Robotic assisted Total Knee Arthroplasty (TKA) is not associated with increased patient satisfaction: a systematic review and meta-analysis

PURPOSE

Total knee arthroplasty (TKA) is a common orthopedic surgery, yet postoperative dissatisfaction persists in around 20% of cases. Robotic total knee arthroplasty (rTKA) promises enhanced precision, but its impact on patient satisfaction compared to conventional TKA remains controversial (cTKA). This systematic review aims to evaluate patient satisfaction post-rTKA and compare outcomes with cTKA.

METHODS

Papers from the following databases were identified and reviewed: PubMed, Scopus, Web of Science, and the Cochrane Online Library, using keywords like "Knee replacement," "Total knee arthroplasty," "Robotic," and "Patient satisfaction." Extracted data included patient satisfaction measures, Knee Society Score, Oxford Knee Score, Forgotten Joint Score, SF-36, HSS, and KOOS. Statistical analysis, including odds ratio and 95% CI was performed using R software. Heterogeneity was assessed using Cochrane's Q test.

RESULTS

The systematic review included 17 articles, involving 1148 patients (571 in the rTKA group and 577 in the cTKA group) assessing patient satisfaction following rTKA. An analysis of proportions reveals rTKA satisfaction rate was 95%, while for cTKA, it was 91%. A meta-analysis comparing rTKA and cTKA found no statistically significant difference in patient satisfaction. Additionally, various patient-reported outcome measures (PROMs) were examined, showing mixed results across different studies and follow-up periods.

CONCLUSIONS

The results of this study found no difference in patient satisfaction outcomes in the short to mid-term for rTKA compared to conventional methods. This study does not assert superiority for the robotic approach, highlighting the need for careful consideration of various factors influencing outcomes in knee arthroplasty.

Opiate prescription after hip and knee arthroplasty: a retrospective cohort study

AIMS

Excessive opiate analgesia in relation to orthopaedic surgery is associated with morbidity and mortality. Pre-operative use of opiates is associated with higher post-operative use. There is little information about opiate prescribing practices in relation to elective total joint arthroplasty (TJA) in New Zealand rural centres. The aims of this study were to describe opiate use before, immediately after and 1 year after TJA, and to compare prescribing practices with local guidelines.

METHODS

A retrospective cohort study of elective primary hip and knee arthroplasties was conducted between January 2018 and April 2019. Opiate use was evaluated from clinical records and from electronic prescribing records and described in morphine milligram equivalents (MME) with a particular focus on pre-operative and post-operative periods, and use after 1 year.

RESULTS

In the study period, 199 patients underwent 203 joint arthroplasties. Of these, data from 157 patients were analysed. Patient data were not analysed because of unavailable files (N=20), non-elective procedures (N=11), bilateral arthroplasties (N=4), deaths (N=4) and incomplete information (N=3). Pre-operative opiates were used by 92 (59%) patients, of whom 70 (76%) were not using opiates after 1 year. There were 126 (80%) patients who were discharged with opiate prescriptions and the vast majority, 121 (96%), did not receive discharge prescriptions that conformed to local guidelines.

CONCLUSION

Despite undergoing joint arthroplasty, about one quarter of patients who had been prescribed opiates before the operation were still receiving opiates after 1 year. There was poor compliance with local guidelines.

The Role of Three-Dimensional Custom Printing in Revision Total Hip Arthroplasty

Acetabular revision accounts for approximately 18% of all total hip arthroplasty (THA) procedures. This was the third most common reason for THA revision in 2020. One of the unique challenges faced by reconstruction surgeons performing revision THAs is the issue of acetabular bone loss. The aim of this paper is to present the role of custom acetabular reconstruction with marked bone loss for undergoing revision THA, using a local case study as an example. We described utilization of custom components to address the highly complex cases with Paprosky classification of III and above. Recent studies have shown comparable clinical results to conventional methods and improvement of postoperative patient-rated outcome scores. However, larger clinical trials focusing on the long-term outcomes in comparison to off-the-shelf components in complex acetabular revisions would be of merit.

Three Episodes of Presumed Culture-Negative Septic Arthritis Following Intramuscular Antipsychotic Injections: A Case Report

CASE

We present a male patient of low socioeconomic status and Māori ethnicity who experienced 3 episodes of presumed culture-negative septic arthritis of the native hip between ages 43 and 52 years. Each episode occurred within 3 weeks of intramuscular antipsychotic injection into the ipsilateral gluteal muscles. The right hip was involved in 2 presentations and the left hip in 1 presentation. No coexisting infection or underlying immune suppression was identified, and at follow-up 2 years after the last episode, he has no sequelae of septic arthritis.

CONCLUSION

This report describes 3 episodes of presumed culture-negative septic arthritis after intramuscular antipsychotic injection.

High early failure rate for a new unicondylar knee system

Background

This single-center retrospective study evaluated early failure rates for an unicompartmental knee arthroplasty (UKA) system with an anti-allergic surface.

Methods

We studied 87 consecutive joints received an UKA at a single center between 2017 and 2020. All patients received a fully cemented anti-allergic Univation-Aesculap partial knee replacement implant with a corundum blasting surface. All joints had precise indication of unicompartmental arthroplasty according to the current criteria of this procedure. The current series was restricted to patients undergoing medial cemented UKA. Medial compartment osteoarthritis was the main indication.

Results

We found early failure (aseptic loosening) was documented in 20 of the 87 joints (23%). The time to failure ranged from 7 weeks to 3 years, for an estimated 33% (15-46%) cumulative hazard rate for implant loosening over three years. No cases of periprosthetic joint infection were found. On average, the patients began complaining about first symptoms during the third month after surgery. In most cases (66.66%), the cement remained fixed to the bone.

Conclusions

Based on these early results, the manufacturer of this implant stopped all further distribution. Continued efforts should be made to understand the clinical and radiographic outcomes of alternative and anti-allergic surface coatings in knee arthroplasty.

Five-year results after total knee arthroplasty in lymphoedema and lipoedema: encouraging functional and clinical outcomes and low rates of infection

BACKGROUND

The aim of this study was to define outcomes after total knee arthroplasty (TKA) in lymphoedema and lipoedema patients managed by a multidisciplinary team and daily compression bandaging.

METHODS

A retrospective study was performed in a single centre. Between 2007 and 2018, 36 TKA procedures were performed on 28 consecutive patients with a diagnosis of lymphoedema and lipoedema. Oxford Knee Scores (OKS), EuroQol-5D (EQ-5D) scores, satisfaction scores, radiographs, and complications were obtained at the final follow-up. Patients were admitted to the hospital up to two weeks prior to surgery and remained on the ward for daily compression bandaging by the specialist lymphoedema team.

RESULTS

Over the study period, 36 TKAs were performed on 28 patients (5 males, 23 females) with a mean age of 71 years (range 54-90). Of these, 30 TKAs were in patients with lymphoedema, five with lipoedema, and one with a dual diagnosis. Overall, 28 TKAs (21 patients) were available at the final follow-up with a mean follow-up time of 61 months (range 9-138). The mean BMI was 38.5 kg/m². The mean pre-operative and post-operative Oxford Knee Score increased from 18 (range 2-38) to 29 (range 10-54); p < 0.001. EQ-5D score increased from 0.48 (range 0.15-0.80) to 0.74 (0.34-1.00) (p < 0.001). Mean post-operative satisfaction was 7.6/10 (range 2-10), with 89.3% TKAs satisfied. Complications were one (4%, 1/28) deep vein thrombosis, one superficial wound infection, one prosthetic joint infection, one stiff knee requiring manipulation, and one intra-operative femoral fracture.

CONCLUSIONS

Lymphoedema and lipoedema should not be seen as barriers to TKA if adopting a multidisciplinary approach.

Dual-mobility bearings in complex revision hip arthroplasty

BACKGROUND

Revision total hip arthroplasty (rTHA) is associated with an increased dislocation risk. Dual-mobility (DM) bearings have been used to address this issue. Such constructs offer increased range of motion and enhanced stability whilst avoiding some issues associated with fully-constrained devices. DM bearings have been used in our unit since 2013.

METHODS

All rTHA cases since 2013 were reviewed using the following criteria: (1) use of a DM bearing; (2) extensive soft tissue or bone loss resulting from ARMD, infection or multiple revisions, or requiring custom or megaprosthetic reconstruction; (3) minimum 2-month follow-up.

RESULTS

52 cases were identified with a median of 2 previous operations (range 1-6) and mean follow-up of 14 (2-41) months. The Novae-Stick component was used in 50 cases, the Avantage in 2 and the Trident MDM in 1 case. 19 required acetabular reconstruction using trabecular metal and four required custom acetabular components. 19 required femoral reconstruction with a proximal or total femoral replacement.Postoperatively, 8 patients (15.4%) sustained a dislocation at a mean of 1.6 (range 1-3) months. 3 (5.8%) requiring re-revision. 1 required excision arthroplasty and 2 a constrained liner, 1 of which went on to have further instability. There were no intraprosthetic dislocations.

CONCLUSIONS

Dual-mobility components are a viable option in the complex rTHA setting. Early dislocations can occur but the rate of instability is acceptable in this high-risk group.

Ankle arthrodesis in patients with haemophilia-associated ankle arthropathy - does the technique influence the outcome?

Management of symptomatic osteoarthritis (OA) of the ankle in patients with haemophilia can be challenging. Arthroscopic ankle arthrodesis has been shown in non-haemophiliac patients to provide similar or superior rates of fusion to open ankle fusion. However, the literature regarding ankle arthrodesis in patients with haemophilia is limited. Our aim was to compare the rate of successful fusion between open and arthroscopic assisted ankle arthrodesis in patients with haemophilia. A retrospective study was performed. All patients with haemophilia who underwent ankle arthrodesis at our centre were included. Outcomes including peri- and post-operative complications, and lengths of stay were extracted from patients' records. Radiographs were reviewed for signs of successful arthrodesis. Seventeen arthrodesis procedures were performed in 13 patients between 1980 and 2017. Nine procedures were performed arthroscopically and eight were open. Ten patients were diagnosed with haemophilia A and three with haemophilia B. The success rates of arthroscopic and open tibiotalar arthrodesis were 100% and 87.5% respectively. Four complications occurred. In the open technique group, there was one non-union. The same patient also developed subsequent haematoma after revision surgery. One patient developed a superficial wound infection which resolved with antibiotics. In the arthroscopic group, one patient developed a pseudoarthrosis of the distal tibiofibular joint which required a revision procedure. The results of this study suggest that arthroscopic ankle fusion for haemophilia- associated arthropathy is a viable option, with the rate of successful fusion being comparable to open procedures.

The multidisciplinary approach to managing prosthetic joint infection: could this lead to improved outcomes?

Periprosthetic joint infection (PJI) is a devastating complication of the total joint arthroplasty (TJA). It presents a great challenge for the treating clinician. Diagnosis as well as management can prove difficult with significant morbidity for the patients and cost for patients, health care providers and society as a whole. Outcomes of equally challenging pathology such as tumors and polytrauma have been shown to be improved when patients are managed by a team as specialists as opposed to single individuals. The purpose of this study is to review the role of the multi-disciplinary team (MDT) approach in the diagnosis and management of PJI. We examine the influence of this approach on clinical outcomes in patients with PJI. We also discuss the organisational and logistical issues associated with establishment of a MDT as well as several other issues not mentioned in the contemporary orthopaedic literature. All published literature examining the role of multidisciplinary care in the management of PJI and the influence of this approach to the management and outcomes of patients with this diagnosis were included. Studies published in languages other than English were excluded. There is a paucity of data on the influence of multidisciplinary care on outcomes of the management of PJI. Evidence suggests that the MDT has important role in ensuring all factors in the management of this complex group are considered and best possible care is delivered. Multicentre randomised clinical trials are required to assess the influence of MDT'S on outcome as well as important questions around the structuring of these teams.

Adverse reaction to metal debris due to fretting corrosion between the acetabular components of modular dual-mobility constructs in total hip replacement: a systematic review and meta-analysis

Modular dual-mobility (MDM) constructs can be used to reduce dislocation rates after total hip replacement (THR). However, there are concerns about adverse reaction to metal debris (ARMD) as a result of fretting corrosion between the metal liner and shell. This systematic review reports outcomes following THR using MDM components. It was registered with PROSPERO and conducted in line with Cochrane and PRISMA recommendations.Sixteen articles were included overall, with meta-analysis performed on relevant subsets using a random intercept logistic regression model. Estimated median incidence of ARMD requiring revision surgery within study follow-up period was 0.3% (95% CI 0.1 - 1.8%, from 11 cohort studies containing 1312 cases).Serum metal ion levels were mildly raised in 7.9% of cases, and significantly raised in 1.8%, but there was no correlation with worse clinical hip function scores within studies. Dislocation rate was 0.8%. Revision rate was 3.3%.There are mixed reports of wear on the backside of the metal liner from the acetabular shell and screw heads. Both implant design and component malseating are implicated, but currently it is unclear to what extent each factor is responsible.Studies were poor quality with high risk of confounding, especially from trunnion corrosion. We have made recommendations for further work. In the meantime, surgeons should be aware of the potential risk of ARMD when considering using an MDM prosthesis, and, if selecting one, must ensure proper seating of the liner and screws intraoperatively. Cite this article: EFORT Open Rev 2021;6:343-353. DOI: 10.1302/2058-5241.6.200146.

What is the optimal duration of intravenous antibiotics following single-stage revision total hip arthroplasty for prosthetic joint infection? A systematic review

Prosthetic joint infection (PJI) is 1 of the most challenging potential complications following total joint arthroplasty. Several surgical treatment strategies have been proposed for management of this diagnosis. The single-stage approach has been gaining popularity in contemporary literature. 1 fundamental aspect in the management of hip PJI is the administration of antibiotics, usually intravenously immediately after surgery, followed by a period of oral antibiotics. The optimal duration of the period of antibiotic therapy is undecided. The aim of this paper is to examine the trend in intravenous antibiotic use over the last 18 years and examine the influence this has had on the results of single-stage revision over that time period.

High Rate of Reinfection With New Bacteria Following One-Stage Exchange for Enterococcal Periprosthetic Infection of the Knee: A Single-Center Study

BACKGROUND

A wide range of success rates following the surgical management of enterococcal periprosthetic joint infection (PJI) with a tendency toward worse outcomes have been reported. However, the role of 1-stage exchange remains under-investigated. Therefore, we aimed to evaluate our results after the 1-stage knee exchange for enterococcal PJI.

METHODS

Forty patients were retrospectively included between 2002 and 2017 with a mean follow-up of survivors of 80 months (range 22-172; standard deviation [SD] = 5). Polymicrobial infections occurred in 45% (18/40) of patients. Patients' characteristics, joint-related data, and antibiotic therapy were recorded. Rates of enterococcal infection relapse, reinfection with new microorganisms, and re-revision for any reason were determined. Bivariate analysis was conducted to identify risk factors of infection recurrence.

RESULTS

Revision surgery was required in 22 cases (55%) with a mean time to revision surgery of 27 months (range 1-78; SD = 25). Indications for aseptic revisions (18%) included aseptic loosening (10%), periprosthetic fracture (5%), and patellar instability (3%). The most common cause of re-revision was a subsequent PJI (15/22; 68%) after a mean time of 22 months (range 1-77; SD = 24). Overall infection recurrence rate was 37.5% (15/40), substantially due to entirely non-enterococcal infections (9/15; 60%). Infection relapse with Enterococci occurred in 4 cases (10%) within 16 months postoperatively. Older patients (P = .05) and male gender (P = .05) were associated with a higher risk of infection recurrence.

CONCLUSION

Overcoming the Enterococci using the 1-stage exchange for knee PJI is achievable but the rate of reinfection due to new microorganisms is high . However, the overall infection recurrence rate is comparable to other treatment approaches.

International Organism Profile of Periprosthetic Total Hip and Knee Infections

BACKGROUND

There is scarce literature describing pathogens responsible for periprosthetic joint infections (PJIs) around the world. Therefore, we sought to describe periprosthetic joint infection causative organisms, rates of resistant organisms, and polymicrobial infections at 7 large institutions located in North/South America and Europe.

METHODS

We performed a retrospective study of 654 periprosthetic hip (n = 361) and knee (n = 293) infections (January 2006 to October 2019) identified at Cleveland Clinic Ohio/Florida in the United States (US) (n = 159), Hospital Italiano de Buenos Aires in Argentina (n = 99), Hospital Asociación Española in Uruguay (n = 130), Guy's and St Thomas' Hospital in the United Kingdom (UK) (n = 103), HELIOS Klinikum in Germany (n = 59), and Vreden Institute for Orthopedics in St. Petersburg, Russia (n = 104). Analyses were performed for the entire cohort, knees, and hips. Alpha was set at 0.05.

RESULTS

Overall, the most frequent organisms identified were Staphylococcus aureus (24.8%) and Staphylococcus epidermidis (21.7%). The incidence of organisms resistant to at least one antibiotic was 58% and there was a significant difference between hips (62.3%) and knees (52.6%) (P = .014). Rates of resistant organisms among countries were 37.7% (US), 66.7% (Argentina), 71.5% (Uruguay), 40.8% (UK), 62.7% (Germany), and 77.9% (Russia) (P < .001). The overall incidence of polymicrobial infections was 9.3% and the rates across nations were 9.4% in the US, 11.1% in Argentina, 4.6% in Uruguay, 4.9% in UK, 11.9% in Germany, and 16.3% in Russia (P = .026).

CONCLUSION

In the evaluated institutions, S aureus and S epidermidis accounted for almost 50% of all infections. The US and the UK had the lowest incidence of resistant organisms while Germany and Russia had the highest. The UK and Uruguay had the lowest rates of polymicrobial infections.

Dual surgeon operating lists for complex revision arthroplasty surgery: changing orthopaedic surgical practice

There is an increasing trend towards dual surgeon operating in complex surgeries in various specialties. This is driven by regionalisation of services, increasing complexity of surgical procedures, the ageing population and challenges imposed by changes in surgical training. Dual surgeon cases have lower complication rates and better quality of patient care. This practice not only facilitates professional and personal development, but also provides valuable support to surgeons in the early part of their career. There is a paucity of literature to support this practice, however, and prospective studies are required to demonstrate the benefit of this approach.

Informed Consent in Patients Undergoing Primary Hip and Knee Arthroplasty: What Do Patients Want to Know?

Introduction The consenting process has been surgeon-focussed traditionally, but there is a recent trend towards making the process more patient and procedure-focussed. The primary aims were to identify the risks considered most important and requiring further discussion by the patients undergoing primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA), as well as to identify the sporting and recreational activities these patients would like to pursue after surgery according to the age group, taking into consideration their values and expectations. The secondary aim is to assess the compliance of the current consenting process with guidelines set out by a governing body in a tertiary referral arthroplasty unit. Material and method A prospective study reviewing the consenting process was carried out on 137 patients undergoing THA or TKA over a 12-month period in a tertiary teaching hospital. Patients unable to complete a questionnaire and undergoing revision or uni-compartment arthroplasty were excluded. A standardized anonymous questionnaire was administered. Patients were asked to fill in the specific activities they considered important to be discussed. The data were tabulated in Microsoft Excel (Microsoft Corporation, Redmond, Washington) and subgroup analysis was performed using the student's t-test. The level of statistical significance was p=0.05. Two-hundred consent forms were reviewed to assess whether the information entered correlated to the guidelines presented in Ortho-Consent. Results One-hundred thirty-seven questionnaires were reviewed. The mean age was 66 (range 45-91), with the majority of patients undergoing TKA (114) versus THA (23). The patients in active employment were more concerned about blood clots, pain, joint failure, limb length discrepancy, and infection. Patients undergoing TKA wanted more information on pain management and joint longevity, which achieved statistical significance. There was a significant difference in the activities patients would like to pursue as well as in expectations amongst different age groups. The quality of documentation in the consent form was quite variable in discussing complications, surgery benefits, and alternative treatments. Conclusion Obtaining consent is a patient-specific process. Patient perception of important points that merit discussion can vary with age and employment status. Return to driving is important for all ages, however, as the population ages, the ability to return to activities of daily living becomes an increasingly important discussion point during the consent process.

Cortical Strut Graft for Enigmatic Thigh Pain in Uncemented Total Hip Replacement

Aims

Enigmatic thigh pain in uncemented femoral components of a total hip replacement can be severe and disabling. Treatment can be conservative or surgical with cortical strut graft or revision of the femoral stem. Cortical strut grafting may offer good results with reduced morbidity. The aim of this study was to report the functional and radiographic outcomes of four patients with enigmatic thigh pain treated with cortical strut allograft.

Materials and Methods

Between 2016 and 2018, four women underwent cortical strut allografting at two centres. All patients had an uncemented, proximally porous S-ROM femoral implant (DePuy, Warsaw, In, USA). All other causes of anterolateral thigh pain were excluded. The mean age was 36.7 years (range: 29-51 years). Patients were followed up for a minimum of 14 months (range: 14-38 months). The University of California, Los Angles (UCLA) activity score, pain scores, complications, and radiographs at six weeks, three months, six months, nine months and one year were recorded.

Results

Mean UCLA activity scores increased from 3.2 (range: 2-4) to 6.2 (range: 6-7) post-operatively. Radiologically, all four patients had complete osseointegration of their strut grafts. Pain scores decreased at six weeks and at six months. One deep venous thrombosis occurred. One patient experienced recurrence of anterolateral thigh pain 26 months post-strut graft, which resolved with protected weight-bearing and analgesia for three months.

Conclusions

In uncemented femoral prostheses, cortical strut grafting to treat enigmatic thigh pain can reduce symptoms and increase activity without the need to revise a well-fixed femoral stem. We add to the growing body of evidence that this can be a successful surgical technique.

Managing the multiply injured patient: the impact of multidisciplinary teams

Management of trauma has been tackled at a national level to improve patient care and mortality. Decision making through a multidisciplinary team approach has resulted in improved patient outcomes through a complex combination of changes. While the focus of trauma care delivery has been towards establishing an effective multidisciplinary trauma service, there are still improvements which can be made. This article reviews the history of trauma care in the UK, and the impact that multidisciplinary teams have had on the management of the multiply injured patient.

Cryotherapy following total knee arthroplasty: What is the evidence?

BACKGROUND

Total knee arthroplasty (TKA) is an important option in the management of severe osteoarthritis. Despite excellent long-term results following TKA, the immediate postoperative period is often associated with pain, bleeding, edema, and reduced range of movement. Cryotherapy has been shown to provide some benefit in addressing these factors but results are largely controversial. This study aims at reviewing the current existing literature on the effects of cryotherapy following TKA.

METHODS

A comprehensive review of the current literature on the use of cryotherapy in knee arthroplasty was performed. The literature search was performed using PubMed, Cochrane Library, Google Scholar, and cross references using the search words "cryotherapy" AND "knee arthroplasty" for articles published between January 1990 and November 2016.

RESULTS

A total of 51 articles were analyzed and 24 of them were selected based on clinical relevance.

CONCLUSION

Immediate and early postoperative management following TKA remains challenging. Cryotherapy has been shown to have some benefits but the severe lack of level 1 studies supporting its use make it difficult to reach a suitable conclusion. Further multicenter randomized controlled trials with representative populations and fair comparison of devices are needed.

Do patients with von Willebrand disease exhibit higher blood loss and revision rates in hip and knee arthroplasty? A case-control study

BACKGROUND

The aim of the study was to compare the perioperative blood loss, need for transfusion and one-year revision rates in patients undergoing hip and knee arthroplasty who also have a diagnosis of von Willebrand disease (VWD) with a matched control group.

METHODS

A retrospective single-centre case-control study was conducted. Fifty-eight patients with VWD and 116 controls (1:2 match) who were operated for primary or revision hip and knee arthroplasty at our hospital were included. Blood loss, haemoglobin (Hb)-drop, need for blood transfusion, intraoperative complications and revision rates within one year were noted in all cases. Outcome measures for subgroups of the primary hip, primary knee, revision hip and revision knee procedures, were also analysed.

RESULTS

The mean perioperative Hb-drop was 3.47 (±1.27) g/dL and blood loss was 293 (±97) ml for the VWD group while Hb-drop was 2.85 (±1.21) g/dL and blood loss was 232 (±105) mL for the control group (P < .001). There were no significant increased transfusion rates (P = .264) and revision rates in the VWD group (P = .634). Patients having primary hip surgery had significantly higher Hb-drop (3.68 ± 1.25 g/dL vs 2.62 ± 1.19 g/dL; P = .003), higher blood loss (293 vs 203 mL; P = .002) and increased need for a transfusion (21% vs 2.6%; P = .038) compared to the controls. No outcome measure was found to be significantly different for primary and revision knee surgery.

CONCLUSIONS

The results of this study suggest that patients with VWD undergoing primary or revision total hip and knee arthroplasty have higher levels of blood loss than the control cohort. Perioperative protective measures including meticulous surgical techniques should be considered.

Serial C-reactive Protein Monitoring in Prosthetic Joint Infection: A Powerful Predictor or Potentially Pointless?

Background Serum C-reactive protein (CRP) is an important test in the initial diagnosis of prosthetic joint infection (PJI). There is no widely accepted algorithm for the resolution of PJI. Surgeons have traditionally used CRP to determine if the infection has resolved. However, this practice is not currently supported by significant data.  Methods A retrospective analysis of our departmental arthroplasty database was conducted to determine mean values of CRP pre and postoperatively for PJI treated with the debridement, antibiotics and implant retention (DAIR) procedure, single-stage revision and two-stage revision. Receiver operating characteristic (ROC) curves were calculated to determine the sensitivity and specificity of CRP testing in diagnosing persistent infection. Results Of the 121 patients who had undergone treatment (75 hip replacements and 48 knee replacements), there were 26 cases of persistent infection. There was no statistical significance in the mean CRP values between successful and unsuccessful treatment groups. The areas under ROCs (AUCs) for CRP values predicting outcomes ranged from 0.46 to 0.73. Conclusion Our study does not support the use of serial CRP monitoring as an indicator of the successful eradication of PJI.

Simultaneous or Staged Bilateral Total Hip Arthroplasty? An Analysis of Complications in 14,460 Patients Using National Data

BACKGROUND

Simultaneous bilateral total hip arthroplasty (SimBTHA) is often performed in younger, fitter patients with bilateral hip disease. If patients are deemed not suitable for SimBTHA due to concurrent comorbidity, it may be more appropriate to perform staged bilateral total hip arthroplasties (StBTHAs) 3-6 months apart to minimize complications and morbidity. Complication rates following hip arthroplasty are low and large national datasets are helpful for assessing these rare events. We aimed at comparing SimBTHA vs StBTHA in order to determine any differences in morbidity and mortality.

METHODS

Hospital Episode Statistics data for all patients who underwent bilateral THAs in the English National Health Service between April 2005 and July 2014 were obtained. Patients were grouped into SimBTHAs (same day) or staged, with the second THA occurring between 3 and 6 months after the first. Medical and surgical complications were compared and total length of stay was assessed.

RESULTS

A total of 2507 underwent SimBTHAs and 9915 had StBTHAs. SimBTHA patients were significantly younger (60.6 vs 65.5 years, P < .001) and more likely to be male, but had similar Charlson comorbidity scores. Compared to StBTHAs, patients undergoing SimBTHAs had a greater risk of pulmonary embolism, myocardial infarction, renal failure, chest infection, and inhospital death. Patients undergoing SimBTHAs had a significantly shorter overall hospital stay (8.9 vs 10.4 days). Patients undergoing SimBTHA at high-volume units had a lower average Charlson score and subsequent complication rate than low-volume units.

CONCLUSION

These findings highlight the greater risks of SimBTHA in patients with Charlson score greater than 0 performed at lower-volume centers in England.

Prolonged suppressive antibiotic therapy is successful in the management of prosthetic joint infection

INTRODUCTION

Prosthetic joint infection (PJI) remains one of the major challenges facing orthopaedic surgeons. There is a paucity of evidence on non-operative management of PJI. We present the results of prolonged antibiotic suppression therapy (PSAT) in PJI from a single centre.

METHODS

A retrospective study was performed. Twenty-six patients were included. Two patients were excluded due to the lack of follow-up data. Failure was defined as admission for sepsis from the joint or amputation.

RESULTS

Average age was 72 years (range 35-93). Mean Charlson co-morbidity index was 4.3. Mean follow-up was 3.2 years (range 1.3-5.7). Staphylococcal species were isolated in 11 cases (44%) (MRSA 1, MSSA 5, Staph. epidermidis 4 and Staph Pasteuri 1). Other bacteria included E. Coli (2), Streptococci spp. (3), Propionebacterium acnes (1) and Pseudomonas aeruginosa (1). Four cases were polymicrobial infection (16%), and no organisms were identified in two cases (8%). Candida albicans was identified in one case. All cases of bacterial infection were treated with prolonged oral doxycycline or amoxicillin. Twenty patients (80%) received 6 weeks of intravenous antibiotics prior to commencing prolonged oral antibiotics. Two patients experienced persistent symptoms and required amputation (both TKA). Two patients experienced sepsis but were treated successfully with IV antibiotics alone. The success rate of PSAT was 84% (21/25) successful at an average 3.2-year follow-up.

DISCUSSION AND CONCLUSION

Prolonged suppressive antibiotic therapy is a viable option for the management of PJI with a low incidence of complications.

Interprosthetic Femoral Sleeves in Revision Arthroplasty: A 20-Year Experience

BACKGROUND

Interprosthetic femoral fractures in patients with ipsilateral stemmed total hip arthroplasty (THA) and total knee arthroplasty (TKA) can be technically demanding to treat surgically. Nonunion and implant failure are among the main complications following fixation of interprosthetic femoral (IF) fractures. Total femoral arthroplasty (TFA) is associated with a high incidence of infection and instability. IF sleeves have been designed to avoid the disadvantages of these techniques and to provide a stable construct. The aim of this study was to present the results with this device from a single center.

METHODS

We reviewed 26 patients who underwent revision arthroplasty procedures, using custom-made cemented IF sleeves between 1997 and December 2017 in our institution. Two-part sleeves were used in 18 patients and one-part sleeves in 8 patients. The most common indication was an IF fracture (18 patients). Patients were monitored for postoperative complications, implant failure, and re-revision. The minimum follow-up of the survivors with nonrevised sleeves was 12 months.

RESULTS

Twenty-three patients were included for the final analysis. The mean survivorship of the IF sleeve was 4.6 years at latest follow-up (mean 48.5 months; range 12 to 156). The overall rate of complications was 47.8%. The rate of mechanical failure was 21.7%. Late infections occurred in 3 patients (13%). At the latest follow-up, the mean Harris Hip Score was 69.9 points (range 39 to 94), and the mean functional Knee Society Score was 42.5 points (range 0 to 90), with average knee flexion of 95° (range 90° to 100°).

CONCLUSION

The IF sleeve is a valid technique for the management of selected patients with IF fractures, particularly when a stable fracture fixation is not possible. Hip instability is not a concern, and functional improvement is achievable. Careful planning is required preoperatively to avoid mechanical failure.

Do Biologic Agents Increase the Risk of Infection in Patients Undergoing Lower Limb Arthroplasty Surgery?

BACKGROUND

Biologic agents have contributed significantly to the management of patients with in rheumatoid arthritis (RA). A significant proportion of patients with RA still require arthroplasty procedures however. It is unclear whether these agents increase the risk of post operative infection after lower limb arthroplasty.

METHOD

A literature search was performed for articles published over the last 10 years in the English language examining the association between anti-tumour necrosis factor inhibitors and the incidence of post operative infection in patients with RA undergoing hip and knee arthroplasty procedures.

RESULTS

One large meta-analysis has been published suggesting a 2-fold increase in infection rates following orthopaedic surgery in patients receiving biological agents. When subgroup analysis of arthroplasty cases alone was performed the finding failed to reach significance. However, several further studies have demonstrated both an increased risk for surgical site infection with the use of biological agents and several conflicting articles argue the opposite.

CONCLUSION

There is no current consensus on this topic. The safety of continuation of perioperative anti-TNF-α therapy in patients undergoing lower limb arthroplasty procedures is unclear. There is also little robust guidance from specialist rheumatologic societies. There is need for large scale multicentre randomised controlled trials to address this issue.

Three Cases of Femoral Stem Failure in Rotating Hinge Revision Total Knee Arthroplasty: Causes and Surgical Considerations

Catastrophic failure of stemmed components in arthroplasty is an uncommon but a serious complication. Stem fractures and techniques for addressing these have been described following hip arthroplasty but much less so following total knee arthroplasty (TKA). We review three cases of catastrophic failure of the stem in rotating hinge revision TKA prostheses. We discuss the possible mechanism of failure and review the current literature addressing this topic. Metaphyseal support needs to be optimized in order to minimize load transfer to the stem and to the junction (and the risk of fracture) if a modular component is used. When constrained components are used, radiographs need to be carefully assessed for signs of proximal loosening. Nonmodular stems are also an option in this situation.

Cement-in-cement femoral component revision in the multiply revised total hip arthroplasty: results with a minimum follow-up of five years

AIMS

We present the clinical and radiological results at a minimum follow-up of five years for patients who have undergone multiple cement-in-cement revisions of their femoral component at revision total hip arthroplasty (THA).

PATIENTS AND METHODS

We reviewed the outcome on a consecutive series of 24 patients (10 men, 14 women) (51 procedures) who underwent more than one cement-in-cement revision of the same femoral component. The mean age of the patients was 67.5 years (36 to 92) at final follow-up. Function was assessed using the original Harris hip score (HHS), Oxford Hip Score (OHS) and the Merle D'Aubigné Postel score (MDP).

RESULTS

The mean length of follow-up was 81.7 months (64 to 240). A total of 41 isolated acetabular revisions were performed in which stem removal facilitated access to the acetabulum, six revisions were conducted for loosening of both components and two were isolated stem revisions (each of these patients had undergone at least two revisions). There was significant improvement in the OHS (p = 0.041), HHS (p = 0.019) and MDP (p = 0.042) scores at final follow-up There were no stem revisions for aseptic loosening. Survival of the femoral component was 91.9% (95% confidence intervals (CI) 71.5 to 97.9) at five years and 91.7% (95% CI 70 to 97) at ten years (number at risk 13), with stem revision for all causes as the endpoint.

CONCLUSION

Cement-in-cement revision is a viable technique for performing multiple revisions of the well cemented femoral component during revision total hip arthroplasty at a minimum of five years follow-up. Cite this article: Bone Joint J 2017;99-B:199-203.

No Difference Between Trabecular Metal Cones and Femoral Head Allografts in Revision TKA: Minimum 5-year Followup

BACKGROUND

Encouraging clinical results have been reported with the use of femoral head structural allografts and, more recently, trabecular metal cones for the management of large structural defects of the femur and tibia during revision total knee arthroplasty (TKA). However, to our knowledge, there are no published studies comparing these two techniques.

QUESTIONS/PURPOSES

Compared with bulk allografts, do trabecular metal cones result in (1) better validated outcomes scores; (2) a lower risk of loosening or revision at 5 years; and (3) fewer surgical complications when used for the management of bone loss in revision TKA?

METHODS

Between 2002 and 2008, three surgeons performed 450 TKA revisions, 45 (10%) of which were performed using augmentation of host bone; in those, femoral head allograft was used in 30 (75%) and trabecular metal cones in 15 (25%). From 2002 to 2007, femoral head allografts were used in all patients (28 patients); from 2007 to 2008, trabecular metal augments were used in all patients. There was a period of 1 year (16 knees) in which there was some overlap; during that time, femoral head structural allografts were used in cases in which we were unable to fit the defect or achieve adequate stability with trabecular metal cones. Followup was at a mean of 9 years (range, 5-12 years). No patients were lost to followup. Knee function and quality of life were assessed using the Oxford Knee Score, WOMAC, SF-12, and the UCLA activity score. Radiographs were assessed for signs of loosening. Surgical complications included superficial or deep infections, iatrogenic fractures, symptomatic deep venous thromboses or pulmonary emboli, and blood loss requiring transfusion; these were obtained from our database and from review of patients' charts.

RESULTS

The mean Oxford Knee Score in the allograft and trabecular metal cone groups was 91 (SD 10) and 91 (SD 14), respectively (95% confidence interval [CI], 88-94; p = 0.29). Mean WOMAC scores were 94 (SD 10) and 92 (SD 14), respectively (95% CI, 80-105; p = 0.52) and mean UCLA scores were 6 (SD 1.2) and 6 (SD 1.5), respectively (95% CI, 4-8; p = 0.49). Five- and 10-year survivorship of the allografts was 93% (95% CI, 77-98) and 93% (95% CI, 77-99), respectively. Survivorship at a mean of 5 years in the trabecular metal cones group was 91% (95% CI, 56-98). With the numbers available, there were no differences between the groups in terms of the frequency of surgical complications (3% [one of 30] versus 7% [one of 15]; odds ratio, 0.5; p = 0.632).

CONCLUSIONS

With the numbers available, we found no difference in pain, function, or repeat revision when comparing femoral head allografts and trabecular metal cones for severe bone defects during revision TKA. However, we used allografts for the larger bone defects. Based on these results, we believe that femoral head allografts and trabecular metal cones can both be used for the management of Anderson Orthopaedic Research Institute Types 2 and 3 defects. Future multicenter studies are required with larger numbers, cost analyses, and a longer duration of followup.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Nonmodular Tapered Fluted Titanium Stems Osseointegrate Reliably at Short Term in Revision THAs

BACKGROUND

The ideal femoral component for revision THA is undecided. Cylindrical nonmodular stems have been associated with stress shielding, whereas junctional fractures have been reported with tapered fluted modular titanium stems. We have used a tapered fluted nonmodular titanium femoral component (Wagner Self-locking [SL] femoral stem) to mitigate this risk. This component has been used extensively in Europe by its designer surgeons, but to our knowledge, it has not been studied in North America. Added to this, the design of the component has changed since early reports.

QUESTIONS/PURPOSES

We asked: (1) Does the Wagner SL stem have low rates of rerevision and other complications at a minimum 2 years after surgery? (2) Is the Wagner SL stem associated with high levels of patient function and pain relief at a minimum 2 years after surgery? (3) Does the Wagner SL stem have low rates of subsidence at a minimum 2 years after surgery? (4) Is the Wagner SL stem associated with proximal femoral bone remodeling at a minimum 2 years after surgery?

METHOD

Between May 2011 and December 2012, we performed 198 femoral revisions, of which 104 (53%) were performed using the Wagner SL femoral stem; during that period, our institution gradually shifted toward increasing use of these stems for all but the most severe revisions, in which modular fluted stems and proximal femoral replacements still are used on an occasional basis. Median followup in this retrospective study was 32 months (range, 24-46 months), and one patient was lost to followup before the 2-year minimum. The femoral deformities in this series were Paprosky Type I (10 hips), Paprosky Type II (26), Paprosky Type IIIA (52), Paprosky Type IIIB (nine), and Paprosky Type IV (two). Functional assessment was performed using the Oxford Hip Score (OHS), WOMAC, SF-12, and the University of California Los Angeles (UCLA) activity score. All complications and cases of revision were documented. All patients had radiographs performed within 1 year of the latest followup. These were assessed by two surgeons for signs of proximal femoral bone remodeling and subsidence.

RESULTS

Complete preoperative scores were available for 98 patients (98 of 104; 94%). The mean OHS preoperatively and at final followup were 39 (SD, 15) and 87 (SD, 19), respectively (p < 0.001; mean difference, 48; 95% CI, 43-53). Average WOMAC scores were 44 (SD, 15) and 87 (SD, 20), respectively (p < 0.001; mean difference, 43; 95% CI, 38-48). At final followup, signs of restoration of proximal femoral bone stock was noted in 45 of 103 hips (44%). Six (six of 104; 6%) patients had subsidence of 10 mm to 15 mm. In the remainder (98 of 104; 94%), the mean subsidence was 2 mm (range, 0-9 mm). One revision was performed for loosening associated with infection.

CONCLUSIONS

The Wagner SL stem is a viable option for patients with Paprosky Types II and III defects undergoing revision THA. This component provides high levels of patient function with low revision rates and low rates of subsidence during the early postoperative phase. They provide a viable alternative to modular components for treatment of Types II and III defects without the risk of junctional fractures. They can be used for very selected Type IV defects, however this extent of bone loss is most easily addressed with other techniques such as a proximal femoral replacement.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Use of Teriparatide to improve fracture healing: What is the evidence?

Teriparatide is a recombinant form of the biologically active component of Parathyroid hormone. It has been shown to increase bone mass and prevent fractures in osteoporotic bone. It is licensed by the Food and Drug Administration for the treatment of Osteoporosis. Over the last decade, a growing body of evidence has accumulated suggesting a role for Teriparatide in the management of fractures. Studies in both normal and delayed healing models have shown improvement in callus volume and mineralisation, bone mineral content, rate of successful union and strength at fracture sites. However most of these results have been derived from animal studies. The majority of this research on humans has comprised low level evidence, with few randomised controlled trials, many case reports and case series. Nevertheless, the results from these studies seem to support research from animal models. This has led to a growing number of clinicians using Teriparatide “off license” to treat fractures and non-unions in their patients. This review presents a critical appraisal of the current evidence supporting the use of Teriparatide for fracture healing, delayed unions and non unions and in the setting of osteoporotic fractures, the studies producing this evidence and their transferability to human beings.

Tapered, fluted titanium stems in revision total hip arthroplasty: role and results in contemporary practice

The burden of revision total hip arthroplasty (THA) is rising. As increasingly younger patients are treated with THA procedures, it is likely that this trend will continue. The results of revision THA are greatly influenced by the quantity and the quality of available femoral bone stock available for reconstruction. Modular and nonmodular tapered fluted titanium stems are increasingly used in revision THA. It is helpful to be familiar with the use of these components in revision THA.

Patella resurfacing during total knee arthroplasty: have we got the issue covered?

Background

Management of the patella during total knee arthroplasty (TKA) is controversial. Multiple studies have examined mechanical and clinical results of TKA with native and resurfaced patellae with no clear consensus.

Methods

We surveyed a large cohort of consultant surgeons in a questionnaire based study in order to assess the indications for patella resurfacing and to correlate practice with degree of specialization, experience and volume of procedures performed.

Results

Six hundred and nineteen surgeons were included. The main indication for patella resurfacing was patellofemoral arthritis. The ratio of those who always:sometimes:never resurfaced was 1:2:1 irrespective of experience or volume performed. There was no difference between knee specialists and non-specialists (p = 0.977) or between high and lower volume surgeons (p = 0.826). Senior and high volume surgeons tended to always resurface.

Conclusions

The majority of surgeons only sometimes resurfaced the patella. The number who always and never resurfaced were similar. There was a tendency for more experienced and high volume surgeons to always resurface.

Primary total hip arthroplasty with hydroxyapatite coated titanium femoral stems. Does design philosophy influence long term outcome?: Results of a prospective randomised controlled trial with follow-up of 10-15 years

We present results of a prospective randomised controlled trial examining two cohorts of patients treated with proximally (Group A) and fully coated (Group B) femoral components with long term follow up. Patients were reviewed preoperatively and 6, 12, 26 and 52 weeks post operatively then annually. The Merle d'Aubigne Postel (MDP) hip score was used to assess clinical outcome. A Visual Analog Score (VAS) was also recorded. Statistical calculation was performed using the student's t- test and Kaplan Meier survival analysis. One hundred and four patients were included in group A and 103 patients in group B. Mean age was 60.4 years and 60.8 years respectively. Mean follow- up was 12.9 years. Mean pre-operative MDP scores were 8.8 and 9.5 in Groups A and B respectively. Mean pre-operative VAS score 7.8 and 7.4 respectively. At final follow up mean MDP and VAS were 16.9, 16.6 and 2.1, 2.4 respectively. Three femoral revisions occurred in Group A. Seven revisions occurred in Group B. Survival of the femoral component with revision for any reason as the end point was 96% in Group A and 94.8% in Group B. Both components produced symptomatic relief and similar revision rates. Thigh pain occurred only in Group A.

Primary total hip arthroplasty with a tapered Trabecular Metal™ coated femoral component: experience with a minimum 24-month follow-up

We prospectively reviewed the clinical and radiological outcome of the first 32 patients (32 hips) undergoing primary total hip arthroplasty using a Trabecular Metal™ coated tapered femoral component. Seventeen males and 15 females were included. Average age was 71.6 years (range 61.5-85 years). Mean duration of follow-up was 34 months (range 24-48 months) Average preoperative Oxford, Harris, and WOMAC scores were 34, 51, and 44, respectively. Mean postoperative scores were 18, 82, and 11, respectively (P < 0.001 for all scores). All patients reported relief of preoperative pain. There were no revisions. These results suggest that the Trabecular Metal™ taper femoral component successfully relieves pain and leads to a significant functional improvement in patients with symptomatic hip arthritis in the early postoperative period.

Revision of the well fixed Birmingham Hip Resurfacing acetabular component--results using a novel device

Revision of well fixed uncemented Birmingham Hip Resurfacing (BHR) acetabular components is challenging due to their dual radius design and their stabilising fins. These features preclude use of the standard Explant device. We investigated a novel device designed to simplify revision of this socket. This prospective study included 6 male and 14 female patients. The reasons for revision, technique of revision and the scientific basis for use of this device are discussed. The sizes of revised and implanted components were measured and the amount of bone loss was calculated. Patient satisfaction was assessed as well as pre and post operative hip scores. Six men and fourteen women were included. Average ages were 58 and 623 years respectively. The average diameters of the explanted and re-implanted sockets were 50.7 and 54.6 mm respectively. Average time for revision of the cup was less than 5 minutes. The average duration of follow-up was 13.2 months. All patients were satisfied with their outcomes. This device simplifies the use of the Explant in removing well fixed BHR sockets with predictably minimal loss of host bone.

Revision of failed hip resurfacing to total hip arthroplasty rapidly relieves pain and improves function in the early post operative period

We reviewed the results of 25 consecutive patients who underwent revision of a hip resurfacing prosthesis to a total hip replacement. Revisions were performed for recurrent pain and effusion, infection and proximal femoral fractures. Both components were revised in 20 cases.

There were 12 male and 13 female patients with average time to revision of 34.4 and 26.4 months respectively. The mean follow up period was 12.7 months (3 to 31). All patients reported relief of pain and excellent satisfaction scores. Two patients experienced stiffness up to three months post operatively.

Pre operative Oxford, Harris and WOMAC hip scores were 39.1, 36.4 and 52.2 respectively. Mean post operative scores at last follow up were 17.4, 89.8 and 6.1 respectively (p < 0.001 for each score). These results show that conversion of hip resurfacing to total hip arthroplasty has high satisfaction rates. These results compare favourably with those for revision total hip arthroplasty.

Metal on metal hip resurfacing versus uncemented custom total hip replacement--early results

Introduction

There is no current consensus on the most appropriate prosthesis for treating symptomatic osteoarthritis (OA) of the hip in young, active patients. Modern metal on metal hip resurfacing arthroplasty (HR) has gained popularity as it is theoretically more stable, bone conserving and easier to revise than total hip arthroplasty. Early results of metal on metal resurfacing have been encouraging. We have compared two well matched cohorts of patients with regard to function, pain relief and patient satisfaction.

Methods

This prospective study compares 2 cohorts of young, active patients treated with hip resurfacing (137 patients, 141 hips) and custom uncemented (CADCAM) stems (134 patients, 141 hips). All procedures were performed by a single surgeon. Outcome measures included Oxford, WOMAC and Harris hip scores as well as an activity score. Statistical analysis was performed using the unpaired student's t-test.

Results

One hundred and thirty four and 137 patients were included in the hip replacement and resurfacing groups respectively. The mean age of these patients was 54.6 years. The mean duration of follow up for the hip resurfacing group was 19.2 months compared to 13.4 months for the total hip replacement group.

Pre operative oxford, Harris and WOMAC scores in the THA group were 41.1, 46.4 and 50.9 respectively while the post operative scores were 14.8, 95.8 and 5.0. In the HR group, pre- operative scores were 37.0, 54.1 and 45.9 respectively compared to 15.0, 96.8 and 6.1 post operatively. The degree of improvement was similar in both groups.

Conclusion

There was no significant clinical difference between the patients treated with hip resurfacing and total hip arthroplasty in the short term.

Early results of the Birmingham mid-head resection arthroplasty

We report the early results of 10 consecutive metal-on-metal resurfacing arthroplasties performed between May 2006 and July 2007 in young, active patients with gross femoral head defects. Failure was classified as revision for any reason. The mean age of our cohort at the time of surgery was 42.8 years and the minimal period of follow-up was 6.9 months. No patients were lost to follow-up. Up to the time of last review, there were no failures and all patients have returned to their preoperative levels of activity. This study shows promising early results of a bone-conserving, hydroxyapatite-coated, uncemented metal-on-metal bearing prosthesis in young, active patients with bony defects of the femoral head.

A displaced acetabular component causing femoral neck notching following hip resurfacing

We describe the case of a patient who developed a notch on the femoral neck following a hip resurfacing operation as a result of a displaced acetabular component. The acetabular cup displaced in the coronal plane and impinged on the femoral neck leading to a large notch in the inferior femoral neck.

Revision of the Birmingham Hip Resurfacing cup: technical notes and the use of a novel technique to overcome unique problems

The number of hip resurfacing procedures performed in the United Kingdom has doubled in the last four years reflecting its popularity among orthopaedic surgeons. Of the available options the Birmingham Hip Resurfacing (BHR) prosthesis has been the most popular choice in this country. Despite this revision rates have been shown to be higher in the resurfacing group compared to the total hip arthroplasty group particularly in the early postoperative period. Revision of the BHR acetabular component is technically demanding due to several unique design features of this component. We discuss these features and describe a novel reliable and reproducible technique for revision of the BHR cup.