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Background: Valgus knee deformity is observed in nearly 10% of patients undergoing total knee arthroplasty (TKA). The degree of polyethylene constraint required to balance a valgus knee remains controversial, and historically, posterior-stabilized (PS) designs have been favored. This study evaluated the survivorship of TKA done in valgus knees based on implant design and specifically compared posterior-stabilized (PS) and ultracongruent (UC) liners., Methods: A total of 549 primary TKAs performed on valgus knees by fellowship-trained arthroplasty surgeons from 2013 to 2019 were reviewed. Demographics, comorbidities, degrees of preoperative deformity, implants used, and all-cause revisions until final follow-up were recorded. Cox regression analyses evaluated survival to all-cause revision in each cohort. The mean follow-up was 4.9 years (range, 2 to 9)., Results: There were 403 UC liners compared to 146 PS liners. There was no difference in patient age (68 versus 67 years; P = .30), body mass index (30.9 versus 30.4; P = .36), or degree of deformity (8.6 versus 8.8 degrees; P = .75) between the cohorts. At final follow-up, there were 5 revisions in the PS cohort (3.4%) versus 11 revisions in the UC cohort (2.7%) (P = .90). The most common reason for revision in both cohorts was periprosthetic joint infection (4 PS; 8 UC). Multivariable regression analyses controlling for age, body mass index, Elixhauser comorbidity score, sex, and degree of deformity demonstrated UC polyethylene liners were not associated with revision (hazard ratio 0.76; 95% confidence interval [CI] 0.26 to 2.21; P = .62). There was no difference in eight-year survivorship to all-cause revision, including aseptic and septic failure., Conclusions: Alternative polyethylene liners from the historically utilized PS liners for TKA for valgus deformity did not reduce survivorship. With modern polyethylene designs, UC inserts can be utilized for this deformity without increasing the risk of failure., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Aims: Tibial cones are often utilized in revision total knee arthroplasty (TKA) with metaphyseal defects. Because there are few studies evaluating mid-term outcomes with a sufficient cohort, the purpose of this study was to evaluate tibial cone survival and complications in revision TKAs with tibial cones at minimum follow-up of five years., Methods: A retrospective review was completed from September 2006 to March 2015, evaluating 67 revision TKAs (64 patients) that received one specific porous tibial cone during revision TKA. The final cohort was composed of 62 knees (59 patients) with five years of clinical follow-up or reoperation. The mean clinical follow-up of the TKAs with minimum five-year clinical follow-up was 7.6 years (5.0 to 13.3). Survivorship analysis was performed with the endpoints of tibial cone revision for aseptic loosening, tibial cone revision for any reason, and reoperation. We also evaluated periprosthetic joint infection (PJI), risk factors for failure, and performed a radiological review., Results: The rate of cone revision for aseptic loosening was 6.5%, with an eight-year survival of 95%. Significant bone loss (Anderson Orthopaedic Research Institute grade 3) was associated with cone revision for aseptic loosening (p = 0.002). The rate of cone revision for any reason was 17.7%, with an eight-year survival of 84%. Sixteen percent of knees developed PJI following revision. A pre-revision diagnosis of reimplantation as part of a two-stage exchange protocol for infection was associated with both PJI (p < 0.001) and tibial cone revision (p = 0.001)., Conclusion: Mid-term results of tibial cones showed a survivorship free of cone revision for aseptic loosening of 95%. Patients with significant bone loss were more likely to have re-revision for tibial cone failure. Infection was common, and patients receiving cones at reimplantation were more likely to develop PJI and undergo cone revision. Cite this article: Bone Joint J  2021;103-B(6 Supple A):158-164.

Background: Metal-on-metal (MOM) total hip arthroplasty is associated with unacceptable failure rates secondary to metal ion reactions. Efforts to identify which patients will go on to failure have been limited; recently, there has been a suggestion for a potential genetic basis for the increased risk of revision in MOM hip replacements (MOMHRs). The purpose of this study is to determine whether certain immunologic genotypes are predictive of the need for revision in patients with MOM total hip implants., Methods: This is a case-control study of all patients undergoing primary MOMHR between September 2002 and January 2012 with a minimum of 5-year follow-up. Our investigational "case" cohort was comprised of patients who underwent revision for MOMHR for a reason other than infection. A single-nucleotide polymorphism (SNP) array analysis was performed to identify a potential genetic basis for failure., Results: Thirty-two patients (15 case and 17 control) were included in our analysis. All patients in the revision group had a chief complain of pain; revision patients were more likely to have a posterior approach (P = .01) and larger head size (P = .04) than nonrevision patients. No patient or implant characteristics were independently associated with revision in a multivariate analysis. Patients with SNP kgp9316441 were identified as having an increased odds of revision for MOM failure (P < .001)., Conclusion: This study identified an SNP, kgp9316441, encoding proteins associated with inflammation and macrophage activation. This SNP was associated with significantly increased odds of revision for MOMHR. Future studies are warranted to validate this gene target both in vitro and in vivo., Level of Evidence: III., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Management of implant corrosion remains a challenge for the revision arthroplasty surgeon. Our field continues to gain insight in to how to manage this clinical scenario but there are still gaps in what is known to be considered to be the standard of care. There is a significant amount of effort going in to determining the best means of managing this issue but more work is needed. There is no doubt more studies are needed to further delineate the appropriate treatment algorithms for this clinical problem., (Copyright © 2018. Published by Elsevier Inc.)

Background: There is a high rate of dislocation after revision total hip arthroplasty. This study evaluated the outcomes of 1 modular dual mobility component in revision total hip arthroplasty in patients at high risk of dislocation., Methods: We reviewed 64 revisions performed in 27 (42%) patients for recurrent dislocation, 16 (25%) for adverse local tissue reaction, 11 (17%) for reimplantation infection, and 10 (16%) for aseptic loosening, malposition, or fracture. Complications, reoperations, and survivorship were evaluated., Results: Three-year survival was 98% with failure defined as aseptic loosening and 91% with failure as cup removal for any reason. With mean follow-up time of 38 months, there were 14 complications, including 2 dislocations treated with closed reduction, 9 infections, and 12 reoperations. All complications occurred in patients revised for instability, adverse local tissue reaction, or infection., Conclusion: The early results of this component are promising, with good overall survival and low rate of dislocation., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Metal-on-metal (MoM) hip articulations were thought to represent a biologic and biomechanically favorable alternative to conventional metal-on-polyethylene total hip arthroplasty implants. However, concerns emerged when registry data reported significantly higher failure rates associated with MoM implants compared with other contemporary hip implants. These high implant failure rates have been attributed to the release of metal particles into the periprosthetic space, creating macroscopic necrosis; corrosive osteolysis; large, sterile hip effusions; and periprosthetic solid and cystic masses (ie, pseudotumors)-a spectrum of findings termed adverse reaction to metal debris. A thorough clinical history and physical examination, along with laboratory data and imaging surveillance of these patients, is critical for appropriate diagnosis and treatment. The decision to perform revision hip arthroplasty of a metal-on-metal implant is multifactorial and should be based on documented, objective clinical indications. A systematic and objective approach to this evaluation and treatment is essential to optimize the care of patients who undergo total hip arthroplasty with MoM implants., (Copyright 2015 by the American Academy of Orthopaedic Surgeons.)

Revision knee data from six joint arthroplasty centers were compiled for 2010 and 2011 to determine mechanism of failure and time to failure. Aseptic loosening was the predominant mechanism of failure (31.2%), followed by instability (18.7%), infection (16.2%), polyethylene wear (10.0%), arthrofibrosis (6.9%), and malalignment (6.6%). Mean time to failure was 5.9 years (range 10 days to 31 years). 35.3% of all revisions occurred less than 2 years after the index arthroplasty, 60.2% in the first 5 years. In contrast to previous reports, polyethylene wear is not a leading failure mechanism and rarely presents before 15 years. Implant performance is not a predominant factor of knee failure. Early failure mechanisms are primarily surgeon-dependent., (© 2013.)

Background: The Articular Surface Replacement™ (ASR™) metal-on-metal hip arthroplasty system (DePuy Orthopaedics, Inc, Warsaw, IN, USA) reportedly has a higher than anticipated early failure rate leading to a voluntary recall. This prompted us to evaluate all ASR™ components implanted at our center., Questions/purposes: In all ASR™ components, we reported (1) revision rate, (2) blood metal ion levels, and (3) intraoperative findings for revisions related to adverse reaction to metal debris (ARMD)., Methods: We retrospectively reviewed all 172 patients (190 hips) who underwent THA (149 hips) or hip resurfacing (41 hips) with the ASR™ system. We determined failure rates. We obtained blood metal ion concentrations from 93 patients at last followup. We evaluated MRI studies and intraoperative histopathology. Minimum followup was 12 months (mean, 40 months; range, 12-74 months)., Results: At latest followup, we had revised 24 of 190 hips (13%): in 18 patients with THA and five patients with resurfacing. Mean time to revision was 45 months (range, 12-75 months). Mean blood concentrations were 13 μg/L (range, 0-150 μg/L) for cobalt and 6 μg/L (range, 0-87 μg/L) for chromium. Mean prerevision blood metal ion levels were higher in the revised group (cobalt: 48 μg/L; chromium: 18 μg/L) than in the nonrevised group (cobalt: 5 μg/L; chromium: 2 μg/L). ARMD was present in 14 of the 24 hips revised in this study., Conclusions: Surgeons must have a low threshold for concern for ARMD in patients with ASR™ systems. Blood metal ion levels and MRI can be used to evaluate patients with underperforming implants. Intraoperative histopathologic analysis and joint fluid cytology can help diagnose ARMD at the time of revision., Level of Evidence: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Recent advances in polyethylene fabrication have led to the introduction of highly cross-linked polyethylene tibial and patellar components for use in total knee arthroplasty (TKA) with the goal of reducing wear-related osteolysis. However, some reports suggest decreased mechanical strength as a result of the additional thermal and sterilization treatments in the manufacturing of implants. Complications related to the patella are among the most common causes of failure in TKA, but patellar component fracture is rare. The authors report a case of a highly cross-linked all-polyethylene patellar component that failed as a result of fracture in vivo in a patient 3 years after TKA.

It is estimated that 35% of total hip arthroplasties (THAs) involve a second-generation metal-on-metal (MOM) prosthesis. A novel complication has appeared in a subset of patients with MOM THAs that is described as an aseptic, lymphocyte-dominated vasculitis-associated lesion (ALVAL). The clinical features of ALVAL are nonspecific, but patients complain of pain and may develop "pseudotumors." It is hypothesized that metal ions are released from the prosthesis and form haptens with native proteins that elicit a type IV hypersensitivity response in the local soft tissues. Histopathologic descriptions of ALVAL are similar to those of failed arthroplasty in general, with the addition of a dense perivascular inflammatory infiltrate that is the hallmark of ALVAL. We report 3 cases of ALVAL with clinical, radiographic, and histologic findings. Accurate assessment is crucial because an intraoperative diagnosis of chronic inflammation suggestive of ALVAL will necessitate a replacement of the prosthetic component surfaces.

Fracture of the femoral stem is a rare manifestation of femoral component loosening in hip resurfacing. The patient had undergone successful hip resurfacing 3 years prior to presentation, presenting with complaints of groin pain, but without radiographic evidence of loosening. At 6 years post-operatively, the patient again presented with groin pain. Radiographs demonstrated a mid-stem fracture. Analysis of the retrieved implant and resected femoral head following conversion to total hip arthroplasty indicated that component failure and fracture appeared to be secondary to failed fixation and implant loosening not related to osteonecrosis or acute femoral neck fracture. The case report highlights the difficulty in diagnosing femoral component loosening in hip resurfacing in the absence of gross implant subsidence or stem radiolucency.