-rp, per- (31.1%).8r Dislocation after THA is a cause of much
certage of loss to follor,v-up, prospective calculation of the comorbidity.sl Risk facrors for instal¡i1itv are patienr-
s:rmple size, compar:able co¡trol group, contemporary con- related and surgerv-related. Amongst ¡he forrer are female
trol groups, baseline equivalence of groups and the acle- ge nder, advancing age,81,8-t previous l-rip snrgelr.,s6-t8 neLrro-
qLlateness of thc statisrical analysis. The stuclies r,ve¡:e scored nuscular disorders, cognitive disorders. ¿rlcohol abuse and
trom 0 to 2 points for each of these items. Low-qua1itr,. and abductor r.,,eakness.Ej.8l,89 e3 Amor]gst rhe i:1¡ter are sr_rrgi-
high clualitr studies rvere defined as earning < 16 and >16 cal approach,E:,e4 malpositioning of components,ga 96 fail-
poir.rts. respecri\ elv. rrs previous[,v dcscribed.80 The global Lrre to restore 1eg length or offset." ''tl preserving the
ideal score uas 16 for nor-conrparative studies a¡d 24 for abductor mechanism, crpsular r:eprir. - impingement,eg
comparatir e- srudjes. the experience of the surgeorr,tl !:r 1 ,¡r. size of the femoral
-*t***stir.eé a*.*tr-=:+ Categortcirl
trariables are presentecl as ¡.r¿8e'10r and the head-neck r¿rrio.r I The last rwo are
frequency and percer-irages. Continuous variables ¿1re pre- related to choice of implant rarher rir;rrr .ursic¿rl technique.
sented as means u-ith srarrclard deviations (SD). A p-vahre < In randomised controllecl tri:1ls. .rr:.r iemora] heads (>
0.05 u,as considered sr¿rrisrrcallr significant. 36 rnm) h¿rve shorvn a lou-er u.rcjJe :;¡ ,ri dislocation both
in prirlar1.103 and in rer-isior.i - TH \. T¡c ¡e ¡so¡rs for the
fl*e¿¡i€s improled stabilitv in largcr:ci'- ,:1 -. r!:: .lre the increased
The 59 articles that r¡et the inclusion criteria were divided jump distance, increased h¡,r;- -.-- ::,(r. And possibll, the
into tw,o groups: str-rdres dealing r,l.ith DM componenrs in mismatch betr,r,een the .iz. ,--,: -.:-..i ¡¡d the outer
primarl.THA and those dealing with these componenrs in diameter of the acet¿rbul¿ : .: : . . :, - 'However caL-
revision THA. tion is advisecl in nstns -- _: : :... hr¿ds in young or

ccJR sl?plafl\l To rHE BONE & JOINT JOURNAL


DTSI-OCAT]O\ |OLLO\\'INC TOT \T HIP AI{THI{OPLAST\ USINC l)tl\t \tOBtLtTYACETABLL.\R LL)\il'f'\ lr : l1

rctive patients because, although linear rn"'e¿rr u,ith higl-rly additional external slots for scre\\'s. Thrs r.-pr;.;r:is e pr'ol.-
¡rosslinked PE seerns to be independent of the size of the 1em in revisio¡ surgerv rvhen bone loss does n,r lÉ:nrit .l
temoral head, heads r.vith a large diameter have tlore volu- stable initial firation. This can be or.ercome. ior c:..rnrp c.
netric r'vea¡ which may or may not cross the threshold for bl, cementing the cornponent in a cage.lrr') \errer hLghi,
r¡steolysis.t06'107 Hence, this could jeopardise thc long-term porolrs coatings and supplementar,v scre\\' l-roles 1-re1p ro
sLrrvivorship of these reconstrlrctiors.t0E Furth.r[]()re, in provide better firation.
'§fe
-rn acetabular cornponent of a given outer diameter, a liner found ¿1 mean r¿lte of disloc¿rtion of 0.9"/,, (sn 1.9r irt
,ri, for instance, > 36 mm rvill be thinner than a 28 r¡m liner 12 844 primary THAs rvith a mean follolv-r-rp of 6.8 r r¡r'
-rnd, despite the increased'nvear resist¿rnce of highly (sD -t.1). This result is in line rvith the rate of disk¡cation
¡rosslinked PE, this m¿rv lead to increased rvear and poten- reported l¡v several authors and registries.l15 Hor.r.,ever, it
:ial fracture of the liner- DVI components, horveve! al]or'r, should be noted that DM componellts in onr revien' uelc
:he nse of thicker PE.10e DN,l cornponents represent an lrsed nrosth' in patients i,r,itl-r a high risk of dislocatior-r. Tl-re
:Lltern¿ltive to the use of large femoral heads in an attempt mean rate of dislocation in 5064 revision THAs r'r,as .1.09u
:o pre\¡ent dislocation, but cr¡[cems stilI exist. The two (sD 3.0) at a me¿1n follor,r-up of 4.4 ,vears (sn 2.4). This alscr
.najor concerns
',vith DM conponents rel¿1te to potentially compares favourabll u,ith other reports of rates n hich v¿rrv
ncre¿rsecl PE lr,ear. First, in the DM design be,vond the clas- 5% and 307o.e'r16 118 All 1¡ut ten of the stndies
betrnn,een
.ic hard-on-soft articulation there is a second soft-on-hard included in our revicrv were single-¿lrm studies; hence, ncr
;oupling, ."vith the convex snrface of the PE ¿lrticlllating comparisons can be made betr'veen fixed beirring and DI t-
l ith the concave polished nretal surface of the acetabular THAs based on these data.
.omponent and this could lead to increased rvear. Secondll', This revier'r, has sever¿,11 limitations. First, the stndies rrre
-Ll.-rpingement of the neck on the rin.r of the retentive PII level III evidence or less and the design is often retrospec-
¡ould contribute to its clamage and the production of tive. N{oreover their overall quirlitv r.vas 1oir,. This, in tur:n.
lebris. Some author-s have focnsed on these issues in ¿n limits tl¡e level of evidence of our paper. Secondlr', thele is
.rrtempt to clarifv the behaviour of the PE in dual mobility. selection bias as rve extracted specific data from the articles.
\clam, l-arizon and Fess1,110 analvsed 40 retrieved PE Thirdlr'', patients in the studies \vere ertremell heteroge-
rmplants after a mean period of in-rplantation of eight l'ears nous in terms of demographics, diagnosis and indications
-rnd shor.ved total rve¿rr to the same order as reported for for the oper:rtion. Fourthl,li r've used onlt- three databases ir-r
.onventional metal-PE bearings u,ith 22.2 mm femoral our search of the liter¿ture, potentiall,v ercluding some
'¡eads. iVIore recentl),, D'Apuzzo et allll assessed surface papers from analysis.'§le decided to use onll'the most com-
.lamirge and performed lever-out tests on 33 components mc¡n databases and chose not to include other more periph-
:etrieved at short-term after THA (mean time l -5.7 months eral literature, rvhich could har.e reduced the publication
.D 19) and reported dirmage on both bearings, but predorn- bias. Ho"vever, considering the absence of a rigorous peer-
n¿rntl). o11 the inner surface of the liner, suggesting that revieu, process for sr-rch literature and the frequent differ-
rlore firovement occurred at the inner PE bearing. The force ences betu,een conference abstracts ar-rd fin¿r1 published
-equired for the dislocation of the cobalt/chromium femo- artic1es,11e lve decided not to introdLrce this additional bi¿rs.
-¡l head ',,",rs unrelate d to the length of implantation. Netter Fifth11,, r've onl1, includecl papers in English, causing the
:r al 112 simulatecl adverse conclitions and testecl the behav- exclusion of man,v other l¿rnguages and in particr-r1ar, in this
,rrr of the highl.v crosslinked PE of DM during microsepl- context, French. Tl-ris design of component r.virs developed
r-:rtion and third bodr- .,vear and sh<¡rved high tolerance of in Irance and the literature in French initiallv contributed
rhe material in these cr¡nditir¡ns. Another paper from the more than others to this to¡ric. -Nlost authors, holveveq
,¡br¡ratorl' of a manufacturer (Stryker Ortl-ropaedics, reported their results both in French and in English, r:educ-
\ Iahr,r,ah, Ner,v Jerse,v) shor.ved ¿r reduction in u,ear b), r-tp to ing the linguistic bi¿rs of our review.
-j9á r,vith DM components using a highly crosslinked Based on the cnrrent clata, it appears that DM compo-
..Lnnealed PE compar:ed r.vith a conventional gamm:r/inert nents are effective in minimising dislocation in high-risk
PE be:rring.Il3 Thus, less friction and r,r,ear have been patients in primary and revision THA. This benefit rnust Lre
reported in laboratorl studies, but independent clinical l¡alanced u,ith continr-ring concerns about the additional
still lacking.
¡1ara are modularifi,'and the nerv failure mode of intraprosthetic dis-
Another issue to be cor-rsiderecl r'r,ith DM components is location. Due to the poor qualit,v of the studies in the liter-
;ost. Epinette et al 114 reccntl.y reportecl that consiclering the Atllre, \\¡e beLieve that a large, randomised control stucly
rcduced risk of dislocation and its consequent costs, DM- shoulc] be r-rndertakcn to further analvse the leduction in
THA ma,v bar.e substantial cost salings compared lr,'ith pri- the inciderrce of dislocation after THA.
rnarv firecl bearing THA, in France.
Fnrther concerns about the use of D\r[ components are
r-elated to t[¡e inabilit,v to assess its scating, due to thc lack This study demonstrates that dual mobility acetabular compo-
oi holes on the surface of the component u,ith the mono- nents decrease the r sk of post-operative instability both in

rlock desigr.r. Furthermore, many designs do not offer primary and revision hip arthroplasties

t)L 99 B. No 1, T\NLTARY 101;


I DI] I\IARTI\O.R D'APOLITO.\I G, SORANoGLoI]. t- A,PoLiLISIDES.P Ii sC.L'LCo T. P \( I]I(,o

5 r: ppáen: *art ary zztat*ria\


H T.hl.t
showing the det¿rils and clemographic data of
1! ,n. included srudies can be found alongside this
paper online at wrvu,.bjj.bonerrndjoint.org.uk
Author contr¡butions:
I De Martino: Literature search, Data collection, Data abstraction, Data analysis,
23. Asselineau A, Da S- C, Beithoon Z, Molina V. Prevention of dis ocation of tota
Writ¡ng and editing of manuscript
rip arthrop asty. the dual mobtJrty cup lnreract SurgZA0l,Z 16A $4
R DApolito: Data collection, Data analysis, WrÍting manuscript
V G Soranoglou: Literature search, Data coliection, Data abstraction, 24. Bauchu P, Bonnard 0, Cyprés A, et al. The dua mobi ity P0LARCUp: first results
L A Poultsidesr Data analysis, Writing and editing of manuscript from a mu trce rter study ]nhopedics 2008,31
P K Scu co: Data analysis, Writing and editing of manuscript 25. Bensen AS, Jakobsen T, Krarup N. Dua mobi ty cup reduces dislocat o r ancl re
T P Sculco; Editing and approval of manuscript operat on wn used to treat displaced femoral neck fracltres lnt 0rthop
No benefits in any form have been received or will be received from a commer- 2414.381241 245
cial pafty reiated directly or indirectly to the subject of this article 26. Bouchet R, Mercier N, Saragaglia D. Posterior approach and dislocat on rate a

This article was primary edited by J Scott


This paper is based on a study which was presented at the 32nd annual Winter
2015 Current Concepts in Joint Replacement meeting held in Orlando, Florida,
gth to 12th December

É*fere**ss
1 Learmonth lD, Young C, Rorabeck C. The operatior of the ce¡tury. tota hp
replacement lance¿2007;370 I 508 T 519.
29 Combes A, Migaud H, Girard J, Duhamel A, Fessy MH Low rate of dislocatro¡
of dua mobtlity cups in pr mary total hip arthrop asty t/i, )rth0p Belat Bes
2013;471 3891-3900
30 D'Apuzzo MB, Nevelos J, Yeager A, Westrich GH Felat ve head size i¡crease

31 Epinette JA. C inlca outcoT¡es, survivorsh p and aclverse events with mot¡i e-bear

5. De Martino l, Triantafyllopoulos GK, Sculco PK, Sculco Tp. Dua mobi ity cups
in tota hip arthroplasry. Waild J ArthapZAl4;S.tB0 t87.

6. Dripps RD New c assif cat on of physicaJ status riresrhes/o/ 1963;24.1 I 1 32. Epinette JA, Béracassat R, Tracol P, Pagazani G, Vandenbussche E. Are mod

34. Fresard PL, Alvherne C, CartierJL, Cuinet P, Lantueioul Jp. en year resu ts
of a pressJit, hydroxyapattecoated double moblity acetabu comp0nert in
patrents aged 65 years or older. Eur J ]rthop Surg kaumat\l ZA13 425 4?9.

36. Haughom BD, Plummer DR, Moric M, Della Valle CJ. ls There a Be ref t t0 Head
Size Greater Than 36 mm in Tota Hip Artrrop asll? J Anhraplasty2o16,3l :l 52 T b5
11. Bousquet G, Gazielly DF, Deb¡esse JL, et al The ceram c coated cement ess tota
hp afth asty Bas c concepts and surgica technique J )nhop Surg Tech
1985 rr 8

12. Fa¡izon F, de Lavison R, Azoulai JJ, Bousquet G. Besu ts with a cementiess a u-


m na-coated cup tvrth dua mobi ity A twe ve-year foliow up study lnt )rthap
199822219 ??4
39. Massin P, orain V, Philippot R, Farizon F, Fessy MH. F xailon fai ures of dua
mob ty cups. a mrd term study 0f 2601 hip rep acements Ctin Arthop Relat Res
2A12,41A.1932 194A

17 Bunoughs BB, Hallstrom B, Golladay GJ, Hoeffel D, Harris WH. ange of


mot on and stab ¡, - .::: : :":.r.r ast\i w th 28 , 32-, 38 , and 44-m femora
-
head sizes J Arthroptes,'..,': .- " I I
18. Amstutz HC, Lodwig BM, Schurman DJ, Hodgson AG. Range of motton
for tolal hip rep acernents: a corp:':. .
s.:C, .r ih a tew expérimental ap
Clin Arthap Rel Bes'1975,1 1 1.124'3.

20 Crowninshield BD, Maloney WJ, Wentz DH, Humphrey SM, Blanchard 45. Philippot R, Camilleri JP, Boyer B, Adam P, Farizon F. Tre use ot a clual articu-
CR.
Biomechanics of large femora heads what they do arcl ¡:ar -. ta Clin 0tthap Belat
Res2A04,4291A2 1Aj

CCTR sUPPLEIII \T IO THE BONI-- & JOÍNT JOUI1NAL


ffi E-EEP Tffi#Hru*L*Gñfr§
tJ Reconstruction of non-containe d acetabular
*
$
.4r<
defects with impaction grafting, d
reinforcement mesh and a cemented
polyethylene acetabular component
B. S. Waddell, This review summarises the technique of impaction grafting with mesh augmentation for
{. GonzalezDellaValle the treatment of uncontained acetabular defects in revision hip arthroplasty.
The ideal acetabular revision should restore bone stock, use a small socket in the near-
trom Hospital for anatomic position, and provide durable fixation. lmpaction bone grafting, which has been in
\pecial Sur7er)t, Netu use for over 40 years, offers the ability to achieve these goals in uncontained defects. The
York, United States precepts of modern, revision impaction grafting are that the segmental or cavitary defects
must be supported with a mesh; the contained cavity is filled with vigorously impacted
morselised fresh-frozen allograft; and finally, acrylic cement is used to stabilise the graft and
provide rigid, long-lasting fixation of the revised acetabular component.
Favourable results have been published with th¡s technique. While having its limitations,
it is a viable option to address large acetabular defects in revision añhroplasty.
Cite this article: Bone Joint J 2017;11 Supple A):25-30.

4.,,2*z*r,"=i**l *** a*t-i*2*t¿i**5 **tzzzrj*r *1í*rz* parrticle-loaded fluid can generate expansive
The peculiar morphologl' of the iliac bone retro-¿rcetabular osteolytic lesions that shoulcl
shonld be taken into consideration rrhile p1¿rn- be addressed dr-rring revision surgery. This
r-ring revision acetabular sllrgery. The largest n-rode of failr-rre w,as pr:evalent in first genera-
vohrme of bone stock ¿rnd surface area av¿lil¿- tion trodular ¿rcetabnlar components with
h1e for non-cementecl firation is located imme- multiple holes, which h:rd primitive locking
diatell-cephalad to the acetabular cavity. The mechanisms and suboptim¿rl characteristics of
iliac bone narrows proxinralIl, in the coronaI pol,vethl.lene u,ear. Finall-r', bone also deterio-
and sagittal planes ancl consequentlv ¿rcetabu- rates rvith the natural ageing process and stress
Iar bone loss associated rvith ¿rcetaL¡ular corn- shielding that predominantll- occLlrs in non-
ponent faih¡re jeoprrrclises the possibiliq, of cemented acetabular implants.a
achieving dr-rrable, non-cemented, hemispheri- The pelvic bone ¿lvailable for acetal¡ular
cal acetaL¡ular component fix¿rtion. I component firation diminishes 'nvitl-r er.er)- ace-
Bone loss after total hip arthroplast\. (THA) t¿rbr-rlar revision. Revisions to larger diameter
occlrrs as a consequence ofn-rechanical, biolog- hemispl-rerical devices frequentlv result in
ical ¿rncl adaptive processes. Movement n-redial, posterior, anterior and sr-tperior ace-
betrveen the irr-rplirnt and the underl1,-ing bone tabnlar bone loss. The deficier-rt anterior and
resultir.rg from mechanical loosening, produces posterior columns jeopardise the qr-ralitv of the
B S Waddell, MD, Fellow
bone erosion and progressive nrigration of the component's press-fit, u,hile the loss of supe-
A Gonzalez Della Va le, l\4D, ¿rcet¿rbular component. Loosening is initialh, rior iliac support jeopardises its coverage, bone
Onhopaedic Surgeon
Hospital for Special Surgery,
asr.mptorlatic and bone loss frequenth' occurs available for firation, and the possibility of
535 East 70th Street, New York, at a slou, pace. In non-cemented acetabul¿rr using suppiementary scre\\rs.
NY 10021, USA
components, backside rvear and micromotion ln 1994, Paproskl,, Perona a¡d l-¿r.nvrence'
Correspondence should be sent betr,veen the po11.ethylene insert and the inter- proposed a classification system of acetabular
to A Gonzalez Della Valle;
email:gonzaleza a0 hss edu nal surface of the shell develops u.ith time ln bone loss to aid in revision sllrger\-. Acetabular
sl/¿r.2 Under these conditiolrs, particle-loaded defects are classified from 1 to -3. Type 3A and
.2417 fhe British Editorial
Society of Bone & Joint s)rno\¡ial fluid is forced from the backside sur- 3B defects have ertensrr e superior and poste-
Su rge ry
doi:10 1302/0301 620X 9981
face of the sl-rell thror-rg1-r the scre."v-holes, into rior u,all deficienc¡. T1-re lack of posterior and
BJJ 2016 0322 R1 $2 00 the iliac bone during dailv u.eight-beirring superior sLlpporr fr:equentlv precludes the use
Bone Jo¡nt J
activities. Aspenberg and van der Visl higl-r- of a conventional hemispherical acetabular
2017;99-B('l Supple A):25 30 iighted that under these conditions, the com1lonelrt supplernented rvith screr,r,s. The

YOL 99 B, No l. J.\NUARY 201: 25


B S \\Ii\DDELL

lBG for acet¿rbular revision snr-


riccl .1-3 THAs (21 primarv and
ror¡ 1978 to 1 983. The authors
used a cori-ii.,:t.tir,, , -.-.: , ,,so¡s r-rr-rd allogeneic bone. The
techniqne rnciu.ic.r rr.-i.:..,::rg morselised bone into the
defect, augr-nertraiio:t ,... : -. -- :irrhlr r¡erallic mesh or anti_
prOtrusiO cage. :-rn.l :,,.r:t ; \.tLLrn \\ith acr,vliC cement.
After a fo11ot-r-rp of '-l ::,, :ir.. rrll patients had radio-
gr:aphic e'icience of gr.:tr r.;, ,J:\r ,r¡ri, ,n *-ithout eviclence
of
resorptton.
Tlie ideal ¿rcetabnl¿tr rer isior'l r. one \\-hich restores bone
stock, uses a standard-size socker in rhe near_anatomical
position, and provicles dural¡lc iir¿¡ior.r. IBG rvith mesh
augmentation and cemeltted ¿rcer¿rbul¿r cotnponent fixa_
tion can achieve these three eo¿rls.
The precepts of modern rerisior IBG are that the seg_
mentaI or c¡rvitarv deiecrs musr be strp¡orted r,r,ith a mesh]s
The mesh should either support the lack of medi¿rl rvall. or
shi¡uld convert a peripheral u¡cont:Lined defect into a con_
tained one. Once conr¿rined, the cavitv is filled r,vith vigor_
ously-impacted rnorselisecl fresh-frozer allograft. Finalli,:
acr1.[ic cerrrenr should be usec] to stabilise the
ireit ur-rJ prá_
vide rigid socket fixation.
ln contained clefects u.here the peripheral bounclaries of
the native acetabulum are preserved, a cemented or rlon_
cemenred implant r,vith rim fittir.rg car-r be r_rsed after filJing
optlons to reconstruct non_contained acetabnlar clefects the defect rvith impacted graft. Uncontained defects are
include the use of structural graft, reinforcing cirges, bi_lobed
more challenging. Large rim defects frequentJl, affecting rhe
non-cerlented sockets, hemispherical non-cementecl implants
supenor and the posterior boundaries of the acetabulur¡
r,vith tantalum augmentsi crlstom tri-flange devices, ancl (Paproskv 3A and 38) shouid be containcd with
impaction bone grafting (IBG) r,vith ¿r reinforcenrent mesh ancl a mesh
before gratting.
a ccmented implant.6 l2

* r * - * V * r'*tz'..¿ * a *s *.§ * rz2 e #z


T'rt* *É*l*rq *€ i<z=p**ti*ti ***{: ,1r**->z* The presence of infection should be excluded. The surgeon
1970s. Hastings and parkert3 should detern.rine anv clin cal and/or actual leg_length dis-
impacted ¿llrtosenous graft to crepanc)', and muscular deficienc,v that could affect post_
in rheumatoid arthritis patients operirtive gait. As manv of these patients rvill have under_
and ir-r selected parients under- gone muJtipJe operarions, previous incisior.rs can help
going revision. No follo,,v-up \,\ras proviclecl. dere r_
mine the surgical approaches that may have been usecl.
The hitial concerns u,itl-r this technique revolved arouncl Radiological irvestieation should include anreroposrerior
t\'vo issues. Fir:stlr,,, could the bone graft
and Judet vier,vs of the pelvis, rvhich allolv assessn.rent of thc
r'vhen contained by a mesh, and, second
anterio¡ ¡-rosrerior and superior defects (Figs I and 2). progres_
viable after being erposed to the exoth
si.,,e superior ¿lcetabular component mi¡lration and
merisation? Mendes, Roffman and Sil subsequent
destructir¡n of tire iliac bone are frequenr finclings. The defi_
canine autogenolrs bone graft in uirtr: model to study these ciencies in the poster:ior and superior bounclaries of rhe acetab_
asty \ n eight ulum are parricularh.eviclent on rhe obrrlraror vier,v (Fig. 2).

t:i::
of .rn
:ffi:
;; ,;;
Depending on rhe severiry of the bone loss or if the defect
cannot be fullv visualised, CT or \..1R imaging lvith metallic
artifact mininrisation can help stage rhe ecetabular defect
ancl ten months rer-ealecl neu bone formation ancl trabecula
and plan the sur:gerr.. CT scan r,vith 3D ¡econstruction is use_
generated from the natire acerallnlar bone into the graft.
At ful to plan the strategy for implant and h¿rrdrvare removal,
ten months post-operativelr, there \\¡i1s intense lrerv bone and to anticipate the size, shape and location of the rein_
formation r,vith osteohlast and osreocl¿rst activit),. The\. forcemenr mesh lvhich is likelv to be required (Fig.3). If
concluded that the bone graft could retain osteogenic pelvic discontinuitl is detected, meshes are nor strong
potential after the exotl¡ermic reacrion and induce nerv
er-roughto stabilise pelvic cliscontinuities. The1, can be used,
bone forllration.la
bnt only in combin¿rtion rr ith ¿d.lrtiorral plating for stabilitl..

c(_.lR SLrptL_E_\t t_NT TO THI_ BONE &


JOINT TOLTRNAI
II.F (]ONSTRL,C]TTON OF NON-CONT.\INTD ]\CIT.\BUL.\R DEFECTS \\'ITH I-UI) \(- ] I.)\ I,:\

Fi7 2 Fi7 4
Judet views of the 62-year-old woman demonstrating deficiencies in A small reamer can be used to estimate the size of the new socket ln a
the posterior wall and superior socket migration (Paprsoky 38). near anatomical position before mesh fixation,

tral rresh can be used to address central clefects. The


peripheral mesh is then secured to the boundaries of the
defect rvith sma11 fragment r,vith Arbeitsgemeinschaft fr-ir
Osteosvnthesefragen screws, u'hich are placed 1 cm tcr
1.5 cm apart. Good fixatic¡n of the corners of the mesh both
anteriorly and posteriorly is essential. Once the mesh is
firmlv secured, the sr-rrgeon sl-roulcl be able to rock the pelvis
gently with no obvious rrovement of the mesh.
Fresh-frozen bone chips (1arge morsels approximatell
7 mm to 10 mm in cliarneter) are used to fill the defect. Each
lirl,er of bone graft is applied and then impactecl with dedi-
cated instn-urentation. Henr i sphe rical acet¿r bular impacrors
of progressively smaller diameter are Lrsed to compress rhe
multiple graft lavers until the defect is fillecl rvith graft and
li
a nerv acetabr-rlar bed is created in a near-anatomical posi-
Fig 3 tion. Attention should be paid to avoid excessive later¿rlisa-
3D CT reconstruction of the 62-year-old woman tion of the reconstructed acet¿rbulum bl'r.isr-ralisation of the
confirms the progressive destruction of the teardrop during the procedure. Cement pressurisation r,vith
anterosuper¡or, superior and poster¡or peri-
acetabular bone The medial wall of the nat¡ve a plastic seal over the cement direct11. on top of the graft is
acetabulum is marked with an asterisk and the essential during implantation of ¿rn all polvethl-lene compo-
poster¡or wall plate with a black arrow
n ent.

*:*zz *gÉí*rz*
# *z r ta r2¡ n s¿.2; *
gi r; * 2 z The vast majoritv of clinical experience ."vith this technique
A wide exposure should be obtained, frequently through a has been made u,,ith fresh-fr:ozen allograft morsels. Vlost
posterolateral approach. Erposure shoulcl allor,r, complete techniques call for the use of fresh-frozen femorrrl herds.-
visualis¿rtion of the defect inclucling the ¿rntcrior and the After removal of the residual articular cartilage the bone is
posterior wxlls; the superior boundaries of the clefect in the morselised using ¿:r rongeur to generate chips appro-rinatelv
iliac bone; and the teardrop, r,vhich r,vill be usecl as ¿r land- l0 rnm:l in size. These rel¿rtivel,v large-size chips incrcase
trark to guide acetabular component positioning. Remc¡'n,al stabilit,v of the impacted grarft.16'1- Arts et all'' r¡sed an in
of the irlplant and debridement of the granr-rloma should uitro rnodcl to studv the effect of graft size ¿rncl u'ashing on
not result in unnecessar), loss of acetabular bone. Hemi- the n-rechanical stability of IBG recorstrtrctions. The most
spherical reamers can Lre used as intra-operative templates stable reconstructions r,vere those in s hich rvashed morsels
to detennire the approrimate di¿lmeter and position of the of a large diameter (8 mm to 1l mm) u ere nsed.16 The use
new cornponent (Fig. 4). A flexibte stainless steel mesh is of freeze-dried bone, tricalciur¡ phosphate and ceramics in
trimrned to fit the defect, r'r,hich t,vpicalll' ¿rffects the poste- combination r,vith fresl.r-frozen allograft has been
rior wall and the superior :rspect of the acetabulum. A cen- reported. I8

\trJ 'q lr, \,, l. J.\\t \R\ l,,l-


r-

B \ \\\l)l)ltl \ (.r)\Z1lr Z t)t1 i \ \\lTE

Fig 5 Fig 6

Anteroposterior radiograph obtained three years Judet views demonstrate restorat¡on of bone stock
and 6 months post-operat¡vely demonstrate an ace and stable mesh fixation
tabular component in an anatomical position with no
radiolucencies

Animal and human studies reported slrLrstanrral incorpo-


=*=lé"2.=
ration of impacted morselised bone graft. Van der Donk et Earlr- radiographs tr picallv shon, restoration of the ana-
alle reported on 2,1 acetabular bone biopsies from 21 hips tomical centre of rotation, lrdeqlrate filling of the defect
obtained three months to 15 years alter acetabular recot.r- u,ith bone, ar-rd a st¿rble mesh reconstruction.
strllction Lrsing IBG and a cemented acetabular component. Radiographic anall,sis of patients lvith mid- and long-
Histological erantination shou,ed rapid revascularisation term follow-up, focuses on assessing graft incorporerion
of the graft, directlv follorved b1, osteoclastic resorption and and socket fixation. Standard anteroposterior and Judet
\,'o'ven bone formation on the graft remnanrs. The graft radiographs should be part of routine follor,v-r-rp. A
remodelled into a nelr, trabecular structure, with normal fer,v millirnetres of prorimarl n.rigratior.r of the acetabular
lanrellar bone ¿rnd or-rl,v scarce remrrrlrts of gratt material. component can be seen in the first year after srlrger:y
Thev conclucled that impacted trabecular bone chips incor- particularly in patients rvith large acetabular defects. This
porate bv a mechanism that is similar to that previously is probabl.v due to graft cornpaction and is nor
observed in a¡in-rai studies.14'1e Heekin, Engh and Vinhzo inclicative of loosening unless accompanied b¡ progres-
studied post nlortem specimens from three patients ¿1t 1.5, sive radiolucencies.
fr¡nr and 6.-5 vears follor.r.ing IBG ¿rnd ¿r non-cemented ace- Our expcrience of IBG r.vith a reinforcement mesh for
tabular component. Histological analysis revealed earlv the treatment of Paproskv 3A and B defectsll has been
graft penetration bv'n,ascul¿rised tissne, osteoclasric resorp- encouragin¡1. In our most recent revier,v of 21 patients at c
tion of sraft trabeculae ancl application of living bone. mean follorv-up of 40 months (12 to 128), we have
After four r ears ir¡ ,.1/¿r, gr¡fr fregrnents rvere ren-rodelled observed no re-revi:iorrs2 I tFigs 5 ro -r. One pltient rves
and shor,,.ed progressi\-e r.ascular ingror.vth. Bv 6.5 years, diagnosed r'vith radiographic loosening eight vears post-
the graft was almosr completelv incorporated. operativel),. Her radiographic findings have ren-rained sta-
ble in the last two ¡rears and she remained asymptonaric.
Fest-*¡:*rativ* **a.sr** No re-revision sLlrgery- has been recommended. The
Patients are instructed to bear ri-eight 'uvith onlv toe-touch results reported by other investigators including those
force for three months and rhen progressed to bearing r,,,ho perfected the technique have been promising as well.
weight as tolerated. Posterior hip replacen-rent precautions In eight clinical studies summarisecl in Table ¡,1'e.ro.zz-zt'
are ¡Jenerallv discontinued sir u-eeks posr-operarivel,v. the survivorship with aseptic loosening as an endpoint
Patients are seen sir r,veeks, three months, one I'e¿1r post- ranged fron T)'% to 96',/, after a follow-up from one to
operatively,, and elery two years thereafier. 25 1'ears.

CCTR STf PPt I-i\lENT TO THE BO\I & JOINT]OUR\AL-


RECONS I ItL]C]T]ON OF NON CO NT,\ INED .\CETABL]LAR I)I. I-ECTS \YITH I\IP \C Ti( )\ ..r.-j :

Fig 7

Judet views demonstrate restoration of bone stock


and stable mesh fixation

Table l. Published results of impaction grafting with morselised allograft and mesh augmentation for the treatment of uncontained acetabular
defects

Mean follow-up Survival free of Survival free of


Autho¡ n (range) (yrs) Defects aseptic revision (%) re-revision (%)
Schreurs et ale 35 (8 ro 19) Cavitary and combined 77
van Egmond et al7 27 88(3to141) AAOS ll and lV 925 88
Garcia-Cimbrelo et allo 181 75 (0 3 to '177) Paprosky 34 and 38 83.9for 3Al 81 6for 38 72 3for 3Al 75.6for 38
Buttaro et al2a 23 1.5 (2 to 4 6) AAOS 3 90 8 90.8
lwase, lto and Morita22 66 66\281012) AAOS lto lll 94 7 87.9
Busch et al26 42 \20 to 25) Segmental, cavitary, combined 85 al20 yrsl 77 at25 yrs 73 aI20 yrsl 52 at25 yrs
Comba et al25 30 7.2 12.8¡o 19) Cavitary and combined 96 89
van Haaren et al2s 71 1.2 11 6to97) AAOS I to lV /z o5
AAOS, American Academy of Orthopaedic Surgeons

The long-term outcome of these reconstructions is lim- rc\risions performed in patients yoLrnger than 55 years and
ited by two factors. Firstl¡ surviyorship may be worse in folloived for a me an of 86 n'ronths.2i The proponents of rbis
very large defects.z2-24 Van Haaren et al23 reviewed the techniqr-re reported a progressive deterioration of clinical
results of 71 revisions using IBG. At a mean follow-up of and radiological outcomes in 42 patients l-ounger than 50
7.2 years, they observed that 1,4 of 20 acetabular recon- )'ears at the time of IBG revision sllrgerv. The survivorship
structions that required re-revision originally had an AAOS free of revision for any reason was 7370 (95% confidence
Type III or fV defect.27 Secondl¡ acrylic component fixa- intervals (CI) 58 to 87) :rfter 20 r'ears, and 52% (95% CI 35
tion into allograft bone may deteriorate over time and the- to 72) after 25 ,vears' follorv-up.26
oretically should not surpass the survivorship of cemented
acetabular components in primary THA. It is reasonable to ***t **re*íd*rat¡#ng
believe that acrylic cement penetration into dead bone sup- In our institr.rtion the cost of implants and bone graft used
ported by a mesh as observed in these complex reconstruc- in an acetabular IBG rer,'ision (mesh. scrervs, acryiic cement,
tions is unlikely to survive without loosening as well as that polvethylene socket and three fresh-irozen femoral heads)
observed after primary THA, when cement penetrates in is similar to that of a reir-rforcement cage reconstructiolr
the living cancellous structure of the iliac bone. Comba et rvith a br-rlk femoral head. The cost of implants used in revi-
al25 reported a 1O"A re-revision rate in 30 acetabular IBG sions r,r,ith trabecular metal acerabular component and

VOL. 99-B, No. 1, JANUARY 2017


ts S \\ADDTLL, A'JONZ.\I ]:Z DEIL] \ ]], -

¿lugments, and of those lrsing a tri_flange custom_made


6
acetabular component are 50% and 150% more :^l:rl' lilP,
Netson CL, Springer BD, Fehring TK, paprosky WG.
" :'! Ace ne
erpeusrve, =:-erorrardmánagementJ'4m oi
respectively. Moreover, of all revision options avail,rble §);;¿iár,,- -,
fr.,r-
7. van Egmond N, De Kam DC, Gardeniers JWM, Schreurs
these challenging defects, IBC is the only one capable BW. Bevtstons of
of extensive -
acetabLt ai c¿':;r .. ---::.,.., craft ng and a cñent cup. Ctin Aritip
restoring a substantial amorlltt of bone ,,o.k for. :r potential Bcl¿t He'?0 /60 56 : :
future re-revisior. 8. Schreurs BW, Slooff TJ, Gardeniers JW, Buma p.
Acetabular rec
In conclusiol-1, -uve believs that acetabular IBG is an uncler
.\ ' oole r 0¿ t o" oroft c
,d')riñrizódi!ü!l)Bi'
,¡ vears'
:'D.: 20 ;-.""
^ ,.:i-experience
),st'-'.-
used revision technique. It restores bone stock
ancl hip bio-
mechanics unlike the other techniques used to
¿rdclress
uncontained acetaL-¡ular defects, it has a low implant
cost,
and acceptable long-term olrrcomes. The surgeon 10. Garcia-Cimbrelo E, Cruz-pardos A, Garcia_Rey
should be E, 0rtega_Chamarro J. he
alr,are of the limit¿rti«rns that inclucie long_teim pr:ogressive surviva and fate of aretabui¿r_r:!!-l¡j,-,i:- .,. r
defects. C/in Afthlp Belet fresZA10,t6t:3:r ,:j-:
mpactün grafting foil ge
loosening and some bone graft resorptio; in verv
large ace_
tabular defects. If failure occurs, the restoration of
bone
stock achieved r,r.ith this tcchnique is tikely to be
nseful for 12. lbrahim MS,Xala S, Haddad F_S. ab!
future re-revisions. 6r mpaction bone grafting in rotal hip
repacement. Blne JlintJZAl3,gSB 102
13 Hastings DE, Parker SM. protrusio acetabu i in rheumatoid
a:tfnlts Clia Arthap
B e I at Re s 1 9i 5,1 0B.t 6-83.

lmpaction bone grafting with a reinforcement mesh


should be
considered for the treatment of uncontained defects 15. SlooffTJ, Huiskes R, van Horn J, Lemmen-s AJ.
Bone gr ttng in total hip replace-
during rnent for acetabular protrusion. Acta Aüop Scand
revision hip arthroplasty I SB+ dS gálSgO

Author contribut¡ons:
B S Waddeli: Stuciy design, Literature review, Originated the
iirst draft
A onzalez DeIa Valre: study cresign, Literature ,""i"*,
e¿ii"i the manuscript,
Pr ided figures and tables.
This study was partiaily funded by the generous
contributions of Mr and Mrs D
C. Forbes.

No benefits in any form have been receivecl or will


be received from a commer_
cial party related directly or inclirectly to the subject
i¡[
,, Buma
B,Stooff TJ, Gardeniers JW, Schreurs BW. orpora
"rt"f" I:1l.1,.j3::l^t;
l r u '0r o.lo,DOr. t."'-- o- -d. O,24","r.b.rdj000..
This afticle was primary edited by G Scott
"+ p"C,n"r" A.|,,OO
¡ ! uP'v ¡Pú'
ñelat BesZaD2 s96 131:141
This paper is baseci on a study which was presented
at the 32nd annual Winter

21. Gonzalez Della Valle A, Nally F, Opperer M,


Beksac B, Boettner F. The
ment of paprosky 3B acetabular defecis'with impaction
gáñinq]á,ntor.,rrrnt
o'rdrenerl"rl^"01¿ó"1 .
r. A ,-s¿¡ t/tset,og o,T.,"Án)i.a l-Ar¿opn, o,A.n
*,*l*r***** dtc Surqeons 2Aj5.

1. Antoniades J, Pellegrini VD Jr Cross_sectiona aratomy ofthe ilium: imp ications


for acetabu ar c0mponent placement rn tota h p arilr0p
asty cltn 0rthap Belat Bes
2412,41A 3fi1 3541

2. Huk 01, Bansal M, Betts F, et al. polyethy ene


and meta debris Qenerated by n0 t_
artrc!latirg surfaces of modul¿r acet¿bu ar comp0nFfts
'i9s4,76
J
Ba,te Joint Surg IBl
568 574
3. Aspenberg P, van der Vis H Fluid pressure r¡ay cause periprosthetic osteoJysis
Pafic es are notthe on ything,4cta arthop Scand 199869.1
4
4. Wright JM, Pellicci pM, Salvati EA, et al. Bone
densrty acJlacent to press fit ace
labl ai:ornponents A prospective ala ysis urith quantitative ilomputed tomography 25 Busch VJ, Ga looff TJ, Schreurs BW. Acetabu_
J §¡.6,r¡ir;i s¡rs 1/ nlZAU,A3 A 529 536 lar reconstruct und a cemented cup In patients
5. Paprosky WG, Perona pG, Lawrence JM.
youngerthanf, ershtvears' or
Acetabular clefect classification and a previous repo ili|;lt¡;;t*'*'
surgica reci.s.ucton n revision arthroplasty A 6_year
foliorv-up evaluation ,/
Átth'0p ¿.') ro¿ . I -j-

c(_.JR SUPpLF-\I1 \t IO THE p,oNE &.loINTJOURNAI_


ffi ?é4* &*T## *{&*7Y: e€*e*\tuÉ* e?"é* &{'é&*A{4* ?ft***L*
=
J Obesity in total hip arthroplasty
ñ
DOES IT MAKE A DIFFERENCE?

J. Haynes, Air¡rs
D. Nam, The purpose of our study is to summarise the current scientific findings regarding the
R. L. Barrack impact of obesity on total hip arthrqplasty (THA); specifically the influence of obesity on the
timing of THA, incidence of corhplications, and effect on clinical and functional outcomes.
From Barnes Jeruish
$lBateria ls a¡rd lVlethods
Hospitdl, St. Louis, We performed a systematic review that was compliant with the Preferred Repofting ltems
Missouri, United for Systematic Reviews and Meta-Analyses guidelines to identify prospective studies from
States
the PubMed/Medline, Embase, and Cochrane Library databases that evaluated primary THA
in obese (body mass index (BMll > 30 kg/m2) patients.
ffiesuEts
There were 17 articles included in the review, which encompassed 13722 THA patients.
Analysis of the included studies showed that, when compared with non-obese pat¡ents,
obesity was associated with younger age at time of primary THA, and an increased
incidence of complications (up to four-fold). Results were mixed on the influence of obesity
on the outcomes of primary THA, with three studies showing a detrimental effect on
outcomes of a BMI > 30 kg/m2, while eight studies showed no effect.
Ccnelusio¡'¡
Obesity is associated with significantly younger age at time of primary THA and obese
patients are likely to experience a higher rate of peri-operative complications. More
investigation is needed into the effect of obesity on clinical outcomes, as the current
literature is mixed.
Cite this afticle: Bone Joint J2017;ll Supple A):31-6.
C)l¡esitv is ar grou'ing challenge facing the ated rvith higher rates of peri-operative
American healthcare s)'stem, including for complications and neecl for revision surgerv
arthroplasty surgeons. Currentl,r,', more than following primar.v- TJA.U'u Despitc thc
trvo-thirds of Americans are classified as obese increased previrlence of complications, obese
(bod.v mass index (BN'II) > 30kg/mr).r Addi- patients have shorvn improvetnents in clinical
tionallr'', the groups rvith the highest B,\4[ are olltcomes scores follor'r,ing TKA that do not
J Haynes, lvlD, Resident increasing in size at the f¿rstest r¿lte, as evi- differ significrrntly comparcd rvith a non-ol¡ese
Physician
D Nam, MD MSc, Assistant clenced by the greater than -50% annual patient population.ll 1:l The prlrpose of our
Professo r increase in prer.alence of patients u.ith a BMI studr" is to summarise the current scientific
R L Barrack, lvlD,
Distinguished Professor > 40kg/m2.2'r -Nledic¿rl costs associated r'vith findings regarcling the impact of obesitl' on
Washington University obesit.v erceed $27.5 billion, and account for total hip arthroplasn' (THA); specificall), the
Orthopedics, Barnes Jewlsh
Hospital,660 S Euclid Avenue, over 207o of all the United States healthcare influence of obesity on the timing of THA,
Campus Box 8233, St Louis, expenditure. t incidence of complications, and effect on clini-
MO 63110, USA
The ohesit.v epidenric directl-v affects the cal and functional oLrtcomcs.
Correspondence should be sent
to R L Barrackj emai :
undertaking of total joint arthroplast,v (T.JA).
barrackr@wudosis wustl edu Changr-rlani ct ala shorved that morbidly ol¡cse a**erial* *.-* *Z****
42017 fhe British Editorial
prrtients undergo tot¿rl knee arthroplastv *e*¡<:*z ,;zt'é|**c. \I'e perforfi]ed a systematic
Society of Bone & Joinl (TKA) at an avera€le :rge of 1.3 years )rollnger revier.v that rvas compliant i,vith the Preferrecl
Su rge ry
doi:10 1302/0301-620X 9981
than non-obese controls.4 This is relatecl to the Reporting ltems for S¡rstematic Revier'vs and
BJJ-2016-0346 R1 $2 00 earlier onset ¿lnd more rrrpid progression of Ivleta-Anal¡-sis gr-ridelines.l4 We se,lrched the
Bone Joint J
osteoarthritis in obese patients.r Multiple srud- PubMed/Medline, Embase and Cochrrne
2017;99-B(1 Supp eA):3'1 6 ies have also ilh-rstrated that obesit-v is associ- Library databases, from inception to -\l¿r¡h

\'(r[. qo-B. \o. l.] \\l \R\ l,ll


J HAYNES D \{\I RL IJ\1Ri'\

Table l. Characteristics of included articles

Author Yr Patients (n) Follow-up duration {yrs)


Haase et alr6 2016 2391 <1
Motaghedi et alrs 2014 60 <1
Dowsey et al 2010 471 <1
Raphael et al 2013 50 <l
Andrew et al2e 2008 1 059 E

Chee et al 2010 '110 5


'19'1
Michalka et al27 2012 <,1
Lübbeke et al2r 2010 503 5to 10
Patel and Albrizio25 2007 550 1

Kessler and Káfer2a 2007 67 <1


Sadr Azodi et al23 2008 2085 3
Mclaughlin and Lee22 2006 198 '10 to 18
Lübbeke et al26 2007 2495 5
Bowditch and Villar2o 1999 82 <1
Uavrs et al ' 2011 1617 5
Jackson et alrs 2009 1 659 < '11
Dienstknecht et alrT 2013 134 <1

f-l

t.-
Records identified through Records identified from other
lo database search (n = 1059) sources (reference lists, etc ) (n = 0)
t+
IE
lo
l-
t-

f;-l
l. Studies after removal of
l- duplicate afticles (n = 402)
lb
L:]
Articles with title/abstract Excluded studies
screened (n = 402) (n = 359)

l¡1
l=1
l!1ol
;l Artic es where fulltext was Full text afticles excluded
LI assessed for lnc usion criteria
(n = 43)
(n = 26)

LI tl
-l
zl
.l Articles included in descriptive
tl -l review (n ='17)

Fig 1

Preferred Reporting ltems for Systematic Reviews and IVeta-Analyses f lowchart show¡ng identifica-
tion, selection and inclusion of studies for descriptive review

20L6, for prospective cohort studies. Our search used a of THA, and clinical and functional status. Studies r,vere
combination of free keywords and MeSH terms: "hip ercluded if a BMI value for obesitl- was either not desig-
-:'throplasty", "hip replacement", "THA" AND "obesit1,", nated, or differed from B\II > 30 kg/ml. the study design
r:se", "body mass inder", and "BMI". rWe included \\ras non-prospective in nature, or outcomes of interest r,vere
i,'.ldies written in the English language. The reference not reported. Additionall),, studies \\'ere excluded if they
' :.iih included article was reviewed and cross- met the following classification(s): sr stern¿rtic rer-ieu', meta-
- - insLlre inclusion of all eligible stLldies. analvsis, surgical technique articles. erpert opinion, and
: :: ' -studv criteria for inclusion included: pro- proceedings from meetings.
. : -r. isolated to primary THA, obesitl, *zs*lzlv a*ee*s*'r**1 *a4 4'¿Z= *v.z{zeiE*t, Stud,v selection and

. ., .,.-,T.:,1Lrj,l...HT#::1:11jil; extraction of data \\,as performed 1.r tri o of the authors


(JH and RB). Studies \\'ere not blincled cluring the revie.uv

C-C.II{ SLPPLT \LI \T TO THI BC)\E & ]OINT JOLTRNAL


O Bt-51IY IN TO I \L IIIP .\RTHI{OPLI\STY

process. Ontcomes of interest \'vere incidence of post- 9.3, respectively) u,hen compared uirh patien:s ri ith B\lI
operati\¡e complications, incidence of primarl' THA in the < 25 kg/m2 (normal). A second series of '1-1 parrei.rl-r. alscr
obese population, and clinical and functional outcomes for-rnd an increased incidence of post-oper,rtii e cot.npLtca-
scores. Additionall,r,', data from each article including first tions in the obese (odds ratio (OR) 1.81) and mor'oidlr
allthor's surname, and date of publication were rect¡rded. A obese (OR 5.77) partient populations, when compa¡ed u itlr
narrative review of the included studies was performed in non-obese controis.3l In a series of 2-495 hips, evalnatrng
order to address the specific objectives of this relierv. obesiq- and gender, ol¡ese rvomen had an adjusted incidence
rate for infection of 4.4 \95'/" Cl 1.8 to 10.8) when con-r-
ffiesults pared i,vith non-obese patients.26 Additionalll', c¡besil-
St*dy *hara*terlsties" A total of 1059 studies r.vere identi- increased the ir-rfection rate in r'r,omen but appeared to ha"'e
fied through the d¿rtabase searches. Screening for dr-rplicate no effect in men. There u'as also an increased incidence of
articles eliminated 657. A total of 359 str-rdies r.vere dislocation, u,ith obese partients showing an adjusted inci-
exch-rded after revie.,r, of title and abstract. The remainirrg dence rate ratio for dislocation of 2.4 (95% CI 1.4 to
43 articles were read in their entiret,vr and 26 articles were 4.2).)6 h a large series of 1617 patients from the United
eliminated as they did not satisfl, either the inclusion c¡r l(ingdom it was found that increased BN'II correlated lr'ith
exclusion criteria. The rcmaining 17 articles rvere ir-rcludecl an increased incidence of instabilit,r.', and for-rnd that for
in this review.ls 3l 16. included studies contained a total oi e\¡er.y ten point increase in BMI, the risk of dislocation
13 722 THA patients (Fig. 1). The included studies increases 113.9% (p = 0.023).1e Furthermore, the stud\
excluded patients undergoing simnltaneous bilateral THA. highlighted that obese patients l-rave up to a 3.7 increase
The stud,v publication dates ranged l¡etu'een 1999 and20l6 (str-rdent's /-test) in the relative risk for a superficial infec-
(Table I). All studies defined obesit,v as a BIvII > 30 kg/mr. A tion follor'ving THA. 1e
total of five studies made a separate clistinction for obese A total of three of the included studies found that there
patients with a BMI > -3.i kg/mr.rq'21'li'l-'ls A further five \'vas no effect of obesit.v on the complication rate fo11or'ving
studies additionall,v defined patients r'vith a B\rtI > 40 kg/m2 primary THA. Mclaughlin and Lee,22 in study comparison
as "morbidly o1r.r.rr.2o'28 -11 olrtcornes of THA in 100 obese (BMI > 30 kg/m2) and 109
lnfluenee of eb*sity sn tile t;ffiiíig *{ THA. A total of t',vo of non-obese (BIVII < 30 kg/m2) patients, founcl no difference
the eligible studies included data on the influence of obesitv in the incidence of complications including deep vein
on the incidence and timing of THA.26'2e Andrerv et al,le in thrombosis, pulrnonarv embolus, sciatic palsv and disloc¿r-
a study of 1421patients undergoing primary THA shoived tion. This reflects the results of a study prospectivel)' evalu-
a significant ini,erse correiation betr.veen BMI and age at ating the outcomes and cornplications of 198 non-obese.
time of THA.2e Their findings shou,ed that the tnern age oi obese, and morbidl,v obese patients undergoing THA,
the patients at time of surgery in the non-obese (BMl < 30 r,vhich found no significant difference in the rate of compli-
kg/m2), obese (BMI >30 kg/m2 to < 40 kgÁl2) and n-rorbidl,v cations betr'veen groups (p = 0.51, log rank analvsis).2-
obese (BMI > 40 kg/rn2) group was 69.1 .vears,65.5,vears, Andreu, et a1,2e in a study of 1427 piltients, stratified into
and 60.6 years respectivell, (analvsis of variance (ANOVA), three groups by BMI (< 30 kg/mr, 30 kg/mr to 40 kg/m2 and
p < 0.001). Lilbbeke et a1,26 also shor'ved that patients ',vith > ,10 kg/m2) shor'ved no difference in the incidence of dislo-
a BMI < 30kg/m2 rvere nearl.y a mean two ,vears older at the cation (p = 0.221), deep infection (p = 0.115), deep vein
time of THA than patients u.ith a BMI > 30 kg/m2 169.0 tl-rror.nbosis (p = 0.754) and pulmonary embolus (p =
uerstts 67 .2 years of age, respectively). 0.769; all ANOVA).
in*idenee ol *anrpiicati*ns. A total of nine included studies Finally, three studies evaluated factors that may be asso-
directly eran'rined the effect of obesity on the incidence of ciated '"vith an increased risk of peri-operative complica-
complications follor'ving primar,v 111¡.1e'22'23'2-5-2e'31 ¡n tions. Bowditch and Villar2o found that patients r'vith a BN'II
total sir of the studies found that obese patients undergoing > 30 kg/m2 had an increased mean estimated blood loss of
primary THA had a higher incidence of con-rplications than 380 mlr'vhen compared r.vith non-obese patients (p < 0.001)
non-obese patients. Chee et al28 showed that obese patients in a total cohort of 92.10 Obesitr- r,vas aiso shown (Fisher's
had a significantl,v higher rate of complications, including exact test) to be associated with increased post-operative
dislocation and infection, in the peri-operative period ivhen levels of interleukin (IL)-1b, IL-6, and tumour necr<¡sis
compared with patients r'vith a BMI < 30 kg/m2 (22oA uer- factor-alpha, which may indicate a pro-inflammatory state
sus 5oA, respectively; p = 0.012, chi-squared test). Patel and of the innate immune system in a study of 60 patients.l5 In
Albrizioz't also found that patients with a BMI > 35 kg/m2 a study of 50 patients, Raphael et al30 found that morbid
had an increased incidence of local and systemic complica- obesit,v (BMI > 40 kg/m2) .nvas significantly associated r.vith
tions in the post-operative period. These findings are in longer operative time (p = 0.003, Vilcoxon signed rank
accord with a series of 2106 patients, published bv Sadr test) and time to administer spinal anaesthetia (p = 0.018.
Azodi et a1,23 rvhich illustrated an increased hazard ratio Spearman's rank correlation coeffieientt.
(HR) for overu.eight and obese patients (HR 2.5, 957o con- É#ect en Gutcoi-¡:€s. Of the 11 included studies e\lrr', rrrf
fidence interval (CI) 1.1 to 5.5 and HR 3.7, 95% CI 1.5 tcr the influence of obesity on post-operati\-e oLltcomes :r,Ll, -'-' -

VOL 99 B. No I..IANUARY 201;

.
:itr> 'i .,. . -,, :\-iu::- ¡ei rI.Le inciclence of complications,

lor,ving primarv TH.\ in nr¡n-o'¡e s¡ p:ritnrs E-\ll < ll


f,¿
m2) r'vhen compared l irh oL.c-<e p.,i.,.,,. B\1I > jD kq,r.,.,!,
(9I.8 uerstts 85.r1. p < l.rr r1. -\l¡rtr-\\ hrrner L resrt. In rhe

rhe mean scorc\ ior nhr.;. 1 .L:1.r. ,.- :...' ::...-_\ t: :. :.sF\onii Irotr thr. ir¡n¡rc ir-nt¡nlte \\-s¡em, all of which
were significanth uorse in ¡he mori¡:ulr ,,it¡s¡:!r:-r.1:i()rr are
,.rr:.)is : r.l¡ likclr conrribute ro the increased rate of com_
Both gr,,trp5 dtJ cr¡.rierr.c ..t .:Jn j;- t.tt :r).r-:.- :r. tl.r p Lrca.iorL:.
mean scores of all SF--16 dr¡m,riris. e\.efr menr¡l he¡lrh ¿ncl
\\e rlso shoueci thar parients u,ith elevated BMIs are
general health perceprion. shen comparrne
tr_.rc_operarirc \ollnger ¡t rhe rin¡e of prirn:n. TH_\. Morbjdlv obese
to post-operative scores (p < 0.001 r.li In a separere senes of
2495 patients, obese \\¡olnen u-ere shol.n ro har-e the lorvest
post-operative functional scores, after accounting for lorver
\-ollnger than non-obese controls.l6.re These fir-rdings shotv
pre-operarive function, on rhe HHS, Short torm_12 (SF_
a similar trend to a rc.rieu-of registn. data from the Mayo
i2)la and §lesrern Ontario and McMasrers Universities Clinic rvhich shos.ed rhar l¡enveen 199-i and 2005 there
osteoarrhriris index (§íOMAC)35 clinical ourcomes scores
was a significarr decre¿1se in the mean age of patients
bese men and non-obese men and undergoing primarv THA bv 0.7 r..ears (p < 0.002) which
et al,ie found that increasing BMI r,r,as inversely associared u,irh ¿.Ln increase of 1.6 kg/m2
ted rvith rvorse HHS and SF--36 five (p < 0.001) in the BN,II of prirrarv THA patients over
year outcome scores, dcspite controlling for age, gender, rhe
san're stud,v period.a0 This is n .on..rnirrg trend, as
pre-operative outcome scores ¿rnd cor¡orbidities. a
younger age ar time of initial THA is ¿rssociared
A total of eight srudies found that obesitl, did not have a rvith an
increased risk of requiring a revision in ir pirtient popr_rlation
negative effect on clinical outcomes ..or.r.l á,1;.:t,22.1'1,27,2e.i t
that has been shown to have higher rates of per:i_operative
HHS and found no sig_ compiications.3e
and non-obese patierlt controverst¡ still erists r,vhen evaluating the effect
_Some
rs follor,ving primary of obesitl, on the clinical ourcomes of THA. The majoritv of
OHS¡:e was included in studies included in this revieu, examinecl clinical olrrcorles.
three studies, all of which reported no difference l¡etr.veen
the The HHS and OHS were rhe most frequent outcomes
obese and non-obese patient cohorrs, tools
at final follow_ applied. There r,r,ere mixed results ivhen the HHS i,vas used
up.17,u:'uv Lastlr., studies evaluating clürical outcomes with to evaluate outcomes. A total of three studies founcl no sig_
:,.37
Qol EQ--5D,16'r urr¿ sfOX,lAC nificant difference between the mean final posr_operarive
ce¡lr differencc herucen pf,rients HHS scores of obese and non-obese patients, lvhile three
d those rvith a BIyII > 30 kg/mr. A separate stLrclies noted a significant difference in the post_
studl' also found that increased operative scores betr,veen patient populations aite¡ coDtrol_
BMI was ltot associated with increased rates of osteol_vsis ling for the lower pre-operative function of the
around the femoral implant post-operarively at ten y."rr.., obese
patienr cohort. The OHS was reporte<l in three of the
'*i**c¡:;*í*41 incir-rcled articles, and in all three there was no difference
in
post-operative scores betr.veen obese and non_obese
patients. Overall, 11 included studies evaluated the effect
of
obesity on clinical outcomes scores, anci eight of these stud_
ies (72.7%) fourd no neqative effecr of ohesity on final

increased rate of peri-operi.rtt\,e complications in obese


patients undergoing primarr- THA.6.9 B¿rsed on the
increased risk of peri-operative complicatiolrs, the
Ameri_
can Association of Hip .üforkgroup
released a statemenr in that TJA in by the OHS and Ee-5D.a1 This reflects recenr data from
patients with a BMI > 40 ecially in the the Ner,v Zealand Joint Registrn which founcl at sir
setting of comorbid cond monrh
s included in follow-up that patient reported outcomes, as measured
by
(-(]JR SLIP]'LEI{E\T IO I HE I]ONE & IOIN f IOLTR\AL
OBESIT)' IN I oTAL IIIP .\RTHROPI,AS tY

the OHS, u,ere significanti]- worse for obese patients (BMI 7. Friedman RJ, Hess S, Berkowitz SD, Homering M

> 30 kg/m2) rvhen compared i.vith non-obese controls or knee arthroplasty in morbidly obese ;;. .- .. -
2013,47T.3358 3366
(p < 0.001).ar . .:
8. Ke¡khoffs GM, Servien E, Dunn W, et al. The nf rei-¡: :=, --
This revier,v does have limitations. -First, on11'studics rvith cation rate and outcome oftota knee arthroplastY a mei¿ ¿'¿ r, : , , . i'
Iterature revlew J EoneJointSurg[An]2012,94 4.1839 1811
¿ prospective design rvere includecl, u,hich mav have lir.nited
9. Namba RS, Paxton L, Fithian DC, Stone ML. Obesity and per ol; . - - -
the number patients rr,,ith more Lrncomnlon complications. n tOtal hip and total knee arthroplasty paÍ¡efis J Arthr1plas¡y2005;20 i l.::: : -:
Additionallv, erplicit adjustment for confounclir-rg factors 50

was not performed in the majoritl, of the included strldies, 10 Malinzak RA, Biner MA, Berend ME, et al. Morbidly obese, d abet c, ycu r:.' : .
un atera jornt arthroplasty pat ents have elevated tota lo nt arthrop ast! ''.-. -'
as r.vell as r¡ther factors knolvn to influence outcomes fol- ñtes J Arthraplasty 2009;24(6 Supp ):84 88
lo.,ving THA such as anaesthetic type, use r¡f antitriotic 11 lssa K, Pivec B, Kapadia BH, et al Does obesity affect the outcomes cf p'-¿'
proph,vlaxis, deep vein tl-rrombr¡sis prophr.laris, surgeon tota knee arthrop asty? J Knee Surg2A13',26.89-94
volume, operating room time and blood 1oss. This n-right 12. Satoglu lS, Akqay S 0besity d0es n0t imp y poor 0utcomes in asians aft€i i.1¿
knee arthr0plasty Clin Arthop Relat les2013,411.3381
have lead to identification of a false relarionship betr,veen
13. Raigopal V, Bourne BB, Chesworth BM, et al. The impact of morbid obes t¡ c'
obesity and the stud,v questions that this revier'v sought tcr patient outcomes aftertota knee arthr0plasty J ArthroplastyZAAE;23:795 800
Ans\,\rer. Also, in the studies rvith longer term follou,-up (ten 14. Moher D, Liberati A. Tetzlaff J, Altman DG, PBISMA Group PreferreC report ,r
vears or greater) the determination of patient obesit,v r.r,as terns for systematic reviews and meta-ana yses: the PR St\4A statemeft J Ciin;rr
d e m i o I ?0A9,62j006 1012
made pre-operiltivelv, br-rt no data were provicled on an)'
l5.Motaghedi B,BaeJJ,MemtsoudisSG,etal.Assoclationof obestywth r.flanr-
subsequent change in t1-re patient's BNII, and if this had anv maton a¡d pa n after tota h p arthrOp asly Ütn Arthop Belat Res 2414,41214!?
effect on outcome. Finall1,, dcspite a thorough search of tl-re T 448

includcd databases there is a possibilit¡, that ¿rn eppropriatc 16 Haase E, Kopkow C, Beyer F, et al. Pat ent reported outcomes and outco re pre-
dctorsafterprimarytota hparthropasty resutstrorntheDresdenHpSurger,lBeg
stlrdv was ovcrlooked. islr'¡ Hip lnt7A16,2613 81
lnconclusion, this rer.ielv of 17 prospective stlldies 17. DienstknechtT, Lüring C, Tingart M, Grifka J, Sendtner E. A min ma ly inl,as,ve
shou,,s that obesitl, is associated r,vith a lor-rnger age at the approach f0r total hip arthrop asty does not dim ¡ sh ear v post-oper¿tlve 0utLome n
obese pat ents. a prospective, rand0misec tria lnt 0rthlp2A13',31 .101 3-T 0l B
time of prirnarv THA, and that obese paticrts are at an ele-
18. Jackson MP, Sexton SA, Yeung E, et al. The effect 0f obesity on the m cl term s,:r
r.ated risk for peri-operarive compIications u.hcn compared vlva and c l¡ical outcome of cement ess tota hip replacement J Bone Jotnt Surg IE i
u,ith non-obese controls. AdditionaJJl', obese patients do 2009:9T 8 T296-1300

see impro'n,ement in thc olltcomes scores follo\\,ing THA 19. Davis AM, Wood AM, Keenan AC, Brenkel lJ, Ballantyne JA. Does boCy mass
ndex affect c nrcal outcome post operat ve y a¡d at f ve years after prlmary r r at-
but there remains mixed inforrlation ',vhether obesitl. is era tota h p replacement performed for osteoarthr trs? A multivar ate ana irs s of
to worse post-operativc clinical ancl function:.rl prospective da¡a J Bone Jotnt Surg [Br]2A11,93 B:T T7B-1 182

:::1::1 20. Bowditch MG, Villar RN. Do obese pat ents b eed more? A prospect ve study of
b o0d oss attotal hiprep acement Ann B Coll Surg Engl1999,81:198 200

21. Lübbeke A, Garavaglia G, Barea C, et al lnf uence of obesity or femoral osteo -


ysis five and ten years fol ow ng tota hip arthroplasty J Bone Jaint Surg [Am]
Obesity is associated with s¡gn¡f ¡cantly younger age at time of 2010,92 A:1964 1972
primary THA and obese patients are likely to exper¡ence a 22. McLaughlin JR, Lee KR. The outcome 0f tota hip rep acemert in obese and non-
higher rate of peri-operative complications obese pat ents at I 0- t0 18-years J Bone Jatnt Surg [Bt]20A6,88 B'l 286 T 292

23. Sadr Azodi 0, Adami J, Lindstróm D, et al. High body mass index ls assoc ated
Author contributions: with ncreased risk of imp ant d s ocati0n fo lowing pr mary total hip replaceme¡t:
J Haynes: Data collection, Writing and editing of the manuscript
2,106 pat e¡ts fo lowed for up to I years Acb Arthap20AB,19.141 141
D Nam: Data collection, Writing and editing of the manuscript
B L Barrack: Data collection, Writing and editing of the manuscript 24. Kessler S, Káfer W Overwe ght a¡d obesity: two predictors for worse ear y 0ut
come ln tota hip replacement? Abesity (Stlver Spring)2AA1.,15..284A 2845
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectiy to the subject of this article 25. Patel AD, Albrizio M. Re ationsh p of body mass ndex to early comp cations in
knee rep acement srrgery Arch 0rthop Trauma Surg2008;128:5-S
This article was primary edited by G Scott
26 Lübbeke A, Stern R, Garavaglia G, Zurcher L, Hoffmeyer P. Differences in out
This paper is based on a study which was presented at the 32nd annual Winter comes of obese women and men undergo ng primary total hip arthrop asty ,4dhrilis
2015 Current Concepls in Joint Replacement meeting held in Orlando, F orida, Bheun7AAl .51.321 334
gth to 12th December
27 Michalka PK, Khan RJ, Scaddan MC, et al. The inf uence of obes ty on ear y Out
comes in primary h p artrroplasty J Atthraplasty?012;27:391 3gG

fr*€*t*c=*** 28. Chee YH, Teoh KH, Sabnis BM, Ballantyne JA, Brenkel lJ Tota h p rep ace
1. Ogden CL, Carroll MD, Fryar CD, Flegal KM. Preva ence of 0bes ty Among Adu ts ment in morbdy obese patients with osteoarthritis: resuts of a prospectvey
I matched study J Bone Jaint Surg [Bd20T0;92-8:]066 1071
and Youth: llnited States, 2A11 2A14 NCHS Data Bríef2a15,?19.1

2. Smith KB, Smith MS. 0besrty Statistics Pim Care2A16',43.121-135, tx


29. Andrew JG, Palan J, Kurup HV, et al. 0besity r tota hip replacement J Bone
J o i nt S u r g I Br ] 20A8,9A-8. 4?4-4?9
3. Mokdad AH, Ford ES, Bowman BA, et al. Preva ence of obesity, diabetes, and
30 Raphael lJ, Parmar M, Mehrganpour N, Sharkey PF, Parvizi J. 0besity and
obesitv-related hea tr r sk factors, 200T J4M42003,289.16 19
operatrve t me in pr mary total joint arthroplasty J Knee 5ur92A13,2695 99
4. Changulani M, Kalairalah Y, Peel T, Field RE. The re ationsh p between obesity
31. Dowsey MM, Liew D, Stoney JD, Choong PF The impact of obesity on we ght
and the age at which hlp and knee rep acement is undertake¡ J Bane Jaint Surg [Br]
changeardoutcomesatT2months npatientsundergolngtotalhparthropasty /r/:i
2008;90-B.360 363
J Aust?414,193.11 21
5. Stürmer T, Günther KP, Brenner H 0besity, overweight and pattems of osteoar- 32. Harris WH. Raumatic artritis of the h p after d s ocati0n and acetallu ar fra.t:-..
ir,
thrit s: the Ulm 0steoarthrit s Study J Epideniol ?000,53.301 313 treatment by mo d afhroplasty An end result study using a new methoc .'--.
6 Ward DT, Metz LN, Horst PK, Kim HT, Kuo AC. Comp cat ons of Morbid 0besity evaluatlon J Bone Jornt Surg [AmJ1969,51 4.131-]55
lnTota JontArthropasty BskStratifcationBasedonBMl JArthroplasly20l5;30(9 33. Ware JE Jr, Sherbourne CD. The ]V0S 36 ltem short form hea th . - ::
Suppl ):42-46 Conceptua framework and item selection lv4ed Care T992,3li l-i l::

VOL 99 B, No 1, T.\NU-\RY 2.017


ffi fr*IF AffiTF§ffi*FL&STY: &VüEffiÉ¡UG ÁTdM ftd}ANAG¡NG PROBLETfoS§

Spinopelvic mobility and acetabular


component position for total hip arthroplasty

M. Stefl, Aims
W. Lundergan, Posterior tilt of the petvis with sitting provides biological acetabular opening. Our goal was
N. Heckmann, to study the post-operative interaction of skeletal mobility and sagittal acetabular
B. McKnight, component position.
H.Ike, Materials and Methods
R. Murgai, This was a radiographic study of 160 hips (151 patients) who prospectively had lateral
L. D. Dorr spinopelvic hip radiographs for skeletal and implant measurements. Intra-operative
acetabular component position was determined according to the pre-operative spinal
From Keck Medical mobility. Sagittal implant measurements of ante-inclination and sacral acetabular angle
Centre of USC, Los were used as surrogate measurements for the risk of impingement, and intra-operative
Angeles, California, acetabular component angles were compared with these.
United States
Resu!ts
Post-operatively, ante-inclination and sacral acetabular angles were within normal range in
133 hips (83.1%). A total of seven hips (a.a%) had pathological imbalance and were
biologically or surgically fused hips. ln all, 23 of 24 hips had pre-operative dangerous spinal
imbalance corrected.
Conclusions
ln all, 145 of 160 hips (90%) were considered safe from impingement. Patients with highest
risk are those with biological or surgical spinal fusion; patients with dangerous spinal
imbalance can be safe with correct acetabular component position. The clinical relevance of
M Stefl, 4.4D, Resident the study is that it correlates acetabular component position to spinal pelvic mobility which
Physician, Department of provides guidelines for total hip arthroplasty.
Orthopedics
W Lundergan, MD, Resident Cite this article: Bone Joint J2017;99-Bll Supple A):37-45.
Physician, Department of
Orthopedics
There has been recent research abont the influ- that spinal jmbalance occurs by trvo structLlral
N Heckmann, MD, Resident
Physician, Department of ence of spinopelvic rnobilit,v and the acetabular changes, either stiffness or h,vpermobilitl'"r
Orthopedics
component inclir-ration and anteversion for This mobiliq,, and its effect on sergittal acetab-
B McKnight, BS, USC
Medical Student, Depa¡1ment total hip arthroplasty (THA).1 Lazennec et r-rlar corlponent position, can be measured on
of Orthopedics
ala'i have shor'vn that tl-re change from standing lateral spinopelvic-hip radiographs (Fig. 1).
H lke, N,4D, Research Fellow,
Department of Orthopedics to sitting is accompaniecl b.v posterior tilt of the These measurements of sagittal acetabltlar com-
R Murgai, BS, USC N4edical
ponent position are named ante-inclination and
Student, Department of
pelvis u,hich allow's the acetabulum to open for
O rtho ped cs
i clealance of the hip (Fig. I ). The irnportance of sacral acetabular angle.2's Ante-inclination is a
L D Dorr, MD, Professor of
Oft hopedics, Depadment of
this fleribilitl. of the acetabulum has L.¡een coml¡inatio¡ of both the antet,ersion and incli-
Orthopedlcs emphasised by an increased risk for instabilitl n¿rtion of the acetabular component, and is a
Keck Medical Centre of USC,
in patients r,vith spinal fusion ¿rfter there dynamic measurement of the opening of the
1 520 San Pablo Street, Suite
"vhich
2000, Los Ange es, CA 90033, is alm<¡st no spinopelvic mobilitv so the acetab- acetabular component with posterior tilt of the
USA
ulum does not c,pen.1': Since spinal deformin', pelvis.2 The sacral acetabular angle is a meas-
Correspondence should be sent stenosis and h,vpermobilit,v are often present in ure of the link betr'',,een the sagittal acetabular
toL D Dorr; email:
patriciaipaul @yahoo com patients undergoing THA, and previousl,v ar.rgle and the sacral endplate so it is directlr-
reported results of THA ha'n'e not considered related to spinai movement and remair.rs the
O20'17 The Britlsh Editorial
Society of Bone & Joint spinopelvic movement, there is soue qttestiot-t same for the standing and sitting positior-r.s \\te
Su rgery as to rvhether it should be considered in rvere curious rvhether the sagittal acetabuler
doi:10 1302/0301-620X 9981
BJJ-2016 0415 R1 $2 00 patients for whom THA is plalrncJ. cornponent positions following prin-rarv TH\
We have been conducting spinopelvic hip lvould remain r,vithin estab[shed norma]s ii,:
Bone Jo¡nt J
2017;99 B(1 Supp e A)i37-45 studies for the past five yeiirs, ancl have learned ante-inclination and sacrai acetrl¡Lrlar ¿nc ¡ l

VOL 99 B, No. l, JANUARY 201 7


\I STEEI, \\/ LLINDEIIG,\N, \ HECKN,I,\NN, B IIC}i\ICHT. H I(E R \IL I{G.\I. L D I)ORR

Fig la Fig .t
b

rmal values marked ("). The pelvic inci-


pef vic femoral angle (PFA) 189o: ante-
r angle (SAA) 75o. b) Sitting lateral spin-
umbers that are the same stand¡ng and

we targeted the acetabular component inclination alld ante- combined anteversion in its safe ,one.l3,'4 Parients ,uvere
version according to rhe parient's spinopelvic mobility. discharged the s:rme or follorving dai,,, full r,veight-bcaring
Outliers were those who werc not in the normal range for without precautions, but told the,v could ber-rd as necessarv
these two measlrrelnents, and these abnormal results l,lrere to do shoes and socks as long as the,v did so betr.veen their
considered to be a higher risk for impingement.e Our firsr knees (u,.ith the legs abducted). \X/alking was rheir onlv
question was whether targeted acetabular com¡ronent ¡-r65i- phl.siother:.rpv.
tior-rs woulcl pre\¡ent the occurrence of post-oper¿tj\.e ()L1r- Pre-operatively, radiographs obtained were a lo-nv ¿rntero-
liers at risk for impingement. A second quesrior $¡as posterior (AP) pelvis rvith proximal femur rvith the beam
rnhether lve could correctly identify thosc hips at highest centered on the symph,vsis pubis, an iiiac oblique Judet vierv
risk for in'rpingement. ir.rcluding the fen.rur w,as used as the lateral view, and a 1at-
eral spine-pelvis-hip-prorim¿rl femur in the star.rding and
*f|*t*rí*i*a*zd *É**4* sitting position (Fig 1). AIJ radiographs rvere made by the
This was a prospective stucl,v of raciiographic outcomes of same radiographers. Fol the stirnding lateral spir-ropelvic-
primary THA according to spinopeLvic rnobiliry. These proximal femor¿rl filrn. the patierrt's left hip w:rs placed
operations were performed betr,veen December 2014 and adjacent to the cassetre ri ith rheir ¿lrms resting at 90o on a
lVlarch 2016. OLrr [nstitutional Revielv Board approved the support regardJess u-l-rerher rhe nght or left hip was of incer-
study design, and patients sigled rn informecl consent for est. The x-rar Lteant § as centred ¿1r rhe greater trochanter
release of their data. Clinical data for correlation ro radio- perpendicuiar to the L¡arienr's arial 1ine. and the source-film
graphic data was limited ro gender (females = 75/151 distance s.rs 1S-l cn-r. The sarle radiographic criteria r.vas
patients (50%), mean age is 62.9 years (27 to 86), mear-r then used s'i¡h tl.ie p¿rienr sitting or.r e s¡ool with his or her
body n.rass index is 2.7.7 (16.9 to 45.3) and the diagnosis b¿.rck srr¡ishr ¡nci ¡he.rnqie herueelr rhe thighs and trur-rk
u,as (hips): osteoarrhritis: 137, developmer-rtal c1r splasia ot u es approrrr¡:L¿reh 1 (-J0' . r'ior 90n, because better visualisa-
rhe hip: nine. osteonecrosi': ser cn. post-rritut.t.'tri!: I,,Lt-. rior-roi the pr¡f¡¡ srn'iphrsis ¡as possible ¡-ith that angie,
others: ¡hree. A total of 151 pirtients r160 hips \\er- .rnd ir u'as rhe comfortaL¡le sittn.rg position. Post-
enroled in the studr- u.ith no erclusions. and thcr.- \\.1s .onl- operati\ elr, the radiogrephs u-ere repearecl ¡t the first clinic
plete pre-operatl\-e. intra-operatile and posr-of-.crarir e dara lisit rvhich rvas betrveen six seeks ¿rnd rhree months. A
at three to six months. Surgerr u-as periormed rhrough a total of 8,1 patients (84 hips) had rachograpl-rs repeated at
mini posterior approachl 11 f,1 ,.t si¡Lqle surqer)n (LDD) the six month to one vear iollou -up. From the pre-
with the use of computer naliganon ior ¡rcetebul¿rr cornpo- operative AP pelvis u,e obrained thc hip lcngth and offset;
nent centre of rotation, inclln.lrion ¿rnd ¡nrer-ersion from the post-operarive AP pellis u'e ol.rained hip length,
(ORTHOsoft, Zimmer Biomet, -\lon¡real. Canada). offset and acetabular coñiponelir inclin¿rion and antever-
Acetabular component angles were adjusted bv the soft- sion.l't r: Hip length and oifsetru'ere .o1rp¿1red u,ith the
r.vare used for the nar.igation to the radiogri.rphic plane of opposite hip if it was nor diseased.
Murray.11'12 Femoral preparation rr".as perforn'red first so From the pre-operative ancl posr-oper.rtive lateral spin-
the acetabular componenr lnteversion \\.uLlld achieve opelvic radiographs, the skeletal me¿suremenrs of pelvic

CCIR SUPPLE\IE\T Tal THF BO\E \ IOIN I IOURN.\L


SPINOPELYTC \,1OBII IT\ ,\ND .\CEI ABt,L 1R C]O\,IPONENT IOSLTTON FOR TOT.\L HII' ,\]{THROPI,.\,> .I 39

Fig 2a Fig,2b

a) Post-operative stand¡ng lateral spinopelvic-hip radiograph of hypermobile flex construct: pelvic incidence {Pl) 660
(high Pl). Sacraltilt (ST) 55" (high) lntra-operative computer navigation acetabular component positions: inclination
35o, anteversion 21o, combined anteversion 33o results in normal sagittal component positions: ante-inclination (Al)
30o, sacral acetabular angle (SAA) 85o, pelvic femoral angle (PFA) 181'. b) Post-operative sitting lateral spinopelvic-
hipof hypermobile-flexconstructiSf 22o soAST33'(high) Al 63';SAA85';PFA126'(all normal forhypermobile
patients ).

incidence, sacral tilt (ST) (also n¿lmed sacral slope) arld pe1- \fle determined the appropriate acet¿rbular component
vic ferror¿rl alrgle werc obtained using PACS Sl.napse bv position :rccording to the spinopelvic mobility from our
tr'vo observers (HI, RNt) (Fig 1). From the posr-operrrrive earlier stlrd),.2 For nonnal hips, arrd kvphotic hips r.vith nor-
film thc implant measurements of anre-inclin¿rtion and mal nrobilitv-, the inclination -uvas 40u ancl antcversion 20"
sacral acetabular angle were also measllred (Figs 1 and 2). u.ith combined anteversion of 2-io to 45". For hyper:mobile
Pelr,ic incidence is ¿1 static measurement so is the same for normal hips, ancl hl.permobile k.vphotic hips, lesser inclina-
both star-rding and sitting (our norma) = 42" ro 64o), and is tion of 3-i" to,10" and lesser anteversior-l of 15u to 20o is
the me¿rsure of the l'vidth of the pelvis so thar as pelvic inci- necess¿lrv to prevent excessive verticaiity oi the acetabr-rlar
dence increases from 1olv to high vahres the lordosis of the cornponent rvith sittir.rg. Stiff hips needed inclination near
spine increases, and the fenroral head moves further anteri- 45", and anteversion of 20" to 25o i,vith colnbir-red ante\¡er-
orly.s tVe established normals from our data combined s,itl-r sion of 35o to 50", ro open the orientation of acetabulum to
those in the literature.-s'8'18 51 is a drrnamic measure of pe1- compensate for loss of the pelvic movemeut. Centre of rot¿-
vic tilt from the anteriorlv tilted standing posirion (normirl tion r,vas measured intra-operatively frorn the computer
= 40" +l- 10") to posterior tilt with sitting (norma) =29' *¡ and hip length and offser from posr-oper¿rive radio-
- 9'). AST is the difference berween the standing and sitting grapl-rs.1a
ST (normal = 11"to 29o). Pelyic femoral :rng1e is the me¿rs- Data collection tested ir.hether the ¿cetabular: component
ure of fenoral extension standing (norn.ral = 180o +/- 10") positions used resulted in ante-inclination and sacral
¿rndof flexion sittir.rg (nonr-ral = 132' +l- 12").8 From the acetabular angle in the norm¡rl rarnge. Abnormal ante-
post-operative filnrs the it]rplant measurenlents of ante- inclination or sacr¡rl acerablrlar angle did not alr,vays have
inclination (stancling normal 35" +/- 10", sitting 52u +/- 1 1o) the same consequence so severitl, of imbalance was catego-
and sacr¿rl acetabnl¿rr angle (75o +/- 15") were also meas- rised as pathological, dangerons or inconsequential. Patho-
ur:ed (Figs 1 and 2). logicaI in this setting r,vas defined rvhen evel ideal
Spinopeh.'ic mobility is classified as normal, stiff or acet¿lbular component position \r,as obtained it did not
hypermobile according to the movenlent rrreasured bv the o\rercome the spinal imbalance and a high risk remained for
change in AST betn,een sranding and sitting (Fig. 1).2 §le impingemer-rt; dangerolrs imbalance meant that colrect ace-
consider hl,permobility of the spine, not caLlsed b,v kyphosis tabular component position r.,,ould result in ¿rnte-inclina-
of the spine, as a variant of nornral '"vith greater mobility tion and sacral acetabular angle rn rhe normal range, but
(AST > 30"). ln patients with hvpermobilitv, their normals precision of the component position is required; and incon-
are al1 increased b1' 10". There are some patients who have sequential imbalance me¿lnt there is an abnormal measure-
hypermobility because of severe flattening and kyphosis of ment, usually of one value, w-hrch bv itself is not a risk so
the spine rvith sitting and an absolute sitting ST < 10o. ivrs c]inie¡llv irreler:rnr. t
These patients are pathologic arrd this is not normal hvper- -*za|É*'ti*a1 Stata version 13.0 (StataCorp, College
"z=+}V-¿ir.
n-robility. Converselr,', stiff hips rvith spir-ral imbalancc have a Station, Texas) was used for all statistical analyses. Studcnt
difference bet-"veen standing and sitting AST of < 10". ,-test u¡as used for cout¡nuous variables, and Fisher's exact

\()l.or¡.\,, l.l\\t .\R') l0 l-


\lt STFFT,.\\:LL\DERC\\ \ HL(Ñ\1\\N.B. IICKNIGHT.H IÑE.R,\IURC-\I.L.D DOITR

Fig 3a Fis 3b

Fig, 4a Fig 4b

a) Post-operative standing lateral spinopelvic-hip radiograph of construct f¡xed in posterior tilt and stiff: pelvic
incidence (pl) 35" (low pl); sacral tilt (ST) 27o which meáns this structure is stuck sitting. Computer navigation
¡ntra-operative component position: inclination 45o, anteversion 21o and combined anieversion 33" results in
normal sagittal imPlant position: ante-inclination (Al) 38o. sacral acetabular angle (SAA) 65. and pelvic femoral
angle (PFA) 1860 b) Post-operative sitting lateral spinopelvic-hip radiograph oi construct fixed in posterior
tilt:
ST 24o so AST 3'(fusion), Al 41" so AAI 3" (stiff acetabulum) PFA 1ó9o which is more flexion than normal
because all movement must occur at the hip This hip remains at risk for impingement even with correct
ace-
tabular component angles

test for categorical variables, with a p-r'alue < 0.05 used to had no change in their rleasuremerrs. nine impror.ed and
signify statistical significance. Inter-observer r-eliability
r.vas two became worse. Therefore, the srr-g eek rlacliographs
measured by Lin's1e concordarlce and the correlation provide a reliable picture of the
l-¡arier:s oLlrcome.
coefficient can range frorn -1 to 1 r.vith 1 indicating perfect §7e ide¡tified five patterns of :¡.1¡1¡r¡.¡ i rr mobilirv: nor-
agreement' mal iFig. 1), hvpermobile r-¿rrran- I .- -'--r1 Fig. 2), and

ffiesu*s :ii:iffi[::l*:x]l_:]i:,.¡..
The inter-observer reliability for this rtrdiographic olltcome (stuck sitting, Fig. ,l);
'-. _..;,i.]:::.,J;",T;
l-'-::- ,: ; i : i . Hrpermobile
study was 0.993 (95% confidence interval 0.926 to 0.969) hips have pelvic mobilirr "n.¡1
of l -. :-,: -. . i¡errveen stand-
which is considered ercellent asreemerlt. In addition, 73 of ing and sitting; stuck .r:r.- : - :: -r-:-:r
rhat the pelvis
34 patients (84 hips)rvith six months to one year follow-up is fixed in anterror tii¡. .-, : - : . -.: cloes not shift
\L Ñ JOINT IOURNAL
SPINOPEL\¡IC\loBrr,ITyANDACETABULARc-or\IpoNENTposlTroNFoRrorAlHlr_\rirHRrrl,i:.::

*:t

Fig 5a
Fig,5b
a) Post-operative anter¡or-posteJior radiograph showing a dislocation.
lntra-operative computer nav¡gation
component pos¡tion: inclination 38o, anteversion 23', com-bined
anter"rsion iái in¡" pos¡t¡on gave
normal skeletal and sagittal acetabular component positions
on the post-operative "Lipon"n,
iateral spinopelvic radio-
srapl Pl Pre-operative s¡tting spinopelvic hip radiografh of same p"i;;i;Á-"; ¿fpñotic spine pos¡tion. The
sacral tilt 0o.

nation rvas 44.3" (34n to 51o), anteversion 20.4o (9o to 30o).


and combined anter..ersion 34.9,, (24r' to 46,r). post_
operati\¡ely, 13 of 1 8 (72%) r,vere safe lrom impingernenr. A
total of five of sir fnsed hips ,ur.ere consiclered at risk er.en
lr,ith correcr acetabu]ar component positions (Table III).

logical or surgical fusion ¿rnd thus rvere termed fused hips.


Hips that had fusion also had a stiff acetabulum so that the
ante-inclination berween standing and sitting \\.as < 5o.
l'drrrnal. Pre-operatir.el,v 87 hips had normal ST measure_
ment, and post-operatively seven (g%) changed to an inclination for a[] 21 hips r,vas 4.1 .2o (33. to 4g,,), antever_
abnormal measuremenr (Table I). post-operativety 45 hips sion 20.7o (3" to 31"), combined ante\rersion 33o (1go to
converted ro normal so overall 12-5 hips had normal §T 44o). Post-oper¿tiveh,, six of nine hips u,ith kyphosis s 5o
measurements atter THA. For normal hips the mean incli_
had abnormal ante-inclination or sacral acetabr_rlar angles
nation was 40.1o (19'to 48,,), anreversion r.vas 1g.4,,(10o to (Table IV).
25") and corlbined an (1g,, to 43.). A F***r} *ips. Pre -operarivel,,- 1 8 hips r,vere fused, 15 of rvhich
total of four hips ',vere ent and three of rvere due to biologicrrl reasons and the other three were
sur_
these rvere because of and not spinal gicallv fused. Post-operativel). seven of these lvere at high
imbalance because ac < 35o ar.rd/or risk, ar-rd 11 had ante-inclination ¿lnd sacral acetabular
anteversion < I 5o. angle rvithin rhe norrlal range. The 15 hips i.vith biological
i-iyperrnchile norffi*i. Pre-oper:atir,.eJy there rvere 19 hips in fusion are listed in Table III.
this categorl,', and for these hips the mean inclinarion r.vas Post-operative[1', overall, 133 hips (g3.1%) had ante_
39.3' (32" to 50"), anreversion 17.2" (1" fo 21,,), and com- inclination and sacral acetabular angles r,vithin the normal
bined anteversion 33.3,, (14. to 47") (Table ll). post_ range. A total of 27 hips 16.9%) had abnormal measure_
operativel),, no hip was ar risk for impingement.
ments u.ith 12 considered inconsequential spinal imbal_
Fixed ar¡ter¡er tí!t {*f¡.¡ck sta*d!*gi pre-operatir.el1. 15 hips ance; seven pathological imbalance whicl-r were a]l fused
were so categorised, incli_
nation was 42.2" (3 5,,to
27"), and combined
Post-operativel,v and
two thar were at risk were fused hips.
Fixed posterior t¡lt {stu*k e :ttingJ. pre-operatively 1g hips
were so categorised, and mean acetabular component incli_
componellt posltlon.
YOI. qo B. \,, t, I \\¡ .\tt\ ]ut
\i.STE}t.\\iLU.\I)ERG\\,\ HI'CKIIANNi,B NICK\IGHI F{ 1ÑF R \LI R( \I.L D DOI1R

Table l. Normal pat¡ents (hips) who had abnormal parameters (.) post-operatively

Pre-operative values Post-operat¡ve values


Sacral tilt Ante-inclinat¡on Sacral tilt Ante-incl i natio n lmplant posit¡on
Sifiing Comb
Standing Sitting Standing S¡tting A Standing S¡üing A Stand¡ng Sitting PFA lnclination
^
A Anteversion ant
,]
34 t3 21 62 71 15 35 31 4 41 49 I 123 44 24 34
2 29 12 11 52 67 15 22 175 43 44 113/. 22 31
3 35 23 12 Contralateral THA 32 -1 114 42 19 39
I
4 15 23 47 59 12 36 306 40 3 124 43 20
5 36 '18 39 50 923
11 32 60 23 123 1B 18
6' '18 42 56 621
15 14 27 24 50 26 130 41 11 32
7 30 13 11 Contralateral THA 21 -2 29 38 55 17 110 45 14 3'l
Mean 336 156 180 484 618 134 303 17.6 121 36 1 411 11.O 122-6 ¿13 3 19 1

12 'l 3 1't 1 47
ll SE 14 08 19 52 42 24 35 41 3.2 06 12 26
I
A the difference between standing and sitting measurements
* one patient had an abnormally lcw post
l operative bular angle
Contraiatera THAmeasurementscouldnotbedone usetheacetabulumwasobscuredbythemetalshel ofacontraalera
Patients with normal pre-o
hp
became ab
Patients 1 to 4 became bio ents 5 to 7 hips also had a fr acetabu um whlch me¿ns these hips remaineci at risk for
impingement even though used d¡d c within the norm range
PFA, peivic femoral angle; nteversion, SE, standard err

Table ll. Radiological results (.) for hypermobile patients

Pre-operative values Post-operative values


Sacral tilt Ante-inclination Sacral tilt Ante-incl¡nation lmplant position
S¡tting Comb
Patient Standing Sitt¡ng Standing Sitting Standing Sitt¡ng A
A Stand¡ng Sitting A PFA lnclination Anteversion ant
146 32 35 5t t6 42 18 24 Contralatera THA 152 50 '10
30
246 14 32 30 56 26 42 18 24 38 62 24 152 39 4 14
346 1?
"" 52 24 50 13 37 12 56 44 129 43 '13
38
448 13 35 Contralateral THA 42 15 21 30 54 24 144 39 21 36
549 12 37 37 72 35 40 24 16 36 54 '18
131 44 21 31
650 11 39 45 76 31 42 26 16 2A 41 21 't't
3 36 19 31
750 '15 35 38 69 31 55 18 37 26 63 150 36 22
I 51 14 37 29 56 21 41 22 19 25 46 21 119 39 21 43
953 23 30 43 73 30 54 23 31 2A 58 30 128
,T0 54 13 41
41 17 37
Contralateral THA 5'l 30 21 34 53 19 121 31 tb 31
11 54 13 41 39 81 42 55 25 30 34 64 111 42 24 42
12 54 18 36 17 58 41 45 18 21 37 66 29 134 38 '19
31
13 54 21 33 Contralateral THA 52 28 24 21 55 37 18
14 55 22 33 49 75 26 55 26 29 35 64 29 137 41 19 41
15 5b 23 33 28 64 36 54 24 30 29 65 36 126 35 21
16 58 17 41 Contralateral THA 46 14 32 28 49 21 132 35 13
17 58 15 43 41 74 '10 44 26 66 40 143 32 t'l 26
18' 59 19 40 34 64 22 36 35 66 31 '149
41 16 26
'19 63 23 40 39 l4 31 21 36 59 23 147 41 22 47
Mean 528 165 364 355 663 309 489 213 21.6 301 5A2 241 134 9 11.2
,]
SE 1
't 0 09 43 25 11 14 14 17 22 16 18 09 12 11
A change between standing and s¡tt¡nq measurements

abulum was obscured by the metal shell of a contralateral hip


nclination was normal in all hips. S¡tt¡ng PFA is higher ¡n these patients becaus€ t'. ith sitting there is
eptforoneoutlierpatient(numberr),thecomponentinclinationwasnearra:o. orrerunáco-oo-
PFA, pelvic femora angle; comb ant, combined antevers¡on; THA, totar hip arthrop asty; sE, stanclard error

Biomechanic¿11 reconstruction data shorved the centre of was reamed further mediall¡ but not superiorl% to allow
rotation as measured b,v
coml.uter n¿t\.igation u-as cephalad the acetabular component to be covered rvith both correct
r.vithin 4 mm i¡.r 1161160 hips (72.5%); cephalad wirhin anteversion while not increasing the superior displacement
5 mm to 9 mm in ,11 hips ¿lnd > l0 mrn in three hips. Only of the centre of roration. The hip length rvas clinically
in hips rvith dysplasia 'uvas the centre of rotation elevatec.l within 3 mm in every patient. The hip offset was radio-
> I0 mm. The centre of rotation nceded ro be balanced graphically within 6 mmtn 137/1,60 hips 186%). Offset was
with coverage of the metal shell of the non-cemented ace- between 6 mm to 10 mm in 21 hips. and > 10 mm in rwo
tabular componenr. If the anteversion of the acetabular hips. It was purposely increased in some hips to ensure
component needed to be increased, and that u,,ould Llncover avoidance of bony impingement ar the extremes of the
the posterior edge of the rr.retal shell, then tl.re acetabulum range of moyement.
SPINOPEL\']C]\IOBILITYANDACET.\BUL\11 CONIPO\t\TPOSITIO\FORTOTAI HIP-\RTHROPL\iI\ 43

Table lll. Radiological results (') for pat¡ents with biologically fused hips
Ple-operative values Post-operative values

Sacral tilt Ante-¡nclinat¡on Sacral tilt Ante-inclination lmplant pos¡tion


Sitting Comb
Patient Standing Sitting A Standing Sitt¡ng A Standing Sitting A Standing Sitting A PFA lnclination Antevers¡on ant

1 16 1424a50 210 8249 51 2 136 42 21

2' 26 2244453 927 24339 41290 45 21

25 4 Conlra ateral THA 30 21337 38 T 109 46 19 39

4' 29 25 4 Contralateral THA 32 29353 55 2 120 4A 16 26

5 '18 1536469 5 16 12454 61 7 130 48 30 40

622 2204243 134 48 3 117 49 22 42

721 22 5 Contraiatera THA 37 31636 49 13 124 40 18

37 2 Contralateral THA 34 21142 50 8 104 45 21 4/


944 3955258 643 50 12 111 42 20 40

10' 49 4544448 441 39833 44 11 117 43 22

11' 39 3544049 945 31 14 39 49 10 115 47 20 30

12 34 2954455 11 41 24 11 23 31 14 114 45 20
'13 34 2953746 941 24 11 32 46 14 117 43 21 46

14- 2A 2444146 526 I 18 40 62 22 1'15 51 21 36

15 24 2043441 121 4 2544 65 21 131 49 13 31

Mean 31 0 21.4 36456 7


5',1 61 33'l 227 82 400 486 86 1',158 453 211 369
SE 24 23 0465 24 10 2A 31 18 21 21 11 30 08 11 16

A difference between standing and sitting measurements


+ patients who received dual mob¡lity component
Contralatera THA = bony acetabulum was obscured by the meta shell
Pre-anclpostoperativeradiographicmeasurementsandimplantpositionsforhipswlthbioogicalorsurglca fusion Al pre-operativeASfare<5o
post-operatively ten of 15 patients remained stiff (AST< 10o), but only two patients had sitting ante-inc ination values that were below the normal range (< 41o) A tota of
seven hips had a stiff acetabulum and the sitting PFA in two patients (7 and 4) were below norma which means these patients had high risk for impingement and disloca-
tionevenwiththecorrectcomponentposltionsusedsothatdualmobiityadicualionsweTelmpanted Theimplantpositionshavemeaninclinationof45oandcombined
anteversion of 37o which is necessary in stiff patients
PFA, pelvic femoral angle; Comb ant, combined anleversion; THA, tolal hip arthrop asty; SE, standard error

Three hips dislocated, and all three u,ere positional dis- ponent inclination and anter.'ersion. lf r,r.'e could r.rot, could
locations u.ithin rhe first tr'vo months post-operatively,2o we identif-v those hips that ret'rained at high risk for
although one also had contriL¡ution from ir kvphotic spin- impingement. V/e for:nd that with the targeted acetabular
opelvic imbalance seen on the sitting lateral radiograph component positions rve used '"ve coulcl keep atrte-
(Fig. 5). Positional dislocations were caused bv the patient inclination ancl s¿cral acctabular angle ir-r their normal
plrtting the hip into an extrerte position before capsular rar.rge in f45l160 hips (90%). ln al[, six of the 1-5 hips had
healing u.ith this position probably permitting impinge- risk for impingement because rve did not achie\¡e the
ment to occur. One patient r'vith hvpermobile k1'photic desired acetabular component position and nine hips rn ere
imbalance flered their hip so that their knee approrimated at risk because of spinal imbalance. A total of seven hips
to their chest dr-rring sexu¿ll intercor-rrse at r'vhich point the that had pathological imbalance also had biological or:
hip dislocated (Fig. 5); a second patient had norrnal spin- surgical fusion, and it is these hips which lvere at highest
opelvic measlrrements and was sitting in ¿1 chair n'ith her risk for impingement. These hips were at risk because
oper¿rted leg placed cross-legged uncler her opposite leg, restricted pelvic movement does not allorv the acetabulun.r
and leaned foru.ard to pick up her dog from the floor; the to open during flexion of the hip r.vith sitting. So the ace-
third patient also had normal post-operative measuremellts tabular comporert must be mecharricall,v opened i'vith
and fell in the shorver with her legs doing the 'splits'. All high inclination and anteversion angles. If inclination
three u,ere initiall,v tre¿rted with closed reduction, but the erceecls 4-!", there is a trade-off of potential[y increasing
third patient had a second dislocation, ancl at sr-rrgerv her u,e,1r22 so the surgeon rnust balance the risks of disloca-
'§íith
posterior capsule rvas repaired and a Dual Mobilit,v articr-r- tion lvith the age and activitt level of the patient.
lation w¿rs implanted. higher angles of inclination and lnteversion, the ante-
inclination and sacral acetabular angles were in the nor-
*í**zs*sá** mirl range for patients ri-ith stiff hips (stuck standing or
This study \\.as condLlcted to understand the cons.,-luencc of stuck sitting). Hor'r,ever. e\-en \\ith these high acetabular
spinal disease, primarilv degenerative disc disease and arthritic componeni angles, seven fr-rsed hips remained at risk for
change of the spine ',vith ageing,z1 on the optimal acetabular impinger-r-rent rrt the extremes of movement because the
cornponent position r'vith primary THA. The first qr.restir»r wc acetabular opening [¡etr'veen standir.rg and sitting is stitf.
asked i.vas if we could control the angular cl-range of the The high component angles protected the patients in this
acetabular component, u,hich occurs betrveen standing stuclv from dislocation, but r,".e have observed this colrel¡-
(ante-inclination), by the intr¡-trper,rrive acetabul¡rr com- tion in patients rvith late disloc¿tion.

\/OL 99 B. No l.JANti.\RY20t-
]I STEFL, \iI LUNDERC;,\N, 1.\. HECI(\,IANN, B ÑÍCKNIGH T. H ]KE. R \IL-RCi.\I L D DORR

-:: : V r¿diological results (") for kyphotic patients


Pre-operat¡ve values Post-operative values
Sacral t¡lt Ante-incl¡nation Sacral tilt Ante-incl i n atio n lmplant position
S¡tting
Patient Standing Sitting A Standing Sittin g Standing Sitt¡ng A Comb
Stand¡ng Sitting PFA Inclination Anteversion ant
^
1 34 -9 43 33 42 34 35 21 60 33 157 43 23
2 45 -1 52 33 15 42 45 4 41 26 62 36 149 35 22 42
33 3 36 43 77 34 32 0 32 49 74 25 131 22 34
4 52 -2 54 Poor quality radiograph 45 12 51 34 114 40 29 44
5 29 0 29 42 70 20 13 36 45 9 109 38 23
631 2 29 Contralateral THA 36 23 54 11 126 40 '18
/30 4 26 30 31 30 25
1 51 131 42 20
842 4 38 41 71 30 46 5 41 17 6'l 44 160 43 16 34
941 4 31 31 70 13 25 36 64 154 4B 20
10 36 5 44 0 32 41 72 31 139 23
11 45 5 40 45 17 32 43 9 34 39 17 38 141 46 20 30
12 34 5 29 41 57 '16 34 10 24 39 64 25 118 37 21 36
t3' 36 5 31 31 65 34 30 '13
17 30 41 11 123 48 3 21
14 45 6 36 73 37 47 1B 29 35 63 142 18 33
15 26 7 19 36 66 30 35 11 24 21 56 29 128 18
16 41 7 34 33 61 34 44 33 42 '139
11 73 31 42 31 36
17 31 1 30 47 11 24 34 12 22 42 63 21 137 40 23 18
18 40 7 33 31 60 23 42 14 28 24 51 21 25 30
19 31 1 24 47 65 '18 35 14 21 36 53 17 tib 39 20 30
20 34 7 2l 38 73 35 41 18 71 3B 119 41 19 3'l
21 42 I 37 63 26 42 16 26 35 '138
51 22 44 21 36
Mean 37.3 3.i 340 388 695 307 380 95 286333 61 0 21.7 137.0 412 201 330
SE 14 't 'l
19 29 14 16 12 18 22 17 19 19 35 09 12 14
A difference between standing ancl ing measurements
* patients who received dual mobil
comoonent
f normal tabular anole
acetabuluri was obscrrred so measurement not available pre and post-operative radiographic
3 "m:' measurements and implant
D is sittin

ty; SE, standard error

To correctlv position the acetabular component ar slrr_ erceedec'l. Kyphotic hips with normal mobility should
ger\¡, one tnust recognise the five patterns of spinal move_ have the same inclination and anteversion as normal hips;
mer1t. Two are normal wirh one of these being hypermobile, kyphotic hips r,vhich have the pelvis fixed in posterior tilt
and these have almost no rsk for in.rpingcment if the bio- (stuck sitting) need high inclination and anter.ersion ¡o
create a mech¿rnically openecl acetabular component for
sitting, t¡ut this creates the risk of a vertical ante_
inclination so we considered these hips to l.r:.n patholog_
ic¿rl imbalance and r.vould consider the use of ua1 mohil_
it1' articulation.
\rerted to norm¿ll spinopelvic movemenr after release of hip The critical limitation of this studl- is rh¿rr. as ¿r radio_
contractures xportant to recog_ graphic study of the relationship of inrr.r-oper.l¡ive ace_
nise that the rtions targetecl for tabular component position to spinopeiuc rnobilitv, we
hypermobile (Tab1e II), and for have only surrogate measurements i(,r rr-¡rF\rlgement, and
stiff hips are higher than normal (Table III). no clinical episodes which we can me.1sL.ii. h rhis study we
Hips rvith a kr.photic spine presenr the unique problem do not have evidence of a correlation l¡-:,... ¡.1 rhese outliers
that when seared rhe pelvis is tilted as far posteriorlv as and late dislocation, but u'e h¡r¡,,:..,¡¡
possible so wirh an,v increased flexion, such as knee to
¡his in an
ongoing study of acute and 1¿rte clisl,
;--.: , . T:¡e r alidation
chest movement or deep squats, all the movement occLrrs of our data for primary THA s'i i. : .. _- . r hen the rela-
at the hip which means either bonv or componenr
impingcment can occur. and po.terior dislocation can be
the result. Hypermobile kyphotic hips are the ones that inclination and sacral ace¡:!-...
have 'drop out' dislocation if the acetabular cornponenr
,:.. - : .r : .roirecl. A sec_
ir-rclination and anteversion are high because with sitting
the sagittal acerabular component position is vertical (> of
ourstud,v st¿rti¡ :-.: _---t : -_ : :til:rted this
75o), and the jump distance of the femoral head can be r nvestigation .
SPINOPEL\TIC MOBILITY AND ACETABULAR COMPONENT POSITION FOR
TOTAL HIP.{RTHROPLL{T\ ,15

There is a recent study of ceramic-on-ceramic articula- Th¡s article was primary edited by G Scotl
tions that squeak, that showed the anteversion of the ace_ This paper is based on a study which was presentec ¿:-.-: :_-. a- - ,: - .-
tabular component 2015 Current Concepts ¡n Joint Replacement meetlng re : - I - :: : :, ::
gth to 12th December, =
revealed the cause of
using a different flexi
finding that the sagittal component position is more **l*r*x***
informative of functional component position than that on
the supine AP pelvis film. §7here instability has occurred
after THA, it would be beneficial to examine sagittal
spinopelvic-hip radiographs to derermine if the criteria for
impingement is present. There are studies using dual mobil-
ity articulation-in all patients to manage the problem of spi_
nal imbalance.24 Our data show that with high acetabulai
component angles even the hips with fused spines can have
an open acetabular component, and we had no complica_
tions in the patients operated with conventional articula_
rions. However, the patients with pathological imbalance,
fused and flat kyphotic, are those in whom we may choose
to use more constraint.
In summar¡ we found that correct intra-operative ace_
tabular component inclination and anteversion by the sur-
geon will compensate for most spinal imbalance. pre_
operatively there were 24 híps with dangerous imbalance
6.2"A of our pop-
cetabular compo- 9. Mali k A, Maheshwari A, Dorr LD. pingeme rt with tota I hi p replacement J Bone
Joint Surg [Am]2A07,89-A 1832-184
of 24 hips with
pathologic imbal-
ance, had normal post-operatiye ante-inclination and sacral
acetabular angles. In seven hips with pathological imbal-
ance the acetabular mobility remained sriff (A anre_
l2.MurrayDW.Thedefintionandmeasurementofacetabuarorieftat 0r JBaneJoint
inclination < 5o) so that the risk for impingement remained S u r g I B r] 1 993;7 5-8.228 Z3Z

high. These are rhe hips that may be candidates for 13. Dorr [D, Malik A, Dastane M, Wan Z. Combine versior temnique
f0r tota
increased constraint such as dual mobility articulation. h p arthrop asty Clin 0rthop Belat BesZAA},46l.11

14. Ranawat CS, Maynard MJ. [Vodern techniques 0f cenrented t0ta h p arthroplasty
Tech )rthop 1991 ,6 17 23

ance, as well as pat¡ents with component malposition, are at r¡sk for


rmptngement.

Author contributions: 18. LegayeJ,Duval-BeaupereG,HecquetJ,MartyC.pevc


M Stefl: lnstitutional review board communication, Data collect¡on, Data
ncdence:afu en_
anal_ tal pe vlc pararneter for three dimen§ional regu afion 0f sp nal sagittai Eurcu
ysis, Manuscript composition. SpineJ19987 99
W Lundergan: Data collect n, Data analysis, Manuscript composition
N. Heckmann: Data analysi Manuscript composition
B. McKnight: Data collection, Data analysis (specifically patient ciemographics
and chaft data). 20. Dorr LD, Wan Z. Causes of and tre¿ roroco for nstabi ty of total hrp rep ace
H. lke: Data collection (specifically odds ratios data), Data analysis. rer t f'-
0 t ap R"t¿¡ pp, too3.,35
B. Murgai; Data collection (specifically patient demographics and
chart data).
L. D. Dorr: Principai investigator, Data analysis, Cmposition of manuscript,
Coordination of project.
L. Dorr receives royalties from Don-Joy Orthopaedics and Joint Develop
m t lnc.
The authors wish to thank N. Trasolini, medical student at the University
of 23. Pierrepont JW, Feyen H, Miles Bp, et al. Functit]fa or entatton
Southern California, Los Angeles for his help with this study as well as p paul of the ac at
for her preparation of the maquscript. comp0nent in ceramlc-o¡ cÉtantc t0ta i_. p arthrop asty and its re evance
ing. Bone Joint J?Ci69B 98
to k

The author or one or more of the authors have received or will receive
enefits
for personal or professional r¡se from a commercial party related cli ctly or
ind¡rectly to the subject of this article.

\/OL 99-B, No 1. JANL,.\RY 201;


ffi &#.V?é* *,*&*TT: &V
WE*
&?é* **¿A Z*é Pffi#BLEIUT§ e*Z?é*
Post-operative neurop athy after total hip
',lJ
arthroplasty

E. P. Su
following total hip arthroplasty, but ís highly
Frorn Hospital for cause difficulty with the post_operative
Special Surgery, lleT¿ ent. Nerve palsy may result from compression
York, I'letu Yrtrk,
United States post-operative hematoma. ln the literature,
h
an uncemented femoral component,
and fem
nerve palsy. We examined our experience
at a
found an overail íncidence of 0.3% out of
39 0l
found to be associated with the incidence
of nerve palsy at our institution included
presence of the
ase, age younger than 50, and smoking.
nerve palsy lf a
y and surgical evacuation ot. .ornpr"rair"
haematoma slow to recover, supportive care such as
bracing, the
stays of treatment.
Cite this article: Bone Joint J 2017;(l Supple
A):46_9.

pated. As a result patients and their


families

over 909á of cases, Éollou,ecl b1. the femoral


l.l As both of
,e.r.e. these peripheral ner\¡es are
nixed nerr-es u,ith l¡oth sensor\¡ and motor com_

can occur as a result of intra_operative


manip_
ulation of the limb or as a resuli of lengthenirig
of the limb.
E P Su, N4D, Assoc¡ate
Professor of Clinical The peroneal division of the sciatic nerve
is
Orthopaedics, Weill Corneil thought to be particularl¡.- at ¡isk for .r.r.o_
lVedical College and Assocjate cia¡ion of Hip and Knee Surgeons founcl
Attending Onhopaedic that
nerve irjurv rvas the nLrmber one r:e¿lson
Surgeon, Adult Reconstruction for li¡i_
and Joint Replacement Division g,ation after hip arthroplastv snrgerl,.i
Hosp¡tal for Special Surgery,
Surgeons
535 East 70th Street, New york,
should be au.are r¡f the inciclen.. oir.ro.."pnlru
NY 10021, USA follolr..ing THA so that they m¿rr.be t
.*.l: oü1.,á
Correspondence shoulcl be sent
to E P Su; email: sue@hss edu

42017 The British Editorial


Society of Bone & Joint
anaromicall¡ placing it closer ro rhe sureical
S u rgerv field of the posterior approach.a
doi:10 1302/0301-620X 9981
The first indication tbar a neu¡opraxia
BJJ-2016-0430 R.1 S2 0o
* *{* * p *y *É *Z * has
*V a'*? rj * * = * {13 rz r¿
-{
occurred is wirh post-operarire motor
Bone Joínt J A]tIo¡gh ncri c pal,y is a knorvn =.2.:i
conrpl¡¡,1¡¡o,,
weak_
ness in rhe dorsitlerion of rhe foot.
2017;99 B(1 Suppte A):46 9
of THA, it occurs infreqr_rentiy ancl is unantici_ If epidural
anesthesia has been use,J. it is o.c.srrr/to
dis_
16
ccJR SUppLL\rL\-Í TO THE EIJ\T ñ
JOL\I JOURNAL
POST-OP I-11 \TI\'F N I-t IROPA I H Y .\FTE I{ TOT'\L HIP ARTHROPL \5T¡ 47

Table l. lncidence of nerve palsy after total hip arthroplasty (fHA) in the literature
% incidence of % incidence of palsY
Yr THAs (n) palsy overall Primary THA (n) in primary THA
Schmalzried et al2 1991 2355 18 1 661 1.3

Johanson et alro 1983 5667 06


Park et allr 2013 9570 032
Farrell et alr 2005 27 004 017 21 004 017
Navarro et alr2 1995 1000 0.8 630 05
Wilson and Scalesr3 1973 108 3/ 108 3.7

continue the administr-ation of anesthetic so that the lou'er placed on the posterior soft tissues may be a cattse of sciatic
limb rr-rotor function can be properly assessed. If the sciatic nerve pals,v.
nerve has been involved, the t-vpical presentation is a foot Some slrrgeons also believe that the gluteus mrximus
drop, with $'eakness of the tibiaiis anterior! ertensor l¡al1u- femoral insertion (gluteal sling) can compress the sciatic
cis longus, and extensor digitorLrm longus. Eversion r'vith nerve Lrpon 90' of internal rotation of the leg, a position
the peroneal muscles is also commorrly affected. Often, the i,vhich is necessary dnring femoral Preparation. Hurd et als
tibial division of the sciatic nerve is unaffected; thlts, the found that magnetic resonance imaging revealed oedema
tibialis posterior, gastrocnemills and solelts muscles con- r,vithir.r the sciatic ner\¡e at the level of the gluteal sling, in a
tinue to function. There are r-rsua11,v sensory deficits in the series of patients u,ho had post-operirtive ner\re palsl'. Fur-
skin areas slrpplieci by the peroneal division (dorsum of the thermore, there u'as a significant difference in the incidence
foot and first -uvel¡ space). Because of the r,veakness or ina- of sciatic nerve palsy in patients r'vht¡ had the gluteal sling
bilitv to dorsiflex the foot, patients mav be unable to clear released ¿,ers¿rs those r'vho did not.
their toes from hitting the ground, causing them to trip. An Anatomical variants in tvhich the sciatic nerve Penetrates
ankle-foot-orthosis (AFO) that maintains the ankle ilr a the piriformis muscle erist in up to 20% of cadaveric spec-
neutral or dorsiflered positi,,n is necessarl to prevent con- jmens." This is also a possible location of tension to the sci-
tractures of the Achilles tendon ar-rd to aid walking. atic nerve! as in a posterior irpproach, the tendon is released
If the femoral nerve is involved, patients ma1'have rveak- and may pull on the nen,e as it retracts. It is also allother
ness in the quadriceps and iliopsoas, r'vith scnsor)'loss over point at which the nerve may [¡e tethered.
the anterior thigh. Patients ma)' also have difficLrJt.v u'ith Finallr', bleeding irt the surgical site can collect in ¿rn

walking and activities that require quadriceps function, enclosed space after surger\', causing compression of nearbl'
particular[,v stair cl i mbing. ner\ es. lea.ling to neuroprlri.t.

tu*íí*á*py l*cí*1*rt*e aná rí*k f a*t*:*


In the conrse of a THA, the lor'ver limb is maniplrlated and The incide¡ce of ner"ve pnlsy after primar,v THA ranges
tissues are stretched for exposltre, placing tension up,,u from 0.17oA to 4.0% (Table I).r'r'r0li In a large regrstrr-
nerves. Specifically, the act of dislocating the hip ma.v database, Farrell et alt examined risk factors for motor
cause tension or compression of nen,es. The position of nerve palsy after primarl' THA, and fonr-rd that pre-
the hip and knee during surgery har.e been shown to aficcr operative diagnoses of der.'elopmental dvsplasia of the hip
the amount of strain ar-rd intraneural pressures in the sci- or post-traum¿tjc arthritis hacl higher rates. The theory
atic nerve: flexion of the hip and extension of the knee h¿rs behind this association is that the altered an¿1toml' of d-vs-
been found to increase tensile strain in the sciatic nerve b.v plastic patients ma,v result in an aberrant course of the sci-
26o/o, and leads to ir significant increase in intranenral atic ner\¡e, making it more susceptible to injur.v. In the post-
pre s s.,re.5'6 traurlatic situation, scar tissue or adhesions may tether the
A second cause is the placement of surgical instruments sciatic nerve. Other associated risk factors found in this
in proximity to neural structures. Acetabular retractors stud¡' lvere tl-re use of a posterior :rpproach, lengthening of
may irnpinge upon the femoral nerve anteri(tr1-v, or on the the extremity, and the r-rse oi rn ttncemented femc¡ral
sci¿rtic nerve posteriorly. A cad¿rveric str-rdy for-rnd that on implant.
average, the femoral and sciatic rlerves are onl,v 2 cm from Excessive lengthening of the extremit,v places tension
the a¡terior and posterior acetabular rim, respectivelv.' Lrpon the nerve; in this str-tdr-. the average lengthening of the
Placement of retractors on the peripher-v of the acet¿rbular limb in the patier-rts t'ho sustained a nerve Palsv \\-¿1s
rim cluring prep¿lration of the acet¿rbulum m¿rv therefore 1.7 cm, significantl,v greater th¿rn a matched cohort ulrrr
compress the nearbv neural structures. During femor¿rl did not have a nerve pa1s1'. The use of ¿n uncemented i!'r1l
preparation, a femoral elevator retractor may be used to aid oral implant may result in more arial impaction in¡t, ::¡
exposure of the femoral car.ral. This compressive force fernoral canal, lvhich could repeatedly stretch I.ter\ i:,

\¡OL 99 B. No. l. JANLIARY 20 l-


-

¡]. P SLI

- :- -:::.trors ht\-e reported ol1 a higher


incidence pla,v i,r large role in the der.elopmenr of post_operative
' :- : r, ., rn icm¿rlepatients.l0,14-t6Schmalzried,Noor_ ne¡.ve
palsy.
- .'-. i r.rLrtzli iound that in a lneta_analysis of over
:- TH-\s. iernales had a 1..5% risk of ner:ve pals1., ?{extz.ag*zzz*rzt
.:.,.. .:r¡Le p¿rienrs 6ad a 0.77,A r.isk. Johanson .t nl i,l
. -- ¡-,'.,Lrcls. Tullos and Noblela reporred that 79,,/n and
i :espectir-e11, of their cohorts of patients i,vith
nerve
r: r--s \\ ere iemale. The se analyses, hor,.n,ever, did not acljust
: ;oniounding factors such ¿ls the prevalence of dysplasia.
i,J, hcr rheories of r,vhy females may be more su b jecr ro nerve
.-,risr include different skelerrrl srructu.re (gr.necoicl pelvis s¡retch on the affected nerve: r.vith sciatic involr,ement,
¡nd reduced hip offset) and lorver muscle ,-,o., ,o protect the
hip is ertended and rhe knee is flexed lvhile for a femoral
¿g¿rinst nerve compression. 14, t6

A higher body mass index (BMI) is also commonlv


thought to be associated r,virh a greater risk of ,..r,. pulry
because of a need to applv more forceful retraction
cluring
sLrrgery, blrt was not found to be a risk factor.
bv eirher
F¿lrrell et al1 or Park et a].11

*z;r *xpem*re**
\üle revi
THA ar
imatel,v
October
and examine associated risk factors. Over that period,
93
patienrs had experienced nerve palsies (0.24%)
of a total of
39 056 primarv THA performed thr:ough ¿ posrerior
approach.'0 Of these 93 parients, 63% were fem¿le.
with
an mean age of 62.6 vears (21.3 to g6.4). The mear.r
Blyll
for nerve palsv patients r,".as 2g.2 kg/mz (11.1 to 60).

J
rlnctu re.
In the absence of an,v pathology that ,"vould \\¡arranr a

edge angle, lateral offset, neck-shaft angle, acetabular


com_
poneltt alignment and stcm alignment r.vere analysed for ¿t
correlation r,vith nerve palsy. The p¿rrameters that reached
a
p-value of 0.20 or less in the univariable analr-sis
were
inciudecl in a multivariable regression analvsis.
From r¡Lrr multivariable anall.sis, the risk factors founcl
to r"r*#Et#sÉ5
be associated u.ith nerve palsv r,vere a historv of lumbar
The prognosis of a nerve pals,v is
spine disease or spine sur-ge¡.y. spinal stenosir, smoking,
and classic teaching is that the palsr-
age yorlnger than 50. The strongesr risk factor
for the devel_ man). researchers have found pers
ful examination at follow-up. Ed

motor function, and that j8no h.ld,.. :¡:.rsrent rnild defi_


cit. Schmalzried et rll' reporreJ r:..:- , . :.rJ .r
l.ersistenr
neurological deficit at t\\-o \ e :rr>. .- ::-.r ;ohort of
both
sciatic and femoral nerre p:1s:;s, l.-, e: a1,lr in
- their
series of sciatic nerve p:rl .. .. -; , :.r¡ onl¡,
57"A of
palsy patients recor.ercd ¡,. : ;-:, _.-- :r.1 o \ ears. Several

CCJR SL"PLL\IL\T TO I.HE BO\T & JOINT


JOURNAL
POST OPEfu\TIVE NFT]ROP,\IHY.\I'|ER TOTAL HtP ARf HROII AST\

aLlthors have sougl-rt tt¡ define prognostic frctors for Author contributions:
E P Su: Llterature review, Writing the paper
reco\¡er-v such as the cleglee of the pals.v. Schmalzried et
No benefits in any form have been received or will be recelved from ¿ commer
al1-t reported that tl-re lesser the degree of mc¡tol involve- cial party relatecl directly or indirectly to the subject of this article
lnent or the quicker recoverv of motor fr-rnction ('"r'ithin This arlicle was primary edited by AD Liddle
tu,o r,veeks), consequently the better the prognosis. Dl'ses- This paper is based on a study which was presented at the 32nd annual Wlnter
thesi¿rs seemed to be ¿ssoci¿rted r'vith a Lloorer outcome'1-i 2015 Current Concepts in Joint Replacement meeting held in Orlando, F orida,
gth to 1 2th December
By contrast, Park et alll clid not find that the clegree or
completeness of pa[s,v rn"'as related to prognosis; the onll'
prognostic factor for a full recovery was a lou'er BNII. The ffi.*4*r*z=***
1. Fanell CM, Springer BD, Haidukewych GJ, Morrey BF- l\ilomr nerve palsy
nerve affected appears to be important lvitl-r femoral nerve owing primarytota hip artrr0p astt' J Bone Join¡ Surg [Am]?AA587-4.2619-26
palsv appearing to hirve a better oLltcome than a scjatic 2. Schmalzried TP, Amstutz HC, Dorey FJ. Nerve paLsy associated wtlr total hip
nerve pals,v.1-5 This is thor.rght to be due to the closer prox- rep acement Bisk factors and prcg ros s J Bane Jotnt Surg I/m/ 1 99T ,73 A.'1 074
080
imit,v of the lesion to the spinal cord compared r'vith the
T

3. Upadhyay A, York S, Macaulay W, et al. ca ma pract ce rn h p and knee


sciatic nelve, perhaps requiring less regeneration of nen'e arthrop asty. J Arthrcplasty2001,22{6 Supp 2)
fibres for recover.v.
Nerve palsy folJorvir-rg THA is a serious complication
paedic Surgeons; 1993 361
that leads to anxiet)', concern, and potential litigation. Due on ve I rito
5. Fleming P, Lenehan 8,0'Rourke S, et al Strain an sci¿tlc ne
to the prorimity of nerves to the surgical site, manipulation cluring movement of the hip and knee. J Sone Jorn¡ S 003;85 B;363 365

of the leg during the procedr-tr:e, insertion of surgical retrac- 6. Borrelli J Jr, Kantor J, Ungacta F, Ricci W. rtra retlra sc atic nerve essures

tors and instrumeuts, and post-operative sl-elling' neLlro- re at ve t0 the pos ti0n 0fthe hip and kree. a human cadavet c study. -i,r¡h Trautna

2000;l 4:255-258
praxia of the femoral or sci¿ttic nerves c:ln occur. This rvill
result in sersory disturl¡ances and/or motor tt'eakness,
affecting the patier-rt's recoverv arrd rehabilitation. Upon
8 Hurd JL, Potter HG, Dua V, Ranawat CS. Sc atrc nerve palsv after pr firary tota h p

recognition of a nerve palsl', it is advisable to image the sur- arthr0p asty: a new perspectlve J Afthr1plasry2AA6;21:796-802
gical area to assess for compressive lesio¡s that could be I
Pokornli D, Jahoda D, Veigl D, Pinskerová V, Sosna A.
pographic var at ons of

alleviated b,v a lepeat procedr-ire' Hor'veve¡ most cases will the relai orship 0f the sc at c ¡erve and the p rLformis mu e and lts relevance to
pa sy aftertotal h p arthroplasty Surg Badiol Anat2006,28 88 9T
not reveal any patholog.v that can be corrected surgicallr''
10 Johanson NA, Pellicci PM, Tsairis P, Salvati EA. Nerve njury I total r p arthro-
At our institution, :r neurologist is an integral part of the plastv C/rrr Arthop Belat Bes 1983.,119..214-2?2
teanr evaluating the patient tvith a nert'e pals\', to aid tl-re 11. Park JH, Hozack B, Kim P, et al Common peronea nerve pa sy follotv ng tota h p

arthrop asty: proqnostic factors for recostery J Bone Joint Surg [An]2A13,95.55
assessment the likel,v recover,v of nerve function. The prog-
12. Navarro BA, Schmalzried TP, Amstutz HC, Dorey FJ. Slrg ca approach and
nosis after nerve palsf is generalll'good, rvith at least par- ferve pa sy iI tota h p arthroplasty J Arthrcplasty1995,1A1 5
tial recoveri.' ir-r the maioritl' of cases. Nlore research is 13. Wilson JN, Scales JT. The Sta rmore meta 0n meta tota h p prosthes s us ng a

needed to ini'estigate the risk factors for this unfortu¡ate three pln type cup A follow'up of 1 00 arthrop asties over I neyears Cltn arthop flelat
Bes T 973,95:239 249
compiication.
14. Edwards BN, Tullos HS, Noble PC Contribltory factors and etiology 0f sciatic
nerve pa sy n tota hrp arthroplastY Clin Anhop RelatRes 1987;218:136-147

15. Schmalzried TP, Noordin S, Amstutz HC Update on rerve palsy assoc ated w th
is a rare but distressing complication tota hip rep acernent Cr, 0rthap Belat Bes 1997;344:1 88-206
patient outcomes The arthroplasty sur- 16 Weber ER, Daube JR, Coventry MB. Periphera neuropathles assoc ated w th tota
geon should be familiar with the incidence, risk factors, and potentially h p arthroplasty J Bone Joint Surg [Anrl 1 976,58-4.66 69

modifiable elements in order to better counsel patients and avoid its 17. Lewallen DG. Neurovascu ar inlury assoc ated wlth hip arthrop asty lnstr Caurse
Leü1998,41 215 283
occu rrence.

*,,,o*,oo,0,,
,l _ :,,-:
w maP &*T#ffi*#L&,#TV: &V*E*ENG AiliD v.,4&,{zé&. águ# Fffi#ffil* #
Periprosthetic femo ral fracrures and trying to
re
.A
avoid them
§7HAT IS THE CONTRIBUTION oF FEMORAL
CoivpoNENT
DESIGN TO THE INCREASED RISK OF PERIPROSTI{ETIC
FRACTURE? FEMORAL

A. V. Carli, Ai¡"ns
J. J. Negus, Periprosthetic femoral fractures (PFF) following
F. S. Haddad
total hip arthroplasty (THA) are devastat¡ng
complications that are associated with functional
limitation, ¡n"r"r"ed overall
mortality. Although cementless implants "nd
From Uniuersity the precise contribution of implant geom lncreased risk of PFF,
College London and post-operative pFF remains poorry inve both intra-operative
Hospitals, London, aggregate all of the pFF riterature with speci w was performed to
United Kingdom implant used.
Pat;ents a¡.¡d lVlethods
al databases and recent proceedings from
the
was pedormed. Clinical articles were included
y two
rmed,
literature.
Results
ln total 596 articles were initially identified,
with 34 being eligible for analysis. Aggregate
analysis of 1691 PFFs in 34271g primary THAs
revealed a significantly higher number of
PFFs with cementless femoral implants (p
< O.OOI ). Single_;edge and double-wedge (fit_
and-fill) femoral implants were associated
with a threefold ¡ncrJase in pFF rates (p < 0.001)
compared with anatomical, fully coated
and tapered/rounded stems. within cemented
stems' loaded'taper (Exeter) stems were associated
(charnley) stems (p 0'004). Review
with more pFFs than composite-beam
= of the fur damental literature revealed very
comparing cementless component designs. few studies

Gonclusion
AV Carti, MD, MSc, FRCSC,
I\4aur¡ce Muller Fellow Very few studies within the pFF literature
Hospital for Special Surgery, implants, specifically those of single_wed
535 East 70th Street, New york,
NY
,]0021,
USA
in the literature, with most investigations
J J Negus. I\,4D, FRCS,
with osteoporotic bone. This review illust
Orthopaedic Fellow to record implant name and information for future
E S Haddad, BSc MD(Res),
anarysis. Furthermore, future
biomechanical investigations comparing modern
FRCS(Tr&Orth), professor of implants are needed to clarify the precise
Orthopaedic Surgery contribution of implant design to pFF risk.
University College London
Hosp¡tals, 23b Euston Road, Cite this article: Bone Joint J 2O17;(l Supple
A):50_9.
London, NW1 2BU and NIHR
University College Lonclon A periprosthetic femoral fracture (PFF) is a surgical complications and
Hospitals Biomeclical Research devastating complication that can occur fol- frequently remain
Centre, UK fun"ctionally ir-ri"J even after surgical
lowing total hip arthroplasty patients treat-
Correspondence should be sent
(THA). ment.2,s
toA V Carli; email: with PFF have been found to have an 11"A Despite
longstanding awareness of the con-
aJbefto carlj@maiI mcgijl ca increase in overall mortality risk within
12 sequences of pFF, the prevalence of this com-
aa2o17 The Br¡tish Ediloriai months of the complication, a rate which
Society of Bo.e & Joint approaches that of the hip fracture patient
S u rgery
doi:10 '1302/0301 620X 99B1 population.l,2 In addition to increased
mortal-
BJJ-2016 0220 R1 $2 00 ity risk, PFF patients often require complex
Bone Joint J revision surger¡3,a are four times more fiLely
2017;99 B(1 Suppte A):50_9
to require post-operative readmissio., fo.
-t0
CCJR SUPPLL\fE\I TO TI{E BO\T &
JOINT JOURNAL
PT,RIPROSTHETIC FI\IOR,\L }RA(] tI]RIS \Nt) TR)'INC TO AVOID THL\1 i1

thetic fractures increased by 2.2% from 2012 to 2015, cul- oral component n¿1lne and r¡anufactltrcr. :-ta ,. ,t.r,rr-L Ut
minating in the current figure ctf 9.2",, according to thc eithe¡ intra-operative or post-operatir e PFF:, R¡i ¡r,, ¡rs
National Joint Registrl, of England, \fales, Northern Ire- met follor'ving the second round of article selectir)n :r) r.,:. -.
lancl ¿rnd the Isle of Man (NJR).s consensus regarding included articles. A standardrse.l .1,.1:.:
Although several patient factors inchrding increrrsing cxtractioll form lvas developed with e¿ch revieu,er indep.311-
áBe,''1'l gender,9 l+ the presence of ostcoporosis14'15 and dently ertractir-rg data from each included study.
rheumatoid arthritisr0 have been associatcd rvith the rising From each qualifying stud1,, mean patient age, gender.
rates of PFF, the contribution of implant design or-r PFF risk body mass index (BMI) and time of fracture fron prirn:rr-
is less clear. Cementlcss femoral components have been surger,y rvere collected. The name and manufacturer of thc
¿rssociated lvith a higher incidence of intra-operativel't-16 femor¿rl component were recorded and the stem was then
and post-ope.",iu.l4'17't8 PFF. Hoi,r,ever, surprisinglv fer.". classified. Cemented femoral ste rrs were classifie d as
reports pertaining to thc clinical PFF rates among differer-rt belonging to either the 'loacled-taper' (Exeter) category or
cementless stem designs exist. Furthermore, lr.hile sotrc t1.re'composite-beam' (Charnle,v) categon..24 Cementless
comparative investigations have been perfonr-red for femoral stems \\rere classified according to the s),stem estab-
cementecl femoral components and PFF, their lorv individ- lished bv Khanuja et ,11,25 consisting of tvpe 1 ('single-
ual prevzrler-rce rnakes drarving conclusions from individual .,vedge' or 'blade-t1,pe') stems, type 2 ('dor"rble-wedge' or 'fit-
studies difficult. In response to the lack of large compara- and-fill'), t.vpe -3 (tapered rour-rd/spline/rectangle), ti,pe 4
tir.e in'n,estigations of PFF rates erxong different ferloral (cylindrical, fti11y coated), t1,pe 5 (modular) and t1,pe 6 (ana-
component designs, \ve pcrformed a s,vstematic re'n,ie\v of tomical). For the fundamental component of the revieu.,
the topic with the hope of finding a common thenrc that u,,ithin the initial search, anv article which evaluated femoral
could guide safe femoral component selection. Although PFF risk using computerised, cadaveric or sau.bone models
clinical studies bore the focus of this revieu,', r,ve also evalu- and pror.ided the femoral in-rplant rame and manufecturer,
ated biomechanical and cad¿r.eric erperiments of PFF to were retainecl and their full terts were anah,sed. Conclr-r-
determine if these investigirrions could help explail clinic¿rl sions pertaining to implant clesigr.r, length, geometr,v and
observ¿rtions. snrface finish from each study were extracted anc'l compared
lvith the impl:rnts described in analysed clinical studies.
at*rir-trs *r.z* *Z**** The proportion of ceme nted and
'út=*2i*i:i+a1e**iy=i*"
A s,vstematic review of the liter¿rture rvas conducted accord- cementless stems was calculated, as r,vell as proportions of
ing to the Preferred Reporting Items for Svstematic Reviervs each stem c¿tegorv or classification. Comparisons arlong
and Meta-Analyses guidelinesle using the online databases proportions lvere performed using a chi-squared test of
Ovid Medline, EMBASE and ISI \feb of Science (frorn indcpendence ivith Yates' correction, u,ith significance set
inception of e¿rch database to trI¿rrch 2016) and the last at a p-value < 0.0-i. '§l'hen comp,rrisons u,ere made among
four Proceedings of the Annual lvleetings of the Americ¿rn more than two proportions, conser\¡ative posl /:oc cor-npar-
Acadern.v of Orthopaedic Surgeons (AAOS; 2013 to isons using a Bonferroni correction were performed. All
23
2-01 6) .24 Articles rvere identified using an electronic search st¿tistical tests \\¡ere performed using SigmaPlot Version
of the follorvir-rg ke,vr.vord terms and their respective con'rbi- 1 1.0 (Systat, Erkratl-r, Germany).

nations: "periprosthetic femoral fracture". "periprosthetic


fracture", "irnplant design", "implant geometrl.,!!, "cement- ***r¿|tz
less stem follo'"v up", "cenrented stern follorv up". Further- Sqzlera*1*r*.¡i*,:¡.In total 596 articles u,ere retrieved
more, two revie'nvers (AC, IN) manually revieu,ed the through the primarv search, rvith 122 describing intra-
bibliographies of retrieved articles for addition¿rl citations. operative or post-operative periprosthetic femoral fractures.
Tr:anslated abstracts from foreign language publications The full texts of these articles were reviewed in derail, with
were also considered for analysis. 342r t6 meeting inclusion criteria for anal,vsis. Included arti-
Tr,vo reviewers (AC, JN) independently screened the titles cles represented 1691 PI'F patients u,ithin a cohort of 342
and abstracts of all retrieved articles. For the clinical com- 719 priman, THA patients. Of the 34 included clinical stud-
ponent of the revierv, articles describing clinical cases of ies, six compared cementless and cemented sten-rs (Table l).26
intra-operative or post-operative primary THA PFFs ¿rs r0'je Jn rctal 22
studies evaluated cementless stems onl1,,J1-'t'l
w-ell as the femoral implant name and manufacturer were rvith 13 evaluating one stem onlv (Table II) and nine of these
retained and their ful1 terts retrie.,,ed. Clinical arricles compared t\Á./o or more stems (Table III). Just seven articles
which failed specificallv to provide the implant name, or ar errluared cemerrred rrenr. onlr.in t' wirh five comparing
the very least, detailed description of the implant to infer composite beam and loaded-taper designs, and two evalu-
implant identification, \\¡ere excluded. Articles reporring ated one design (Table IV).
PFFs in the context of revision THA were also excluded. A With regard to knor,vn PFF risk factors, increased age.
second round of article selection ."vas performed bv the female gender ar.rd pre-operative diagnoses of femoral neck
same t\\,o inclependent revierrn,ers, with the article being framure and developmental hip dysplasia u¡ere significanrLr
selected onlv if it included the follorving information: fem- associated (Tables I to IV). Hor.veveq such as:ocr¿rr, r.

VOL- 99-8. No 1, JANUARY 201;


A, V CARLI, J. J. NEGUS, F. S. HADDAD

Table l. Studies retained for analysis which compared


cementless and cemented ferroral stems

Age
Author lmplant name Manufacturer Time to
Classification PFFs, hips (n) (mean so) Gender M:F PFF Study conclusions
Langslet et al26 Spectron Smith & Nephew Composite 1 of 112 834sD57 25:87 -
Cemented beam Femoral neck fracture
Corail patients only Recom_
DePuy 2 8 of 108 83sD69 38:80 mended against using
lnngul et al27 Bi Metric cementless fixation
B¡omet 2 9of74
Exeter
8'1,3 42:99 - Femoral neck fracture
StrykelHomedica/ Loaded taper 0of67 81 2 patients only No risk
Osteo n ics
associated with age
(p = O ¿), Higher risk with
Phillips et al28 Austin Moore - males (p = 0 001 )
1 54 of 2378 86 893i2297 35 mths Austin IVoore pFFs occurred
Exeter StrykelHomedica/ Loaded taper 4 of 812
in first year Exeter pFFs
Osteonics
occurred after 5 yrs. No risk
assocjated with gender
Foster et al2s Austin Moore (p = o tae),
1 5of7O 83 < 45 days No association of pFF with
Thompson Composite Oof '174 80 - age (p = 0 75) and gencier
beam (p = 1.0).
Thien et al3o Exeter Stryke r/H o med ical Loaded taper 120 of 85336 71 4 sD 9 5 1j7262:208468 Within Exeter stem found to I.tave
Osteo n ics
2 yrs 5x increased Haz¿rd raLio [or
Lubinus SP ll Link Composite 32 of 94917 PFF compared to Lubinus
beam stem
Bi-Metric B¡omet 2 135 of 23943 .11
60 8 sD 3 59306:52893
CLS Spotorno Zimmer 3 25 of t6g2
Sign¡ficant association of
PFF with increased age
(p = 0.0005) and pre
operative diagnosis of
femoral neck fracture
(p < 0 0005)
Co rail DePuy z b1 of 17932
ABG I Stryker/Ho med ical 6 16 of 4186
Hazard ratio for ABG stem
Osteonics
ABG was highest (1 61) vs Bimet_
II Stryker/Homedica/ 6 39 of 5024 ric while Corail lowest at
Osteonics
0 47.
Sheth et al3s Accol¿de Stryker/Homedica/ 'l 634
TMZF Osteonics
12 of 66 b 09:23 W¡thin Odds ratio of 13.56 for ppF if
ML Taper 90 days using Type 1 Stem, odds
Zimmer 1
rat¡o of 4.1 for PFF if using
Kinectiv Zimme¡ 1 lype 2 Stem,
14'Fit_and_filt, 5 Manufacturers 2 12 of 1623
stems Significant association of
12 ,Ful y 5 Manufacturers 4 PFF with increasecl age
coated'stems
I of 2563 (p = 0.0006), female gender

13 Composite 3 Manufacturers
\p=0.0147) and diaqnosis of
Composite 1 of 493 developmental hip
Beam Stems beam dysplasia (p < 0 000T 1

Classification: stem de
PFf, periprosthetic fem

were nor necessarily ll qualifl,ing stud_


ies. Of rhe l3 .rudies
found no differenc i3l,ll'llli';ll

A significantl,v higher proporrion of pFFs were found


wirh
cementless srems (901 of 86 761, I.O3%) rersrs cemenred
PERIPROS'|HET]C f I,I,IOR]\I FR.\CÍT]RE5 .AND TRYING TO A\/OID
THL\ í

Tabie ll' studies retained for anarysis


which evaluated one type of
cementless femoral stem

Author ,
lmplant name Manufacturer PFFs, hips Age (yrs)
Classification Gender
(n) (mean sol
Cooper and Rodriguez3l M:F Time to PFF Study conclusions
Accolade Stryker/Homed-
TMZF
l 6 of 2220 725(sD146)
ica/Osteon ics 2:4 65 8 days PFF patienrs:.:
(sD 120) lower canal,ca c:,
ratio, higher can¿ -
flare index Vancou-
Capello et al3z ver 82 fractures
Omnifit HA Stryker/Homecl- noted in 5/6 pFFs
ica/Osteo ics
2 38 intra- 51 11. a8
n
operative Significant assocla_
of 1039 tion of PFF with
20 post- rncreased age
o pe rative
58 12:08 3 3 yrs (p = 0.025), femate
of gender (p = g 91 71
1039
Skoldenberg et al33 and diagnosis
BFX Stem Biomet (p < 0.01
6 of 50 Bt (sD S) 14:36 After 2 yrs
),
Femoral neck
fracture patients
only Recommendecl
agatnst cementess
stems in older
Danesh-Clough et ala3 femoral neck
Synergy Smith & fracture patients
Nephew
2 7 of 193 59 124:69
Nishino et alaa Synergy Smith & 2 1 of37 59
Nephew, N/A
Goetz et afas Summit Depuy
García-Cimbrelo et afa6
2 1 of88 61 6 '13:51
Summit Depuy 2
pOD #4
10 of 488 65 1
235:250 AII intra_
Busch et alaT
Delaunay and Kapandjias
Zweymulller Zimmer 3c 1of67 operative
Zweymulller Zimmer 43 41:26 9 yrs
3c 4 of 198 65,9 '102:83 lntra- 2 grealer trochanter
Streit et o perative fractures,2 calcar
alas CLS Spotorno Z¡mmer 3b fractu res
i4 of 354 52,4 178:176 10 yr
Cordero-Ampuero et al5o Furlong
Joint 2 fo llow_u p
Replacement
10f65 64 39:26 3 yrs
n stitute
I
Barlas et alsl
Furlong Joint 2 28 of 273 80
Replacement 36:228
No increased
nstitute
I
PFF risk with age
(p = 0.892), gender
Shetty et ¿¡s: (0.563) or diaonosis
Furlong Joi nt 2 iof134 75
(0.685).
Replacement
n sti tute
I
Classification: steñiIig,.r
qe,sr r for
¡ur cemented." and cementless
rri penprosthetic femoral fracture; stems%
SD,
"trrd;;;;;;;;;";

atron was associated with


a
compared wirh 0.9% r,vith §lhen dil'iding cemertress s¡ern
performance acco¡:ding
al27in a more recent rancl to geolxetr)¡, the l-righest over¿1li
p.opor,ior., of pFFs
\\,ere idenrified in tvpe
higher PFF rate of 12.2,%
wt 1 (single_w'e,l;:".; blrrde_tvpe;
Bi-Nletric srem (Biomer, 7.07 o-f 7277, 1.49,%). The
,
W.arsa oi,uj. 1 pFFs r,,,as
incijen..
07o in an Exeter ster¡
.,:,,j; .:#.1,1il:,, significantl.v greater rhsn rhe
...nn j'tir*rl.r, srem
p n,i,. u."-
cemenred srems were associared
;;,.T' :i.J,: *H,
type, the rvpe 2 ,tir-¿rnd_fill,
chi-squared = 5.7§. o
stems teL.l'"i' Si'l+2,1.15.A;
r,r,ith a threetlold reduction =.0.017). t o¿-l ,rr.l .na ,r0.2 srems
in the rate of pFF.3e on a larger hrd signilicanrly rrore l,FF. ct
,."1., i;i.;;t al:r0 reported
olr :rirnosr half a mi|ion tU,l, 6 (115 of 13 783,0.839á; p
over a 15-year period. In the
fr.;;;i;rdic registr:v tivel,v) and a combined grou
stems w.as associated with
registrR r_rse ;r cernentless Iuli¡ coared r) pe ,+ (6 j ot I
over five the incidence oftiles cementless stems. FIo\\.e\
t
PFF' (0.45% uersus o.o8yo).
They."r;r;;;-i;.m this com_ riolrs lronr c¿ch oi
er, .

parr'son that cementless ¿lle l


srelrs should be avoidecl when
advanced age, female gender
anct a femoral ,..k fru.tr..
cement r es s,] p.,, ;].; ; ]'
six st,dies. tvpe 6 srems had
ff: i:: :iT ru,il: JH.:: J.1: l

ar-e present. They aJso


identifiecl differences among
specific
rhe rrvo srudies, ht;h;r;;;:;
cemetitless and cemented
stem designs- orle srudy found increar.Jpefr'r'rrpe
i3d.,""1I J srems.
a I j.s?
§7hi1e this iatter stucly founcl
\-ot . q. B. \,,. l.l.{\t .\R) 20l
l",,r" pFF
"alr a. i¡
.\ \, C\RLI. J J NIC;US. F. S H\DD.\I)

multiple types of cementless femoral


stem
lmp¡ant name Manufactu¡er Age (vrs)
Classification PFFS, hips (n) (mean so)
tlealy et al5 Trilock - Cobalt Gender M:F Time to pFF
Depuy 1
0 of 'tgg
Study conclus¡ons
Ch rome 652 202:188
rítock Iit¿nium Depuy
van der Wal et alQ ABG 1
Stryker/Homedica/
1
1 of 19't 66 99r92
Osteonics
6 14 of 619 676 155:464
FrLgeEld et als 3x higher pFF incidence in
Porous Coatecl Stryker/Homedica/ 6 20 af 341 female pat¡ents.
A nato m ¡c Osteo n ics
Omnifit HA All PCA pFFs were ¡ntra
Stryker/Homedica/ operative
Osteon ics
2 I
Watts et al35 ProxiLock Zimmer 2
Omnifit 39 of 736 60.1 (sD 13) 448:2BB
St ryke r/H o m e d i ca,/ 2 28 ot 3228 Sii.7 (sD 13)
lncreased patient age
Osteon ics 1765:1463 (p < 0.0001) and use of
¡ecu tsF tt Stryke r/H o m ed icai Prox¡Lock were signifi-
2
Osteon ics cantly asso¡ciated with pFF
mit Su m De Puy No increasecl risk associ-
2
Synergy ated with preoperative
Smith & Nephew 2 d iag nosis (p
Zimmer TM = O.27).
Zimmer 2
Hdnforn and Knowles,. ML
Taper Ztmmet 1 10 of 250 6d
Co ra ¡i 186:303
DePuy 2 rcof241 No increased pFF risk with
age (p = 0.13), higher risk in
females (p = 0.048). Risks
specific to anterior
app¡oach: BMI > 40, smaII
Miettinen et al37 Dorr ratio, small implant
Co n
Profemur TL
serve Wright Medicat 2 13 of 1'18 stze
60 114t122
Proximal femoral morphol_
M/L taper Zimmer .l
ogy assoc¡ated with pFF:
Cora i I
DePuy 2
V¿rus neck, champagne
tluted canals, Dorr
B etric
i -M Biomet 2 proximalfemur
C

Synergy 96 of 118
Smith & Nephew 2 No s¡gnificant association of
Reach Biomet PFF with age (p = 0.3) or
I of 118
CHF Biomet 3
07). A diagno-
mentaJ hjp
sjg n if¡ca ntly
Van Eynde et al38 lmage h PFF
profi le
Sm¡th & Nephew 6 16 of 1 r
(p<0001)
570 lsñ 6ql
DePuy 2
R 'l 69 yrs (sD
1 66) High tnc¡dence
of Vancou
6 of 2A7 53 2 (sD 10 62)
8 38 yrs (SD 5 73) ver 82 fractures Authors
recommended caution with
Taunton et alr prorilock Zimmer
rntroduction of new,
untested femoral stems
Hydroxy¿petire ' 11 of 662 63 j2:18
28 days
ApR All PFFs were Vancouver B
Zimmer 6
(2 to 88) type fractures Adv¡secl to
omnifrex 10 of 3442
stryker/Homedica/ 1 use multiple taper stems for
osteonics 4 of 942 p¿tients w¡th weak pro\ jmal
Summit Depuy femoral bone.
secur_Fit HA
-2 3 of 120a
stryker/Homed¡ca/
2 of i213

3 5 of 263 7)
Bencox lD entec 79 6 (sD 386:1177 44 4 mfhs (sD 30) Nlajofity
of pFFs wjthin firsl
5 of 230
taper
l\¿,/L
mer yr, Vancouver B type. No
Accoiade TMZF
-j 3 of 196 difference in fracture
stryker/Homed¡ca/
osteonics o of 'il populat¡on wjth regard to
Taperloc stem length or length or
Biomet 1 porous coating
Bencox corenfen
o of 8
." 15 of so1 No significant association
of
Benfix Long sr"- corunt"" pFF w¡th age (p
= 0.055),
corair Depuy of 217
7 gender (p = 0.959) or pre_
r^a 2 0 of 5 operaljve diagnosis
IlcP,,. (p = 0.690).
Classificatio n 2 of 132
PFE oerio¡osr
oeriorost il dcLUre: sD. slandard devi¿tion; pcA. po.
ous coated anatomicj BMl, body
mass index

b, the study.
al,l0 'llTf.l'
are. dwarred
from Thien er '1'l;
,,11' +*::"1: nhi.l, i',.i.,,c*"á",r''rr.i_".:rt.)il
srem, none of *;,.h rlr!luuccl
:i:1,:-:l,hra,,cemenrtess
\ü/hen
yv rrLlr suUrracllng
"rr i"j"a.á
subtracuns thts resisrr_v Jrt, f.or., th.
rhis registr_v
:li.^l :l:i:
remai¡t jng 22 cementless
steln .tlrJi(.. ,"¡"- r,.
472, 6.35,/.) ¿rnd proxjlock
type 2 srems rose ro
to be significanrly srearer
r.,r;;j'(';;':?;l ;?;i:fl::lJ;l: Oberdorf, Switzerlancl) (.!0 of l3j
lh:l ,rO. i iU, of 7217; l.rave the highest o\¡erall pFF
chi-squared = 62.01, p < 0.001) ".nrr'f rates. The Bi_Iletric (Biomet)
and all
stem rypes (p < 0.001). Furthermore,
nth.,..._.rtl.s, contriblrred the most p_FFs (1aa)
no significant differ_ ," ,l_,. ,,;;l group, fol_
ence could be found between iou.ed. b,v the Corail (Depu1-)
t¡.pe 1 srem pFF rates and t72 pFFsl. ij_re Corail stem
was also the type 2 stern stucried,l.,.,lrnr.
lfive articres),
CC]]R SUPPLE\IE\T TO lHE BONE &
JOTNT JOU]{NAI
PERIPROSTI IETIC. FEIvIOR.\ t l'RAC_Tt RES AND TRYING -rO AVOID THE\I

Table lV. Studies retained for analysis which evaluated cemented femoral stem

Age
lmplant (yrs) Time to
Author name Manufacturer Classif ication PFFs, hips (n) (mean) Gender M:F PFF Study conclusions
Cook et al5a Charnley DePuy Composite beam 43 of 2725 2361:4097 6 3 yrs
67.1 Significant association
Exeter Stryker/Homedica/ Loaded taper 77 of 3506 of PFF with increased
Osteo n i cs age (p < 0001 ) Exeter
stem had higher PFF
risk per yr
Sarvilanna et al55 Exeter Stryker/Homedica/ Loaded taper I 71 6 yrs Significant assoc¡ation
Osteonics of PFF with pre-
Thompson Composite beam 5 operative diagnosis of
Lubinus Lin k Composite beam I femoral neck fracture
patients (odds ratio of
44;p=002)
Lindahl et als6 Exeter Stryker/Homedica/ Loaded taper 230 77.9 - 53% of PFFs were Van-
Osteo n ics couver 82 Type 66""
Cha rnley DePuy Composite beam of PFFs occurred in
Lubinus Lin k Composite beam loose stems Sign¡fi-
cant association with
pre-operative diagno-
sis of femoral neck
fracture (p < 0,001 )
Lindahl et al57 Charn ley DePuy Composite beam 61 of 20826 7.4yts
14 82T. of PFFs were Van-
couver B1 or 82, Better
cement mantle noted
w¡th Lub¡nus stem,
may offer long-term
PFF prevention
Exeter Stryke lHo m ed ical Loaded taper 3a of fi771
Osteonics
Lubinus Lin k Composite beam 30 of 30786 Significant association
of PFF with younger
age (p < 0.01), femoral
neck fracture
(p<0001)and
rheumatoid afthr¡tis
(< 0.001).
Grammatopolous et Exeter Stryker/Homedica/ Loaded taper 1 5 766 6 yrs Exeter stems with PFFS
al58 Osteo n ics had good cement
CPT Zimmer Loaded taper 6 mantle. Maiority of
PFFs were Vancouver
82 with wedge
fragment
lnngul and EnocsonseExeter Stryker/Homed ica/ Loaded taper 63 of 2757 82 738.2019 < 1 yr Half of PFFs were Van-
Osteo n ics couver 82. Mortality in
PFF patents was 25Yo
after 1 yr. Lateral
approach could con-
tributed to cemented
stem malalignment
and PFE
Brodén et al6o CPT Zimmer Loaded taper 47 of 1403 82 380:977 7 mths S¡gnificant associat¡on
to'1 yr of PFF risk and patient
age (p = 0.04), diagno-
sis of femoral neck
fracture (p = 0 01 ), but
not gender (p = O.e).
Early PFF associated
with wedge-shaped
stem.
Classification: stem design for cemented24 and cementjess stems25
PFf, periprosthetic femoral fracture

with a combined PFF risk of 0.1% (O% ro designs (412 of 1,50 277, 0.27%; chi-squared = 12.36,
7.4"A¡.2e,:o:e''l7,at The Austin Moore was the Type 1 sten.r p = 0.004). Of the four articles comparing the r,"r,o srer¡
with the most (59) PFFs. The ABG II (Stryker/Horvmedica/ designs, all four reported a higher incidence of pFF with the
Osteonics, l(alamazoo, Michigan) was rhe Type 6 stem Exeter stenr. Specificalll,, Thien et alio four-rd that r_rse of the
with the most (39) PFFs. rü7hen reporred, a high proporrion Exeter stem was associared'"vith a fivefold increaseci hazard
of Vancouver B-type fractures6l were identified when ratio for PFF comparecl u,,ith composite-bealr stems. \{'rthin
cementless slems were used. the con.rposite beam rypes, rhe srraight Charnler- (Dep,.r-
For cemented stems, a significantly greater pr:oporrion of and anatomical Lubinus srems (rX/aldemar I_ink Ciml.H :r
PFFs were identified with loaded-taper or Exeter-type srems Co., Hamburg, Germany) were directly conrp.rre.l .
(378 of 105 681, 0.36%) compared wirh composite beam articles,j6'i; with both reporting a lou.er inci.lc:--. :
\¡Ot 99 ts, No I,JANUARY 201:
-\, \. c.ARLr. J J. NECUS. F. S H\DD{D

, '., .:-'.':,r.ial,,:;i:TlrT::sio,s'theauthorsnote<l affect ioacl-to-failure, rhe presence


of a higr.r friction rita-
, : >,: -.- :hj¡kre:s ,ri cemen¡ ,la :red axial, iroop and mean proximal
bone
'.- . '.. -. '. i',,rirr oiLcme¡ted )tem
. " .-- r.r \ r.lr. iror¡ the index arf
,. ¡¡¡;c1e tinding that 66,'/n of p
!r:,1:r- u-irh deticient cement mantle
\\ 1.ie n drstingr_rishing rhe ¿lbove r
i.-rarile pFFs, 236 ctrses from eigh
ere iound. A1l intra-operari\.e p
Ith cementless stems. Cementless a Sreater maximum load-to-failure.
relabll' deterrnined in 202 of the 23 ing, such results may be difficult
ro rnrer-
-rses.i2'-l'+'3;,'13.'16.5 l..tl. ferent femoral preparation and
rrVithin ,t-r.r.
.=r.., 90.01,,1, (1R) .,F angres
.,"^r. as 'uveil as rengths stem taper
202) orall reported,;,Xl:xi:;Tliiil'j:.li;3ji,,fffi.T
srems, rvith remainder attributed
to the porous coatecr An¿r_ *á*e*ss!*r¡
romlc q'pe 6 stem.
f*ndar¡:er¡tai lite¡ature A total trst
of fi'
lmo
har
o[s
mponenr identification. Within arricies

v¿rtecl pFF risk rvit


nts, onlv articles r,vhich is concord
found. The v¿rria_ longituclinal
stucl
ngth anc.l the num_ subitantial vari¿r

rncrease tn ener:g)¡ neecied. Xrlorisham ms i'ielded significantly lou,er rates


of
similarlv sized and offser Exerer er, Exeter-t)'pe stems rvere
ster found to have
150 mm iength. They found
thar s¿r

rm compared rviti.r straight, Charnlsl-


tnore consisrent cement m¡ntle
rhick_
found that verv ferv fLrndamental
stud_
pFF risk erist,
making it clifficult to
otheses from the clinical literature.

slstent, suggesting th¿rt other l.ariables


al geometrl_, cortical thickness and
§fith surgical technique may also influence
regar<1 ro cementles fracrn¡e risk. Further-
cles evaluated the influence
fracture resistance. X.{iles et
type 2 stem rvith a proximal hvdroxl.ap
distal grit blasted surface and medial
s

(or stern) relared cortical remodelling


sponsible.
I limi¡a¡ions rvirh this studr,.
s c¿rlculared ¿1mong clifi.erent
inro acco Lrr_rt the 1_reterogeneous

CCJR SI,"PIEMENT TO THE


BONE &JOINT JOURNAL
PT]RIPROSTHETIC, FE\,fOI{AL FIiACTURES AND TRYING To AVOID THE\I

nature of studies included in this review. Specificall¡ the single-wedge and anatomical stems L,€rstrs cemented
effect of confounding factors including patient age, gender, implants,:7 r,et in both cases, neither studl, evaluated loading
pre-operative diagnosis (femoral neck fracture, presence of to failure. The lack of comprehensive investigarion in ¡he
effect of individual stem features on fracture resistance is
verv worrying given that the number and variation of
cementless implants has increased over time. As shown in
the fundamental study bv -\Iiles er al,n5 investigative efforts
in collaboration u,ith industry can provide very useful
external validity and statistical power of our results. Fur_ information to surgeons and, r,r,hen coupled with novel
thermore, performing a meta-analysis would not be possi- computer models that rake implant stabilitl. and patient
ble due to no single study clearly defining all of the above proximal femoral bone density into accounr,78,7e can hope_
listed risk factors and implants used. A second limitation is fully permit surgeons to identify pre-operativel,v r,vhich
poorly performing stems could implant places a specific risk to the patient for pFF.
n occurs when noting that the In conclusion, this systematic revier,v found that cemenr_
ted half of PFFs reported in the less stems, specifically those rvith a ,single, o¡ ,double,
type 1 group. Although the Ausrin-Moore did nor have the rvedge were associated with the highest incidence of pFF
highest prevalence of PFFs (2.4%) among cementless stems, among pooled studies. Perhaps more concerning, the
the presence of a collar and unique windows within the review found that less than a quarter of periprosthetic
stem body do make it different from modern type 1 stems. investigations reported on the type of implant involr.ed.
A third limitation, which was touched on in the results sec_ Due to the paucity of literature regarding implant design
tion, was our decision to report pFF rates with the largest and PFF risk, we propose that orthopaedic journals reqlresr
sample size3o included and excluded. This decision was specific implant information in future pFF-related submis-
made because findings from several case-controlled studies sions ancl that impJant characteristics (beyond cement rler_
conflicted with the larger study. Furthermore, the larger sls cementless) be regu[arly recorded in clinical registries.
study reported PFF rates for cementless stems that were In ight of the recent increase in both frequeno, and severity
J

considerably lower than any other stud¡ raising concerns of PFF,80 comprehending the precise contributior-r of
about the completeness of the registry data.7o Registry data in'rplant design on PFF risk i,vill greatly assisr surgeons in
for PFFs are specifically difficult in that they often fail to selecting the implant u,hich is safest for the patient and help
record the number of PFFs that do not undergo operarive them to avoid a potenrially catastrophic complication.
treatment such as for type-A fractures6l (up to 5% of all
PFFs)57 and in medically unfit patients. e ihi.¿ potential
limitation is the cementless stem classification used.
Although this classification separates cementless stem
design according to geometry, it does not separate other cantly higher risk of periprosthetic femoral fractures lmplant name and
pertinent stem characteristics such as method of femoral geometry should be reported in all future studies related to per¡prosthetic
fractu res
preparation. Ream-and-broach designs generally remove
greater amounts of cancellous bone compared with broach_ Author contribut¡ons:
only systems7l and this difference in preparation could A V Carli: Devised study methodology, Retrjevecl articles, performed añicle
analysis, Wrote manuscript,
affect PFF risk. Furthermore, cobalt chrome stems are J. J. Negus: Retrieved articles, Assisted with article ana ysis, Edited manuscript.
stiffer than those of titanium alloy and this difference has E S. Haddad: Assisted with developing study methodoiogy, nterpreted
afticle
analysis, Edited manuscript.
been implicated as a potential cause for increase pFF in a
specific type 2 stem design.32 Th research/study/project was supported by the National lnst tute for Health
Re arch University College London Hospitals Blomedical Besearch Centre.
§7hile the effect of cementless stem geometry on proximal
The author or one or more of the authors have received or w I receive benefits
bone strain was a topic of tremendous interest ten to 20 years for personal or professional use from a commercial party related directly or
ago when these implants were introdvced,T2'7s very little lit- indirectly to the subject of th¡s articie.

erature has emerged since. In an editorial jn 1992, HorneT6 This article was primary edited by G Scott

questioned the rationale behind ,fit-and-fill, stems, noting This paper is based on a study which was presented at the 32nd annuar winter
2015 Current Concepts in Joint Replacement meetlng he d in Orlando,
patients varied tremendously in their metaphyseal_ gth to 1 2th December.
Florida,

diaphyseal geometry and that radiographs produced erro-


neous rep y up to 40"A oÍ Referer'¡ces
thetime. sasubsequent 1. Young SW, Walker CG, pitto Rp. outcome of femora periprosthetrc
in uitro c ¡apered-spline ¿st,i
fracture and Ter,rsl¡r¡ ¡ p e.."r!c d-pair study from the New Zea and
Begistry. lc¡a Cr¡¡oo 2008,79 483-18
stem in cadaveric femurs showed significant differences in
2. Bhanacharyya T, Chang D, Meigs JB, Estok DM ll, Malchau H. [/]Orrali
afier
the dynamic response and total movement each stem exhib_ peripros,het c Íracture of the femur. J Bone Jornt Surg
[Am]Z0Al:g9 A:2658_ 62
ited in response to load.s3 Such differences have also 3. da Assunqáo BE, Pollard TC, Hrycaiczuk A, et al. Bevrsion arthrop
as t
periprosthetic femora fracture using an uncementecl modu ar laperecl
been reported in both the sagittal and coronal plane among Bane Jaint J 2015,97-B: T 031 -t 037.
conica

VOL. 99-B, No. 1, JANUARY 2017


r MANAGEMENT FACTORIALS IN PRIMARY
TOTAL KNEE ARTHROPIA§ry
Correcting severe valgus deformity
TAKING OUT THE KNOCK

J. Lange,
S. B. Haas unique surgical challenges for the total
knee
typical patterns of bone and soft_tissue
From Hospital for for appropriate surgical planning. This
Special Surgery, New on with an understanding of surgical
York Ciy, United knee arthritis.
States racted lateral soft tissues, attenuated
medial
all be present in the valgus arthritic knee.
A
in order to guide surgical management,
and a
bed with satisfactory clinical results.
variety of TKA implant designs may
be
Regardless of an operating surgeon's preferred
surgical strategy. adherence to a step-wise
approach to deformity correction is
advised.
Cite this article: Bone Joint J 2O17;(l
Supple A):60_4.
total knee arthro_
for a diagnosis of
s is the most com-

Glassification
Pathoanatomy
J Lange, MD, Clinjcal Feltow
S B Haas, MD, MpH, Chiefof
the Knee Service
Hospital for Spec¡al Surgery,
Department of Orthopaed jc
Surgery, 535 East TOth Street,
New York, Ny 10021, USA

Correspondence shouid be sent


to J Lange; email:
llange'1@partners org

c)2017 The British Editorial


Society of Bone & Joint
Surgery
doi:'10 1302/030.1-620X 99Bl
BJJ-20't 6-0340,8 1 S2 oo

Bone Joint J
2017;99-B(1 Suppte A):60 { may undergo metaphyseai valgus remodeling.3
extra-arricular deio¡r¡j¡ies. T1 pe I is defined as
60
CCJR Sl, PfLl \1 E\, . :i;
- r !O \F \ JOI\T IOURNAL
CORRECTING SE\/ERE \¡ALCLIS DE}ORN{ITY 67

lf tibia valga is presenr and if the plar-rneJ rrt¡i.rl resection


relies on proximal tibial anatom,v u,,ithout considerarron oi
the tibia's distirl rrorphoJogl., then the post-operrrr\.e coro-
nal alignment of the lorver limb ma,v demonstrate nndesired
residual valgus.

Surgical cúnsideratá8ñ§
Di*ta! femanai resestian The distal fen-roral resection and
its resultant VCA can be srandardised at 3" to all patients3.-t
or the VCA can be customised ro fit the parienr's require-
ments r,r,ith use of pre-operative long-leg r:irdrographs, intra-
operative cotnputer-assisted techniqLlesl or patient-specific
cutting guides (Fig. I ). Althoug}r rhis individualised
approach has been shorr,,n to result in in-rpror ed component
Fig
positioning this has nor been reflected rn an improved clin-
1

ical outcome.l0'12'13 Patient-specific instrumentation has


lndividualised valgus correction angle not been shown to result in better posr-operative limb
(VCA) based on a pre-operative ful -
length anteroposterior femur radio- :rlignment or clinical outcomes as compar-ed to st¿rndald
graph.
instrnmentationla and so there is no clear consenslls as to
the optimal straregv for distal femoral resection.
Fosterior fen¡cral rese*tion and femora! eoe"npúr:er¡t rota-
tios¡. §lith nolmal or near-normal lateral femor¿rl condyle
anatomv, the posterior cor-rdrrlar axis can be used to ensure
correctible valgus deforn-rit1'lvith ro fi-xed deformitl.and an correct fen-roral component rotation. Hou,et.er, in the val-
intact NÍCL; tvpe II is a fixed valgr-rs deformitl. with an gus malaligned knee, the posterior femoral condy,le is often
intact N,ICL; q.pe III, a valgus and h).perextension deform- deficient and so relving on the posrerior condvlar axis can
ity u,ith an intacr MCL; [,pe IV, valgus and a fixed flexion result irr malrotation of the femoral component. Instead,
deformit,v with an intact MCL; r),pe V severe r.algns the anteroposterior (AP) axis15 and the transepicondr,lar
deformitv u,,ith an incompetenr MCL and type VI, valgus axis should be used as reference to achie'n,e correct femoral
secondarv to extra-articul¿rr deformit1,.6 For each §,¡re, the component lotation.s'15,16 Alternativell., the posterior con-
authors describe the surgical management to correct both dylar resection shouid be parallel to the tibial cut and so
the bone and soft-tissue componenrs of the deformitl'. orthogonal to the tibial mechanical axis, as described l:y
Ranarvat et al.3 Failure to recognise posterolareral femoral
lfáechan iceÉ alÉgeT rnent deficieno. can result in ar.r inappropriate femoral cornpo-
MechanicaJly aligned TKAs aim to have a neurral coronal nent sizrng resulting in ir-rstabilifi, in flerior.r or malrotation
plane alignment and a tibial cur that is orthogonal to the of the fen-roral component resulting in posterolateral insta-
mechanical axis.' In a valglls knee, both femoral and tibial bilit1.. If there is significant larerai femoral deficiency then
pathology mav need to t¡e addressed u.ith respecti\re bone femoral component augments such as r,vedges rna1, be
clrts to achieve this goal. The norn-ral knee t1,pica1ly has a required. Finall¡ if a posterior-stabilised TKA is used, the
femoro-tibial angle of approrimatelv 6" valgus,- horve'n,er femoral bor cut should be lateralised to oprimise patellar
in some cases, after surgical correction and despite achier,- tracking.
ing this desired 6' femoro-tibial valgus angle, there may be Tibial resectiom In a mechanicalll. aligned TKA, the tibial
some residual valgus malalignment. Nlullaji et als reported cut should be orthogonal to the tibial mechar-rical axis.
a negative correlatiot-r benveen increasing valgus deformity Hou,ever, as noted above, if the planned tibial cut is based
and the distal fe moral valgus correcrion angle (VCA) on proximal tibial anatomy, this mar- result in under correc-
! required to create a distal femoral resection perpendicular tion of the deformitl, if rhere is unrecognised distal tibia val-
to the mechanical axis. Vith increasing severit,v of valgus gus.lI In the presence of more ser-ere valgus deforrnities,
deformitl., the magnitude of rhe VCA cut decreased. The lateral side tibial cornponents ¿lugments mav be necessary
average VCA among the 44 r,algus knees in tl.reir cohort of as '"ve11 as the release of Iateral soft rissues.
: 503 arthritic knees rvas -5.9',8 and other investigators have Kinen¡atic aligi:l::ent. Surgeons ma) nse surgical strategies
reported mean VCAs in valgr-rs arthritic populations to be other than mechar-rical a[gnrnent, including anaromic
I less than 5o.e,10 alignment or its modern 3D iteration kinematic alignrnent.
As u.ell as femor¿rl deformitv, there mav be a valgus
I deformitl of the tibia. The prei,alence of tibia valga r,vas
The goal of kinematic alignment is to recreare the 3D anat-
omy of the knee's pr:e-arrhriric joint surfaces.- In the colo-
I noted to be 53% in Alghamdi et al's cohortrr of 97 r,algus
arthritic knees, and the mean tibia valga angle was 5o.
na1 p1ane, this technique produces increased femor.al
component .,,algr-rs and increased tibial component \ arus as

t \ OL 99 B. No 1, J\NLI-\RY 2011
I
t
J. LANGE, S. B. FIAAS

Posterolateral
corner
llliotib¡al
Poste rior
cruciate
ligament

Fis 2
Fig 3
Posterior and posterolateral release as described
by Ranawat et al 3 lliot¡bial band pie_crusting technique

compared ro lnechanicallv aligned TI(As. The rarger of neu-


tional correction u,as necessar)1 The authors did note that
tral mechanical lorver lin-rb alignrlent can still be careful assessmelrt of all soft tissues rvas important as the
¡chicr ed.l LCL r,vas not ahvays contracted even r,r,ith valgus deformit),
Kinen.ratic and mechanical alignmenr use significanrly and associated l¿rteral soft-tissue contracture. As this study
different tissr-re management principles. In kinematic align_ r,r,as performed on cadavers, clinical correl¿tion §,as
ment, rhe implar.rt thickness is meant to eqlraI the sum of the
aclvised.
thickness of c:rrtilage worn, rhe width of the sar.v blade used
§lhiteside20 recommended a patient specific approirch ro
for resectior-r, and the thickness of bone relnovecl. Tipicallv, the management of sofr-tissue balance. He nored that soft
appropriate solt-tissue balance is ¿rcl-rieved thror-rgh bone tissues attaching close ro the femoral epicondr,le (I_CI_, pop_
manasement, including osteophyte rernoval and resection liteus ¿rnd the posterolateral capsule) contribute to tensior-r
adjustments, rather than through soft-tissr_re managerxent ir both flexion and extension, whilst those soft tissues that
techriques (see 'Soft-tissue balancing, below). In the case of
are attached relatively disranr from the epicondyles (poste_
fixed r,algus deformities, however, an additional 2. of tibial rior capsule ¿rnd IT band) can affect either flexion or exren_
\''arus ¡rescction combined with lateral soft_tissue release has
sion, but nor lroth. Therefore, bv noting the soft_tissue
becn recommended tc-r correct the overall cleformity of the
tension of borh extension and flexion gaps prior ro release,
limb. Howell, Roth and Hull et:r117 report excellent shorr_ the appropriate structures can be identified to provide max_
term clinic¿.rl r:esr_rlts using these methods. Hor,veveq this imum correction throughout knee range of movement
technique has not been widely adopted ro dare, and irs (ROM). In his series oÍ 2)g pirienrs, §lhiteside20 reported
long-term performance regarding the appr:opri;re m¿nage_
the results of this surgicai technique using a cruciate_rerain_
me nt of severe deformities is unclear given the lack
of avail_ ir.rg implant and there \\,ere no cases of clinicaI knee
insta_
able data.
bilit,v at six l.ears follorv-up.
Elkus et a121 described an ,.inside-our,, technique ro
* *?7^cé**a-s e * *rz*E at E achieve soft-tissue balar-rce. After femoral ar.rcl tibial resec_
=Z
As lvell as achieving correct bony alignrnent with planned tion, the soft tissues are balanced in ertension to achieve a
femoral and tibial cuts, ir may be necessar_y to adjust soft_
rectangular gap. To achieve this, rnarginaJ osteophvtes are
tissue tension about the knee in order ro prori.l. optimal soft-
removed and the posterior cruciate ligan.rent tpCL) is
tissue balance. \\¡ith the correct medial and lateral soft_tissue
released. Next, the posterior capsule and posrerolateral
tension, there will be joint stability throughout the full range
capsular complex is released along rhe
of knee movernent. In t[-re case of valgus deformit,li failurc ro ¡rori,nal tibial bor_
der (Fig. 2). Release of the poplirelrs \\ as nr¡r Lrsu¿llr neces_
correctlv balance the soft tissr-re s with a careful steprvise sary. If the IT band was tighr, rhe au¡hors o¡¡recl a ..pie_
approach ma,v lead to high rates of post-operarive instabilitl,.ls
crusting" technique by creating nrulti¡.1¡ s I curs in the IT
In a studr. of sir cadaveric knees, l(rackor,v ar.rd band to ailorv it to
Mihalkole shou,ed that stepwise Iareral soft-rissne release
lengthen bur re::r:i¡r in ¡onrinuity
(Fig. 3). §lith the exrension gap brrl;n;-:. .:.:.r irlLr.rl flexion
resulted in progressive correction of illignment and that
release of the LCL had rhe grearesr effect on the flexion
and
extension gap and rhev reconmended that the LCL should
be released first with popliter_rs or IT band release if addi_
to 15-year fo1lo.,l'-up. ri ho -:,:: -. a.:: r¡ .l Dosterior_

CCJR SLIPPLL\ÍE\I TO THE BO\T & JOINT JOURNAL


C,o]t REC]TI\ C 5 I,\'El{E v ALC;LI5 D EFOR-\,I tTY
63

stabilised or consrrained TI(A ar.rd this ,,insic1e_out,, soft_


recommended29.-10 r,vhen there are ser ere cl.iornriries
tissue release. There were lto reported cases of delalecl in
ivhich stabilit) cannot be achieved u,irh a less consrr¿Lneci
instabilit¡, and implant survivorship was 100% at ren years
prosthesis, long-term follorv-up stuclies hale nor been
and 83'/o at 15 vears.21
reported.
Although other series4.l.t,22 h"ve repo::ted tl.re results of
lateral ligament advancement, mediai ligament advance_
*lzz=ie*N *zÁt**=z**
lnent with imbricatio¡, eprcondl lar siiding osteoromies arrd
Revisior.r rates follo*,i.g TKA for'algus arthritis have been
compllter:-¿lssisted release techniques, no singie soft_tisslre
reported ¿rt befi,r,een 0o./o ¿rnd 17o,t, ¡tten- to 1S_year follow_
managemenr technique has proven to be the most effective
up.21'3t':: Higher failure rates h¿,Lr-e been reportedi:l with
in the surgical treatment of r.algr_rs deformiry. significant pre-operative defonnitv o, an inaáequare surgi_
cal correction. The correlation betrr-een ribial componÁr
*diaÉ agpr*a=* varus and higher TKA failure rares is less clear.3.+,3-t
Although the short-term resulrs of krner-naticallv aligned
TKA which incor:porates tibial conrponent \ a¡us as part of
the appropriate surgical technrque are promising, rhere are
no long-term outcomes reported.t-.i6 Bourne et ,-rlit dem_
onstrated that pre-operative valgus knee deformirr was nor
posterolater:rl corner, cler.ascularis¿rtio, of the pate lla .,vith
predictive of one 1,s¿¡ post-operative satisfacrion scores.3l
a concommitent lateral lelea
There are ferv TKA outcorne studies comparing r.algr_rs
relea:e of medirl .oir rissurs or
.,,arus knees. two studies38,39 have dentonstrated no sig_
Just
ever, the clinical results of usi
nificant differences in oi,erall clinical ourcome at micl_term
factory u,ith good shorr- and
folloiv-up.
The treatment of valgus knee deformity r,vith a TKA pre_
L&***ral e**?r;;***
scnts a number of challenges. Multiple surgical tecl.rniqr-res
Keblish2't popularised the lateral parapatellar approach.
have heen described r,",ith satisfactor,,- .lir-ri.al resulrs.
The reported :rdvantage of this included a more clirect Regardless of the chosen technique, rve advocare a srep_
r,r,ise approach to correcti¡g the defonnity r,vith
both the
bon,v and soft-tissue re-alignment. Vjrh lesser deformities,
cruciate-reraining or cruciate-sacrificing implants can pro_
vide sufficient stabilin,. §flith a more sigi-rificant valgus
deformitl,, a more constrained implant trl"v b. requir:ed.
Valgus associated arthriris rreated with a TKA and careful
attention to the mechanical axis can resulr in mid_ ancl
approach to address these concerns ancl have reported sat_ long-terrn survivorship r-ates of over 90,%.
isfactory clinic¿rl results.

!a'a:pl*u:É *?t{ri*q

;llJ *:, ",'.Tl'"


:ü:ll"xiiL" il.1 deformity correction is advised
rul,r.l,'1.5,2r1 \X/hen there is advanced Author contributions:
deformity ,vith significanr medial soft-tissue raritv or if there 1 ^Lange:
Work through clesign, Data collection, Writing and editing
S B Haas: Work through design, Data collection, Writiñg
is multiplanar deforrnity then a consrrained implant n.ray and editing
be Figures 2 and 3 were illustrated by
required to achieve appropriate stabilitl-. Easley et alzi A Darllng,

reported their rcsults of 44 consecutir.,e priman, stemrned Dr Haas receives royalt¡es as a designer of a specific total knee replacement
system
The author or one or more of the authors have received
or wili receive benefits
for personal or professional use from a commercjal party re ated directly
or
indirectly to the subject of this afticie
This art¡cle was primary edited by M Barry
bility' at final follorv-up (mean 7.8 r,ears, 5 to 11 ). Anclerson ]ll"_
p^rO"r is based on a study which was presentecl at
the 32nd annual Winter
2015 Current Concepts in Joint Replacement meeting held in Orlando,
et a12a also reported excellent clinical results at a mean of gth to 12th December FIorida.
44.5 monrh' follon -rr¡ in i.i
TI(As withour srems for the **€*s*t's***
Again, there r,vas no radiog 1. Nikolopoulos D, Michos l, Safos G, Safos p. Current
surg cal strateg/es f0r total
implant failure, peroneal n arthrop asty I I va gus knee Woild J 0rthopZAIS;6:469_4g2

instability ¿rt final follorv-up (mean 44.5 months, 2,to 6). 2 Long WJ, Scuderi GB Varus and Valgus Deformtties n: Lotke pA,
lonner JH, eds
Aithough Lrse of hinged prosrheses has been
Knee Arthnplasty, Masters Techniques in 0rthopaedic Surgery.3rr)
LippincottWi liams &Wi kins,2009:11t T25
ed ph adelph a.

\'(rL o--8. \u t.J.\\(.\R\ 20t-


+
#E&flU,&GEñffiF.{,ÁT #&*TÚffiE&t# ¡r'J Fffi§ ÁffiY TÜTAL KruEE A#T'***?L&*7V
Conversion of a unicompartmental knee
3
arthroplasty to a total knee arthroplasty
CAN WE ACHIEVE A PRIMARY RESULT?

:. Thienpont Objectives
Unicompartmental knee arthroplasty (UKA) is a potential treatment for isolated bone
on
'om Uniuersity bone osteoarthritis when limited to a single compartment. The risk for revision
of UKA is
i,tspital Saint Luc- three times higher than for totat knee afthroplasty (TKA). The aim of this review
was to
CL, Brussels, discuss the different revision options after UKA failure.
: tlgium
Materials and Methods
A search was performed for English language articles published
between 2006 and 2016.
After reviewing titles and abstracts, 105 papers were selected for
furtheranalysis. of these,
39 papers were deemed to contain clinically relevant data
to be included in this review.
Results
The most common reasons for failure are liner dislocation,
aseptic loosening, disease
progression of another compartment and unexptained pain.
UKA can be revised to or with another uKA if the failure
mode aflows reconstruction of
the ioint with UKA components. ln case of disease progression
another uKA can be added,
either at the patelrofemorar joint or at the remaining tibiofemorar joint.
often the
accompanying damage to the knee joint doesn't allow
these two former techniques
resulting in a primary TKA. ln a third of cases, revision
TKA components are necessary. This
is usually on the tibiar side where augments and stems
might be required.
Conclusions
ln case of failure of uKA. several less invasive revision
techniques remain available to obtain
primary results' Revision in a late stage of failure
or because of surgical mistakes might ask
for the use of revision components rimiting the crinicar
outcome for the patients.
Cite this article: Bone Joint J 2017:(l Supple A):65_9.
unicompartmental knee arthroplasty (UKA) is the tibial
component. Along with revision for
a surgical option in the management of osteo- unexplained
pain arrd infection, these are the
arthritis (oA) of the knee limited to one com- fr.qu.rt ,.r*r.
for ¡evision.S,e Revision for
partment'1 Most often this is the medial unexplained
pain often leads to more pain
compartment, but in 10%" of cases the lateral after
a.r.* more invasive surgical pá..-
compartment is involved.2 Clinical outcomes dure.3,10 ".rd
of UKA are promising but survivorship with If revisionisnecessary, severaltechnicaloptions
: Thienpont, I\,1D, MBA, revision as an endpoint is not. Registry results are available.
::d of Knee Surgery rh. ti"e of implant ..qrir.d to
- - versity Hospital Saint Luc show that UKA are revised three times more obtain a
lL, Department of
satisfactory'swgical result should be
:hopaedic surgery, Av
often and much earlier than total knee arthro_
- rDocrate'10,'1200 Brussels, plasties (TKA).3 5 The reasons for this can be
:: gtum either obvious technical mistakes made by low
I : rrespondence shou ld be sent volume UKA surgeons, performing often less
:: Thienpont; email:
:-manuel thienpont than 15 UKAs per year 6,7 or the belief of the
: rclouvain be revising surgeon that coversion of a uKA to The aim of this review was to study the differ-
:017 The British Ed¡torial TKA is simple, easy and comparable to a pri- ent surgical
options available to obtain a primary
::
lary TKA, thereby potentially_ reducing the resu.lt after conversion of UKA to a TKA.
? ety of Bone & Joint
: raerv
: 10'1302/0301-620X 998.1 threshold for such a conversion.T
a_J 2016-0272$200 The most common failure modes for LKA are &4áterÉa ls a nc! flúletsi*ds
a.ne Joint J instabilit¡ progression of
disease to anorher com_ trVe
performed an extensive preferred Reporting
:r17;99-B(1 Suppte A):65_9 partmendcompartments and aseptic loosening of Items for Svstemaric Review and \ ler¿_
OL. 99-B, No I , JANUARY 20 t 7
65
a
E. THIENPONT

Harrg e r alll found that UI(A is better revised to TKA than


to ¿rnother UK-\ rvith a mllch lo'nver le-revision r¿te.
;¿2":z-z --,, +:2*x.*+r \:á&.The nlost colnmol.r
=r-z?.é*,.: =:j1:z::::z
tvpe of this surgen is a con'rbination of a medial UI(A r'r'itlr
pateliofemoral arthroplast) (PFA) or combin¡¡ion ot
medial and lateral UKA. The former indication exists ¡s ¡
result of the progressior-r oler time of existing patellofemo-
ral (PF) clisease or the development of l¿teral PF arthritis
due to trochlear c11'splasia. The l¿rtter inclication is related to
disease progression of the lateral comp¿'trtt-nent as a result of
overcorrection of limlt alignnrent. This is rnost often due to
over:stuffing of the extension gap. The fear of poll'ethylene
dislocation in n-robile-bearing UKA can lead to the develop-
mei-rt of this complication in the less experienced surgeon.
In these cases, another UKA can still be implanted realign-
Fig'1
ing the lorver lir-r-rb aucl correctiug osteoarthritis in the to-
Shows failure of PolYethYlene
l
be-treatec'l comparlment.2
and therefore Potential indica-
tion for isolated PolYethYlene Rolston and \tloore2a published a case r'vhere a lateral
exchange UKA u,¿rs convertecl into a tricortpartinlental ioint replace-
ment with retentjon of both cruciates. A bicompartmental
Anah,sss (PRISMA)1t compliant sear:ch in lvlarch 2016 implant (Dcuce; Smith & Nepheu', Nlemphis, Tennessee)
Llsing PubMed, Embase reseerch and Google scholar, look- rvas added for disease progressiort leading to s¿ttisfactor\
ing for English language erticles published betrveen 2006 results for the patient.
and 2016. The search terrns Llsed were "unicompartmental **n ¿+¡::i*tz 2:r: :z ?r:',r,'+:'{ 7{"9.lf bicompartmentaI clisease

knee arthroplast-v"; "unicompartmental knee replace- to :r primar,v TI(A can be


progressior-r occLlrs, conversiolt
ment"; "revision knee :rrthroplast,v"; "failure of unicom- perfomed. Either a crLlciate retaining (CR) or postero-
partmental knee arthroplasty". \ü7e reviewed the list of titles stabilised (PS) implant can be used. In cases rvhere the tibial
and selected :r11 papers r.vith rele'n'ant abstracts. This search cur in the UI(A i.r'¿rs consen,ative, further bone cuts for a
led to 3208 citations ft¡r initial ¿lssessrrent. After revierling TKA can make the implantation of a primarv TI(A possi-
titles and abstracts, 10-5 papers r,vere selected for furthcr ble. C)ften this is possible in a r,vell-erecnted UKA that pre-
analysis. Of these, 39 papers urere deemecl to contain clini- sents rvith infection, earl,v aseptic loosening or unidentifiecl
call1, relevant data to be included in this review. patn.
Khan et alr't for-l-rd that 78% of conversions from UKA
*É**a*eir;* to TKA could be perfornred r.vith CR implants. In 8% of
tl\&.x*
?,evisi*zz r:t ;LLlz, This tvpe of revision is rare. In the cases they r-reeded revision components in particular tibial
Iiterature this is mostl,v reported as either case reports or stems rvith or rvithout tibial augments.
case series.l2'16
1s 16. following scenarios c¿rn be cor-rsid- Craik et alll obsen,cd a 5.-l% revision rate at 25 months
ered. Liner change could be an oPtioll in case of mobile for UKAs perforrned at their institution. The most common
bearing dislocation r,vith revision to a thicker polyethvl- re¿sons for revision were ¿rseptic loosening and progression
ene.1e Another case u,ould be u,ith isolatecl polyeth,vlene of osteoarthritis. Of the converted Ul(As, 349o of patients
wea! diagnosed ear11', and revised before metal-on-metal needed a conversion to ¿r revision tvpe of TI(A with ar-rg-
wear or osteolr,sis could nccur (Fig. 1). Luneboltrg et al20 ments, stenls or bone grafts.11 Robb et a126 found the same
described their results for isolated liner exchange in wcl1- revision rate of 57o at a me¿rn of three 1'ears. ln bToo of
fixed metal-b¿rcked fired-bearing UI(A. A total of 20 cases, primary colllponents could be used. In 33% revision
mediai UI(As revised ¿rt mear of 8.2 standard deviation (s») components r.vere needed u'ith the majoritv on the tibial
2.6 1,ears r,vere clinicallv assessed.20 In total,79'A oi side. Sierra et al27 also found a re-revision rate after revision
patients were enthusiastic or satisfiecl and a sun'ival rate of TKA frorn UI(A of '1.5% at an average of 75 months fol-
71'A (sD 15%) cc¡nsidering revision for any reason \\¡as loiving UKA. The,v observed at this time after surgery asep-
obtained at 12 years.20 UKA to UI(A can also be perforn-red tic loosening of components (55 % ) and disease progression
in case of early aseptic loosenir.rg of a single component.lT (34%) as the most corlmon reasons for f¿ih-rre. Polyethyl-
Epinette et al2t r.vere able to revise 36 out of 425 (8.5%) ene \\¡ear (4'%)and ir.rfection (3%,)rvere rare.l'Seldenha et
UKAs to another UI(A. They also found a re-revision rate al2t found the same causes of failure for the mobile UI(A.
of 8% due to aseptic loosening in this rer"ised group. At Leta et a12e anal,vsed the outcomes of UKA after aseptic
eight years follow-up, clinical outcome for the UKA to re-nision to TI(A (n = 578) in the Norri'egian Arthroplast,v
UKA revision grorr.p was satisfactory rvith high l(nee Soci- Register and compared them to r-evision of TKA to TI(A
ety Scores.2L Analysis of the Ar-rstralian Joint Registry b.v (n = 768). The ol'era11 rate of revision (UKA to TKA, 12%

CCTR SIIPPLE\,IENT IO THE BON I] & JOINT JOURNAL


C]O.\\¡ERSION C)F ,\ UNICOIIPART]\]FNT.\L I(NEI ARIH]{OPLASTY TO A TOÍAL KNEE \RTHR\].-L -i \

Fi7 2 Fis,3

Unicompartmental knee arthro- Revision total knee arthroplasty of


plasty with low tibial cut, varus case shown in Figure 2 with medial
angulation and tibial stress frac- block and tibial stem.
ture because of important varus
alignment

and TI(A to TKA, 13o/o) lr,as comparable with a ten l'e¿1r ir primary component and arrtograft to fill the contair.red
survival oi 82o/,, and 81'% respectivel,v. The risk of re-revi- defects.3l Osteolysis is not alwal,s present and levisior-r
sion was tr'vo times higher for TKA to TKA in pirtieltts o\ er components rr-right be necessary as a result of technicaI mis-
70 years old (risk ratio (RR) 2.2). The reasolrs for re- takes ¿t the inder surgert'. It ca¡ be secondarl, to e\cessivc
revision of UI(A to TKA grorlp and for TKA to TI(A groLrp varLrs, excessive posterior slope or due to a dor.vnsized tibial
were tibial loosening (28"A uerstts 17%), pain alone (22'Á tray having no cortical support resulting in subside¡ce and
uersus l2o/u), instability (19o6 uersus 19%) and deep infec- bone loss (Fig.2). Meclial bone loss can also occllr at the
tion (16% uerstrs 31"A, RR 2.2) repecti\reh. The observed time of cornponent removal or in the presence of a tibial
diferences were not significant except for deep infection keel.ri)
which was significantlr, higber for the TKA to TI(A group Since both the posterior and anterior cruciate ligaments
(RR 2.2, p = 0.03) The surgical revision procedure took are intact, a UI(A can most often he converted to a PS TKA
more time for TI(A to TKA revision (mean 1-50 minutes lvithc'rut the need for more constraint. Increased constraint
uersus 714 minutes) and required more stenrs (58'% r¿rsz,. to the level of a condi'lar constrained kr.ree lvill onlr, be nec-
19%) and more constrairt (27o1, uersus 9Yo).)') essan. if important gap mismatches erist. Sarraf et al32
Cerciello et a1-10 shor,ved that the medi¿rl bone loss after found that constraint was necessar,v in 4.2'/' of UKA to
failed medial UKA can be grafted r'vith autogr:tft comirrg TKA conversion, lvhile this vnas only necessarl' for' 2?o of
from the lateral tibial plateau. In these cirses prirnar:v TKA prin-rarv TKAs. UKA to TI(A conversion u,as accompanied
componellts can be used. bv the use of thicker polycthylenes (12 mm instead of 10
Unexplained pain is a major cause for conversion from mm).32 Rancourt et al33 also observed the need for thicker
UI(A to TKA and if remov¿rl of components is performed polyeth),lenes and found lolver \üTestern Ontario and
conservatively', primarl. TKA components can be used. The McNlaster Universities Arthritis [nder scores and techni-
'§fl'nn
hazard r¿rtio for conversion of UI(A for ttnexplained pain is cal11,, a more difficult procedr-rrc. Jones et alsa
6.76 compared to TKA.I Hor.vever I(erens et al r0 sho'nn,ed obsen ed th¿rt UKA to TKA conr''ersion u.ith a thicker polv-
that surgerl' for unerplained pain leads more often tcr ethylene rvas related to the initial pol,veth,vlene thickness of
run:erisfector) result\ afrer rttrg,err. the UKA ¿rnd that these thicker poll,ethylene cases more
**s.:u+rsie n t* a T?-§, ts=i*q ravisi*tz .*z?**{}a='z*. A revision often rreeded an aLrgment or a stem.
TI(A (rTKA) r'vith stems and augments might be necessarv I-une bor-rrg et all2 compared surgical characteristics, clitti-
r,vhen converting a UI(A that presents r.vith c¡steolvsis. cal outcomes and complications ¿t an average of se\-cn r erlr''
Reconstruction rvith a nretal augment r.viII help restore the (so 4) follorv-up after: con\rersion of UI(A to TKA. a¡.l
joint line to the primarv 1evel of the contralateral side. The four.rcl results more similar to a rer.ision TI(A than to : :- -
augment usually needs a stem extension because of limitcd mary TKA. Schr'varzkopf et a1'15 studied the ler el of '
contact to the cut surface of bone. The distal segrnent of resection in UKA and four-rd that a more agqrc!> . -
bone is often sclerotic and hard limiting cement inter- resection was corrclated highlv r'vith thc neei :, - :. - '
c{igitation. The fen-roral side can often be reconstructed u.ith augments (odds ratio 26.8) (Fig. 3). O'Do . -
I
\/Ot . 99 B. \o t, J.\NUARY 201;
E IHIE-NPONI'

, P:I:lll,perheram T. Avery pJ, Gregg pJ, Deehan DJ.


Bevision r une¡.
añá totá tnru'*prl.rrnt J e ri¡, B
3f,;iijifi[fingrnicompaitmentat

tota knee arthroplasty a systematic r


u ,::1,."O1,^tirdir H, Judge A, Murray DW. 00r,r¡d
,soqe o, ,r rorp¿
",,Pe¿,l]f0plo.t,o.L,dr0f4.l,9B6ae:+-o¡treNa1o.a,'JOr.Pog;','
r¿,0¿ dAo,e .Bo-cJauJ)A)59/B:
¡06 lrti "'

11. Craik JD, El Shafie SA, Singh


VK, Twyman BS. vision of Unicomparrmen.:
Versus piimary roú'i-«n,u- iÉ,.pr,,iv J
i;i;rd;U1Bf;. Arthroptas

12. lunebourg A, parratre S, 0llivier M, Abdel


Mp,
u ,Lo,od.r. ó,,t¿, r "" a¡¡r-6¡ ¿51," \4orp r,ie Argenson JN. A rsions --
É:;";";;''qe
!' u' I
'_L
Á.
Atthr0plasty\0l|:30:1995 1989 "

,4 WB il, Steinberg J, Schotres S, Mcnamara


lTll! -,,
, Sre0ol'L dA"-.t,dtil "d .o .-e,1" . rene"
tB. [,4edial c

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. ;,-i; :;:;,,
d.r, dn¡ ,,,n,.0,01 ";;;'-,";";";
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15. No authors l¡sted. BiSl\lA statement http//wwwprisma
last accessel'l starement org/ (d;..
I 6 Auo t 20,l 6)

18. Lecuire F,
unicompa
a
total rep acemenl '-
al k¡ss p¡65¡ftg515 .
reasonabie
/2013;23 933 3;E
19. Kim sJ, po

Author contributions:
E. Thienpont: Beviewed the literature and !vrote the paper
21. Epin Sarag^aglia D, pasquier G, Deschamps
Frqn et du-GJnou.
, G; Soc¡été
royaltjes on a patent on persona partia ievrs ;¿; ;;;;;r"io., ,.:,"pr,,.,.
a relrable opton? tlase-coftrao) ,tuii.
Surg lrthop T,ur^r.,
The author or one or more of the 5.
a_uthors have recervect or wi I receive
for personal or professional use.from benefits 22. Hang JR, Stanford TE, Graves
S.E, et aL Ollcome of revision of ullcor¡partme¡..
ind¡rectly to the subject of th,s article. " "o._"r"iuioJir'ru,r,"o directly or knee rep acemeft. Aüa ArthopZ0l0;g1.98
9g.
This article was primary edited by 23. Pandit H, Mancuso F, Jenkins
S Kutty, C, et al.
ap-r ro ihó r.earlF1.0,r,1r,t,, Lateral compartmenta knee rep ac_
This paper is based on a studv wh¡ch o.áq."ii,o; ;;r?.,. rco-np¿.r_F..
reptacement Knee Surg Sparts r,uurutotÁ,tn,ii^ á tiprt u¡iro
was presented at rhe nd annual Winter
3,I ?".iji;T".;lTpts
in Jo¡nr n"pru"".*i.u";;;;"i; órrando, Frorida,
ot pi.lntl

cruclate retain jng trjc0mpartmental


knee

*efer*fi**s
26. Robb CA, Matharu GS, Baloch
K, pynsent pB. Bevtsron surcerv
Do'lnFIldl o",ep'd'pnórtL for fail
tec T.¿,¿)DeLlJU Or;l aolJrtro"a q
Be'q /013, 9:J rl- 3 I /

CICJR SUppLE\,tENf TO THE


BONE s{ JOINT IOUII\ r