ffi F*ffiHw*ffim
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.:
CCJR - an enduring learning continuum
I would like to take this opportunity to wel-
come the readership of The Bone ü Joint Jour-
nal (BJJ) to this fifth annual supplement which
contains hip and knee reconstruction contribu-
tions from the 32nd Annual Current Concepts
in Joint Replacement (CCJR) §Tinter meeting
held in Orlando, Florida in 2015.
CCJR's unique educational meeting format
has contributed to the hip and knee arthro-
plasty education of thousands of orthopaedic
surgeons around the world over the last 33
years. These supplements serve as enduring
written extensions of this continuing activity in
medical education. Its intent is to make aspects
of the meetings' commentaries available to the
journal's global readership.
A1l papers have been peer reviewed by both
- S Greenwald, members of the BJJ and CCJR Editorial Advi-
i rri (Oxon), Course Director
--ent Concepts in Joint sory Boards. In this fifth supplement you will
::r acement, Cleveland Ohio,
18 find commentaries related to topical practice
issues of our day encompassing primary and
: -'espondence should be sent
:: S Greenwald;e-mai :
revision hip and knee arthroplasty outcomes as
:::_ g cclr com well as implant selection, fixation options,
--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-
:-30s200 ologies inclusive of clinical papers, debates,
: : '¿ Joint J surgical techniques and discussions focusing
- - I 99-B(1 Supple A):1 on challenging cases where arthroplasty is an
31
50
65
:!-B.No 1.JANUARY2017
advocatcd solution, ¿rs rvell as facuJty discr-rs-
sions of papers presented at recent interna-
tional meetings. This supplement contains 11
paper selections from these formats. It is hoped
that this st1'1ised approach r,vill assist in the
appreciation of a still very much evolving dis-
cipline.
No undertaking of this magnitucle occurs in
a vaculrm or reflects the effort of a single per-
son. It is s,ithout doubt that this supplement
owes its creation to the dedication exhibited b,v
Christine S. Heirn and Karen L. Lizanich of
CCIR, as w'ell as the timely revie'nvs of the B.lJ
and CCJR Editorial Aclvisory Boards. Both
Fares Haddad, Editor-ir-r-Chief, and Peter
Richardson, lvlanaging Director, of the BJJ are
thanked f<¡r their continued support.
Lastl-r,,, it is my hope that you, the reader, will
gain from the clinical and surgical erperiences
of the authors r,vhose ongoing dedication to
continuing orthopaedic education is reflected
on these pages and sets a tone for enduring
learning in our discipline.
A. Seth Greenrvald, D.Phil.(Oron)
Course Director
Current Concepts in Joint Replacement@
Cleveland, Ohio, United States
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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

-
 D J. BERRY

F quré trg c!mubbre Perce.l R€vson of PnñaryToEl xneeReplacém€ñt(PflmáryD ¿qnossOAl

hqureB16 CuñulábvePercenlRaroñorPrmáryToGlConvenro¡ariPRep¿ceñent(PrmaryDaqnostrOA)

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-l

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

 IoINT
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e
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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.
Fig.5
Graph showing cumulative rate of rev¡sion of total knee
arthroplasty (TKA) for infection Modified with permis-
sion from the Swedish Knee Arthroplasty Registry,
Annual Report 2013 Elvins Grafiska AB: Helsingborg;
20'14
. rsion for infection after TKA is almost twice as common
¡en as women (Figs 4 and -5).1'3 Whi, should this be? It
.::::s unlikely to be a spuriolls observation, bec¡use it is so
. .istent in registries that publish this information. lnter-
- :rgl\-, recent data from the Ner,v Zealand Joint Registrl.
-- rhe Kaiser Joint Registry show similar findings.i'6 This
:-:rr¿rtion has previouslv attracted little attention. lt can
- r ils fertile area for the generation and testing of
r,)theses with more detailed research, and n,ill hopefully
-i ro interventions that reduce the risk.
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§
.-.:r Í{-É+ Él'ca* older pat;Énts" A comparison of cun'es of
, :..lative rates of revision show' modest differences
- ien voung and o1d patients after modern THA for the
- .lecade after surgery,. Thereafter the cnrves diverge,
f : \'oung patients requiring more revisiofls than older
Y .rrs. pr:obably due to increased activitv (Fig. 6a).1 The
, - :s of cumulative failure after TKA follow a dramati-
I , liiferent pattern (Fig. 6b).1 For both men and \Á¡omen,
1 -:er patients have much higher: rates of revision after
t : . er en in the first decade, and the curves diverge
':, \o .J.\NUARY2017
RFClrSTRrr.S
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e riHi!6Éq,s46,
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Fig 6b
Graphs showing cumulative rate of revision for any reason after
total hip (a) and knee (b) arthroplasty stratified by age Repro-
duced with permission from the Australian Orthopaedic Associ-
ation National Joint Replacement Registry, Annual Report
AOA: Adelaide; 20'15
further \\,ith the passage of time. Not only are the rates of
revision higher in young patients, but also, data from the
United Kingdom National Joint Registrv shou, that patier.rt
reported outcomes (PROMs) of TKA are more variable in
younger compared rvith older pxtienrs (I'ig. z¡.: An impor-
tant caveat to these findings is that the collection of
PROt,Is b,v registries is in its infancy and the validity and
value r'vithout cornplex risk adjr-rstment is yet to be deter-
mined. Nevertheless, taken together, these observations
suggest an irnportant role for shared decision n-raking u.ith
yoLlng patients that incorporates discr-ission of these con-
of the technology of TKA, nr alternative surgical strategies
to meet rhe llecdr of v9x¡gs¡ petienrs.
****rz¡ati*r¡ E
ItJew i*ci'¡n*E+*V eiir: have **i{}r *e*.-:ri:;z*i *ffest $n il'?e
=
**lcafl1* *f art\r*plaety As THA ancl TKA have become
more m¿rture, rates of success har-e lncreased, thr-rs making
further dramatic improvements nlore difficult. Some recenr
papers shorved little implovenrent in outcome dr-rring the
last decade with neu' implants.''8 Ho.nvever, the specitic
qrlestions asked and t1-re periods of time rvhich u-ere srudieJ
 I) I BTRRY

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m <55 m 5t59 m 60-54 m 6540 m 70-74 m 75.70 m gO+ MMNl

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

lfi IMdHL!,o,1*4:

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

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

 JOI\T
*-;;.
: cesses?" allor,ving us to capitalise on and adopr rhem.
: ,.'
Z-"
¡"*
Fig 10
Graph showing ceramic femoral head use in different
patient age groups by year. Reproduced with permission
from the American Joint Replacement Beg¡stry American
Joint Replacement Registry Annual Beport 2014 Ameri-
can Joint Replacement Registry: Fosemont, lllinois, 2015
,)r lack thereof) lnay or mav not arise from causalitv. Man\r
-,
pes of bias can affect such associations inch-rding selection
'.res, performance bias, ancl in some cases, reporting bias.
.:rreractions arnong variables ma,v be difficult to tease
The stratification of risk has often ror been per-
,--'-r:lrt.
t rrmed or ma)¡ be rudimentarr'. Finalll', registrics tvpicall,v
-.:c revision as en elrdpoint ancl other outconre measLlres
:.r.h as pain relief and function xre equall,v or poss¡bl)'
rrore lmportant to nlan\. patlents.
The six examples cited aboi.e onh' represent ¿r fer,v obser-
-lrions that calr be made bt'carcfLll revie\\,of current dat¿r
:orn joint registries. As the baseball sage and pundit Yogi
lcrra apparently saic'l: ",vou can reallv observe quite a Jot,
-rst b¡ looking". In depth cvaluation of pub1ic1,v available
-:qrstr,v data, cross referencing of thc data benveen
-gistries for validation, and the thoughtfr-rl co¡sideratiolr
1rotcntial erplanations and rarnific¿rtion of findings, can
:.1c1 to improvements in practice and thc gcneration of
\ potheses for furthcr study. These c1¿rta allou, orthopaedic
:-rrgeons to ask ",uvhere are the current unsolrred prob-
.nrs?", so that \\¡e can attack them and try to fir them.
iL 99 B, No l, JANLIARY 201;
RECISTRIES
These data also allorv Lls to ask "rvhere are our currelrr srlc-
arthroplasty surgeons and their patients.
Author contribut¡ons:
D J Berry: Writing the paper, Content development, Data acquisition and anal-
ysrs
The author or one or more ofthe authors have received or will receive benefits
for personal or professional use from a commercial party related directly or
indirectly to the subject of this article
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
7=*l*r*z-,***
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
ast accessed I 4 Ju y 201 5)
2.No authors listed Nationa Jont Fegistry l2t Annua Bep0rt,20T5 httpr/
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)
3. Sundberg M, Lidgren L, W-Dahl A, Robensson 0. Swed sl¡ Knee Artrrop astl
Reg stry Anrual Report 2013 http//myknee se/pdf/SKAB2013 Eng pdf ldate ast
accessed 14Ju y20T6)
4. Wagner ER, Kamath AF, Fruth KM, Harmsen WS, Berry DJ. Effect of body mass
irdex on complicat ofs and reoperatl0ns after total rip arthroplasty J Bone Jot¡t
Surq [Am]2016',98 A:l 69 1 79
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
Joint Surg [Ant]2A13,95 A.115 182
6. Tayton EB, Frampton C, Hooper GJ, Young SW. The mpact of pat ent and surg cal
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
7. Anand B, Graves SE, de Steiger RN, et al. What is the be¡ef t of introducing nerrr
hip ard knee prosthesesT J Bone Jotnt Surg [Ar¡l20T 1;93 A.51-54
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-
tematjc revlew of five wide y used dev ce technologies BMJ 201 4;349.5 I 33
9. No authors listed. Amer ca¡ Joint Bep acement Registry Annua Beport 201 4 http:/
/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)

&
O Mobile pump deep vein thrombosis
ÉJ
J. Haynes,
R. L. Barrack,
D. Nam
From.Washington
Uniuersity
Orthopedics,
Missouri, United
States
J Haynes, MD, Resident
Physic a n
F L Barrack, ¡.¡D, Professor
D Nam, l\4D, MSc, Assistant
Professo r
Wash ngton University
Ofthopedics, Barnes Je\.,lsh
Hospita ,660 S Euc d Avenue,
Campus Box 8233, St Lou s
MO, 63110. USA
Correspondence shou d be se¡:
to D Nam; email:
namd@wudosis wustl edu
O2017 The British Editorial
Society of Bone & Joint
Su rgery
doi:10 1302/0301-620X 9981
BJJ-2016-0165 R1 $2 00
Bone Jo¡nt J
2017;93 B(1 Supple A):8-'13
8 CC'TR SUPPLF-I\,II,NT TO THE BONE
ñ Aá\Jtr§GT,&T§&Ed
I= prophylaxis
JUST SAY NO TO DRUGS
Aims
The purpose of this article was to review the current literature pertaining to the use of
mobile compression devices (MCDs) for venous thromboembolism (VTEI following total
loint arthroplasty (TJAl, and to discuss the results of data from our institution.
Fatients and Methods
Previous studies have illustrated higher rates of post-operat¡ve wound complications, re-
operation and re-admission with the use of more aggressive anticoagulation regimens, such
as warfarin and factor Xa inhibitors. This highlights the importance of the safety, as well as
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
specificalll', rates of sl,mptomatic VTE follorv- safety and efficacy. In contrast, ACCP guide-
ing total hip arthroplastl' and tot¿ri knee
lines classically emphasise d efficacy, with the
arthroplastv range fron-r 0.83%, to 15% and primary outcome measure being prevention of
2oA to 107o, respectively.47 Based on these a venographic DVI regardless of the presence
d¿1ta! solre form of VTE prophylaxis is indi- of symptoms. However, in 201,2, the updated
cated follou,ing TJA. The purpose of this arti- ACCP guidelines more closely reflected those
cle is to provide a revierrn, of the current put forward by the AAOS, with both now
literature pertaining to the use of mobile corr- focused on the reduction of fatal and sympto-
pression devices (MCDs) for VTE follor.ving matic VTE events.10,11 This was an important
TJ-\. and discuss the results of data from our philosophical shift, as both guidelines now rec-
r nstltL1t1On. ognise the importance of tailoring the prophy-
Historicallr'. there rvas a difference in the laxis regimen to the patient based on both their
philosophl- in gLridelines for VTE prophl,laxis safety and eÍfícacy.
betr.veen the Americ¿rn Acaden-rv of Ort}ropedic The safety profile of VTE prophylaxis regi-
Surgeons (AAOS) and the American College of mens are important following TJA, especially
& ]OI\T JOL]RN-\L
 llOtslLL PU\lP Dl-EP
- rhe current climate in rvhich penalties and rewards are
r,r\ecl on complic¿ition and re-admission rates. Thns, the
:umal VTE prophylaxis regimen is simple, effective, easy
, monitoq and has a high degree of patient compliance.
.':rriarin, an inhibitor of Vitamin K-dependent clottir-rg fac-
,:s. has historicalll,been used for VTE prophl,laris follorv-
-,1 TJA.2 However, rvarfarin is notoriouslv difficult to dose
.s pharmacokinetics va¡1' rvidell' betrveen patients based on
:.netics, body mass index (BMI), drug interactions and
,- e r.'! One recent investigation for-rnd that over a for-rr r'r.,eek
::riod, patients maintained a therapeutic international nor-
:r¿Lised ratio (INR) onl¡, 50%, of the time f osr-
:eratively.l2 Additionallv, the use of lvarfarin peri-
,'-¡eretively has been shor.vn to increase the rate of lvound
,-:ainage, infection, re-operation and revision surgerl, fol-
,,,r ing TJA.13 Lor.v molecular rveight heparin (LNI\IH), an
:r.eversible inhibitor of clotting factor Xa, has also been
..ed for VTE prophylaxis and is simple to dose and does
ot require monitoring. Holvever, its use has ¿rlso been
.'sc¡ciated with increased operative site bleeding and higher
-.rtes of transfusion following TfA.8
l'Í, **iÉ* ** rft presÉ;** dÉqr;cÉg
:rtermittent pneumatic compression l-ras been shown to
rcrease the velocity of venous l¡lood flow in the lorver
:'\tremities and increase local and systemic fibrinoll,sis,
i.rus decreasing the incidence of s,vmptomatic VTE
:rentS.14 Prior limitations to their use included their large
.rze and lack of portabilityi but now rnultiple companies
:.ranufacture MCDs i,vhich are lightr,veight, portable, and
- ln be worn during ambu]ation. Pierce et all'in a s\srem-
.ric review of lorver extremity compression devices, found
lat l¡elow-knee intermittent compressive clevices that
,,rk by synchronising culti eontr¿ction to respir.rtorr-
¡lated venous phasic flor,l, signal, had the highest level of
.r idence to srlpport use in VTE prophylaxis, as .,vell as the
:ighest levels of patient compliance, ease of use, and com-
:Liance with the AAOS, ACCP and Sr-rrgical Care Improve-
'.rent Project (SCIP) guidelines. Furthermore, ma jor
,.1\'antages of MCDs include that there is no increased
:leeding risk and patient compliance w,ith use can be mon-
:ored on the device.
Studies have shown the benefits of pneumatrc compres-
.ion for mitigating VTE risk following TJA. A total of four
.¡.rall studies from roughly 25 ,vears ago fourd an overall
:isk reduction of 56%, for post-TJA VTE with the r-rse of
--.neumatic boots, hor,",ever these were small studies ivith a
:,.rmulative study population of roughly 110 patients.l6 le
Furthermore, the compressiol devices used in these inr-esti-
:.rtions did not h¡ve rhe cepacirl' to monitor respiretorl-
-elated venous phasic florv, and thus generate compression
r.L svnchronisation with this flou,. Synchronisation of com-
'-.ression rvith respiratory-related venous phasic flolv has
..een shown to increase the peak venous velocitl, b.¡ 66t/".ts
L Cohvell et al20 have recently published tr,vo, multi-centre
I .tudies evaluating the effectiveness of mobile compression
I 'l oqB.\,, l.T\NI \R\ l0t-
!El\ fHROr\lIlOSl5 PROPHYL-\\IS
devices for VTE prophylaris follou,ing TJA u-ith rl.re use of
a slnchronised NICD der.ice. The first, a multi-centre. pro-
spective, randomised controlled trial, compared the use oi
MCDs ."vith lorv molecular rveight heparir-r in ¡r¡¡1s¡¡5
ur-rdergoing priman', elective total hip arthroplasty (THA).
All patients received their prophvlactic regimen for a period
of ten da,vs post-operatively., and 6I'A of patients in the
MCD cohort also received 81 mg of aspirin based on the
surgeon's discretion. Efficac,v was determined based on the
results of a screening lor,ver extremity ultrasound con-
ducted at ten to 12 days post-operativel.v of bilateral lorver
ertremities. The stud.v found no significant difference in the
rates of VTE betrveen the MCD (5%; ten ctf 197 THAs) or
L\,I§IH groups (5%; ten of 192 THAs; p = 0.9). Hou,ever,
the rate of major bleeding events were higher in the LM§lH
(6"4) uersus NICD (0%; p = 0.0004) cohorts. Furthermore,
there was good compliance ."vith NICD use in the studv
population, with a mean use of 20 hours per da1..20 Ur-rfor-
tunatell., this studr- i,vas limited b,v the fact that 61% of the
MCD group also received aspirin and that the studl' rvas
powered to assess differences in bleeding rates, not s),mpto-
matic VTE. The second investigation b,v Colwell et a121
\\¡as! a multi-centre revierv of the joint replacemenr regis-
tries fron'r tel institutions. They included 1551 primarr
total knee arthroplasties (TKA) and 1559 primarv THAs.
and found the incidence of s1'mptomatic VTE to be 0.92o,¡
ir.rpatients receiving a VTE prophylaxis regimen of MCDs
for a period of ten days post-operatively ivith or u,ithout
the use of aspirin.zl This rate is comparable to VTE rates
seen previously reported u,ith the use of factor Xa inhibi-
tors, u,arfarin and LM\X/H. Additionally, 46.4'A of VTEs
rvere in patients rvho rvere taking aspirin, .uvhile 53.6o/,,
rl,ere in patients u,ho were not on aspirin, but the associa-
tion ben'veen aspirin and the occurrence of VTE events
could not be assessed.2l Currentll', there is a lack of evi-
dence supporting the duration of MCD use. The ACCP
guidelines recor.nmend using some type of mechanical com-
pression for ten to 14 days, and a minimum of 18 hours per
day.' Other str-rdies examining the efficacy of MCDs have
used a protocoi of ten days of MCD use, though tc orlr
knolvledge, there are no comparison studies examining the
impact of duration of \,ICD use on the incidence of
vTF.2r,2r
?n*áítuti**aE experí*n*e
Thus, a VTE prophylaris regime that is safe, effective, easr
to monitor and achieves high patient compliance is ideal
follorvrng TJA. In the past, the AAOS h¿rs recr¡rnmended
"risk stratification" for VTE events and/or bleeding, but
the abilitl, to effectivel), do so is limited l¡. .r lack of evi-
dence elucidating the specific risk f¿lcto¡s rhat elevate VTE
risk.la Previously, r,varfarin was usecl in rhe vast majority of
patients undergoing TJA at our insritution. Ho.nvever, due
to concerns or.er complic¿rtir¡ns associated with excess anti-
coagulation including haematoma, wound dehiscence, and
infections, our institLr¡ior.r implemented a risk stratification
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
"routine" risk for VTE received lvlCDs in conjur.rction \\¡ith
aspirin, where¿rs those patients deemed "high" risk received
warfarin for thromboproph.vlaxis. Patients \''er:e enrolled
prospectively rvith the prim¿lrl purpose to determine the
efficacy arlcl safet,v of our risk stratific¿rtion protocol.25 The
hypothesis was that, after risk stratification, the use of
MCDs r'vith aspirin would be non-inferior to warfarir in
the prevention of VTE follorving T.lA. The clesign, reslrlts
and methods of the studl' are summarised belou'.
7 ati *¡=?* a'rz # í".* *ttz r: *
="
Patients undergoing primary or revisiorr TKA, unicompart-
mental knee arthroplastl', primary or revisiort THA, and
slrrface replacelnent arthroplast]- at a single ílcaclemic med-
ical centre were approached for enrolment in the studt.
Inclusion criteria were: patients aged 18 yeilrs or older,
ur-rdergoing an elective, unilateral joint replacernent proce-
dure. Patients were excluded if thev currently had a DVT
detected on prc-operative ultrasound (obtainecl in all
patients ."vith a personal histor,v of DVT), or were undergo-
ing treatment for a DVT, had a personal history of PE (as
on warfarin and lou. molecular
the,v r'r''ould be placed
weight heparin post-operatively), were scheduled to
undergo multiple (three or greater) surgeries r'vithin a three-
month period, or were on immlrnosuppressive medication
for a solid organ transplant. Patients were not erclr-rded for
a personal histor,v of DVT, with a negative pre-operatiYc
ultrasound. Patients were then stratified as "rolttine" or
"high" risk for post-operative VTE using our institutional
clinical protocol. Venous thromboembolism pr:ophylaxis
for the rolrtine risk population consisted of MCDs worn for
ten dilr s. :rnd aspirin 325 mg, trvice daily for six weeks. For
the l-righ-risk cohort. sir weeks of lvarfarin (with target INR
of 1.8 ro 2.r r. uith \'lCD Llse during hospitalisrti,)n, was
used.
There were rri.o phlscs to this prospective investigation.
ln the first phase, patierrts \\-ere stratified to the high risk
cohort if they met an\- one oi the foilorving criteria: age > 70
years, personal historl oi a D\¡T with a negatiYc pre-
operative ultrasound, active cerlcer. hvpercoagulable states,
morbid obesitr. (BMI > 40 kg/mr). familr' historl'of DVT or
PE, prolor-rged immobilit,v at the surgeon's discretion, or
two of tl¡e three follor'r,ing conditions: diabetes, lung dis-
ease, or heart disease. After tlvo r-eárs of patient enrolment
(betrveen April 2010 and r\1¿rr 2012.), ¿1 rnid-term analvsis
was performed to deten¡ine the effectiveness of our risk
stratification protocol and to assess if inclusion criteria for
the high risk cohort could be narro\\'ed. It was determined
that there rvas ¿r lor'v incidence of \¡TE in both the routine
and high risk cohorts. Furthermore, there',vas a significant
increase in rnajor bleec'ling,'nvouncl problems, and incisional
clrainage in the high risk cohort. Given our encoureging
pr:eliminarl. results and the knou'n difficLrlt,v in warfarin
dosing ¿nd monitoring, criteria for inclusion in the high
risk cohort ivere modificcl to see if prophl'laxis r'vith rvarfa-
rin cor-rld be s¿rfely avoided in more patients. Age, multiple
medic:rl comorbidities and BNII were no longer used as
inclusion criteria for stratification to the high risk cohort.
The primarv oLltcome measure was the incidence of DVT
or VTE in both cohorts. Patients were contacted at two
u,eeks and underr'vent clinical er,¿rluation in the office at sir
wecks post-operertively. Lower extremit,v dupJex ultr:rsound
and spiral chest computed tomograph.v (CT) r'vere used to
assess for the presence of a thrombus rrn'hen the clinical
s)¡l1lptoms were concerning for a DVT or VTE, respectivel\,'.
Secondar.v outcome measures consisted oi the incidence c¡f
major bleeding events, the number of davs of "drainage"
from the \\roulld, re-admission i'vithin six months of sur-
gerl', all-car-rse patient deaths and patient satisfaction with
their prophl'lactic regimen. Patient satisfaction i'vith their
thromboprophvlaris protocol \\¡as assessed at t\\ro and six
weeks post-operati\¡el). using the follor,ving scoring s\-stem:
1 = very satisfiecl,2 = satisfied,3 = neutral,4 = dissatisfied,
5 = r,er-v dissatisfied.
***'¿1t=
In phase one of the studri 6,{4 (12.9%) of the 1502 patients
enrolled were assigned to the high risk cohort. There r,vas
no statistical difference in the VTE rate between the routine
and high risk cohorts at six §'eeks or six months fo11or'ving
TJA (Tabie l). The cumulative rate of VTE events rvas 0.67o
in the routine risk cohorr uerslts 0.2'A in the high risk
cohort u,irhin six weeks post-operatively (p = 0.21), and
0.6'% in the routine risk and 0.-5% in the high risk cohort
rvithin six months post-operati\.el), (p - 0.9). Additionalll',
the rates of major bleeding episodes, prolonged wound
drainage (greater than three davs) and r,vound problems
lvithin tu'o weeks of TJA w'ere significantl,v highel in the
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
\T ' c re-admissior-rs in the high-risk cohort (4.9'1"; p = 0.8).
-,\'o Lr the second phase of the stud\', after modification of the
.l
:l\ .k stratification criteria, 277 16.9%l of the 641 patients
rrd .: r'olled were assigned to the high risk group. Again, there
:to .rs no significant difference in the incidence of VTE
iJal -::\\'een the routine risk (0.6%) and high risk (1.3%)
- ,horts at six weeks follolving sLlrgerv (p = 0.3) (Table II).
J rrrever, at six months follor.ving sllrger)¡, the cumulative
-.idence of VTE was st¿ltistica11v higher in the high risk
l,-{'l'i,) cohort compared with the routine risk (0.6%)
, ,hort (p = 0.02). The r¿rte of mejor bleeding episodes, pro-
,rqed §'ound drainage (more than three davs), ancl wolrnd
-roblems \\¡ere again lorver in the routine risk cohort. There
':re t\\,o re-admissions in the routine cohort (1.2%)
.l¡ted to the effects of anticoagulation therapy ¿rnd three
.-.rdmissions in the high-risk cohort (6.8'l/o; P = 0.1).
\\¡hen analysing the entire cohort, the rirte of VT-h, i'vas
, -rite lor,r,', with 16 events (0.6%) and 22 events (0.87") doc-
:rented within sir lveek and sir molrths, respectivel)', fol-
,rrrng primary TJA, and there \\¡as no statisticalll'
. gnificant difference in the rates of VTE betu'een the high
-.k and routine risk cohorts. During the initi¿rl six months
r )st-operatively,2t2- patients in the routine risk cohort
L1).3%) and 139 patients in the high risk cohort (16.4"Á;
r < 0.001) were re-admitted to the hospital, ',vith several
r,ltients h¿lt,ing multiple re-admissions (Table III). Or-re lim-
,.ltion of the studf is that the cohort of petients who were
, ,nsidered routine risk under the new stratificetion ploto-
,,r1. br-rt were consiclered high risk under the rtlder protocol
he . ¡re not independently examined to determine if thel' h¿d
Ll- : ei ¿rte d rates of VTE. Compliance u'ith lvlCDs lvas high
for the routine risk cohort, r,vith 84.5% of patients rvearing
the device for greater than 18 hours per day, according to
the MCD readings. Onli' 1.5% of patients \\¡ore the N{CDs
for less than 12 hours per da1'.
7u7z;r'* 4ir**|i*rz*
As arthroplast) surgeons continue to seek the optimal VTE
proph,vlactic regime that minimises the risk of rvound com-
plicirtions, re-admission and re-opcration,',vhi1e providing
the m¿rrimal efficac,v, ¿ fs11, questions remain. First, are
MCDs sr-rfficient as stand-alone VTE prophl'laxis for stand-
ard risk patients? \ülhilc previotts studies have shou''u thc
effectiveness of N{CDs for reducing the incidence of svmp-
tomatic VTE, no studv to date has been adequateh'pow-
ered to detect a difference in VTE rate with N1CD treatment
alone ¿,ers¡rs other proph\''lactic regimens.20'21 Secondll',
what is the optimal duration of N'ICD use? \lhile the ACCP
Guidelines have recommended use of \{CDs for a mini-
mum of l8 hor-rrs per dav and ten to l4 da,vs post-opera-
tivel,l', there have been no randolnised studies exiilnining
the effect of \{CD use on the incidence of VTE. The role of
aspirin in VTE proph,vlaxis is another ¿rea in need of con-
tinued study. The Pulmonary Embolism Prevention (PEP)
Trial shor,",ed a modest clecrease in the inciderlce of DVT
u,ith the dilil.v use of 160 mg of aspirirl in patients under-
going hip fracture sLlrger)', u,hen comp¿rred r'vith placebo
treatment.26 Hort,ever, this difference \\'¿1s not seen in the
population unciergoing elective TJA. Another recent stlldY
evaluating the efficac.v of VTE prophvlaxis, Llsed ¿ dose of
150 mg of aspirin clail¡ anc1 ior-rnd a cumulative inciclerlce
of PE to be 0.6% ancl 1.'17?;, following THA ¿rncl TK-\.
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
investigated the use of aspirin and have postulated that aspi-
rin is an adequate VTE chemoprophylaxis in routine risk
patients following primary TJA, citing their findings of
decreased incidence of wound infection (0.5%" uersus 1,.4Y")
with use of aspirin compared with warfarin, and the fact
that aspirin was an independent predictor of decreased cost
f arin for the prevent 0 ¡', É-0.r. ; r'tr''r¡¡embo lc disease atter tota hip arthrop asty
Evauatondurnghospializat! ¿-.-trr:emonthsafterdlschargeJBoneJotntSurg
1999;8'l 4 932 940
1,4mJ
T.WhiteRH,HendersonMC.Fskfacor¡for';enousthromboembolismaftertota hlp
and knee rep acement surqeTV Curr Ct,ri Pttirn Med2A02,8.365-311
8. Lieberman JB, Pensak MJ, Preve¡t on ¡f ven¡us thromboemb0 c d sease after
total rip and knee arthrop asty J Erre J0if ¡,St rg [Am] ?A13',95 A.T B0T 1 8l 1
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,
achieved largely through a shorter length of hospitalisa-
,iorr.2e-31 Further investigation into the dosing regimen,
duration of treatment, and the impact of the cardioProtec-
tive effects of aspirin during the peri-operative period is
needed to better optimise VTE prophylaxis protocols.
Bone Joint Surg [Br]2012,94 8.3 I
10. Geerts, WH, Bergqvist D, Pineo GF, et al. Preventl0n of venous thromboembolism
American Co ege of Crest Physicians Evidence-Based C in ca Practlce Guide nes
(8th Edit on) Chesr2008 133381S 453S
11. Lieberman JR Amer can Col ege of Chest Physic ans ev dence based guide nes for
venous thromboembo c prophy ax s. tre guide lne wars are ouer J Am Acad Arthop
Surg 201 2;20 333 335

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
H p Arth ro plasty J A tth r a p Ia sty 201 5,30.221 I ?284
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


a
t;)
S. W. Carlson,
S. S. Liu,
J. J. Callaghan
From Uniuersity of
Iowa College of
Medicine, lowa,
United States
S W Carlson, BA, Medica
Student, Depaftment of
Onhopaedic Surgery
S S Liu, N4D, Associate
Research Scientist, Department
of Onhopaedic Surgery
J J Cal aghan, MD,
Professor, Department of
Odho paed lc S u rgery,
University of owa, University
of lowa Co lege of Mediclne,
01073 JPP, 200 Hawkins Drive,
lowa City, 1452242, USA
Correspondence should be sent
to J J Callaghan; email: john-
ca laghana@uiowa edu
4.12017 The British Editorial
Societv of Bone & Joint
S u rgery
doi 10'1302/0301-620X 9981
BJJ-2016 0269 R1 52 00
Bone Joint J
##E*TECH[UOLOGIES
Not all cementless femoral stems are created
equal but the resu[ts ma),be comparable
Airns
The aim of this study was to compare the survivorship and radiographic outcomes at ten-
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).
Fatie¡'lts and Methods
ln Cohort f , 91 consecutive patients (100 hips) underwent THA with a cementless porous-
coated anatomic femoral stem (PCA) between October 1983 and January 1986. ln Cohort 2,
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.
(THA). Cementless femoral components have The purpose of this st¡:dr rv¡rs to compare
demonstrated excellent dLrrabilit¡, and survi- the snrvivor-ship, radrographic and clinical
vorship at ten- to 2O-vear follow-r-rp.r As a results at ten-vear iollos'-up of three prospec-
resr-rlt of this success, 60oA to 90% of rhe tive consecutlle series oi perients prcviously
approximatell, 200 000 THAs performed revielvecl 1¡r our in.¡irurior-i u-ho each received
yearly in the United States use cementless fem- different desigr.r. i¡i ce ¡ncn¡less femoral compo-
oral components.2 F1cr.u.,ever, despite the over- nent, all oi u r;¡-r \\.rú irlplented by. a single
all success of this THA constrllct. there is sLrrqeorl .[]C i ,r :'1, 1, :r'rldics and D. Goetz f«tr
substantial r.ariation in stem design. tl-re ():l-:- --. i. -.-
-..:.r sed br- independent
\fhile the majori¡,of
stem designs continue to '1.. --.'\ '.,ll,
demonstrate ercellent outcomes, joint repl.rce-
ment registry data trom the Australi¿rn Orrho-
paedic Association National Joint Replacei::r: ip. stress shielding and clinical
Regi5rr)'repol.tsl.eri.ionrll[C.I..,ll.::..
.l
compared in three cohorts
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
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 \
Cohort I consisted of 9'l cor-rsecutive patients (surgery
carried out by JJC) (100 hips) who underu,ent THA with a
poroLls-coated anatomic total hip prosthesis (PCA; Horv-
medica, Rutherford, Ner.v Jersey) betr'veen October 1983
and January 1986. This colnponent is a chromium-cobalt
stem that is po«rus-coated over the prorimerl third and used
u,ith ¿r .32 mm diameter modular femoral head. The femoral
component is collarless rvith a posterior bow to confonn to
the anatomical configuratior.r of the proximal femur. The
femoral and acetabular colnponents of this prosthesis are
cornposed of chron.rium-col¡alt allov (Vitallium) r'vith a
double layer of sintered Vitallium beads on the back <¡f the
acetabular componert ancl circumferentixll)' on the proxi-
m¿rl one-third of the femoral stem. The acetabular compo-
nent has two peripheral pegs for rotational stability. A
direct lateral approacl-r rvas used for the first 66 arthroplas-
ties, r'vhi1e the remaining 34 u,ere performed with a poster-
olateral approach. The mean age at the time of
surgery r'vas -¡8 vears (22 to 81). There.nvere 62 men and29
women. At minimum ten-),ear follolv-up, 71 patients (77
hips) u,ere living and 20 patients (23 hips) were dece¿lsed.
All 71 Iiving patients (77 hips)u,ere evaluated c1inicail1, and
radiographicall,v. The mean clinic¿,r1 ar-rd rac'liogr:aphic
fo11ow-up 11.6 ,vears (10 to 13). Revisior-r status was
"vas
known for all livir-rg 77 htps at minimum ren-\'err follow-up
and for the 23 hips of patients lvho died prior to ten-1,s¡¡
fo11ow-up.
Cohort 2 consisted of 86 consecutive patients (100 hips)
lvho underwent THA lvith an extensively porous-coated
cementless stem (Prodigy; DePul', '§farsaw, Indiana
bet.nveen Jtrne 1994 and October 1997. This component
u,as rnade of chromium-cobalt and r,vas a fully coated fer-n-
oral stem r'vith a 22 mm or 26 mm modular femoral head.
The stem rvas mated rvith a Harris-G¿rl¿nte I acetabular
component (68 hips) (Zirnmer, lülarsaw, lndiana) or with a
Duraloc Sector acetabular conrponent (32 hips) (DePuy).
The polyethylene liner used in this series consisted of either
ganrma-irradiated in air polyethylene (for the 68 HG-I ace-
tabular components) or non-crosslinked poll.ethylene (for
the 32 Duraloc acetabular components). All surgerv rvas
performed b,v :r single surgeon (JJC). A posterolateral
approach .,vas used in all cases. The mean age at the time of
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)
rvere deceasecl, and three patients (thr:ee hips) were lost to
follow-up. The mearr clinical follow-up was 11.4 years (10
to 12). Among the 69 living patients (82 hips), 63 patients
(76 hips) (91%) had a minimum ten-year follolv-up radio-
graph.
Cohort 3 cr¡nsisted of 88 consecutive patients (100 hips)
rvho underwent THA ivith a proximallv llorous-coated
triplc-tapcred cemcntless stem (Summit; DePuy) between
April 2002 ancl October 2003 by a single surgeon (D.
Goetz¡. This component is a titanium stem that is porous-
coated over the prorimal third a 28 mrr, 32 mm, or 36 mm
YOL 99 P,,No. l..JANUAJlY20L
II \R \BL: T.'
modular Articul/eze (DePuy) femoral he:rd. The femoral
component was mated .'vith the Pinnacle Sector ' acet¿rl.lt-
1ar corlponent (DePuv) in all hips. The liners used u ere
moderatel¡, crosslinked polyethylene (Marathon; DePur I in
60 hips, galnln¿ vacuum foil (GVF) polyethylene in 1-3 hips,
and cobalt-chromium-molybdenum (CoCrMo) metal liners
in 27 hips (Ultamet; DePuy-). An anterc¡lateral approach
was used in all cases. The mean age at thc tin.re of incler sur-
ger)' was 61.6 years (25.1 to 90.2). There \\''ere 51 women
:rnd l- nlen. The revision stíltus Jt a minimunl of ten lears
after index THA was known for all 66 living patients (74
hips) trnd att 20 of the deceased patients (24 hips). Mini-
rnum ten-year follow-up radiographs wele available for 61
oÍ the 74 hips (82 9'" ) in 54 of the 66 living patients (82%).
For radiological evaluation correction for magnification
r'vas completed by star-rdardising all nreasurenrents to the
kno."vn size of the femoral head. Femoral components were
inder evaluated for bone ingrol'vth, stable fibrous fixation, or
unstable fibrous fixation according to the criteria of Engh.
Massin and Suthers.' Femoral cornponent subsidence lvas
determined by the relationship of the top of the lesser tro-
chanter to the medial aspect of the stem collar, defined as a
decrease of at least -5 mm between the initial post-operitiye
radiograph and thr¡se from final fo11ow-up.t Osteolysis ivas
defined as any non-linear radioiucency at the bone-
prosthesis interface that was at least 5 mmZ accorcling to
the seven femoral zones defined by Gruen, McNeice ar-rd
Amstutz.e Femoral component stress shielding rvas defir-red
ursing a modification of the criteria defined by Engh and
) Bobyn.r0 !(¡e defined mild stress shielding to he limited to
the upper third of the implant, moderate stress shielding
ertended to the middle third, and severe stress shielding
extended below the middle third of the stem. The acetabu-
lar components were evaluated for bone-prostl-resis radiolu-
cencies and acetabr-rlar component migration according to
the criteria of Massin, Schmidt and Engh.tl The definition
of acetabular osteolysis \\ras the same as that for femoral
osteolysis.
§taiistieal *naiy*i*. In all cohorts, Kaplan-l,Ieier surr-ivor'-
ship analysis was performed with 95%, conficlence intervals
(CI) for the endpoints of revision for any reas()n, revision
for loosenir-rg and radiographic evidence of femoral compo-
ffiesuEts
.1
In Cohort 1 (PCA), there r,vere 1 re-operations at ten-\ eilr
follow-up. In sir hips, onll' the acetabular componel-it \\'as
revised, in one hip onl1, the femoral component u-as rer-ised,
and ir.r four hips both the acetabular and the femoral com-
ponents were revised. Of the five fen-roral rerisions, tivo
rvere performed bec¿ruse of femoral component loosening
and three rvere ¡rerformed because oi ertensive osteolysis.
Femoral loosening was defined as rerision of the femoral
component because of sr mptomatic aseptic loosening
or subsidence of the fen-roral component ¿ls seen
radiographicallr-. Bv these criteria, five femoral componcrlts
 5. \\. C,\RLSON, S. S.
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)
Bevision for any reason (%) 97 (88 to 94)
Femoral component loosening (%) 97 (95 to 99)
were radiographicalh loose, accounting for t\Á,,o of the rcvi-
sions. In all, 7-t of the rcnrainingT2 \92%) fenroral compo-
nents clerxor-rstr¿rted bone ingrowth fixtrtion, while one
demonstratecl stable fibrous fixation (1%). The nrean timc
to revision \\,as 9.4 ,vears (-5 to l3). I(aplan-Meier sur\-ivor-
ship analvsis of the 71 patients (77 hips) at risk, demon-
strated a sur\¡ival rate at ten,vears oÍ 9'l'A (95%, CI 88 to
941 for re\¡ision for anv re¿1son, 95% (95'% CI 93 to 97\ for
revision of tl.re femoral component ard 97 oA (95 %, Cl 95 to
99) f<¡r revision of the fernoral component becanse of asep-
tic Jooser-rir-rg. L-r terns of clinical reslrlts, nine paticnts of the
71 patients (12%) compJained of thigh pain at final follor.v-
L1p. Furthermore, 17 patients (23%), con-rplained of a mod-
erate or severe limp.
In Cohort 2 (Prodigr.), there rvere 14 re-operations at
ten-year fo1low-up. No femoral cornponents r,vere revised
for aseptic loosening or infection. A total of ten hips (ten
patients) underwent liner erchangcs dLle to \vear end disso-
ciation of the line¡ tu,o patients (nvo hips) h:rd re-
olrerations for periprosthetic femoral fractures with rcten-
tion of the femor¿rl co[rponents, and the rem:rining ts.cr
hips undenvent re-operations for recurrent dislocation ¿rnd
r'vith fen-roral head exchange and acetabr-rlar liner erchange
to constrained liners at 0.6 ve¿rrs ancl 4.6 vears after the ini-
tial slrrgerv. The mean time to revision \\-as se\-en -vears (0.2
to 12.3). Survivorship analvsis of the 69 patienrs (82 hips)
at risk demonstrated a survival rate at ten ye¿trs of 88%
(9-t% CI 79 to 97 ) for revisic¡r-r for an1' reason. Survir.orship
rvas 1007o for the endpoir.rt of femoral component reten-
tion ¿rnd radiographic looserring. Of the 63 patients (76
hips) rvith minimum ten-,vear radiographs, all of the femo-
ra1 corrponents demonstr¿1ted Lrone ir-rgrowth. Femoral
stress shielding was n-rild in 54'% (41 hips), moderate in
l6uu (20 hips) and severe in 1'lo (one hip). Lr all, tlvcr
pirtients {29'i,)reported some thigh pain at last follo,,v-up.
In Col-rort -3 tSumn-rit), there r,r.ere fonr re-operarions
(four patier-its) i1t ten-vear follou,-np. No femoral compo-
nents were rer ise d ior aseptic loosening or infection. A total
of three hips u'er:e rer ised for recurlent dislocation and all
were treated r,vith a iemoral he¿rd erchange to a constrained
liner rvith retention oi tLte prirnary femoral component. Just
one hip was revised for a periprosthetic fracture that
required a femoral componenr rer isir¡n. The mean time to
levision was 2.4 )'ears (0 to 5.91. Survir-orship ar-ral1,sis of
the 66 patients (74 hips) at risk demonstrated a survival
rate of 9 5% (95% Cl 91 to 99) ivith an endpoint of revision
for anv reason. Survivorship was 100%, rvith rer.,ision for
LIU, J J CALL-\C;HAN
Cohort 2 (Prodigy) Cohort 3 (Summit)
88 \79 to 9l) 95 (91 to 99)
100 100
ascptic loosening or radiographic loosening as the end-
point. Radiographic evahration of the 6l hips (54 patients)
(82%,) r,vith minimum ten-year radiographic follor,v-up
demonstrated no stress shielding in four hips (7%), nrild in
-50 hips (82%), moderate in sir hips (10'%), and severe in
one hip (1%). All femoral components had bone ingrorvth
and there was no evidence of radiographic loosening. At
latest revier'v one patient (1.-t%,) complained of thigh pain.
*a*r:u**i*ra
Each cohort included a r-rnique cernentiess sten-r design, r,vith
an anatomical stem in Cohort 1, a straight stem in Cohort
2 and a t¿lpered stem in Cohort 3. These represent thr:ee
b¿sic cementless femoral component clesigns. Anatomical
designs are stems that are intended to match the posterior
inner-trochanteric borv of the femur, straight stem designs
involve preparing ir-rternal femoral geometry to accept a
straight stem, and tapered stems are stems that obtain fix-
ation in the metaphyseal-diaphyseal junction. At the time of
the development of each of these stems, each construct rep-
rcscnted a nerv phiiosophl, in THA regarding the best r,vav
to obtain sLrccessflrl fi-x¿rtion ar-rd clinical oLltcomes.
Despite these differences in design philosophl,, each stem
obtainecl good fixation and clinical results. \rVith revision
for any reason as an endpoint, there was sllLlstantial vari¿r-
tion in snrvivorsirip between the three cohorts (Table I).
Horveveq r'r,ith revision for aseptic looser.ring of the femoral
component as the endpoint, fhe tluee femor¿rl cornponents
den-ronstrated ercellent survivorship. ranging irom 97%, to
100% at ten )¡ears (Table I). The r ari¿rtron in survivorship
r'vith the endpoint of revision for'¡r.r,'1'ü.1\,rn can Jargely be
attribr-rted to issues related to thc .rcc-r¿L¡ular component.
There was a differencc bcts-een rhe sr¡ess shielding in
Cohort 2 and Cohort 3, rvith Cohorr ' ienronstr¿ting more
moderate stress shielding il6o, c,r l::¡-i cornpared r,vith
Cohort 3 (10% of hips). This drti-r-r--. 1r srress shielding is
likel,v to be the resulr of the nr.:-.,: ri>..11-diephyseal fix-
ation of the prorimallr l!r:L,.s-., ,:.:i.1 triple-tapered
cementless stem compared ri i:h :. : ,::.rr seal fixation of
the extensivelv porous-.o.1!i: :: :-
=: :1e ss stem. §lith
fixatior.r obtained more cir,\ r , ., ihe n-retaphyseal-
diaphyseal junction. rh.r. - :i: - r::: tr:rnsfer from the
bone to the stern collra.:.--. . .. I i ;:- th¡rt obtains fixa-
tion u,ithin the cl:rphr .:.
shielding.
This study has several frerrghs. including prospective
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


?*
iI
ru
.L
I. De Martino,
R. D'Apolito,
V. G. Soranoglou,
L. A. Poultsides,
P. K. Sculco,
T. P. Sculco
From Hospital for
Special Swrgery, New
York, United States
I De l\rladino, MD. Clinicat
Fellow, Department of
Orthopaedic Surgery, Complex
Joint Beconstruct¡on CEnter,
Adult Reconstruction and Joint
Replacement Division
V G Soranoglou, MD,
Fesearch Fellow, Depañment of
Ofthopaedic Surqerv, Aduit
BeconstructÍon and Joint
Replaceme¡t D¡vis¡on
L A Poultsides, t\.4D. Ctinicat
Fellow, Department of
Orthopaedic Su.gery, Adult
Reconstruction ancl Joint
Replacement Div¡sion
P K Sculco, l\¡D, Assistant
Attending Orthopaedic Suroeon
and Orthopaedic Surgeon,
Depanment of Oñhopaedic
Surge.y, Adult Reco.struction
and Joint Replacement Division
T P Scu co, l\,4D, professor of
Orthopaedic Surgery and
Aftend ng Orthopaecjic Suroeon
Depadment of Ofthopaedi;
Surgery, Aduit Reconstruction
a¡d Joint Replacement Division
Hospita for Special Surge.y, 53S
East 70th Street, New york, Ny,
10021 USA
R D Apolito l\¡D O(hop¿edi.
Besident DecdÍmeni ñf
Geriatr cs, Neurosc ences and
Orthopaedics, Orthopaedtc
Su rgery Divisio n
Cathoiic Univers tV oíihe S¿cre.l
Heart, Agostino Gemelii
Universlty Hospital, Larqo
Agostino Gemelli 8, Rome,
00168, ltaly
Correspondence should be sent
to I De l\4artino; email:
demaftinoi@hss edu
iO2017 The
B.itish Edltorial
Society of Bo¡e & Joint Surgery
doi:10.1302,0301 62OX.99Bl
BJJ 2016-0398 R1 S2 oO
Bone Jo¡nt J
2017;99-B(1 Suppte A)j.j8_24
18
E I{IP TECFII\IOLOGIES
Dislocarion followirg totalhip arrhroplasry
using dual mobili ty acetabulai componenrs
A SYSTEMATIC REVIE§T
Aims
The aim of th¡s systematic review was to repoÉ
the rate of dislocation following the use of
dual mobilitv (DM) acetabular components in primary
and revision total hip arfhroplasty
(THA).
Materials a¡rd Methods
A systematic review of the literature according
to the preferred Reporting ltems for
Systematic Reviews and Meta_analyses gu
h
of Pubmed/Medline, Cochrane LlOráry aia
afticles between January 1g74 and March 20
"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.
Results
ln all' 59 articles met our inclusion criteria. These
included a total of 17 g0g rHAs which were
divided into two groups: studies dealing with
DM components in primary THA and those
dealing with these components in revision THA.
The mean rate of dislocation was 0.9% in
the primary THA group, and 3.0% in the revision
THA group. The mean rate of
intraprosthetic disrocation was 0.7% in primary
and r.3% in revision THAs.
Conclusio¡l
Based on the current data, the use of DM
acetabular components are effective in minimising
the risk of instability after both primary and revision
THA. This benefit must be balanced
aga¡nst continuing concerns about the additionat
modularity, and the new mode of failure of
intraprosthetic dislocation. Longer term studies
are needed to assess the function of these
newer materials compared with previous generations.
Cite this article: Bone Joint J 2O17;(l Supple
A):1g_24.
asry (THA s carrl' considerable economic burden as the
mmon and
It reduces s
ty of life.2
uous rmprovement of healthcare and increas_
ing life expect¿1nc)/, the demand for THA r,r,ill
gro\\. to re flect the more acrive, aging popula_
tion,
tion. The number of THAs p.rfo.-.á in tl-,.
inclu
ULrite d States is projected to increase
bv mobi
L_+ in l0 i0year.3
comparerl u.irh 20U5. rcachirrg nents
572 000 pe. primary THA from about 5% to about 1o%..t
lnsta[¡ilin continues to be a tronb]esome Howeveq there rem¿rirr patients r,vho are at a
complic:rtion after THA ancl has been high risk of dislocation, such as those with
reported to be the main indication for revision
neuromuscular diseases, cognitive dysfunc_
in the United Srates, accoulrting for 22.5'A
ot tion. an Amerie¡n Socierr ,.,f Anesrheriolo_
revisions. I Re-rdm i.rlon ¡nd rJulri,-rn ,rrrger:1 gists score6 of more than three, those aged
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
the hip, in rvhom the rate of dislocation is stiil high, rang-
ing from 4.8% to 13%, despite improvements in the sur-
gical techniques.' In additior-r, the rate of dislocation is higher
in revision surger)', ranging from7.4'% to l4.r+7o.8-l(l
The use of the duaI mobilit.v (DM) acetabular components
has been shorvn to increase stability after THA.' The concept
of dual articulatic¡n .nvas introduced in France in 1974 by
Gilles Bousquet and André Rambertlr'll and cornbined
Charnlev's low friction principlel3 r,vith the Mckee-Farrar
concept of using larger diametcr femoral headsrr to enhance
stabilit,l'. The tirst design rvas a cylindrical/spherical unce-
mented stainless steel componcnt with a poror-rs plasma
spra,ved alurnina coating ancl an inner polished surface; an
external anchor clip for a 4.5 mm 5s¡s¡r, and two Morse
taper pegs provided additional initial fixation.tj The mobile
liner rvas made from Lrltra-high molecul¿rr weight polyethyl-
ene (UHMWPE), gamt'ra sterilised in air ancl articulated
with n.retal femoral head rvith a diameter of 22.2 mm. §lhile
the polvethl,elene (PE) line r and the introduction of ceramic
fen.roral heads have improved the overall tribology., the
underlying concept of the "unconstrained tripolar" r6 THA is
still the san.re. The purpose of this kind of comp,,nent is ro
provide increased range of movement (RO\rI)1- ¿ntl head-
neck ratio,lE a larger effective head sizete ar-rd a grearer jLrmp
distance,20 all of r,vhich lead to increased stabilitv. \lhile the
DM articulation has been r-rsed in Europe for more than 25
\()l .,.,8. \,, l. J\\f \R\ .',,1-
years! it onl.v became available in the United States in 2009.
Recentll', horvever, concerns have been raised about the pos-
sibilitv of ¿rccelerated PE -uvear, osteolysis and aseptic loosen-
ing follor'ving the use of these cc,-po,-rerts,21 in addition to ¿r
ne.nvmode of failure, intraprosthetic dislocation.' This sys-
tematic revier,v summarises the outcomes of the use of DM
components in primary and revision THA and specifically
evaluirtes its efficacy in redlrcing the rate of dislocation.
l* at* rZ*á* *re* 7.& e€h * ds
\le performed a systematic review of the literature in order
to identify articles reporting the rate of dislocation follorv-
ing the use of DM components in THA.
Pul¡mediMedline, Cochrane Library and Embase data-
bases r'r,ere searched for articles published r-rp to March
2016 using the following search terms: 1) dual mobilitl' OR
dual-mobility OR tripolar OR double-mobility OR double
mobility and 2) hip OR cup OR socket. No iimi¡ \\-as ser
'"r,ith regard to the year of publication. Inclusiun cnteria
were original articles investigatir-rg DM in ¡rnnan and revi-
sion THA with an adequate fo11ou,-up (minimum sir
months). Erclusion criteria consisted oi case reports or
series with < 20 patients, revierr, articles, experr opinions,
letters to editors, bion-rechaliical reports, instructional
course lectures, studies inrolrrng animals or cadavers, or
in uitro investigations, book chapters, abstracts from scien-
tific meetings, irnd unpublished reports.
 I' DE MARTINO, R. D'APOLITO, v G. soRANoclou,
3;¿;t- i*::ts2¿,;. Figure 1 sho.nvs an outline of the rer iciv pro_
¡¡ss. The initial search yielded 720 citatior-rs. After screening
ior dLrplicate publications, 249 tyere ercluded, leaving 471.
\irer revieu,'ing the absrracts of these, 73 rvere screened for
cLigibility and 59 rvere idcntified for- inclusion./.1-1,r6.21 76
Trvo independenr revielr,,ers (IDr\I and VGS) separately
conducred the search b,v title and abstract. If the title arrd
abstract <¡f each srudy containcd insufficient information
to deterr¡ine its appropriatencss for inclusion, the fr_rU
manuscript r,vas revierved. A cross-reference search of the
selected articles rvas also performed to obtain other rele-
vant articles. The fLrll texts of the chosen papers were
obtained to decide rvhether tl-rel. were suitable for thc pur-
pose of the str-rd1.. If there w,as disagreement between the
tlvo revie-uvers, a tl-rird (RD) rvas consulted and consensus
r,vas reached. Tl-re 27-item Prcfer.red Reporting Items for
Sl,stematic Review,s and Meta-Anah..ses checklist lvas
used.tT The origir-ral two reviervers ifDM and VS) ir.rdepen-
dentlv extr.rcted the data inchrding the title, vear of publi-
cation, aLlthors, study design, numbeq age and
distribution of patients l¡y gencler, rvl.rether the procedure
rvas primarv or levisior-r, length of folJor,v-r_rp, implant
de sign, diameter of the fer¡oral head, and tvpe of fixation
of the acetabular corlpouent. The primar,v oLltcome \\¡¿ts
the rate of dislocation and the secondar_v olltcome was the
rate of intraprosthetic dislocation.
Ás=e+sme¡:Í t*l ?:ia* The level of evidence of each article
,nl,as recorded.is In
order to assess the qualitv of tl-re studies,
the MethodoJogicaJ Index for Non-Randomised Str_rdies
(MINORS)-e lvas used. This validated instrumenr was
developed to detern-rine the qr-ralitv of observ¿.rtional and
non-randomised studies. Two investigators (IDr\I and RD)
independentlv assessed the quality of each ¿.rrticle. Ther.
rvere scored on ir l2 item scale: aim of the stud1,, inclusion
of cor-rsecutive patienrs, prospecrivc collection of data,
appropriateness of the endpoints, ur-rbiased assessment of
the endpoint, appropriateness of length of follorv-r-rp, per-
certage of loss to follor,v-up, prospective calculation of the
s:rmple size, compar:able co¡trol group, contemporary con-
trol groups, baseline equivalence of groups and the acle-
qLlateness of thc statisrical analysis. The stuclies r,ve¡:e scored
trom 0 to 2 points for each of these items. Low-qua1itr,. and
high clualitr studies rvere defined as earning < 16 and >16
poir.rts. respecri\ elv. rrs previous[,v dcscribed.80 The global
ideal score uas 16 for nor-conrparative studies a¡d 24 for
comparatir e- srudjes.
-*t***stir.eé a*.*tr-=:+ Categortcirl
trariables are presentecl as
frequency and percer-irages. Continuous variables ¿1re pre-
sented as means u-ith srarrclard deviations (SD). A p-vahre <
0.05 u,as considered sr¿rrisrrcallr significant.
fl*e¿¡i€s
The 59 articles that r¡et the inclusion criteria were divided
into tw,o groups: str-rdres dealing r,l.ith DM componenrs in
primarl.THA and those dealing with these componenrs in
revision THA.
L. A. PouLTSiDEs. P. K sclraco. T. p. sculco
*lt4 **t-.;***nts r¡ iirnia¡\,iHÁ. -\ total of 12 84zt hips
u,ith a me¿-Ln .lqc ¿r r¡e rr-l.lc oi sLrrgery of 68.8 years (sl 9.7)
r.vere included. The r¡.re¡r :olloii'-lrp rvas 6.8 years (Sn 5.1).
The mean rare oi dislc¡¡.r:ior.l u'¿rs 0.97o (sD 1.9) and the
mean rate of intr:rprostherc disloc¿.rtion w.¿s 0.7o% (SD 1.4).
The details ancl demoqr¿phic dara are shown in the supple-
rnentary n'rateri¿r1.
¿:::*l-,t¿*. Í-rl, -\ total of 5064 hips rvith
*?.,4 **ttzp<srz*rz1*
a mean age at the tir¡re of surser\ oi 69.3 years (SO 4.6)
rvere included. The rnean iollou -up s-as .1.4
¡,ears (so 2.4).
The mean rare of c|sloc¿rtiorr ri¿s.1.09/o (SD 3.0) and the
mean rate of intraprostheric dislocatron rvas I.3% (so 2.2 .
The details and demographrc data a¡e sho,"vn in the supple-
mentary material.
*.**,ÉÉf.y&3****/1=*-c. The rnean ,\II\ORS score r,vas 12.6
points (9 to 21), shor,.ing rh¿rr rhe clualitl.of the str_rdies rvas
lo.uv. A meta-anal1-srs \\'as nc)r undertaken due to the general
poor qualit.v of the studies.
*i**z;**\*;=.
Our main finding \r-as rhar D-\I-THA is a successful proce-
dure rvith lor,v rares of dislocation borh in primary and revi-
sion THA. Several aspects shor_rld, however, be consic.lered
further.
Dislocation is one of the most common complications of
THA and its incidence increases with the passage of time.sl
Data about the inciclence :rnd prevalence are biased br. the
fact that mosr articles on rhis subject are from high-volume
centres, restricting their generalisation for lolv-volume cen_
tres and community practices.22 According to the Austral-
ian Orthopaedic Association National Joint Replacement
Registry (2015), the most common indications for revision
of a convenrional primary THA are loosening/osteolysis
(28.0%,), dislocation (21.2"A), fracure (18.2%) and infec-
tion (17.3%,) .,r,hereas dislocatiorr follou,ing a first revision
is the most common reason for a further revision THA
(31.1%).8r Dislocation after THA is a cause of much
comorbidity.sl Risk facrors for instal¡i1itv are patienr-
related and surgerv-related. Amongst ¡he forrer are female
ge nder, advancing age,81,8-t previous l-rip snrgelr.,s6-t8 neLrro-
nuscular disorders, cognitive disorders. ¿rlcohol abuse and
abductor r.,,eakness.Ej.8l,89 e3 Amor]gst rhe i:1¡ter are sr_rrgi-
cal approach,E:,e4 malpositioning of components,ga 96 fail-
Lrre to restore 1eg length or offset." ''tl preserving the
abductor mechanism, crpsular r:eprir. - impingement,eg
the experience of the surgeorr,tl !:r 1 ,¡r. size of the femoral
¡.r¿8e'10r and the head-neck r¿rrio.r I The last rwo are
related to choice of implant rarher rir;rrr .ursic¿rl technique.
In randomised controllecl tri:1ls. .rr:.r iemora] heads (>
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
improled stabilitv in largcr:ci'- ,:1 -. r!:: .lre the increased
jump distance, increased h¡,r;- -.-- ::,(r. And possibll, the
mismatch betr,r,een the .iz. ,--,: -.:-..i ¡¡d the outer
diameter of the acet¿rbul¿ : .: : . . :, - 'However caL-
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\
rctive patients because, although linear rn"'e¿rr u,ith higl-rly
¡rosslinked PE seerns to be independent of the size of the
temoral head, heads r.vith a large diameter have tlore volu-
netric r'vea¡ which may or may not cross the threshold for
r¡steolysis.t06'107 Hence, this could jeopardise thc long-term
sLrrvivorship of these reconstrlrctiors.t0E Furth.r[]()re, in
-rn acetabular cornponent of a given outer diameter, a liner
,ri, for instance, > 36 mm rvill be thinner than a 28 r¡m liner
-rnd, despite the increased'nvear resist¿rnce of highly
¡rosslinked PE, this m¿rv lead to increased rvear and poten-
:ial fracture of the liner- DVI components, horveve! al]or'r,
:he nse of thicker PE.10e DN,l cornponents represent an
:Lltern¿ltive to the use of large femoral heads in an attempt
:o pre\¡ent dislocation, but cr¡[cems stilI exist. The two
.najor concerns
',vith DM conponents rel¿1te to potentially
ncre¿rsecl PE lr,ear. First, in the DM design be,vond the clas-
.ic hard-on-soft articulation there is a second soft-on-hard
;oupling, ."vith the convex snrface of the PE ¿lrticlllating
l ith the concave polished nretal surface of the acetabular
.omponent and this could lead to increased rvear. Secondll',
-Ll.-rpingement of the neck on the rin.r of the retentive PII
¡ould contribute to its clamage and the production of
lebris. Some author-s have focnsed on these issues in ¿n
.rrtempt to clarifv the behaviour of the PE in dual mobility.
\clam, l-arizon and Fess1,110 analvsed 40 retrieved PE
rmplants after a mean period of in-rplantation of eight l'ears
-rnd shor.ved total rve¿rr to the same order as reported for
.onventional metal-PE bearings u,ith 22.2 mm femoral
'¡eads. iVIore recentl),, D'Apuzzo et allll assessed surface
.lamirge and performed lever-out tests on 33 components
:etrieved at short-term after THA (mean time l -5.7 months
.D 19) and reported dirmage on both bearings, but predorn-
n¿rntl). o11 the inner surface of the liner, suggesting that
rlore firovement occurred at the inner PE bearing. The force
-equired for the dislocation of the cobalt/chromium femo-
-¡l head ',,",rs unrelate d to the length of implantation. Netter
:r al 112 simulatecl adverse conclitions and testecl the behav-
,rrr of the highl.v crosslinked PE of DM during microsepl-
r-:rtion and third bodr- .,vear and sh<¡rved high tolerance of
rhe material in these cr¡nditir¡ns. Another paper from the
,¡br¡ratorl' of a manufacturer (Stryker Ortl-ropaedics,
\ Iahr,r,ah, Ner,v Jerse,v) shor.ved ¿r reduction in u,ear b), r-tp to
-j9á r,vith DM components using a highly crosslinked
..Lnnealed PE compar:ed r.vith a conventional gamm:r/inert
PE be:rring.Il3 Thus, less friction and r,r,ear have been
reported in laboratorl studies, but independent clinical
still lacking.
¡1ara are
Another issue to be cor-rsiderecl r'r,ith DM components is
;ost. Epinette et al 114 reccntl.y reportecl that consiclering the
rcduced risk of dislocation and its consequent costs, DM-
THA ma,v bar.e substantial cost salings compared lr,'ith pri-
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
oi holes on the surface of the component u,ith the mono-
rlock desigr.r. Furthermore, many designs do not offer
t)L 99 B. No 1, T\NLTARY 101;
USINC l)tl\t \tOBtLtTYACETABLL.\R LL)\il'f'\ lr : l1
additional external slots for scre\\'s. Thrs r.-pr;.;r:is e pr'ol.-
1em in revisio¡ surgerv rvhen bone loss does n,r lÉ:nrit .l
stable initial firation. This can be or.ercome. ior c:..rnrp c.
bl, cementing the cornponent in a cage.lrr') \errer hLghi,
porolrs coatings and supplementar,v scre\\' l-roles 1-re1p ro
provide better firation.
'§fe
found ¿1 mean r¿lte of disloc¿rtion of 0.9"/,, (sn 1.9r irt
12 844 primary THAs rvith a mean follolv-r-rp of 6.8 r r¡r'
(sD -t.1). This result is in line rvith the rate of disk¡cation
reported l¡v several authors and registries.l15 Hor.r.,ever, it
should be noted that DM componellts in onr revien' uelc
lrsed nrosth' in patients i,r,itl-r a high risk of dislocatior-r. Tl-re
mean rate of dislocation in 5064 revision THAs r'r,as .1.09u
(sD 3.0) at a me¿1n follor,r-up of 4.4 ,vears (sn 2.4). This alscr
compares favourabll u,ith other reports of rates n hich v¿rrv
5% and 307o.e'r16 118 All 1¡ut ten of the stndies
betrnn,een
included in our revicrv were single-¿lrm studies; hence, ncr
comparisons can be made betr'veen fixed beirring and DI t-
THAs based on these data.
This revier'r, has sever¿,11 limitations. First, the stndies rrre
level III evidence or less and the design is often retrospec-
tive. N{oreover their overall quirlitv r.vas 1oir,. This, in tur:n.
limits tl¡e level of evidence of our paper. Secondlr', thele is
selection bias as rve extracted specific data from the articles.
Thirdlr'', patients in the studies \vere ertremell heteroge-
nous in terms of demographics, diagnosis and indications
for the oper:rtion. Fourthl,li r've used onlt- three databases ir-r
our search of the liter¿ture, potentiall,v ercluding some
papers from analysis.'§le decided to use onll'the most com-
mc¡n databases and chose not to include other more periph-
eral literature, rvhich could har.e reduced the publication
bias. Ho"vever, considering the absence of a rigorous peer-
revieu, process for sr-rch literature and the frequent differ-
ences betu,een conference abstracts ar-rd fin¿r1 published
artic1es,11e lve decided not to introdLrce this additional bi¿rs.
Fifth11,, r've onl1, includecl papers in English, causing the
exclusion of man,v other l¿rnguages and in particr-r1ar, in this
context, French. Tl-ris design of component r.virs developed
in Irance and the literature in French initiallv contributed
more than others to this to¡ric. -Nlost authors, holveveq
reported their results both in French and in English, r:educ-
ing the linguistic bi¿rs of our review.
Based on the cnrrent clata, it appears that DM compo-
nents are effective in minimising dislocation in high-risk
patients in primary and revision THA. This benefit rnust Lre
l¡alanced u,ith continr-ring concerns about the additional
modularifi,'and the nerv failure mode of intraprosthetic dis-
location. Due to the poor qualit,v of the studies in the liter-
Atllre, \\¡e beLieve that a large, randomised control stucly
shoulc] be r-rndertakcn to further analvse the leduction in
the inciderrce of dislocation after THA.
This study demonstrates that dual mobility acetabular compo-
nents decrease the r sk of post-operative instability both in
primary and revision hip arthroplasties
 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.

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

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

 B S \\Ii\DDELL
optlons to reconstruct non_contained acetabnlar
include the use of structural graft, reinforcing cirges, bi_lobed
non-cerlented sockets, hemispherical non-cementecl implants
r,vith tantalum augmentsi crlstom tri-flange devices, ancl
impaction bone grafting (IBG) r,vith ¿r reinforcenrent mesh ancl
a ccmented implant.6 l2
T'rt* *É*l*rq *€ i<z=p**ti*ti ***{: ,1r**->z*
1970s. Hastings and parkert3
impacted ¿llrtosenous graft to
in rheumatoid arthritis patients
and ir-r selected parients under-
going revision. No follo,,v-up \,\ras proviclecl.
The hitial concerns u,itl-r this technique revolved arouncl
t\'vo issues. Fir:stlr,,, could the bone graft
r'vhen contained by a mesh, and, second
viable after being erposed to the exoth
merisation? Mendes, Roffman and Sil
canine autogenolrs bone graft in uirtr: model to study these
asty \ n eight
t:i::
of .rn
:ffi:
;; ,;;
ancl ten months rer-ealecl neu bone formation ancl trabecula
generated from the natire acerallnlar bone into the graft.
At
ten months post-operativelr, there \\¡i1s intense lrerv bone
formation r,vith osteohlast and osreocl¿rst activit),. The\.
concluded that the bone graft could retain osteogenic
potential after the exotl¡ermic reacrion and induce nerv
bone forllration.la
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
clefects the defect rvith impacted graft. Uncontained defects are
more challenging. Large rim defects frequentJl, affecting rhe
supenor and the posterior boundaries of the acetabulur¡
(Paproskv 3A and 38) shouid be containcd with
a mesh
before gratting.
* r * - * V * r'*tz'..¿ * a *s *.§ * rz2 e #z
The presence of infection should be excluded. The surgeon
should detern.rine anv clin cal and/or actual leg_length dis-
crepanc)', and muscular deficienc,v that could affect post_
operirtive gait. As manv of these patients rvill have under_
gone muJtipJe operarions, previous incisior.rs can help
dere r_
mine the surgical approaches that may have been usecl.
Radiological irvestieation should include anreroposrerior
and Judet vier,vs of the pelvis, rvhich allolv assessn.rent of thc
anterio¡ ¡-rosrerior and superior defects (Figs I and 2). progres_
si.,,e superior ¿lcetabular component mi¡lration and
subsequent
destructir¡n of tire iliac bone are frequenr finclings. The defi_
ciencies in the poster:ior and superior bounclaries of rhe acetab_
ulum are parricularh.eviclent on rhe obrrlraror vier,v (Fig. 2).
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
and plan the sur:gerr.. CT scan r,vith 3D ¡econstruction is use_
ful to plan the strategy for implant and h¿rrdrvare removal,
and to anticipate the size, shape and location of the rein_
forcemenr mesh lvhich is likelv to be required (Fig.3). If
pelvic discontinuitl is detected, meshes are nor strong
er-roughto stabilise pelvic cliscontinuities. The1, can be used,
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
Fi7 2 Fi7 4
Judet views of the 62-year-old woman demonstrating deficiencies in
the posterior wall and superior socket migration (Paprsoky 38).
li
Fig 3 tion. Attention should be paid to avoid excessive later¿rlisa-
3D CT reconstruction of the 62-year-old woman
confirms the progressive destruction of the
anterosuper¡or, superior and poster¡or peri-
acetabular bone The medial wall of the nat¡ve
acetabulum is marked with an asterisk and the
poster¡or wall plate with a black arrow
# *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
posterolateral approach. Erposure shoulcl allor,r, complete
visualis¿rtion of the defect inclucling the ¿rntcrior and the
posterior wxlls; the superior boundaries of the clefect in the
iliac bone; and the teardrop, r,vhich r,vill be usecl as ¿r land-
trark to guide acetabular component positioning. Remc¡'n,al
of the irlplant and debridement of the granr-rloma should
not result in unnecessar), loss of acetabular bone. Hemi-
spherical reamers can Lre used as intra-operative templates
to detennire the approrimate di¿lmeter and position of the
new cornponent (Fig. 4). A flexibte stainless steel mesh is
trimrned to fit the defect, r'r,hich t,vpicalll' ¿rffects the poste-
rior wall and the superior :rspect of the acetabulum. A cen-
\trJ 'q lr, \,, l. J.\\t \R\ l,,l-
\\'ITH I-UI) \(- ] I.)\ I,:\
A small reamer can be used to estimate the size of the new socket ln a
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
a nerv acetabr-rlar bed is created in a near-anatomical posi-
tion of the reconstructed acet¿rbulum bl'r.isr-ralisation of the
teardrop during the procedure. Cement pressurisation r,vith
a plastic seal over the cement direct11. on top of the graft is
essential during implantation of ¿rn all polvethl-lene compo-
n ent.
*:*zz *gÉí*rz*
has been made u,,ith fresh-fr:ozen allograft morsels. Vlost
techniques call for the use of fresh-frozen femorrrl herds.-
After removal of the residual articular cartilage the bone is
morselised using ¿:r rongeur to generate chips appro-rinatelv
l0 rnm:l in size. These rel¿rtivel,v large-size chips incrcase
stabilit,v of the impacted grarft.16'1- Arts et all'' r¡sed an in
uitro rnodcl to studv the effect of graft size ¿rncl u'ashing on
the n-rechanical stability of IBG recorstrtrctions. The most
stable reconstructions r,vere those in s hich rvashed morsels
of a large diameter (8 mm to 1l mm) u ere nsed.16 The use
of freeze-dried bone, tricalciur¡ phosphate and ceramics in
combination r,vith fresl.r-frozen allograft has been
reported. I8
r-
B \ \\\l)l)ltl
Fig 5 Fig
Anteroposterior radiograph obtained three years
and 6 months post-operat¡vely demonstrate an ace
tabular component in an anatomical position with no
radiolucencies
Animal and human studies reported slrLrstanrral incorpo-
ration of impacted morselised bone graft. Van der Donk et
alle reported on 2,1 acetabular bone biopsies from 21 hips
obtained three months to 15 years alter acetabular recot.r-
strllction Lrsing IBG and a cemented acetabular component.
Histological erantination shou,ed rapid revascularisation
of the graft, directlv follorved b1, osteoclastic resorption and
\,'o'ven bone formation on the graft remnanrs. The graft
remodelled into a nelr, trabecular structure, with normal
lanrellar bone ¿rnd or-rl,v scarce remrrrlrts of gratt material.
Thev conclucled that impacted trabecular bone chips incor-
porate bv a mechanism that is similar to that previously
observed in a¡in-rai studies.14'1e Heekin, Engh and Vinhzo
studied post nlortem specimens from three patients ¿1t 1.5,
fr¡nr and 6.-5 vears follor.r.ing IBG ¿rnd ¿r non-cemented ace-
tabular component. Histological analysis revealed earlv
graft penetration bv'n,ascul¿rised tissne, osteoclasric resorp-
tion of sraft trabeculae ancl application of living bone.
After four r ears ir¡ ,.1/¿r, gr¡fr fregrnents rvere ren-rodelled
and shor,,.ed progressi\-e r.ascular ingror.vth. Bv 6.5 years,
the graft was almosr completelv incorporated.
Fest-*¡:*rativ* **a.sr**
Patients are instructed to bear ri-eight 'uvith onlv toe-touch
force for three months and rhen progressed to bearing
weight as tolerated. Posterior hip replacen-rent precautions
are ¡Jenerallv discontinued sir u-eeks posr-operarivel,v.
Patients are seen sir r,veeks, three months, one I'e¿1r post-
operatively,, and elery two years thereafier.
\ (.r)\Z1lr Z t)t1 i \ \\lTE
6
Judet views demonstrate restorat¡on of bone stock
and stable mesh fixation
=*=lé"2.=
Earlr- radiographs tr picallv shon, restoration of the ana-
tomical centre of rotation, lrdeqlrate filling of the defect
u,ith bone, ar-rd a st¿rble mesh reconstruction.
Radiographic anall,sis of patients lvith mid- and long-
term follow-up, focuses on assessing graft incorporerion
and socket fixation. Standard anteroposterior and Judet
radiographs should be part of routine follor,v-r-rp. A
fer,v millirnetres of prorimarl n.rigratior.r of the acetabular
component can be seen in the first year after srlrger:y
particularly in patients rvith large acetabular defects. This
is probabl.v due to graft cornpaction and is nor
inclicative of loosening unless accompanied b¡ progres-
sive radiolucencies.
Our expcrience of IBG r.vith a reinforcement mesh for
the treatment of Paproskv 3A and B defectsll has been
encouragin¡1. In our most recent revier,v of 21 patients at c
mean follorv-up of 40 months (12 to 128), we have
observed no re-revi:iorrs2 I tFigs 5 ro -r. One pltient rves
diagnosed r'vith radiographic loosening eight vears post-
operativel),. Her radiographic findings have ren-rained sta-
ble in the last two ¡rears and she remained asymptonaric.
No re-revision sLlrgery- has been recommended. The
results reported by other investigators including those
r,,,ho perfected the technique have been promising as well.
In eight clinical studies summarisecl in Table ¡,1'e.ro.zz-zt'
the survivorship with aseptic loosening as an endpoint
ranged fron T)'% to 96',/, after a follow-up from one to
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-
ited by two factors. Firstl¡ surviyorship may be worse in
very large defects.z2-24 Van Haaren et al23 reviewed the
results of 71 revisions using IBG. At a mean follow-up of
7.2 years, they observed that 1,4 of 20 acetabular recon-
structions that required re-revision originally had an AAOS
Type III or fV defect.27 Secondl¡ acrylic component fixa-
tion into allograft bone may deteriorate over time and the-
oretically should not surpass the survivorship of cemented
acetabular components in primary THA. It is reasonable to
believe that acrylic cement penetration into dead bone sup-
ported by a mesh as observed in these complex reconstruc-
tions is unlikely to survive without loosening as well as that
observed after primary THA, when cement penetrates in
the living cancellous structure of the iliac bone. Comba et
al25 reported a 1O"A re-revision rate in 30 acetabular IBG
rc\risions performed in patients yoLrnger than 55 years and
folloived for a me an of 86 n'ronths.2i The proponents of rbis
techniqr-re reported a progressive deterioration of clinical
and radiological outcomes in 42 patients l-ounger than 50
)'ears at the time of IBG revision sllrgerv. The survivorship
free of revision for any reason was 7370 (95% confidence
intervals (CI) 58 to 87) :rfter 20 r'ears, and 52% (95% CI 35
to 72) after 25 ,vears' follorv-up.26
***t **re*íd*rat¡#ng
In our institr.rtion the cost of implants and bone graft used
in an acetabular IBG rer,'ision (mesh. scrervs, acryiic cement,
polvethylene socket and three fresh-irozen femoral heads)
is similar to that of a reir-rforcement cage reconstructiolr
rvith a br-rlk femoral head. The cost of implants used in revi-
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
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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_


J. Haynes,
D. Nam,
R. L. Barrack
From Barnes Jeruish
Hospitdl, St. Louis,
Missouri, United
States
J Haynes, lvlD, Resident
Physician
D Nam, MD MSc, Assistant
Professo r
R L Barrack, lvlD,
Distinguished Professor
Washington University
Orthopedics, Barnes Jewlsh
Hospital,660 S Euclid Avenue,
Campus Box 8233, St Louis,
MO 63110, USA
Correspondence should be sent
to R L Barrackj emai :
barrackr@wudosis wustl edu
42017 fhe British Editorial
Society of Bone & Joinl
Su rge ry
doi:10 1302/0301-620X 9981
BJJ-2016-0346 R1 $2 00
Bone Joint J
2017;99-B(1 Supp eA):3'1 6
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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?
Air¡rs
The purpose of our study is to summarise the current scientific findings regarding the
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.
$lBateria ls a¡rd lVlethods
We performed a systematic review that was compliant with the Preferred Repofting ltems
for Systematic Reviews and Meta-Analyses guidelines to identify prospective studies from
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
increasing in size at the f¿rstest r¿lte, as evi- differ significrrntly comparcd rvith a non-ol¡ese
clenced by the greater than -50% annual patient population.ll 1:l The prlrpose of our
increase in prer.alence of patients u.ith a BMI studr" is to summarise the current scientific
> 40kg/m2.2'r -Nledic¿rl costs associated r'vith findings regarcling the impact of obesitl' on
obesit.v erceed $27.5 billion, and account for total hip arthroplasn' (THA); specificall), the
over 207o of all the United States healthcare influence of obesity on the timing of THA,
expenditure. t incidence of complications, and effect on clini-
The ohesit.v epidenric directl-v affects the cal and functional oLrtcomcs.
undertaking of total joint arthroplast,v (T.JA).
Changr-rlani ct ala shorved that morbidly ol¡cse a**erial* *.-* *Z****
prrtients undergo tot¿rl knee arthroplastv *e*¡<:*z ,;zt'é|**c. \I'e perforfi]ed a systematic
(TKA) at an avera€le :rge of 1.3 years )rollnger revier.v that rvas compliant i,vith the Preferrecl
than non-obese controls.4 This is relatecl to the Reporting ltems for S¡rstematic Revier'vs and
earlier onset ¿lnd more rrrpid progression of Ivleta-Anal¡-sis gr-ridelines.l4 We se,lrched the
osteoarthritis in obese patients.r Multiple srud- PubMed/Medline, Embase and Cochrrne
ies have also ilh-rstrated that obesit-v is associ- Library databases, from inception to -\l¿r¡h
\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
ló
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
combination of free keywords and MeSH terms: "hip
-:'throplasty", "hip replacement", "THA" AND "obesit1,",
r:se", "body mass inder", and "BMI". rWe included
i,'.ldies written in the English language. The reference
' :.iih included article was reviewed and
- - insLlre inclusion of all eligible stLldies.
: :: ' -studv criteria for inclusion included: pro-
. : -r. isolated to primary THA, obesitl,
of THA, and clinical and functional status. Studies r,vere
ercluded if a BMI value for obesitl- was either not desig-
nated, or differed from B\II > 30 kg/ml. the study design
\\ras non-prospective in nature, or outcomes of interest r,vere
not reported. Additionall),, studies \\'ere excluded if they
cross- met the following classification(s): sr stern¿rtic rer-ieu', meta-
analvsis, surgical technique articles. erpert opinion, and
proceedings from meetings.
*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
process. Ontcomes of interest \'vere incidence of post-
operati\¡e complications, incidence of primarl' THA in the
obese population, and clinical and functional outcomes
scores. Additionall,r,', data from each article including first
allthor's surname, and date of publication were rect¡rded. A
narrative review of the included studies was performed in
order to address the specific objectives of this relierv.
ffiesults
St*dy *hara*terlsties" A total of 1059 studies r.vere identi-
fied through the d¿rtabase searches. Screening for dr-rplicate
articles eliminated 657. A total of 359 str-rdies r.vere
exch-rded after revie.,r, of title and abstract. The remainirrg
43 articles were read in their entiret,vr and 26 articles were
eliminated as they did not satisfl, either the inclusion c¡r
exclusion criteria. The rcmaining 17 articles rvere ir-rcludecl
in this review.ls 3l 16. included studies contained a total oi
13 722 THA patients (Fig. 1). The included studies
excluded patients undergoing simnltaneous bilateral THA.
The stud,v publication dates ranged l¡etu'een 1999 and20l6
(Table I). All studies defined obesit,v as a BIvII > 30 kg/mr. A
total of five studies made a separate clistinction for obese
patients with a BMI > -3.i kg/mr.rq'21'li'l-'ls A further five
studies additionall,v defined patients r'vith a B\rtI > 40 kg/m2
as "morbidly o1r.r.rr.2o'28 -11
lnfluenee of eb*sity sn tile t;ffiiíig *{ THA. A total of t',vo of
the eligible studies included data on the influence of obesitv
on the incidence and timing of THA.26'2e Andrerv et al,le in
a study of 1421patients undergoing primary THA shoived
a significant ini,erse correiation betr.veen BMI and age at
time of THA.2e Their findings shou,ed that the tnern age oi
the patients at time of surgery in the non-obese (BMl < 30
kg/m2), obese (BMI >30 kg/m2 to < 40 kgÁl2) and n-rorbidl,v
obese (BMI > 40 kg/rn2) group was 69.1 .vears,65.5,vears,
and 60.6 years respectivell, (analvsis of variance (ANOVA),
p < 0.001). Lilbbeke et a1,26 also shor'ved that patients ',vith
a BMI < 30kg/m2 rvere nearl.y a mean two ,vears older at the
time of THA than patients u.ith a BMI > 30 kg/m2 169.0
uerstts 67 .2 years of age, respectively).
in*idenee ol *anrpiicati*ns. A total of nine included studies
directly eran'rined the effect of obesity on the incidence of
complications follor'ving primar,v 111¡.1e'22'23'2-5-2e'31 ¡n
total sir of the studies found that obese patients undergoing
primary THA had a higher incidence of con-rplications than
non-obese patients. Chee et al28 showed that obese patients
had a significantl,v higher rate of complications, including
dislocation and infection, in the peri-operative period ivhen
compared with patients r'vith a BMI < 30 kg/m2 (22oA uer-
sus 5oA, respectively; p = 0.012, chi-squared test). Patel and
Albrizioz't also found that patients with a BMI > 35 kg/m2
had an increased incidence of local and systemic complica-
tions in the post-operative period. These findings are in
accord with a series of 2106 patients, published bv Sadr
Azodi et a1,23 rvhich illustrated an increased hazard ratio
(HR) for overu.eight and obese patients (HR 2.5, 957o con-
fidence interval (CI) 1.1 to 5.5 and HR 3.7, 95% CI 1.5 tcr
VOL 99 B. No I..IANUARY 201;
.
\L IIIP .\RTHI{OPLI\STY
9.3, respectively) u,hen compared uirh patien:s ri ith B\lI
< 25 kg/m2 (normal). A second series of '1-1 parrei.rl-r. alscr
for-rnd an increased incidence of post-oper,rtii e cot.npLtca-
tions in the obese (odds ratio (OR) 1.81) and mor'oidlr
obese (OR 5.77) partient populations, when compa¡ed u itlr
non-obese controis.3l In a series of 2-495 hips, evalnatrng
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-
pared i,vith non-obese patients.26 Additionalll', c¡besil-
increased the ir-rfection rate in r'r,omen but appeared to ha"'e
no effect in men. There u'as also an increased incidence of
dislocation, u,ith obese partients showing an adjusted inci-
dence rate ratio for dislocation of 2.4 (95% CI 1.4 to
4.2).)6 h a large series of 1617 patients from the United
l(ingdom it was found that increased BN'II correlated lr'ith
an increased incidence of instabilit,r.', and for-rnd that for
e\¡er.y ten point increase in BMI, the risk of dislocation
increases 113.9% (p = 0.023).1e Furthermore, the stud\
highlighted that obese patients l-rave up to a 3.7 increase
(str-rdent's /-test) in the relative risk for a superficial infec-
tion follor'ving THA. 1e
A total of three of the included studies found that there
\'vas no effect of obesit.v on the complication rate fo11or'ving
primary THA. Mclaughlin and Lee,22 in study comparison
olrtcornes of THA in 100 obese (BMI > 30 kg/m2) and 109
non-obese (BIVII < 30 kg/m2) patients, founcl no difference
in the incidence of complications including deep vein
thrombosis, pulrnonarv embolus, sciatic palsv and disloc¿r-
tion. This reflects the results of a study prospectivel)' evalu-
ating the outcomes and cornplications of 198 non-obese.
obese, and morbidl,v obese patients undergoing THA,
r,vhich found no significant difference in the rate of compli-
cations betr'veen groups (p = 0.51, log rank analvsis).2-
Andreu, et a1,2e in a study of 1427 piltients, stratified into
three groups by BMI (< 30 kg/mr, 30 kg/mr to 40 kg/m2 and
> ,10 kg/m2) shor'ved no difference in the incidence of dislo-
cation (p = 0.221), deep infection (p = 0.115), deep vein
tl-rror.nbosis (p = 0.754) and pulmonary embolus (p =
0.769; all ANOVA).
Finally, three studies evaluated factors that may be asso-
ciated '"vith an increased risk of peri-operative complica-
tions. Bowditch and Villar2o found that patients r'vith a BN'II
> 30 kg/m2 had an increased mean estimated blood loss of
380 mlr'vhen compared r.vith non-obese patients (p < 0.001)
in a total cohort of 92.10 Obesitr- r,vas aiso shown (Fisher's
exact test) to be associated with increased post-operative
levels of interleukin (IL)-1b, IL-6, and tumour necr<¡sis
factor-alpha, which may indicate a pro-inflammatory state
of the innate immune system in a study of 60 patients.l5 In
a study of 50 patients, Raphael et al30 found that morbid
obesit,v (BMI > 40 kg/m2) .nvas significantly associated r.vith
longer operative time (p = 0.003, Vilcoxon signed rank
test) and time to administer spinal anaesthetia (p = 0.018.
Spearman's rank correlation coeffieientt.
É#ect en Gutcoi-¡:€s. Of the 11 included studies e\lrr', rrrf
the influence of obesity on post-operati\-e oLltcomes :r,Ll, -'-' -
 :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: :.
were significanth uorse in ¡he mori¡:ulr ,,it¡s¡:!r:-r.1:i()rr
Both gr,,trp5 dtJ cr¡.rierr.c ..t .:Jn j;- t.tt :r).r-:.- :r. tl.r
mean scores of all SF--16 dr¡m,riris. e\.efr menr¡l he¡lrh ¿ncl
general health perceprion. shen comparrne
tr_.rc_operarirc
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
pre-operarive function, on rhe HHS, Short torm_12 (SF_
i2)la and §lesrern Ontario and McMasrers Universities
osteoarrhriris index (§íOMAC)35 clinical ourcomes scores
bese men and non-obese men and
et al,ie found that increasing BMI
ted rvith rvorse HHS and SF--36 five
year outcome scores, dcspite controlling for age, gender,
pre-operative outcome scores ¿rnd cor¡orbidities.
A total of eight srudies found that obesitl, did not have a
negative effect on clinical outcomes ..or.r.l á,1;.:t,22.1'1,27,2e.i t
HHS and found no sig_
and non-obese patierlt
rs follor,ving
OHS¡:e was included in
three studies, all of which reported no difference l¡etr.veen
the
obese and non-obese patient cohorrs,
at final follow_
up.17,u:'uv Lastlr., studies evaluating clürical outcomes with
:,.37
Qol EQ--5D,16'r urr¿ sfOX,lAC
ce¡lr differencc herucen pf,rients
d those rvith a BIyII > 30 kg/mr. A
studl' also found that increased
BMI was ltot associated with increased rates of osteol_vsis
around the femoral implant post-operarively at ten y."rr..,
'*i**c¡:;*í*41
:.sF\onii Irotr thr. ir¡n¡rc ir-nt¡nlte \\-s¡em, all of which
are
,.rr:.)is : r.l¡ likclr conrribute ro the increased rate of com_
p Lrca.iorL:.
\\e rlso shoueci thar parients u,ith elevated BMIs are
\ollnger ¡t rhe rin¡e of prirn:n. TH_\. Morbjdlv obese
\-ollnger than non-obese controls.l6.re These fir-rdings shotv
a similar trend to a rc.rieu-of registn. data from the Mayo
Clinic rvhich shos.ed rhar l¡enveen 199-i and 2005 there
was a significarr decre¿1se in the mean age of patients
undergoing primarv THA bv 0.7 r..ears (p < 0.002) which
r,r,as inversely associared u,irh ¿.Ln increase of 1.6 kg/m2
(p < 0.001) in the BN,II of prirrarv THA patients over
rhe
san're stud,v period.a0 This is n .on..rnirrg trend, as
a
younger age ar time of initial THA is ¿rssociared
rvith an
increased risk of requiring a revision in ir pirtient popr_rlation
that has been shown to have higher rates of per:i_operative
compiications.3e
controverst¡ still erists r,vhen evaluating the effect
_Some
primary of obesitl, on the clinical ourcomes of THA. The majoritv of
studies included in this revieu, examinecl clinical olrrcorles.
The HHS and OHS were rhe most frequent outcomes
tools
applied. There r,r,ere mixed results ivhen the HHS i,vas used
to evaluate outcomes. A total of three studies founcl no sig_
nificant difference between the mean final posr_operarive
HHS scores of obese and non-obese patients, lvhile three
separate stLrclies noted a significant difference in the post_
operative scores betr,veen patient populations aite¡ coDtrol_
ling for the lower pre-operative function of the
obese
patienr cohort. The OHS was reporte<l in three of the
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
the OHS, u,ere significanti]- worse for obese patients (BMI
> 30 kg/m2) rvhen compared i.vith non-obese controls
(p < 0.001).ar
This revier,v does have limitations. -First, on11'studics rvith
¿ prospective design rvere includecl, u,hich mav have lir.nited
the number patients rr,,ith more Lrncomnlon complications.
Additionallv, erplicit adjustment for confounclir-rg factors
was not performed in the majoritl, of the included strldies,
as r.vell as r¡ther factors knolvn to influence outcomes fol-
lo.,ving THA such as anaesthetic type, use r¡f antitriotic
proph,vlaxis, deep vein tl-rrombr¡sis prophr.laris, surgeon
volume, operating room time and blood 1oss. This n-right
have lead to identification of a false relarionship betr,veen
obesity and the stud,v questions that this revier'v sought tcr
Ans\,\rer. Also, in the studies rvith longer term follou,-up (ten
vears or greater) the determination of patient obesit,v r.r,as
made pre-operiltivelv, br-rt no data were provicled on an)'
subsequent change in t1-re patient's BNII, and if this had anv
effect on outcome. Finall1,, dcspite a thorough search of tl-re
includcd databases there is a possibilit¡, that ¿rn eppropriatc
stlrdv was ovcrlooked.
lnconclusion, this rer.ielv of 17 prospective stlldies
shou,,s that obesitl, is associated r,vith a lor-rnger age at the
time of prirnarv THA, and that obese paticrts are at an ele-
r.ated risk for peri-operarive compIications u.hcn compared
u,ith non-obese controls. AdditionaJJl', obese patients do
see impro'n,ement in thc olltcomes scores follo\\,ing THA
but there remains mixed inforrlation ',vhether obesitl. is
to worse post-operativc clinical ancl function:.rl
:::1::1
Obesity is associated with s¡gn¡f ¡cantly younger age at time of
primary THA and obese patients are likely to exper¡ence
higher rate of peri-operative complications
Author contributions:
J Haynes: Data collection, Writing and editing of the manuscript
D Nam: Data collection, Writing and editing of the manuscript
B L Barrack: Data collection, Writing and editing of the manuscript
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
This article was primary edited by G Scott
This paper is based on a study which was presented at the 32nd annual Winter
2015 Current Concepls in Joint Replacement meeting held in Orlando, F orida,
gth to 12th December
fr*€*t*c=***
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cation rate and outcome oftota knee arthroplastY a mei¿ ¿'¿ r, : , , . i'
Iterature revlew J EoneJointSurg[An]2012,94 4.1839 1811
9. Namba RS, Paxton L, Fithian DC, Stone ML. Obesity and per ol; . - - -
n tOtal hip and total knee arthroplasty paÍ¡efis J Arthr1plas¡y2005;20 i l.::: : -:
50
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! ''.-. -'
ñtes J Arthraplasty 2009;24(6 Supp ):84 88
11 lssa K, Pivec B, Kapadia BH, et al Does obesity affect the outcomes cf p'-¿'
tota knee arthrop asty? J Knee Surg2A13',26.89-94
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
13. Raigopal V, Bourne BB, Chesworth BM, et al. The impact of morbid obes t¡ c'
patient outcomes aftertota knee arthr0plasty J ArthroplastyZAAE;23:795 800
14. Moher D, Liberati A. Tetzlaff J, Altman DG, PBISMA Group PreferreC report ,r
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
l5.Motaghedi B,BaeJJ,MemtsoudisSG,etal.Assoclationof obestywth r.flanr-
maton a¡d pa n after tota h p arthrOp asly Ütn Arthop Belat Res 2414,41214!?
T 448
16 Haase E, Kopkow C, Beyer F, et al. Pat ent reported outcomes and outco re pre-
dctorsafterprimarytota hparthropasty resutstrorntheDresdenHpSurger,lBeg
islr'¡ Hip lnt7A16,2613 81
17. DienstknechtT, Lüring C, Tingart M, Grifka J, Sendtner E. A min ma ly inl,as,ve
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
18. Jackson MP, Sexton SA, Yeung E, et al. The effect 0f obesity on the m cl term s,:r
vlva and c l¡ical outcome of cement ess tota hip replacement J Bone Jotnt Surg IE i
2009:9T 8 T296-1300
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-
era tota h p replacement performed for osteoarthr trs? A multivar ate ana irs s of
prospective da¡a J Bone Jotnt Surg [Br]2A11,93 B:T T7B-1 182
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
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ysis five and ten years fol ow ng tota hip arthroplasty J Bone Jaint Surg [Am]
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a 22. McLaughlin JR, Lee KR. The outcome 0f tota hip rep acemert in obese and non-
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
with ncreased risk of imp ant d s ocati0n fo lowing pr mary total hip replaceme¡t:
2,106 pat e¡ts fo lowed for up to I years Acb Arthap20AB,19.141 141
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
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
26 Lübbeke A, Stern R, Garavaglia G, Zurcher L, Hoffmeyer P. Differences in out
comes of obese women and men undergo ng primary total hip arthrop asty ,4dhrilis
Bheun7AAl .51.321 334
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
28. Chee YH, Teoh KH, Sabnis BM, Ballantyne JA, Brenkel lJ Tota h p rep ace
ment in morbdy obese patients with osteoarthritis: resuts of a prospectvey
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
30 Raphael lJ, Parmar M, Mehrganpour N, Sharkey PF, Parvizi J. 0besity and
operatrve t me in pr mary total joint arthroplasty J Knee 5ur92A13,2695 99
31. Dowsey MM, Liew D, Stoney JD, Choong PF The impact of obesity on we ght
changeardoutcomesatT2months npatientsundergolngtotalhparthropasty /r/:i
J Aust?414,193.11 21
32. Harris WH. Raumatic artritis of the h p after d s ocati0n and acetallu ar fra.t:-..
treatment by mo d afhroplasty An end result study using a new methoc .'--.
evaluatlon J Bone Jornt Surg [AmJ1969,51 4.131-]55
33. Ware JE Jr, Sherbourne CD. The ]V0S 36 ltem short form hea th . - ::
Conceptua framework and item selection lv4ed Care T992,3li l-i l::

M. Stefl,
W. Lundergan,
N. Heckmann,
B. McKnight,
H.Ike,
R. Murgai,
L. D. Dorr
From Keck Medical
Centre of USC, Los
Angeles, California,
United States
M Stefl, 4.4D, Resident
Physician, Department of
Orthopedics
W Lundergan, MD, Resident
Physician, Department of
Orthopedics
N Heckmann, MD, Resident
Physician, Department of
Orthopedics
B McKnight, BS, USC
Medical Student, Depa¡1ment
of Orthopedics
H lke, N,4D, Research Fellow,
Department of Orthopedics
R Murgai, BS, USC N4edical
Student, Department of
O rtho ped cs
i clealance of the hip (Fig. I ). The irnportance of
L D Dorr, MD, Professor of
Oft hopedics, Depadment of
Orthopedlcs
Keck Medical Centre of USC,
1 520 San Pablo Street, Suite
2000, Los Ange es, CA 90033,
USA
Correspondence should be sent
toL D Dorr; email:
patriciaipaul @yahoo com
O20'17 The Britlsh Editorial
Society of Bone & Joint
Su rgery
doi:10 1302/0301-620X 9981
BJJ-2016 0415 R1 $2 00
Bone Jo¡nt J
2017;99 B(1 Supp e A)i37-45
VOL 99 B, No. l, JANUARY 201 7
ffi fr*IF AffiTF§ffi*FL&STY: &VüEffiÉ¡UG ÁTdM ftd}ANAG¡NG PROBLETfoS§
Spinopelvic mobility and acetabular
component position for total hip arthroplasty
Aims
Posterior tilt of the petvis with sitting provides biological acetabular opening. Our goal was
to study the post-operative interaction of skeletal mobility and sagittal acetabular
component position.
Materials and Methods
This was a radiographic study of 160 hips (151 patients) who prospectively had lateral
spinopelvic hip radiographs for skeletal and implant measurements. Intra-operative
acetabular component position was determined according to the pre-operative spinal
mobility. Sagittal implant measurements of ante-inclination and sacral acetabular angle
were used as surrogate measurements for the risk of impingement, and intra-operative
acetabular component angles were compared with these.
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
the study is that it correlates acetabular component position to spinal pelvic mobility which
provides guidelines for total hip arthroplasty.
Cite this article: Bone Joint J2017;99-Bll Supple A):37-45.
There has been recent research abont the influ- that spinal jmbalance occurs by trvo structLlral
ence of spinopelvic rnobilit,v and the acetabular changes, either stiffness or h,vpermobilitl'"r
component inclir-ration and anteversion for This mobiliq,, and its effect on sergittal acetab-
total hip arthroplasty (THA).1 Lazennec et r-rlar corlponent position, can be measured on
ala'i have shor'vn that tl-re change from standing lateral spinopelvic-hip radiographs (Fig. 1).
to sitting is accompaniecl b.v posterior tilt of the These measurements of sagittal acetabltlar com-
ponent position are named ante-inclination and
pelvis u,hich allow's the acetabulum to open for
sacral acetabular angle.2's Ante-inclination is a
this fleribilitl. of the acetabulum has L.¡een coml¡inatio¡ of both the antet,ersion and incli-
emphasised by an increased risk for instabilitl n¿rtion of the acetabular component, and is a
in patients r,vith spinal fusion ¿rfter there dynamic measurement of the opening of the
"vhich
is alm<¡st no spinopelvic mobilitv so the acetab- acetabular component with posterior tilt of the
ulum does not c,pen.1': Since spinal deformin', pelvis.2 The sacral acetabular angle is a meas-
stenosis and h,vpermobilit,v are often present in ure of the link betr'',,een the sagittal acetabular
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
spinopelvic movement, there is soue qttestiot-t same for the standing and sitting positior-r.s \\te
as to rvhether it should be considered in rvere curious rvhether the sagittal acetabuler
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,:
studies for the past five yeiirs, ancl have learned ante-inclination and sacrai acetrl¡Lrlar ¿nc ¡ l
 \I STEEI, \\/ LLINDEIIG,\N, \ HECKN,I,\NN, B
Fig la
we targeted the acetabular component inclination alld ante-
version according to rhe parient's spinopelvic mobility.
Outliers were those who werc not in the normal range for
these two measlrrelnents, and these abnormal results l,lrere
considered to be a higher risk for impingement.e Our firsr
question was whether targeted acetabular com¡ronent ¡-r65i-
tior-rs woulcl pre\¡ent the occurrence of post-oper¿tj\.e ()L1r-
liers at risk for impingement. A second quesrior
rnhether lve could correctly identify thosc hips at highest
risk for in'rpingement.
*f|*t*rí*i*a*zd *É**4*
This was a prospective stucl,v of raciiographic outcomes of
primary THA according to spinopeLvic rnobiliry. These
operations were performed betr,veen December 2014 and
lVlarch 2016. OLrr [nstitutional Revielv Board approved the
study design, and patients sigled rn informecl consent for
release of their data. Clinical data for correlation ro radio-
graphic data was limited ro gender (females = 75/151
patients (50%), mean age is 62.9 years (27 to 86), mear-r
body n.rass index is 2.7.7 (16.9 to 45.3) and the diagnosis
u,as (hips): osteoarrhritis: 137, developmer-rtal c1r splasia ot
rhe hip: nine. osteonecrosi': ser cn. post-rritut.t.'tri!: I,,Lt-.
others: ¡hree. A total of 151 pirtients r160 hips \\er-
enroled in the studr- u.ith no erclusions. and thcr.- \\.1s .onl-
plete pre-operatl\-e. intra-operatile and posr-of-.crarir e dara
at three to six months. Surgerr u-as periormed rhrough a
mini posterior approachl 11 f,1 ,.t si¡Lqle surqer)n (LDD)
with the use of computer naliganon ior ¡rcetebul¿rr cornpo-
nent centre of rotation, inclln.lrion ¿rnd ¡nrer-ersion
(ORTHOsoft, Zimmer Biomet, -\lon¡real. Canada).
Acetabular component angles were adjusted bv the soft-
r.vare used for the nar.igation to the radiogri.rphic plane of
Murray.11'12 Femoral preparation rr".as perforn'red first so
the acetabular componenr lnteversion \\.uLlld achieve
IIC}i\ICHT. H I(E R \IL I{G.\I. L D I)ORR
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
combined anteversion in its safe ,one.l3,'4 Parients ,uvere
discharged the s:rme or follorving dai,,, full r,veight-bcaring
without precautions, but told the,v could ber-rd as necessarv
to do shoes and socks as long as the,v did so betr.veen their
knees (u,.ith the legs abducted). \X/alking was rheir onlv
phl.siother:.rpv.
Pre-operatively, radiographs obtained were a lo-nv ¿rntero-
$¡as posterior (AP) pelvis rvith proximal femur rvith the beam
centered on the symph,vsis pubis, an iiiac oblique Judet vierv
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
sitting position (Fig 1). AIJ radiographs rvere made by the
same radiographers. Fol the stirnding lateral spir-ropelvic-
proximal femor¿rl filrn. the patierrt's left hip w:rs placed
adjacent to the cassetre ri ith rheir ¿lrms resting at 90o on a
support regardJess u-l-rerher rhe nght or left hip was of incer-
est. The x-rar Lteant § as centred ¿1r rhe greater trochanter
perpendicuiar to the L¡arienr's arial 1ine. and the source-film
distance s.rs 1S-l cn-r. The sarle radiographic criteria r.vas
then used s'i¡h tl.ie p¿rienr sitting or.r e s¡ool with his or her
b¿.rck srr¡ishr ¡nci ¡he.rnqie herueelr rhe thighs and trur-rk
u es approrrr¡:L¿reh 1 (-J0' . r'ior 90n, because better visualisa-
rior-roi the pr¡f¡¡ srn'iphrsis ¡as possible ¡-ith that angie,
.rnd ir u'as rhe comfortaL¡le sittn.rg position. Post-
operati\ elr, the radiogrephs u-ere repearecl ¡t the first clinic
lisit rvhich rvas betrveen six seeks ¿rnd rhree months. A
total of 8,1 patients (84 hips) had rachograpl-rs repeated at
the six month to one vear iollou -up. From the pre-
operative AP pelvis u,e obrained thc hip lcngth and offset;
from the post-operarive AP pellis u'e ol.rained hip length,
offset and acetabular coñiponelir inclin¿rion and antever-
sion.l't r: Hip length and oifsetru'ere .o1rp¿1red u,ith the
opposite hip if it was nor diseased.
From the pre-operative ancl posr-oper.rtive lateral spin-
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-
vic ferror¿rl alrgle werc obtained using PACS Sl.napse bv
tr'vo observers (HI, RNt) (Fig 1). From the posr-operrrrive
film thc implant measurements of anre-inclin¿rtion and
sacral acetabular angle were also measllred (Figs 1 and 2).
Pelr,ic incidence is ¿1 static measurement so is the same for
both star-rding and sitting (our norma) = 42" ro 64o), and is
the me¿rsure of the l'vidth of the pelvis so thar as pelvic inci-
dence increases from 1olv to high vahres the lordosis of the
spine increases, and the fenroral head moves further anteri-
orly.s tVe established normals from our data combined s,itl-r
those in the literature.-s'8'18 51 is a drrnamic measure of pe1-
vic tilt from the anteriorlv tilted standing posirion (normirl
= 40" +l- 10") to posterior tilt with sitting (norma) =29' *¡
- 9'). AST is the difference berween the standing and sitting
ST (normal = 11"to 29o). Pelyic femoral :rng1e is the me¿rs-
ure of fenoral extension standing (norn.ral = 180o +/- 10")
¿rndof flexion sittir.rg (nonr-ral = 132' +l- 12").8 From the
post-operative filnrs the it]rplant measurenlents of ante-
inclination (stancling normal 35" +/- 10", sitting 52u +/- 1 1o)
and sacr¿rl acetabnl¿rr angle (75o +/- 15") were also meas-
ur:ed (Figs 1 and 2).
Spinopeh.'ic mobility is classified as normal, stiff or
hypermobile according to the movenlent rrreasured bv the
change in AST betn,een sranding and sitting (Fig. 1).2 §le
consider hl,permobility of the spine, not caLlsed b,v kyphosis
of the spine, as a variant of nornral '"vith greater mobility
(AST > 30"). ln patients with hvpermobilitv, their normals
are al1 increased b1' 10". There are some patients who have
hypermobility because of severe flattening and kyphosis of
the spine rvith sitting and an absolute sitting ST < 10o.
These patients are pathologic arrd this is not normal hvper-
n-robility. Converselr,', stiff hips rvith spir-ral imbalancc have a
difference bet-"veen standing and sitting AST of < 10".
\fle determined the appropriate acet¿rbular component
position :rccording to the spinopelvic mobility from our
earlier stlrd),.2 For nonnal hips, arrd kvphotic hips r.vith nor-
mal nrobilitv-, the inclination -uvas 40u ancl antcversion 20"
u.ith combined anteversion of 2-io to 45". For hyper:mobile
normal hips, ancl hl.permobile k.vphotic hips, lesser inclina-
tion of 3-i" to,10" and lesser anteversior-l of 15u to 20o is
necess¿lrv to prevent excessive verticaiity oi the acetabr-rlar
cornponent rvith sittir.rg. Stiff hips needed inclination near
45", and anteversion of 20" to 25o i,vith colnbir-red ante\¡er-
sion of 35o to 50", ro open the orientation of acetabulum to
compensate for loss of the pelvic movemeut. Centre of rot¿-
tion r,vas measured intra-operatively frorn the computer
and hip length and offser from posr-oper¿rive radio-
grapl-rs.1a
Data collection tested ir.hether the ¿cetabular: component
positions used resulted in ante-inclination and sacral
acetabular angle in the norm¡rl rarnge. Abnormal ante-
inclination or sacr¡rl acerablrlar angle did not alr,vays have
the same consequence so severitl, of imbalance was catego-
rised as pathological, dangerons or inconsequential. Patho-
logicaI in this setting r,vas defined rvhen evel ideal
acet¿lbular component position \r,as obtained it did not
o\rercome the spinal imbalance and a high risk remained for
impingemer-rt; dangerolrs imbalance meant that colrect ace-
tabular component position r.,,ould result in ¿rnte-inclina-
tion and sacral acetabular angle rn rhe normal range, but
precision of the component position is required; and incon-
sequential imbalance me¿lnt there is an abnormal measure-
ment, usually of one value, w-hrch bv itself is not a risk so
ivrs c]inie¡llv irreler:rnr. t
-*za|É*'ti*a1 Stata version 13.0 (StataCorp, College
"z=+}V-¿ir.
Station, Texas) was used for all statistical analyses. Studcnt
,-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-
locations u.ithin rhe first tr'vo months post-operatively,2o
although one also had contriL¡ution from ir kvphotic spin-
opelvic imbalance seen on the sitting lateral radiograph
(Fig. 5). Positional dislocations were caused bv the patient
plrtting the hip into an extrerte position before capsular
healing u.ith this position probably permitting impinge-
ment to occur. One patient r'vith hvpermobile k1'photic
imbalance flered their hip so that their knee approrimated
to their chest dr-rring sexu¿ll intercor-rrse at r'vhich point the
hip dislocated (Fig. 5); a second patient had norrnal spin-
opelvic measlrrements and was sitting in ¿1 chair n'ith her
oper¿rted leg placed cross-legged uncler her opposite leg,
and leaned foru.ard to pick up her dog from the floor; the
third patient also had normal post-operative measuremellts
and fell in the shorver with her legs doing the 'splits'. All
three u,ere initiall,v tre¿rted with closed reduction, but the
third patient had a second dislocation, ancl at sr-rrgerv her
posterior capsule rvas repaired and a Dual Mobilit,v articr-r-
lation w¿rs implanted.
*í**zs*sá**
This study \\.as condLlcted to understand the cons.,-luencc of
spinal disease, primarilv degenerative disc disease and arthritic
change of the spine ',vith ageing,z1 on the optimal acetabular
cornponent position r'vith primary THA. The first qr.restir»r wc
asked i.vas if we could control the angular cl-range of the
acetabular component, u,hich occurs betrveen standing
(ante-inclination), by the intr¡-trper,rrive acetabul¡rr com-
ponent inclination and anter.'ersion. lf r,r.'e could r.rot, could
we identif-v those hips that ret'rained at high risk for
impingement. V/e for:nd that with the targeted acetabular
component positions rve used '"ve coulcl keep atrte-
inclination ancl s¿cral acctabular angle ir-r their normal
rar.rge in f45l160 hips (90%). ln al[, six of the 1-5 hips had
risk for impingement because rve did not achie\¡e the
desired acetabular component position and nine hips rn ere
at risk because of spinal imbalance. A total of seven hips
that had pathological imbalance also had biological or:
surgical fusion, and it is these hips which lvere at highest
risk for impingement. These hips were at risk because
restricted pelvic movement does not allorv the acetabulun.r
to open during flexion of the hip r.vith sitting. So the ace-
tabular comporert must be mecharricall,v opened i'vith
high inclination and anteversion angles. If inclination
erceecls 4-!", there is a trade-off of potential[y increasing
u,e,1r22 so the surgeon rnust balance the risks of disloca-
'§íith
tion lvith the age and activitt level of the patient.
higher angles of inclination and lnteversion, the ante-
inclination and sacral acetabular angles were in the nor-
mirl range for patients ri-ith stiff hips (stuck standing or
stuck sitting). Hor'r,ever. e\-en \\ith these high acetabular
componeni angles, seven fr-rsed hips remained at risk for
impinger-r-rent rrt the extremes of movement because the
acetabular opening [¡etr'veen standir.rg and sitting is stitf.
The high component angles protected the patients in this
stuclv from dislocation, but r,".e have observed this colrel¡-
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;


',lJ
E. P. Su
Frorn Hospital for
Special Surgery, lleT¿
York, I'letu Yrtrk,
United States
E P Su, N4D, Assoc¡ate
Professor of Clinical
Orthopaedics, Weill Corneil
lVedical College and Assocjate
Attending Onhopaedic
Surgeon, Adult Reconstruction
and Joint Replacement Division
Hosp¡tal for Special Surgery,
535 East 70th Street, New york,
NY 10021, USA
Correspondence shoulcl be sent
to E P Su; email: sue@hss edu
42017 The British Editorial
Society of Bone & Joint
S u rgerv
doi:10 1302/0301-620X 9981
BJJ-2016-0430 R.1 S2 0o
Bone Joínt J
2017;99 B(1 Suppte A):46 9
16
ffi &#.V?é* *,*&*TT: &V
WE*
&?é* **¿A Z*é Pffi#BLEIUT§ e*Z?é*
Post-operative neurop athy after total hip
arthroplasty
following total hip arthroplasty, but ís highly
cause difficulty with the post_operative
ent. Nerve palsy may result from compression
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.
The peroneal division of the sciatic nerve
is
thought to be particularl¡.- at ¡isk for .r.r.o_
cia¡ion of Hip and Knee Surgeons founcl
that
nerve irjurv rvas the nLrmber one r:e¿lson
for li¡i_
g,ation after hip arthroplastv snrgerl,.i
Surgeons
should be au.are r¡f the inciclen.. oir.ro.."pnlru
follolr..ing THA so that they m¿rr.be t
.*.l: oü1.,á
anaromicall¡ placing it closer ro rhe sureical
field of the posterior approach.a
The first indication tbar a neu¡opraxia
* *{* * p *y *É *Z * has
*V a'*? rj * * = * {13 rz r¿
-{
occurred is wirh post-operarire motor
A]tIo¡gh ncri c pal,y is a knorvn =.2.:i
conrpl¡¡,1¡¡o,,
weak_
ness in rhe dorsitlerion of rhe foot.
of THA, it occurs infreqr_rentiy ancl is unantici_ If epidural
anesthesia has been use,J. it is o.c.srrr/to
dis_
ccJR SUppLL\rL\-Í TO THE EIJ\T ñ
JOL\I JOURNAL
 POST-OP I-11 \TI\'F
Table l. lncidence of nerve palsy after total hip arthroplasty (fHA) in the literature
Yr THAs (n)
Schmalzried et al2 1991 2355
Johanson et alro 1983 5667
Park et allr 2013 9570
Farrell et alr 2005 27 004
Navarro et alr2 1995 1000
Wilson and Scalesr3 1973 108
continue the administr-ation of anesthetic so that the lou'er
limb rr-rotor function can be properly assessed. If the sciatic
nerve has been involved, the t-vpical presentation is a foot
drop, with $'eakness of the tibiaiis anterior! ertensor l¡al1u-
cis longus, and extensor digitorLrm longus. Eversion r'vith
the peroneal muscles is also commorrly affected. Often, the
tibial division of the sciatic nerve is unaffected; thlts, the
tibialis posterior, gastrocnemills and solelts muscles con-
tinue to function. There are r-rsua11,v sensory deficits in the
skin areas slrpplieci by the peroneal division (dorsum of the
foot and first -uvel¡ space). Because of the r,veakness or ina-
bilitv to dorsiflex the foot, patients mav be unable to clear
their toes from hitting the ground, causing them to trip. An
ankle-foot-orthosis (AFO) that maintains the ankle ilr a
neutral or dorsiflered positi,,n is necessarl to prevent con-
tractures of the Achilles tendon ar-rd to aid walking.
If the femoral nerve is involved, patients ma1'have rveak-
ness in the quadriceps and iliopsoas, r'vith scnsor)'loss over
the anterior thigh. Patients ma)' also have difficLrJt.v u'ith
walking and activities that require quadriceps function,
particular[,v stair cl i mbing.
tu*íí*á*py
In the conrse of a THA, the lor'ver limb is maniplrlated and
tissues are stretched for exposltre, placing tension up,,u
nerves. Specifically, the act of dislocating the hip ma.v
cause tension or compression of nen,es. The position of
the hip and knee during surgery har.e been shown to aficcr
the amount of strain ar-rd intraneural pressures in the sci-
atic nerve: flexion of the hip and extension of the knee h¿rs
been found to increase tensile strain in the sciatic nerve b.v
26o/o, and leads to ir significant increase in intranenral
pre s s.,re.5'6
A second cause is the placement of surgical instruments
in proximity to neural structures. Acetabular retractors
may irnpinge upon the femoral nerve anteri(tr1-v, or on the
sci¿rtic nerve posteriorly. A cad¿rveric str-rdy for-rnd that on
average, the femoral and sciatic rlerves are onl,v 2 cm from
the a¡terior and posterior acetabular rim, respectivelv.'
Placement of retractors on the peripher-v of the acet¿rbular
rim cluring prep¿lration of the acet¿rbulum m¿rv therefore
compress the nearbv neural structures. During femor¿rl
preparation, a femoral elevator retractor may be used to aid
exposure of the femoral car.ral. This compressive force
\¡OL 99 B. No. l. JANLIARY 20 l-
N I-t IROPA I H Y .\FTE I{ TOT'\L HIP ARTHROPL \5T¡ 47
% incidence of % incidence of palsY
palsy overall Primary THA (n) in primary THA
18 1 661 1.3
06
032
017 21 004 017
0.8 630 05
3/ 108 3.7
placed on the posterior soft tissues may be a cattse of sciatic
nerve pals,v.
Some slrrgeons also believe that the gluteus mrximus
femoral insertion (gluteal sling) can compress the sciatic
nerve Lrpon 90' of internal rotation of the leg, a position
i,vhich is necessary dnring femoral Preparation. Hurd et als
found that magnetic resonance imaging revealed oedema
r,vithir.r the sciatic ner\¡e at the level of the gluteal sling, in a
series of patients u,ho had post-operirtive ner\re palsl'. Fur-
thermore, there u'as a significant difference in the incidence
of sciatic nerve palsy in patients r'vht¡ had the gluteal sling
released ¿,ers¿rs those r'vho did not.
Anatomical variants in tvhich the sciatic nerve Penetrates
the piriformis muscle erist in up to 20% of cadaveric spec-
jmens." This is also a possible location of tension to the sci-
atic nerve! as in a posterior irpproach, the tendon is released
and may pull on the nen,e as it retracts. It is also allother
point at which the nerve may [¡e tethered.
Finallr', bleeding irt the surgical site can collect in ¿rn
enclosed space after surger\', causing compression of nearbl'
ner\ es. lea.ling to neuroprlri.t.
l*cí*1*rt*e aná rí*k f a*t*:*
The incide¡ce of ner"ve pnlsy after primar,v THA ranges
from 0.17oA to 4.0% (Table I).r'r'r0li In a large regrstrr-
database, Farrell et alt examined risk factors for motor
nerve palsy after primarl' THA, and fonr-rd that pre-
operative diagnoses of der.'elopmental dvsplasia of the hip
or post-traum¿tjc arthritis hacl higher rates. The theory
behind this association is that the altered an¿1toml' of d-vs-
plastic patients ma,v result in an aberrant course of the sci-
atic ner\¡e, making it more susceptible to injur.v. In the post-
traurlatic situation, scar tissue or adhesions may tether the
sciatic nerve. Other associated risk factors found in this
stud¡' lvere tl-re use of a posterior :rpproach, lengthening of
the extremity, and the r-rse oi rn ttncemented femc¡ral
implant.
Excessive lengthening of the extremit,v places tension
Lrpon the nerve; in this str-tdr-. the average lengthening of the
limb in the patier-rts t'ho sustained a nerve Palsv \\-¿1s
1.7 cm, significantl,v greater th¿rn a matched cohort ulrrr
did not have a nerve pa1s1'. The use of ¿n uncemented i!'r1l
oral implant may result in more arial impaction in¡t, ::¡
fernoral canal, lvhich could repeatedly stretch I.ter\ i:,
-

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

AV Carti, MD, MSc, FRCSC,
I\4aur¡ce Muller Fellow
Hospital for Special Surgery,
535 East 70th Street, New york,
NY
,]0021,
USA
J J Negus. I\,4D, FRCS,
Orthopaedic Fellow
E S Haddad, BSc MD(Res),
FRCS(Tr&Orth), professor of
Orthopaedic Surgery
University College London
Hosp¡tals, 23b Euston Road,
London, NW1 2BU and NIHR
University College Lonclon
Hospitals Biomeclical Research
Centre, UK
Correspondence should be sent
toA V Carli; email:
aJbefto carlj@maiI mcgijl ca
aa2o17 The Br¡tish Ediloriai
Society of Bo.e & Joint
S u rgery
doi:10 '1302/0301 620X 99B1
BJJ-2016 0220 R1 $2 00
Bone Joint J
2017;99 B(1 Suppte A):50_9
-t0
Gonclusion
Very few studies within the pFF literature
implants, specifically those of single_wed
in the literature, with most investigations
with osteoporotic bone. This review illust
to record implant name and information for future
anarysis. Furthermore, future
biomechanical investigations comparing modern
implants are needed to clarify the precise
contribution of implant design to pFF risk.
Cite this article: Bone Joint J 2O17;(l Supple
A):50_9.
A periprosthetic femoral fracture (PFF) is a surgical complications and
devastating complication that can occur fol- frequently remain
fun"ctionally ir-ri"J even after surgical
lowing total hip arthroplasty patients treat-
(THA). ment.2,s
with PFF have been found to have an 11"A Despite
longstanding awareness of the con-
increase in overall mortality risk within
12 sequences of pFF, the prevalence of this com-
months of the complication, a rate which
approaches that of the hip fracture patient
population.l,2 In addition to increased
mortal-
ity risk, PFF patients often require complex
revision surger¡3,a are four times more fiLely
to require post-operative readmissio., fo.
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
thetic fractures increased by 2.2% from 2012 to 2015, cul-
minating in the current figure ctf 9.2",, according to thc
National Joint Registrl, of England, \fales, Northern Ire-
lancl ¿rnd the Isle of Man (NJR).s
Although several patient factors inchrding increrrsing
áBe,''1'l gender,9 l+ the presence of ostcoporosis14'15 and
rheumatoid arthritisr0 have been associatcd rvith the rising
rates of PFF, the contribution of implant design or-r PFF risk
is less clear. Cementlcss femoral components have been
¿rssociated lvith a higher incidence of intra-operativel't-16
and post-ope.",iu.l4'17't8 PFF. Hoi,r,ever, surprisinglv
reports pertaining to thc clinical PFF rates among differer-rt
cementless stem designs exist. Furthermore, lr.hile sotrc
comparative investigations have been perfonr-red for
cementecl femoral components and PFF, their lorv individ-
ual prevzrler-rce rnakes drarving conclusions from individual
studies difficult. In response to the lack of large compara-
tir.e in'n,estigations of PFF rates erxong different ferloral
component designs, \ve pcrformed a s,vstematic re'n,ie\v of
the topic with the hope of finding a common thenrc that
could guide safe femoral component selection. Although
clinical studies bore the focus of this revieu,', r,ve also evalu-
ated biomechanical and cad¿r.eric erperiments of PFF to
determine if these investigirrions could help explail clinic¿rl
observ¿rtions.
at*rir-trs *r.z* *Z****
A s,vstematic review of the liter¿rture rvas conducted accord-
ing to the Preferred Reporting Items for Svstematic Reviervs
and Meta-Analyses guidelinesle using the online databases
Ovid Medline, EMBASE and ISI \feb of Science (frorn
inception of e¿rch database to trI¿rrch 2016) and the last
four Proceedings of the Annual lvleetings of the Americ¿rn
Acadern.v of Orthopaedic Surgeons (AAOS; 2013 to
23
2-01 6) .24 Articles rvere identified using an electronic search
of the follorvir-rg ke,vr.vord terms and their respective con'rbi-
nations: "periprosthetic femoral fracture". "periprosthetic
fracture", "irnplant design", "implant geometrl.,!!, "cement-
less stem follo'"v up", "cenrented stern follorv up". Further-
more, two revie'nvers (AC, IN) manually revieu,ed the
bibliographies of retrieved articles for addition¿rl citations.
Tr:anslated abstracts from foreign language publications
were also considered for analysis.
Tr,vo reviewers (AC, JN) independently screened the titles
and abstracts of all retrieved articles. For the clinical com-
ponent of the revierv, articles describing clinical cases of
intra-operative or post-operative primary THA PFFs ¿rs
w-ell as the femoral implant name and manufacturer were
retained and their ful1 terts retrie.,,ed. Clinical arricles
which failed specificallv to provide the implant name, or ar
the very least, detailed description of the implant to infer
implant identification, \\¡ere excluded. Articles reporring
PFFs in the context of revision THA were also excluded. A
second round of article selection ."vas performed bv the
same t\\,o inclependent revierrn,ers, with the article being
selected onlv if it included the follorving information: fem-
VOL- 99-8. No 1, JANUARY 201;
i1
oral component n¿1lne and r¡anufactltrcr. :-ta ,. ,t.r,rr-L Ut
eithe¡ intra-operative or post-operatir e PFF:, R¡i ¡r,, ¡rs
met follor'ving the second round of article selectir)n :r) r.,:. -.
consensus regarding included articles. A standardrse.l .1,.1:.:
cxtractioll form lvas developed with e¿ch revieu,er indep.311-
dently ertractir-rg data from each included study.
From each qualifying stud1,, mean patient age, gender.
body mass index (BMI) and time of fracture fron prirn:rr-
surger,y rvere collected. The name and manufacturer of thc
femor¿rl component were recorded and the stem was then
fer.". classified. Cemented femoral ste rrs were classifie d as
belonging to either the 'loacled-taper' (Exeter) category or
t1.re'composite-beam' (Charnle,v) categon..24 Cementless
femoral stems \\rere classified according to the s),stem estab-
lished bv Khanuja et ,11,25 consisting of tvpe 1 ('single-
.,vedge' or 'blade-t1,pe') stems, type 2 ('dor"rble-wedge' or 'fit-
and-fill'), t.vpe -3 (tapered rour-rd/spline/rectangle), ti,pe 4
(cylindrical, fti11y coated), t1,pe 5 (modular) and t1,pe 6 (ana-
tomical). For the fundamental component of the revieu.,
u,,ithin the initial search, anv article which evaluated femoral
PFF risk using computerised, cadaveric or sau.bone models
and pror.ided the femoral in-rplant rame and manufecturer,
were retainecl and their full terts were anah,sed. Conclr-r-
sions pertaining to implant clesigr.r, length, geometr,v and
snrface finish from each study were extracted anc'l compared
lvith the impl:rnts described in analysed clinical studies.
The proportion of ceme nted and
'út=*2i*i:i+a1e**iy=i*"
cementless stems was calculated, as r,vell as proportions of
each stem c¿tegorv or classification. Comparisons arlong
proportions lvere performed using a chi-squared test of
indcpendence ivith Yates' correction, u,ith significance set
at a p-value < 0.0-i. '§l'hen comp,rrisons u,ere made among
more than two proportions, conser\¡ative posl /:oc cor-npar-
isons using a Bonferroni correction were performed. All
st¿tistical tests \\¡ere performed using SigmaPlot Version
1 1.0 (Systat, Erkratl-r, Germany).
***r¿|tz
Sqzlera*1*r*.¡i*,:¡.In total 596 articles u,ere retrieved
through the primarv search, rvith 122 describing intra-
operative or post-operative periprosthetic femoral fractures.
The full texts of these articles were reviewed in derail, with
342r t6 meeting inclusion criteria for anal,vsis. Included arti-
cles represented 1691 PI'F patients u,ithin a cohort of 342
719 priman, THA patients. Of the 34 included clinical stud-
ies, six compared cementless and cemented sten-rs (Table l).26
r0'je Jn rctal 22
studies evaluated cementless stems onl1,,J1-'t'l
rvith 13 evaluating one stem onlv (Table II) and nine of these
compared t\Á./o or more stems (Table III). Just seven articles
errluared cemerrred rrenr. onlr.in t' wirh five comparing
composite beam and loaded-taper designs, and two evalu-
ated one design (Table IV).
With regard to knor,vn PFF risk factors, increased age.
female gender ar.rd pre-operative diagnoses of femoral neck
framure and developmental hip dysplasia u¡ere significanrLr
associated (Tables I to IV). Hor.veveq such as:ocr¿rr, r.
 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
7.4"A¡.2e,:o:e''l7,at The Austin Moore was the Type 1 sten.r
with the most (59) PFFs. The ABG II (Stryker/Horvmedica/
Osteonics, l(alamazoo, Michigan) was rhe Type 6 stem
with the most (39) PFFs. rü7hen reporred, a high proporrion
of Vancouver B-type fractures6l were identified when
cementless slems were used.
For cemented stems, a significantly greater pr:oporrion of
PFFs were identified with loaded-taper or Exeter-type srems
(378 of 105 681, 0.36%) compared wirh composite beam
\¡Ot 99 ts, No I,JANUARY 201:
designs (412 of 1,50 277, 0.27%; chi-squared = 12.36,
p = 0.004). Of the four articles comparing the r,"r,o srer¡
designs, all four reported a higher incidence of pFF with the
Exeter stenr. Specificalll,, Thien et alio four-rd that r_rse of the
Exeter stem was associared'"vith a fivefold increaseci hazard
ratio for PFF comparecl u,,ith composite-bealr stems. \{'rthin
the con.rposite beam rypes, rhe srraight Charnler- (Dep,.r-
and anatomical Lubinus srems (rX/aldemar I_ink Ciml.H :r
Co., Hamburg, Germany) were directly conrp.rre.l .
articles,j6'i; with both reporting a lou.er inci.lc:--. :
 -\, \. 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
nature of studies included in this review. Specificall¡ the
effect of confounding factors including patient age, gender,
pre-operative diagnosis (femoral neck fracture, presence of
external validity and statistical power of our results. Fur_
thermore, performing a meta-analysis would not be possi-
ble due to no single study clearly defining all of the above
listed risk factors and implants used. A second limitation is
poorly performing stems could
n occurs when noting that the
ted half of PFFs reported in the
type 1 group. Although the Ausrin-Moore did nor have the
highest prevalence of PFFs (2.4%) among cementless stems,
the presence of a collar and unique windows within the
stem body do make it different from modern type 1 stems.
A third limitation, which was touched on in the results sec_
tion, was our decision to report pFF rates with the largest
sample size3o included and excluded. This decision was
made because findings from several case-controlled studies
conflicted with the larger study. Furthermore, the larger
study reported PFF rates for cementless stems that were
considerably lower than any other stud¡ raising concerns
about the completeness of the registry data.7o Registry data
for PFFs are specifically difficult in that they often fail to
record the number of PFFs that do not undergo operarive
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
pertinent stem characteristics such as method of femoral
preparation. Ream-and-broach designs generally remove
greater amounts of cancellous bone compared with broach_
only systems7l and this difference in preparation could
affect PFF risk. Furthermore, cobalt chrome stems are
stiffer than those of titanium alloy and this difference has
been implicated as a potential cause for increase pFF in a
specific type 2 stem design.32
§7hile the effect of cementless stem geometry on proximal
bone strain was a topic of tremendous interest ten to 20 years
ago when these implants were introdvced,T2'7s very little lit-
erature has emerged since. In an editorial jn 1992, HorneT6
questioned the rationale behind ,fit-and-fill, stems, noting
patients varied tremendously in their metaphyseal_
diaphyseal geometry and that radiographs produced erro-
neous rep y up to 40"A oÍ
thetime. sasubsequent
in uitro c ¡apered-spline
stem in cadaveric femurs showed significant differences in
the dynamic response and total movement each stem exhib_
ited in response to load.s3 Such differences have also
been reported in both the sagittal and coronal plane among
VOL. 99-B, No. 1, JANUARY 2017
To AVOID THE\I
single-wedge and anatomical stems L,€rstrs cemented
implants,:7 r,et in both cases, neither studl, evaluated loading
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
information to surgeons and, r,r,hen coupled with novel
computer models that rake implant stabilitl. and patient
proximal femoral bone density into accounr,78,7e can hope_
fully permit surgeons to identify pre-operativel,v r,vhich
implant places a specific risk to the patient for pFF.
In conclusion, this systematic revier,v found that cemenr_
less stems, specifically those rvith a ,single, o¡ ,double,
rvedge were associated with the highest incidence of pFF
among pooled studies. Perhaps more concerning, the
review found that less than a quarter of periprosthetic
investigations reported on the type of implant involr.ed.
Due to the paucity of literature regarding implant design
and PFF risk, we propose that orthopaedic journals reqlresr
specific implant information in future pFF-related submis-
sions ancl that impJant characteristics (beyond cement rler_
sls cementless) be regu[arly recorded in clinical registries.
In ight of the recent increase in both frequeno, and severity
J
of PFF,80 comprehending the precise contributior-r of
in'rplant design on PFF risk i,vill greatly assisr surgeons in
selecting the implant u,hich is safest for the patient and help
them to avoid a potenrially catastrophic complication.
cantly higher risk of periprosthetic femoral fractures lmplant name and
geometry should be reported in all future studies related to per¡prosthetic
fractu res
Author contribut¡ons:
A V Carli: Devised study methodology, Retrjevecl articles, performed añicle
analysis, Wrote manuscript,
J. J. Negus: Retrieved articles, Assisted with article ana ysis, Edited manuscript.
E S. Haddad: Assisted with developing study methodoiogy, nterpreted
afticle
analysis, Edited manuscript.
Th research/study/project was supported by the National lnst tute for Health
Re arch University College London Hospitals Blomedical Besearch Centre.
The author or one or more of the authors have received or w I receive benefits
for personal or professional use from a commercial party related directly or
indirectly to the subject of th¡s articie.
This article was primary edited by G Scott
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,
gth to 1 2th December.
Florida,
Referer'¡ces
1. Young SW, Walker CG, pitto Rp. outcome of femora periprosthetrc
¿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
2. Bhanacharyya T, Chang D, Meigs JB, Estok DM ll, Malchau H. [/]Orrali
afier
peripros,het c Íracture of the femur. J Bone Jornt Surg
[Am]Z0Al:g9 A:2658_ 62
3. da Assunqáo BE, Pollard TC, Hrycaiczuk A, et al. Bevrsion arthrop
as t
periprosthetic femora fracture using an uncementecl modu ar laperecl
Bane Jaint J 2015,97-B: T 031 -t 037.
conica
 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
Fig
1
lndividualised valgus correction angle
(VCA) based on a pre-operative ful -
length anteroposterior femur radio-
graph.
correctible valgus deforn-rit1'lvith ro fi-xed deformitl.and an
intact NÍCL; tvpe II is a fixed valgr-rs deformitl. with an
intact N,ICL; q.pe III, a valgus and h).perextension deform-
ity u,ith an intacr MCL; [,pe IV, valgus and a fixed flexion
deformit,v with an intact MCL; r),pe V severe r.algns
deformitv u,,ith an incompetenr MCL and type VI, valgus
secondarv to extra-articul¿rr deformit1,.6 For each §,¡re, the
authors describe the surgical management to correct both
the bone and soft-tissue componenrs of the deformitl'.
lfáechan iceÉ alÉgeT rnent
MechanicaJly aligned TKAs aim to have a neurral coronal
plane alignment and a tibial cur that is orthogonal to the
mechanical axis.' In a valglls knee, both femoral and tibial
pathology mav need to t¡e addressed u.ith respecti\re bone
clrts to achieve this goal. The norn-ral knee t1,pica1ly has a
femoro-tibial angle of approrimatelv 6" valgus,- horve'n,er
in some cases, after surgical correction and despite achier,-
ing this desired 6' femoro-tibial valgus angle, there may be
some residual valgus malalignment. Nlullaji et als reported
a negative correlatiot-r benveen increasing valgus deformity
and the distal fe moral valgus correcrion angle (VCA)
! required to create a distal femoral resection perpendicular
to the mechanical axis. Vith increasing severit,v of valgus
deformitl., the magnitude of rhe VCA cut decreased. The
average VCA among the 44 r,algus knees in tl.reir cohort of
: 503 arthritic knees rvas -5.9',8 and other investigators have
reported mean VCAs in valgr-rs arthritic populations to be
I less than 5o.e,10
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
I noted to be 53% in Alghamdi et al's cohortrr of 97 r,algus
arthritic knees, and the mean tibia valga angle was
t \ OL 99 B. No 1, J\NLI-\RY 2011
I
t
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
positioning this has nor been reflected rn an improved clin-
ical outcome.l0'12'13 Patient-specific instrumentation has
not been shown to result in better posr-operative limb
:rlignment or clinical outcomes as compar-ed to st¿rndald
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
correct fen-roral component rotation. Hou,et.er, in the val-
gus malaligned knee, the posterior femoral condy,le is often
deficient and so relving on the posrerior condvlar axis can
result irr malrotation of the femoral component. Instead,
the anteroposterior (AP) axis15 and the transepicondr,lar
axis should be used as reference to achie'n,e correct femoral
component lotation.s'15,16 Alternativell., the posterior con-
dylar resection shouid be parallel to the tibial cut and so
orthogonal to the tibial mechanical axis, as described l:y
Ranarvat et al.3 Failure to recognise posterolareral femoral
deficieno. can result in ar.r inappropriate femoral cornpo-
nent sizrng resulting in ir-rstabilifi, in flerior.r or malrotation
of the fen-roral component resulting in posterolateral insta-
bilit1.. If there is significant larerai femoral deficiency then
femoral component augments such as r,vedges rna1, be
required. Finall¡ if a posterior-stabilised TKA is used, the
femoral bor cut should be lateralised to oprimise patellar
tracking.
Tibial resectiom In a mechanicalll. aligned TKA, the tibial
cut should be orthogonal to the tibial mechar-rical axis.
Hou,ever, as noted above, if the planned tibial cut is based
on proximal tibial anatomy, this mar- result in under correc-
tion of the deformitl, if rhere is unrecognised distal tibia val-
gus.lI In the presence of more ser-ere valgus deforrnities,
lateral side tibial cornponents ¿lugments mav be necessary
as '"ve11 as the release of Iateral soft rissues.
Kinen¡atic aligi:l::ent. Surgeons ma) nse surgical strategies
other than mechar-rical a[gnrnent, including anaromic
alignment or its modern 3D iteration kinematic alignrnent.
The goal of kinematic alignment is to recreare the 3D anat-
omy of the knee's pr:e-arrhriric joint surfaces.- In the colo-
5o.
na1 p1ane, this technique produces increased femor.al
component .,,algr-rs and increased tibial component \ arus as
 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-

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

tissue release. There were lto reported cases of delalecl
instabilit¡, and implant survivorship was 100% at ren years
and 83'/o at 15 vears.21
Although other series4.l.t,22 h"ve repo::ted tl.re results of
lateral ligament advancement, mediai ligament advance_
lnent with imbricatio¡, eprcondl lar siiding osteoromies arrd
compllter:-¿lssisted release techniques, no singie soft_tisslre
managemenr technique has proven to be the most effective
in the surgical treatment of r.algr_rs deformiry.
*diaÉ agpr*a=*
posterolater:rl corner, cler.ascularis¿rtio, of the pate lla .,vith
a concommitent lateral lelea
relea:e of medirl .oir rissurs
ever, the clinical results of usi
factory u,ith good shorr- and
L&***ral e**?r;;***
Keblish2't popularised the lateral parapatellar approach.
The reported :rdvantage of this included a more clirect
approach to address these concerns ancl have reported
isfactory clinic¿rl results.
recommended29.-10 r,vhen there are ser ere cl.iornriries
in
ivhich stabilit) cannot be achieved u,irh a less consrr¿Lneci
prosthesis, long-term follorv-up stuclies hale nor been
reported.
*lzz=ie*N *zÁt**=z**
Revisior.r rates follo*,i.g TKA for'algus arthritis have been
reported ¿rt befi,r,een 0o./o ¿rnd 17o,t, ¡tten- to 1S_year follow_
up.21'3t':: Higher failure rates h¿,Lr-e been reportedi:l with
significant pre-operative defonnitv o, an inaáequare surgi_
cal correction. The correlation betrr-een ribial componÁr
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
predictive of one 1,s¿¡ post-operative satisfacrion scores.3l
There are ferv TKA outcorne studies comparing r.algr_rs
or
.,,arus knees. two studies38,39 have dentonstrated no sig_
Just
nificant differences in oi,erall clinical ourcome at micl_term
folloiv-up.
The treatment of valgus knee deformity r,vith a TKA pre_
scnts a number of challenges. Multiple surgical tecl.rniqr-res
have heen described r,",ith satisfactor,,- .lir-ri.al resulrs.
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
sat_ long-terrn survivorship r-ates of over 90,%.

!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-

 +
:. Thienpont
'om Uniuersity
i,tspital Saint Luc-
CL, Brussels,
: tlgium
: Thienpont, I\,1D, MBA,
::d of Knee Surgery
- - versity Hospital Saint
lL, Department of
:hopaedic surgery, Av
- rDocrate'10,'1200 Brussels,
:: gtum
I : rrespondence shou ld be sent
:: Thienpont; email:
:-manuel thienpont
: rclouvain be
:017 The British Ed¡torial
::
? ety of Bone & Joint
: raerv
: 10'1302/0301-620X 998.1
a_J 2016-0272$200
a.ne Joint J
:r17;99-B(1 Suppte A):65_9
OL. 99-B, No I , JANUARY 20 t 7
#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?
Objectives
Unicompartmental knee arthroplasty (UKA) is a potential treatment for isolated bone
on
bone osteoarthritis when limited to a single compartment. The risk for revision
of UKA is
three times higher than for totat knee afthroplasty (TKA). The aim of this review
was to
discuss the different revision options after UKA failure.
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
revision as an endpoint is not. Registry results are available.
rh. ti"e of implant ..qrir.d to
Luc show that UKA are revised three times more obtain a
satisfactory'swgical result should be
often and much earlier than total knee arthro_
plasties (TKA).3 5 The reasons for this can be
either obvious technical mistakes made by low
volume UKA surgeons, performing often less
than 15 UKAs per year 6,7 or the belief of the
revising surgeon that coversion of a uKA to The aim of this review was to study the differ-
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.
threshold for such a conversion.T
The most common failure modes for LKA are &4áterÉa ls a nc! flúletsi*ds
instabilit¡ progression of
disease to anorher com_ trVe
performed an extensive preferred Reporting
partmendcompartments and aseptic loosening of Items for Svstemaric Review and \ ler¿_
65
a
E. THIENPONT
Fig'1
Shows failure of PolYethYlene
and therefore Potential indica-
tion for isolated PolYethYlene
exchange
Anah,sss (PRISMA)1t compliant sear:ch in lvlarch 2016
Llsing PubMed, Embase reseerch and Google scholar, look-
ing for English language erticles published betrveen 2006
and 2016. The search terrns Llsed were "unicompartmental
knee arthroplast-v"; "unicompartmental knee replace-
ment"; "revision knee :rrthroplast,v"; "failure of unicom-
partmental knee arthroplasty". \ü7e reviewed the list of titles
and selected :r11 papers r.vith rele'n'ant abstracts. This search
led to 3208 citations ft¡r initial ¿lssessrrent. After revierling
titles and abstracts, 10-5 papers r,vere selected for furthcr
analysis. Of these, 39 papers urere deemecl to contain clini-
call1, relevant data to be included in this review.
*É**a*eir;*
tl\&.x*
?,evisi*zz r:t ;LLlz, This tvpe of revision is rare. In the
Iiterature this is mostl,v reported as either case reports or
case series.l2'16
1s 16. following scenarios c¿rn be cor-rsid-
ered. Liner change could be an oPtioll in case of mobile
bearing dislocation r,vith revision to a thicker polyethvl-
ene.1e Another case u,ould be u,ith isolatecl polyeth,vlene
wea! diagnosed ear11', and revised before metal-on-metal
wear or osteolr,sis could nccur (Fig. 1). Luneboltrg et al20
described their results for isolated liner exchange in wcl1-
fixed metal-b¿rcked fired-bearing UI(A. A total of 20
mediai UI(As revised ¿rt mear of 8.2 standard deviation (s»)
2.6 1,ears r,vere clinicallv assessed.20 In total,79'A oi
patients were enthusiastic or satisfiecl and a sun'ival rate of
71'A (sD 15%) cc¡nsidering revision for any reason \\¡as
obtained at 12 years.20 UKA to UI(A can also be perforn-red
in case of early aseptic loosenir.rg of a single component.lT
Epinette et al2t r.vere able to revise 36 out of 425 (8.5%)
UKAs to another UI(A. They also found a re-revision rate
of 8% due to aseptic loosening in this rer"ised group. At
eight years follow-up, clinical outcome for the UKA to
UKA revision grorr.p was satisfactory rvith high l(nee Soci-
ety Scores.2L Analysis of the Ar-rstralian Joint Registry b.v
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-
ing the lorver lir-r-rb aucl correctiug osteoarthritis in the to-
l
be-treatec'l comparlment.2
Rolston and \tloore2a published a case r'vhere a lateral
UKA u,¿rs convertecl into a tricortpartinlental ioint replace-
ment with retentjon of both cruciates. A bicompartmental
implant (Dcuce; Smith & Nepheu', Nlemphis, Tennessee)
rvas added for disease progressiort leading to s¿ttisfactor\
results for the patient.
**n ¿+¡::i*tz 2:r: :z ?r:',r,'+:'{ 7{"9.lf bicompartmentaI clisease
to :r primar,v TI(A can be
progressior-r occLlrs, conversiolt
perfomed. Either a crLlciate retaining (CR) or postero-
stabilised (PS) implant can be used. In cases rvhere the tibial
cur in the UI(A i.r'¿rs consen,ative, further bone cuts for a
TKA can make the implantation of a primarv TI(A possi-
ble. C)ften this is possible in a r,vell-erecnted UKA that pre-
sents rvith infection, earl,v aseptic loosening or unidentifiecl
patn.
Khan et alr't for-l-rd that 78% of conversions from UKA
to TKA could be perfornred r.vith CR implants. In 8% of
cases they r-reeded revision components in particular tibial
stems rvith or rvithout tibial augments.
Craik et alll obsen,cd a 5.-l% revision rate at 25 months
for UKAs perforrned at their institution. The most common
re¿sons for revision were ¿rseptic loosening and progression
of osteoarthritis. Of the converted Ul(As, 349o of patients
needed a conversion to ¿r revision tvpe of TI(A with ar-rg-
ments, stenls or bone grafts.11 Robb et a126 found the same
revision rate of 57o at a me¿rn of three 1'ears. ln bToo of
cases, primary colllponents could be used. In 33% revision
components r.vere needed u'ith the majoritv on the tibial
side. Sierra et al27 also found a re-revision rate after revision
TKA frorn UI(A of '1.5% at an average of 75 months fol-
loiving UKA. The,v observed at this time after surgery asep-
tic loosening of components (55 % ) and disease progression
(34%) as the most corlmon reasons for f¿ih-rre. Polyethyl-
ene \\¡ear (4'%)and ir.rfection (3%,)rvere rare.l'Seldenha et
al2t found the same causes of failure for the mobile UI(A.
Leta et a12e anal,vsed the outcomes of UKA after aseptic
re-nision to TI(A (n = 578) in the Norri'egian Arthroplast,v
Register and compared them to r-evision of TKA to TI(A
(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
Fi7 2 Fis,3
Unicompartmental knee arthro-
plasty with low tibial cut, varus
angulation and tibial stress frac-
ture because of important varus
alignment
and TI(A to TKA, 13o/o) lr,as comparable with a ten l'e¿1r
survival oi 82o/,, and 81'% respectivel,v. The risk of re-revi-
sion was tr'vo times higher for TKA to TKA in pirtieltts o\ er
70 years old (risk ratio (RR) 2.2). The reasolrs for re-
revision of UI(A to TKA grorlp and for TKA to TI(A groLrp
were tibial loosening (28"A uerstts 17%), pain alone (22'Á
uersus l2o/u), instability (19o6 uersus 19%) and deep infec-
tion (16% uerstrs 31"A, RR 2.2) repecti\reh. The observed
diferences were not significant except for deep infection
which was significantlr, higber for the TKA to TI(A group
(RR 2.2, p = 0.03) The surgical revision procedure took
more time for TI(A to TKA revision (mean 1-50 minutes
uersus 714 minutes) and required more stenrs (58'% r¿rsz,.
19%) and more constrairt (27o1, uersus 9Yo).)')
Cerciello et a1-10 shor,ved that the medi¿rl bone loss after
failed medial UKA can be grafted r'vith autogr:tft comirrg
from the lateral tibial plateau. In these cirses prirnar:v TKA
componellts can be used.
Unexplained pain is a major cause for conversion from
UI(A to TKA and if remov¿rl of components is performed
conservatively', primarl. TKA components can be used. The
hazard r¿rtio for conversion of UI(A for ttnexplained pain is
6.76 compared to TKA.I Hor.vever I(erens et al r0 sho'nn,ed
that surgerl' for unerplained pain leads more often
run:erisfector) result\ afrer rttrg,err.
**s.:u+rsie n t* a T?-§, ts=i*q ravisi*tz .*z?**{}a='z*. A revision
TI(A (rTKA) r'vith stems and augments might be necessarv
r,vhen converting a UI(A that presents r.vith c¡steolvsis.
Reconstruction rvith a nretal augment r.viII help restore the
joint line to the primarv 1evel of the contralateral side. The
augment usually needs a stem extension because of limitcd
contact to the cut surface of bone. The distal segrnent of
bone is often sclerotic and hard limiting cement inter-
c{igitation. The fen-roral side can often be reconstructed u.ith
I
\/Ot . 99 B. \o t, J.\NUARY 201;
A TOÍAL KNEE \RTHR\].-L -i \
Revision total knee arthroplasty of
case shown in Figure 2 with medial
block and tibial stem.
ir primary component and arrtograft to fill the contair.red
defects.3l Osteolysis is not alwal,s present and levisior-r
components rr-right be necessary as a result of technicaI mis-
takes ¿t the inder surgert'. It ca¡ be secondarl, to e\cessivc
varLrs, excessive posterior slope or due to a dor.vnsized tibial
tray having no cortical support resulting in subside¡ce and
bone loss (Fig.2). Meclial bone loss can also occllr at the
time of cornponent removal or in the presence of a tibial
keel.ri)
Since both the posterior and anterior cruciate ligaments
are intact, a UI(A can most often he converted to a PS TKA
lvithc'rut the need for more constraint. Increased constraint
to the level of a condi'lar constrained kr.ree lvill onlr, be nec-
essan. if important gap mismatches erist. Sarraf et al32
found that constraint was necessar,v in 4.2'/' of UKA to
TKA conversion, lvhile this vnas only necessarl' for' 2?o of
prin-rarv TKAs. UKA to TI(A conversion u,as accompanied
bv the use of thicker polycthylenes (12 mm instead of 10
mm).32 Rancourt et al33 also observed the need for thicker
polyeth),lenes and found lolver \üTestern Ontario and
McNlaster Universities Arthritis [nder scores and techni-
'§fl'nn
cal11,, a more difficult procedr-rrc. Jones et alsa
obsen ed th¿rt UKA to TKA conr''ersion u.ith a thicker polv-
tcr ethylene rvas related to the initial pol,veth,vlene thickness of
the UKA ¿rnd that these thicker poll,ethylene cases more
often rreeded an aLrgment or a stem.
I-une bor-rrg et all2 compared surgical characteristics, clitti-
cal outcomes and complications ¿t an average of se\-cn r erlr''
(so 4) follorv-up after: con\rersion of UI(A to TKA. a¡.l
four.rcl results more similar to a rer.ision TI(A than to : :- -
mary TKA. Schr'varzkopf et a1'15 studied the ler el of '
resection in UKA and four-rd that a more agqrc!> . -
resection was corrclated highlv r'vith thc neei :, - :. - '
augments (odds ratio 26.8) (Fig. 3). O'Do . -
 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;','
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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
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Á.
Atthr0plasty\0l|:30:1995 1989 "

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

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tB. [,4edial c

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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,
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total rep acemenl '-
al k¡ss p¡65¡ftg515 .
reasonabie
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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