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Background Ceramic bearings were introduced to reduce wear and increase long-term survivorship of total hip arthroplasty. In a previous study comparing ceramic with metal-on-polyethylene at 5 to 8 years, we found higher survivorship and no osteolysis for the ceramic bearings. Questions/Purposes We asked whether ceramic bearings have equal or superior survivorship compared with that for metal-on-polyethylene at longer followup; we also determined survivorship of the implant systems, the presence or absence of radiographic osteolysis, and incidence of device squeaking. Methods Five surgeons at five sites have followed 189 patients (216 hips) for a minimum of 10 years and average of 10.3 years (range, 10–12.4 years) comparing alumina ceramic bearings (144 hips) with cobalt chrome-on-polyethylene bearings (72 hips). We determined Kaplan-Meier survivorship of the bearing surface and implant systems and collected radiographic and clinical data. Results We observed no difference between the control metal-on-polyethylene and the alumina-bearing couple cohorts with regard to bearing-related failures (98.9% versus 99.1%). Revisions for any reason occurred in 10.5% of the control patients and 3.1% of the patients with alumina bearings. All femoral implants remain well fixed (100%), whereas one acetabular component (1%) is unstable in the control group. Osteolysis occurred in 26% of the control patients and in none of the patients with alumina bearings. Squeaking occurred in two of 144 hips (1.4%) of the patients with ceramic bearings. Conclusions Patients receiving the ceramic-on-ceramic bearings had fewer revisions for any reason and less osteolysis than the control metal-on-polyethylene at 10 years. Our data suggest ceramic bearings continue to provide an option for the young and more active patient and provide for a measure to compare other new alternative bearings that are currently available. Level of Evidence Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Polyethylene wear and osteolysis remain a concern with the use of modular, fixed-bearing total knee arthroplasty (TKA). A variety of highly crosslinked polyethylenes (XLPs) have been introduced to address this problem, but there are few data on the results and complications of this polyethylene in posterior-stabilized knee prostheses. Questions/purposes In a randomized prospective study design comparing standard polyethylene (SP) tibial inserts with XLP inserts, we asked the following questions: (1) Are there any differences in the clinical results (as measured by the classic Knee Society scoring system) and radiographic results (as measured by an evaluation for radiolucencies and osteolysis) between these groups? (2) What is the frequency of reoperation in these two groups? (3) Are there any specific complications related to XLP liners? Methods These are preliminary data from a single surgeon of a planned interim analysis of a prospective randomized study of one modular posterior-stabilized TKA. One hundred ninety-two patients (236 knees) were randomized to receive a SP compression-molded liner or a XLP (6.5 CGy electron beam-irradiated and remelted) polyethylene liner. There was no difference in the number of knees who were lost or refused followup (14 knees [13%] with XLP and 21 knees [17%] with SP). Patients were evaluated clinically using the original Knee Society scores, Lower Extremity Activity Score (LEAS), presence of knee effusion, and by standard radiographs for radiolucent lines and osteolytic lesions. This analysis was performed at a mean followup of 4.5 years (range, 2–8 years). Results There were no clinical differences between 99 knees with SP and 94 knees with XLP in original Knee Society total score (SP mean 95, SD 5; XLP mean 94, SD 7 [p = 0.16]); change in total score (SP mean 41, 95% confidence interval [CI], 39–41; XLP mean 43, 95% CI, 39–48 [p = 0.56]); knee function score (SP mean 64 [SD 25]; XLP mean 64 [SD 24] p = 0.98; change in function score (SP mean 22, 95% CI, 17–27; XLP mean 21, 95% CI, 17–27 [p = 0.79]); LEAS score (both SP and XLP 9 [SD 2]; p = 0.88); and change in LEAS (both SP and XLP mean 1, 95% CI, 1–2 [p = 0.0.38]). There were no differences, with the numbers available, in the presence of effusion (two of 94 XLP and five of 99 SP) with 2 years minimum followup. There were no differences in the frequency of radiolucent lines (13 knees with SP and 15 with XLP) or of osteolysis (two knees with SP and none with XLP). There was no difference in frequency of reoperation between the two groups (three infections in 110 knees allocated to the XLP group and five (two infections, one femoral loosening, one instability, one fracture plating) in 122 knees allocated to the standard group. There were no complications related to the XLP liner. Conclusions In this interim analysis, with the numbers available, there were no complications, but no advantages, related to the use of this XLP tibial liner. Additional enrollment has continued, and longer followup of these patients will be necessary to determine whether long-term wear characteristics differ between the groups. Level of Evidence Level I, therapeutic study.

Background Wear-induced osteolysis is the main factor in reducing the longevity of total hip arthroplasty (THA). The transmembrane Receptor Activator of Nuclear Factor κ B (RANK) and its corresponding ligand RANKL is an important regulator of osteoclast activity and bone resorption and is associated with osteolysis around implant. Inhibiting RANKL with denosumab is effective in vivo in preventing osteoporosis-related fractures. In vitro, osteoclasts can be blocked in animal models of osteolysis. We hypothesize that denosumab is effective in reducing wear-induced osteolysis around uncemented acetabular implants in THA. Methods/design A randomized, double-blind, placebo-controlled trial will be conducted. We will include 110 patients, 40–85 years of age, with a known osteolytic lesion around an uncemented acetabular component ≥7 years after the primary operation. The patients will be randomized in a 1:1 ratio to subcutaneous injections of 60 mg denosumab or placebo for a total of 6 doses with start on day one and every 6 months with last treatment at 30 months. The primary endpoint will be the change in volume of the osteolytic lesion at 3 years measured with three-dimensional computed tomography (3D-CT). Secondary endpoints include functional outcome scores, change in bone mineral density of the lumbar spine, serological markers of bone turnover and adverse events. Discussion In vitro results of both bisphosphonates and RANKL inhibitors have been promising, showing reduced osteolysis with treatment. This is, to our knowledge, the first clinical trial testing the efficacy of denosumab in reducing wear-induced osteolysis. The study is an academic, phase II trial from an independent center and is designed to demonstrate efficacy in reducing volume of osteolytic lesions around a total hip arthroplasty. Trial registration ClinicalTrials.gov ( NCT02299817 ) 2014-11-20

BackgroundAccording to published meta-analyses, cervical total disc replacement (CTDR) seems to be superior to anterior cervical decompression and fusion (ACDF) in most clinical parameters. Despite short-term clinical success of CTDR, there are concerns regarding long-term durability of these prostheses.MethodsThis prospective study involved 382 patients who received standalone CTDR or a hybrid procedure (ACDF/CTDR). A retrospective comparison between different CTDR devices was conducted regarding patient-reported outcome measures (PROMs), failure scenarios, and revision surgeries. The M6-C™ Artificial Cervical Disc (Orthofix, Lewisville, Texas) cohort was compared to the other CTDR devices clinically. Etiological reasons for revision, and the surgical technique of the revision was investigated.ResultsFifty-three patients received M6-C CTDR. Eighteen patients (34%) were revised at an average of 67 months postoperatively for wear-induced osteolysis. There were three additional cases of pending revision. The PROMs of the two groups were similar, indicating that the failure mode (wear-induced osteolysis) is often asymptomatic. The demographics of the two groups were also similar, with more women undergoing revision surgery than men. There were three one-level CTDR, four two-level hybrids, seven three-level hybrids, and three four-level hybrids revised anteriorly. Sixteen patients underwent removal of the prosthesis and were treated according to the extent of osteolysis. There were four vertebrectomies, six revisions to ACDF, and six revisions to another CTDR. One patient underwent supplemental fixation using a posterior approach. The other CTDR cohort had an incidence of 3.3% at the equivalent time, and none of these were due to osteolysis or wear-related events.ConclusionsThere is a concerning midterm failure rate related to ultra-high-molecular-weight-polyethylene wear-induced osteolysis in the M6-C. Patients implanted with the M6-C prosthesis should be contacted, informed, and clinically and radiologically assessed.

Background Pelvic discontinuity is an increasingly common complication of THA. Treatments of this complex situation are varied, including cup-cage constructs, acetabular allografts with plating, pelvic distraction technique, and custom triflange acetabular components. It is unclear whether any of these offer substantial advantages. Questions/purposes We therefore determined (1) revision and overall survival rates, (2) discontinuity healing rate, and (3) Harris hip score (HHS) after treatment of pelvic discontinuity with a custom triflange acetabular component and (4) the cost of this reconstructive operation compared to other constructs. Methods We retrospectively reviewed 57 patients with pelvic discontinuity treated with revision THA using a custom triflange acetabular component. We reviewed operative reports, radiographs, and clinical data for clinical and radiographic results. We also performed a cost comparison with utilization of other techniques. Minimum followup was 24 months (average, 65 months; range, 24–215 months). Results Fifty-six of 57 (98%) were free of revision for aseptic loosening at latest followup. Fifty-four (95%) were free of revision of the triflange component for any reason. Thirty-seven (65%) were free of revision for any reason. Twenty-eight (49%) were free of revision for any reason and free of any component migration and had a healed discontinuity. Forty-six (81%) had a stable triflange component with a healed pelvic discontinuity. Average HHS was 74.8. The costs of the custom triflange implants and a Trabecular Metal ® cup-cage construct were equivalent: $12,500 and $11,250, respectively. Conclusions In this group of patients with osteolytic pelvic discontinuity, triflange implants provided predictable mid-term fixation at a cost equivalent to other treatment methods. Level of Evidence Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Background Dual-mobility (DM) cups were introduced to minimize the risk of THA dislocation. The overall rate of dislocation of DM cups (including both large and small articulations) is controversial and ranges from 0% to 5% in previous studies. Questions/purposes We therefore recorded (1) the dislocation rate, (2) loosening and osteolysis, and (3) subsequent related revisions with DM cups. Methods Between 1998 and 2003, 2480 primary THAs with DM cups were undertaken in 2179 patients. The mean age was 69 years (range, 19–94 years). This group underwent specific clinical and radiographic evaluation at a minimum followup of 0.17 years (mean, 7 years; range, 0.17–11 years) to assess dislocation, reoperation, osteolysis, and cup fixation. Results There were 22 dislocations (0.88%): 15 dislocations of large articulations (0.6%), with two (0.08%) recurring but only one requiring revision (0.04%), and seven intraprosthetic small articulation dislocations (0.28%), all needing revision surgery. At last followup, mean Harris hip score was 91 (range, 60–100); 2439 cups (98%) showed no signs of loosening; and 141 patients (145 hips) had osteolysis (6%). Osteolysis and cup loosening were more frequent in patients younger than 50 years at the time of surgery. The 10-year survivorship considering revision for any reason was 93% (95% CI, 91%–95%). Conclusions DM cups had a low dislocation rate in primary THA, with a limited frequency of adverse effects. We recommend DM cups to minimize dislocation in populations at high risk for instability, but they should be avoided in younger, active patients at higher risk for osteolysis. Level of Evidence Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background Following total ankle replacement (TAR), osteolysis is a known complication. No consensus exists regarding management. Methods Applying the Arksey and O’Malley framework for scoping studies, a study protocol and a data extraction form was created. The research included all studies until March 2025. Study selection and data extraction were performed by two independent reviewers. Results Two hundred and eighty-seven studies were identified, of which 54 studies (case series and case reports) were included. 69% of the studies included below 10 cases. The most common reported treatment was bone grafting in n  = 36 (67%) of studies. The conversion of the TAR to an ankle fusion ( n  = 16 studies, 30%) was more frequent than the revision to a TAR ( n  = 15 studies, 28%). Eleven studies reported multiple treatment options. Long-term follow-up and standardized outcome measurements were infrequently discussed. Conclusion This scoping review demonstrates that the existing literature is highly heterogeneous and insufficient to recommend standard treatment.

BackgroundPeriprosthetic bone loss is a common observation following arthroplasty. Recognizing and understanding the nature of bone loss is vital as it determines the subsequent performance of the device and the overall outcome. Despite its significance, the term “bone loss” is often misused to describe inflammatory osteolysis, a complication with vastly different clinical outcomes and treatment plans. Therefore, the goal of this review was to report major findings related to vertebral radiographic bone changes around cervical disc replacements, mitigate discrepancies in clinical reports by introducing uniform terminology to the field, and establish a precedence that can be used to identify the important nuances between these distinct complications. MethodsA systematic review of the literature was conducted following PRISMA guidelines, using the keywords “cervical,” “disc replacement,” “osteolysis,” “bone loss,” “radiograph,” and “complications.” A total of 23 articles met the inclusion criteria with the majority being retrospective or case reports. ResultsFourteen studies reported periprosthetic osteolysis in a total of 46 patients with onset ranging from 15–96 months after the index procedure. Reported causes included: metal hypersensitivity, infection, mechanical failure, and wear debris. Osteolysis was generally progressive and led to reoperation. Nine articles reported non-inflammatory bone loss in 527 patients (52.5%), typically within 3–6 months following implantation. The reported causes included: micromotion, stress shielding, and interrupted blood supply. With one exception, bone loss was reported to be non-progressive and had no effect on clinical outcome measures.ConclusionsNon-progressive, early onset bone loss is a common finding after CDA and typically does not affect the reported short-term pain scores or lead to early revision. By contrast, osteolysis was less common, presenting more than a year post-operative and often accompanied by additional complications, leading to revision surgery. A greater understanding of the clinical significance is limited by the lack of long-term studies, inconsistent terminology, and infrequent use of histology and explant analyses. Uniform reporting and adoption of consistent terminology can mitigate some of these limitations. Executing these actionable items is critical to assess device performance and the risk of revision.Level of Evidence IVDiagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Background Autologous hamstrings and patellar tendon have historically been considered the gold standard grafts for anterior cruciate ligament reconstruction (ACLR). In the last decades, the utilization of synthetic grafts has re-emerged due to advantageous lack of donor site morbidity and more rapid return to sport. The Ligament Augmentation and Reconstruction System (LARS) has demonstrated to be a valid and safe option for ACLR in the short term. However, recent studies have pointed out the notable frequency of associated complications, including synovitis, mechanical failure, and even chondrolysis requiring joint replacement. Case presentation We report the case of a 23-year-old male who developed a serious foreign body reaction with wide osteolysis of both femoral and tibial tunnels following ACLR with LARS. During first-stage arthroscopy, we performed a debridement of the pseudocystic mass incorporating the anterior cruciate ligament (ACL) and extending towards the tunnels, which were filled with autologous anterior iliac crest bone graft chips. Histological analysis revealed the presence of chronic inflammation, fibrosis, and foreign body giant cells with synthetic fiber inclusions. Furthermore, physicochemical analysis showed signs of fiber depolymerization, increased crystallinity and formation of lipid peroxidation-derived aldehydes, which indicate mechanical aging and instability of the graft. After 8 months, revision surgery was performed and ACL revision surgery with autologous hamstrings was successfully carried out. Conclusions The use of the LARS grafts for ACLR should be cautiously contemplated considering the high risk of complications and early failure.