Introduction: Multiple revision hip arthroplasties and critical trauma might cause severe bone loss that requires proximal femoral replacement (PFR). The aim of this retrospective study was to analyse complication- and revision-free survivals of patients who received modular megaprostheses in an attempt to reconstruct massive non-neoplastic bone defects of the proximal femur.Questions/purposes(1) What were general complication rates and revision-free survivals following PFR? (2) What is the incidence of complication specific survivals? (3) What were risk factors leading to a diminished PFR survival?Materials and methods: Twenty-eight patients with sufficient follow-up after receiving a modular proximal femoral megaprosthesis were identified. The indications for PFR included prosthetic joint infection (PJI), periprosthetic fracture, aseptic loosening, non-union and critical femoral fracture. Complications were grouped according to the ISOLS-classification of segmental endoprosthetic failure by Henderson et al.Results: Overall, the complication-free survival was 64.3% at one year, 43.2% at five years and 38.4% at ten years, with 16 patients (57%) suffering at least one complication. Complications were dislocation in eight patients (29%), PJI in 6 patients (21%), periprosthetic fracture in five patients (18%), and aseptic loosening in six patients (21%). Prosthesis stem cementation showed a lower risk for revision in a cox proportional hazard model (95% CI 0.04–0.93, HR 0.2, p = 0.04).Conclusion: PFR with modular megaprostheses represents a viable last resort treatment with high complication rates for patients with severe proximal femoral bone loss due to failed arthroplasty or critical fractures. In revision arthroplasty settings, PFR cementation should be advocated in cases of impaired bone quality.

Background: An increasing number of elderly patients are becoming candidates for elective total hip arthroplasty (THA). Conflicting results exist with regard to the safety of THA in nonagenarians. The aims of this study were to evaluate postoperative mortality and morbidity after THA in nonagenarians and underlying risk factors. We hypothesized that nonagenarians undergoing elective THA would show higher morbidity than younger patients and higher mortality than nonagenarians in the general population. Methods: This was an observational cohort study using data from the German Arthroplasty Registry (Endoprothesenregister Deutschland [EPRD]). Of 323,129 THAs, 263,967 (including 1,859 performed on nonagenarians) were eligible. The mean follow-up (and standard deviation) was 1,070 ± 641 days (range, 0 to 3,060 days). The exclusion criteria were age of <60 years at admission and nonelective THAs or hemiarthroplasties. The cohort was divided into 4 age groups: (1) 60 to 69 years, (2) 70 to 79 years, (3) 80 to 89 years, and (4) ≥90 years. Comorbidities representing independent risk factors for postoperative complications and mortality were identified via a logistic regression model. Mortality rates were compared with those from the general population with data from the Federal Statistical Office. The end points of interest were postoperative major complications, minor complications, and mortality. Results: Among the greatest risk factors for major and minor complications and mortality were congestive heart failure, pulmonary circulation disorders, insulin-dependent diabetes, renal failure, coagulopathy, and fluid and electrolyte disorders. Compared with younger groups, the risks of major and minor complications and mortality were significantly higher in nonagenarians. Mortality increased when major complications occurred. After 1 year, the survival rate in patients without a major complication was 94.4% compared with 79.8% in patients with a major complication. The mortality rates of nonagenarians in the study population were lower than those in the corresponding age group of the general population. The 1-year mortality rates at 90 years of age were 10.5% for men and 6.4% for women within the study group compared with 18.5% for men and 14.7% for women among the general population. Conclusions: Comorbidities favor the occurrence of complications after elective THA in nonagenarians and thus increase postoperative morbidity. In the case of complications, mortality is also increased. The fact that mortality is still lower than within the general population shows that this aspect can be controlled by careful patient selection and adequate preparation. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: The optimal treatment of patients with a degenerative joint disease secondary to an active or chronic septic arthritis of the hip is unclear. The aim of the present study was to report on our experience with two-stage total hip arthroplasty (THA) using a contemporary treatment protocol without spacer insertion. Materials and methods: Our prospective institutional database was used to identify all patients with degenerative septic arthritis treated with a non-spacer two-stage protocol between 2011 and 2017. Clinical outcomes included interim revision, periprosthetic infection (PJI) and aseptic revision rates. Restoration of leg-length and offset were assessed radiographically. Modified Harris hip score (mHHS) were obtained. Treatment success was defined using the modified Delphi consensus criteria. Mean follow-up was 62 months (13–110). Results: A total of 33 patients with a mean age of 60 years (13–85) were included. 55% of the cohort was male and average Charlson Comorbidity Index (CCI) was 3.7 (0–12). 21 patients (64%) had an active/acute infection and 12 patients (36%) were treated for chronic/quiescent septic arthritis. Overall, 11 patients (33%) had treatment failure, including 5 patients who failed to undergo THA, 2 interim re-debridement for persistent infection, and 4 patients who developed PJI after an average of 7 months (0.3–13) following THA. The most common identified pathogen was Staphylococcus aureus (42.4%). No aseptic revision was recorded following THA. Leg-length and offset were successfully restored. Mean mHHS improved from 35.2 points to 73.4 points. Conclusion: Two-stage THA without spacer placement is a viable treatment option for destructive septic arthritis of the hip, demonstrating comparable rates of infection control and functional outcome. However, definitive resection arthroplasty is not uncommon in these often critically ill patients.

(1) Background: Degeneration of the hip abductor mechanism, a well-known cause of functional limitation, is difficult to treat and is associated with a reduced health-related quality of life (HRQOL). The gluteus maximus muscle flap is a treatment option to support a severely degenerative modified gluteus medius muscle. Although several reports exist on the clinical outcome, there remains a gap in the literature regarding HRQOL in conjunction with functional results. (2) Methods: The present study consists of 18 patients with a mean age of 64 (53‒79) years, operatively treated with a gluteus maximus flap due to chronic gluteal deficiency. Fifteen (83%) of these patients presented a history of total hip arthroplasty or revision arthroplasty. Pre and postoperative pain, Trendelenburg sign, internal rotation lag sign, trochanteric pain syndrome, the Harris Hip Score (HHS), and abduction strength after Janda (0‒5) were evaluated. Postoperative patient satisfaction and health-related quality of life, according to the Short Form 36 (SF-36), were used as patient-reported outcome measurements (PROMs). Postoperative MRI scans were performed in 13 cases (72%). (3) Results: Local pain decreased from NRS 6.1 (0–10) to 4.9 (0–8) and 44% presented with a negative Trendelenburg sign postoperatively. The overall HHS results (p = 0.42) and muscular abduction strength (p = 0.32) increased without significance. The postoperative HRQOL reached 46.8 points (31.3–62.6) for the mental component score and 37.1 points (26.9–54.7) for the physical component score. The physical component results presented a high level of positive correlation with HHS scores postoperatively (R = 0.88, p < 0.001). Moreover, 72% reported that they would undergo the operative treatment again. The MRI overall showed no significant further loss of muscle volume and no further degeneration of muscular tissue. (4) Conclusions: Along with fair functional results, the patients treated with a gluteus maximus flap transfer presented satisfying long-term PROMs. Given this condition, the gluteus maximus muscle flap transfer is a viable option for selected patients with chronic gluteal deficiency.

Aims: There is little information in the literature about the use of dual-mobility (DM) bearings in preventing re-dislocation in revision total hip arthroplasty (THA). The aim of this study was to compare the use of DM bearings, standard bearings, and constrained liners in revision THA for recurrent dislocation, and to identify risk factors for re-dislocation.Methods: We reviewed 86 consecutive revision THAs performed for dislocation between August 2012 and July 2019. A total of 38 revisions (44.2%) involved a DM bearing, while 39 (45.3%) and nine (10.5%) involved a standard bearing and a constrained liner, respectively. Rates of re-dislocation, re-revision for dislocation, and overall re-revision were compared. Radiographs were assessed for the positioning of the acetabular component, the restoration of the centre of rotation, leg length, and offset. Risk factors for re-dislocation were determined by Cox regression analysis. The modified Harris Hip Scores (mHHSs) were recorded. The mean age of the patients at the time of revision was 70 years (43 to 88); 54 were female (62.8%). The mean follow-up was 5.0 years (2.0 to 8.75).Results: DM bearings were used significantly more frequently in elderly patients (p = 0.003) and in hips with abductor deficiency (p < 0.001). The re-dislocation rate was 13.2% for DM bearings compared with 17.9% for standard bearings, and 22.2% for constrained liners (p = 0.432). Re-revision-free survival for DM bearings was 84% (95% confidence interval (CI) 0.77 to 0.91) compared with 74% (95% CI 0.67 to 0.81) for standard articulations, and 67% (95% CI 0.51 to 0.82) for constrained liners (p = 0.361). Younger age (hazard ratio (HR) 0.92 (95% CI 0.85 to 0.99); p = 0.031), lower comorbidity (HR 0.44 (95% CI 0.20 to 0.95); p = 0.037), smaller heads (HR 0.80 (95% CI 0.64 to 0.99); p = 0.046), and retention of the acetabular component (HR 8.26 (95% CI 1.37 to 49.96); p = 0.022) were significantly associated with re-dislocation. All DM bearings which re-dislocated were in patients with abductor muscle deficiency (HR 48.34 (95% CI 0.03 to 7,737.98); p = 0.303). The radiological analysis did not reveal a significant relationship between restoration of the geometry of the hip and re-dislocation. The mean mHHSs significantly improved from 43 points (0 to 88) to 67 points (20 to 91; p < 0.001) at the final follow-up, with no differences between the types of bearing.Conclusion: We found that the use of DM bearings reduced the rates of re-dislocation and re-revision in revision THA for recurrent dislocation, but did not guarantee stability. Abductor deficiency is an important predictor of persistent instability.Cite this article: Bone Joint J 2024;106-B(5 Supple B):89–97.