Brown, Timothy S.

Introduction: Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty (TJA), with treatment failure occurring in 12% to 28% after 2-stage revision. It is vital to identify diagnostic tools indicative of persistent infection or treatment failure after 2-stage revision for PJI. Methods: The Cochrane Library, PubMed (MEDLINE), and EMBASE were searched for randomized controlled trials and comparative observational studies published before October 3, 2021, which evaluated the utility of serum/plasma biomarkers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], interleukin-6 [IL-6], fibrinogen, D-dimer), synovial biomarkers (white blood cell [WBC] count, neutrophil percentage [PMN %], alpha-defensin [AD], leukocyte esterase [LE]), tissue frozen section, tissue culture, synovial fluid culture, or sonicated spacer fluid culture indicative of persistent infection before the second stage of 2-stage revision for PJI or treatment failure after 2-stage revision for PJI. Results: A total of 47 studies including 6,605 diagnostic tests among 3,781 2-stage revisions for PJI were analyzed. Among those cases, 723 (19.1%) experienced persistent infection or treatment failure. Synovial LE (sensitivity 0.25 [0.10-0.47], specificity 0.99 [0.93-1.00], positive likelihood ratio 14.0 [1.45-135.58]) and serum IL-6 (sensitivity 0.52 [0.33-0.70], specificity 0.92 [0.85-0.96], positive likelihood ratio 7.90 [0.86-72.61]) had the highest diagnostic accuracy. However, no biomarker was associated with a clinically useful negative likelihood ratio. In subgroup analysis, synovial PMN %, synovial fluid culture, serum ESR, and serum CRP had limited utility for detecting persistent infection before reimplantation (positive likelihood ratios ranging 2.33-3.74; negative likelihood ratios ranging 0.31-0.9) and no utility for predicting failure after the second stage of 2-stage revision. Conclusions: Synovial WBC count, synovial PMN %, synovial fluid culture, serum ESR, and serum CRP have modest sensitivity and specificity for predicting persistent infection during the second stage of 2-stage revision, suggesting some combination of these diagnostic tests might be useful before reimplantation. No biomarker or culture accurately predicted treatment failure after reimplantation. Level of Evidence: Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Many surgeons are reluctant to use a constrained liner at the time of acetabular component revision because of concerns that doing so might result in early acetabular component loosening related to high bone-implant interface stresses transmitted from the constrained liner. We hypothesized that, with appropriate initial implant stabilization using highly porous acetabular components with robust supplemental screw fixation, constrained liners could be safely used at the time of acetabular revision. Methods: We retrospectively identified 148 revision total hip arthroplasties (THAs) in which a constrained liner of 1 design was cemented into a newly placed highly porous acetabular component fixed with supplemental screws (mean, 5 screws). The mean age at the time of revision THA was 69 years, and 68% of the patients were female. The most common indications for revision were 2-stage reimplantation (33%), recurrent dislocation (30%), and aseptic loosening of the acetabular component (22%) or both the acetabular and femoral components (9%). The mean duration of follow-up was 7 years. Results: There were no failures at the bone-implant interface. No cases of acetabular metal shell loosening were identified on radiographic analysis. The 10-year survival rates with acetabular revision and any reoperation as the end points were 75% and 67%, respectively. Overall, 33 hips (22%) required revision or reoperation because of infection or wound complications (n = 12), dislocation or mechanical failure of the constrained liner (n = 11), periprosthetic femoral fracture (n = 4), femoral loosening (n = 3), or other reasons (n = 3). The 10-year survival rate with re-revision for instability as the end point was 88% overall, which was similar to the 85% 10-year survival rate with re-revision for instability as the end point among hips that were specifically revised because of instability during index revision THA (p = 0.9). Conclusions: Implanting a constrained liner at the time of acetabular revision in high-risk patients resulted in no cases of aseptic metal acetabular component loosening in this large series. This finding is likely related to the fact that a highly porous acetabular component was utilized with robust supplemental screw fixation in each case. Such information is valuable as these data favor a paradigm shift when compared with some traditionally held tenets. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Introduction: Paget’s disease affects 3–4% of the population; however, literature describing outcomes of total hip arthroplasty (THA) in this population are limited. Given the known concerns with bleeding, heterotopic ossification (HO), and component loosening, we describe our results with primary and revision THAs in Paget’s disease with emphasis on implant survivorship, radiographic results, and clinical outcomes. Methods: We identified 25 THAs performed with contemporary uncemented acetabular components in patients with Paget’s disease from 1999 to 2014. Mean age and follow-up were 78 and 7 years. Results: In primary THAs, survivorship free from aseptic acetabular and femoral loosening was 100% and 94% at 8 years. 7 patients (41%) received blood transfusions. HO was seen in 9 (53%). Mean Harris Hip Score (HHS) improved from 49 to 76. In revision THAs, survivorship free from acetabular and/or femoral aseptic loosening was 100% at 5 years. 3 patients (38%) received a transfusion. HO was seen in 5 (63%). Mean HHS improved from 52 to 77. There were no radiographic signs of aseptic loosening among unrevised cases in either group. Discussion: Our investigation demonstrates that concerns with acetabular fixation in Paget’s disease have been mitigated with contemporary uncemented acetabular components. Complications previously noted, namely intraoperative bleeding and HO, continue to be of concern.

Background: Cementation of a constrained liner is a viable option for treating instability after total hip arthroplasty (THA) when the acetabular component is well fixed and well aligned. However, concerns regarding long-term mechanical failure and recurrent instability remain. The aim of this study was to evaluate the long-term survivorship, complications, and clinical and radiographic outcomes of constrained polyethylene liners cemented into well-fixed acetabular components at the time of revision THA. Methods: We identified 125 cases in which a constrained liner of 1 design was cemented into a retained, osseointegrated acetabular component during revision THA between 1998 and 2006. The mean patient age at revision was 70 years. Mean follow-up was 7 years. Survivorship data, risk of instability, and clinical and radiographic outcomes were analyzed. Results: Survivorship free from revision for instability was 86% at 5 years and 81% at 10 years. Survivorship free from aseptic acetabular component revision was 78% at 5 years and 65% at 10 years, with the most common failure mechanism being dissociation of the constrained liner from the acetabular component. Survivorship free from revision for any reason was 76% at 5 years and 60% at 10 years. The most common complications were instability and periprosthetic joint infection, with cumulative incidences at 7 years of 18% and 11%, respectively. Harris hip scores did not significantly improve. Cup position did not affect implant survivorship or risk of dislocation. Conclusions: Cementing a constrained liner into a retained acetabular shell at the time of revision THA has durable long-term results, with 8 in 10 patients free from instability at 10 years. Aseptic acetabular survivorship was worse (65%) at 10 years, primarily due to dissociation of the constrained liner from the acetabular component. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

AimsReconstruction of the acetabulum after resection of a periacetabular malignancy is technically challenging and many different techniques have been used with varying success. Our aim was to prepare a systematic review of the literature dealing with these techniques in order to clarify the management, the rate of complications and the outcomes.Patients and MethodsA search of PubMed and MEDLINE was conducted for English language articles published between January 1990 and February 2017 with combinations of key search terms to identify studies dealing with periacetabular resection with reconstruction in patients with a malignancy. Studies in English that reported radiographic or clinical outcomes were included. Data collected from each study included: the number and type of reconstructions, the pathological diagnosis of the lesions, the mean age and follow-up, gender distribution, implant survivorship, complications, functional outcome, and mortality. The results from individual studies were combined for the general analysis, and then grouped according to the type of reconstruction.ResultsA total of 57 studies met the inclusion criteria and included 1700 patients. Most lesions were metastatic (41%), followed by chondrosarcoma (29%), osteosarcoma (10%), Ewing’s sarcoma (7%), and multiple myeloma (2%). The techniques of reconstruction were divided into seven types for analysis: those involving a Harrington reconstruction, a saddle prosthesis, an allograft and allograft prosthesis composite, a pasteurised autograft, a porous tantalum implant, a custom-made prosthesis and a modular hemipelvic reconstruction. The rate of complications was 50%, with infection (14%) and instability (8%) being the most common. Mortality data were available for 1427 patients (84%); 50% had died of disease progression, 23% were alive with disease, and 27% had no evidence of disease at a mean follow-up of 3.4 years (0 to 34).ConclusionBoth the rate of complications and mortality are high following resection of oncological periacetabular lesions and reconstruction. Many types of reconstruction have been used with unique challenges and complications for each technique. Newer prostheses, including custom-made prostheses and porous tantalum implants and augments, have shown promising early functional and radiographic outcomes. Cite this article: Bone Joint J 2018;100-B(1 Supple A):22–30.

Advances in polyethylene (PE) in total hip arthroplasty have led to interest and increased use of highly crosslinked PE (HXLPE) in total knee arthroplasty (TKA). Biomechanical data suggest improved wear characteristics for HXLPE inserts over conventional PE in TKA. Short-term results from registry data and few clinical trials are promising. Our aim is to present a review of the history of HXLPEs, the use of HXLPE inserts in TKA, concerns regarding potential mechanical complications, and a thorough review of the available biomechanical and clinical data.Cite this article: Bone Joint J 2017;99-B:996–1002.