Although some patients experience a success rate greater than 90% after total hip arthroplasty, others require revision surgery within 5 years after the index procedure. The purpose of our study was to analyze the failure mechanisms in patients who had revision surgery within 5 years after index total hip arthroplasty. We retrospectively reviewed 824 revision total hip arthroplasties performed in 692 patients from 1986-2001. Seven hundred forty-five patients had adequate data. Two hundred ninety-one (39%) patients had revisions within 5 years after index arthroplasty. Ninety-six (33%) patients had revision surgery for instability, 88 (30%) for aseptic loosening, 41 (14%) for infection, 14 (5%) for osteolysis, 44 (15%) for failed painful hemiarthroplasties, and eight (3%) for periprosthetic fractures. Early revisions for aseptic loosening decreased from 38% in the early period to 24% in the current period, whereas revisions for instability increased from 9% to 42%. We were alarmed that 39% of the revisions at our institution were performed during the first 5 years after index surgery. Although improved fixation methods decreased early revisions for loosening, early revisions for instability increased substantially during the same time. Steps to avoid short-term failure must be taken.

A relatively high percentage of monoblock metal-on-metal total hip arthroplasties (THAs) undergo early revision. Revision of these THAs poses challenges unique to this implant type. The early complications after these revisions remain unreported as do the clinical and demographic factors associated with these complications. We describe (1) the frequency of early complications after revision of monoblock metal-on-metal THA; and (2) the clinical and demographic factors associated with complications. A review of our institution’s total joint registry identified 107 patients who underwent 114 revisions of monoblock metal-on-metal THAs. Mean patient age at revision was 60 years (range, 17–84 years), and 65% of the patients were women. Mean followup after revision was 14 months (range, 0–122 months). Revision diagnoses included metallosis (51%), aseptic loosening (27%), infection (7%), pain (6%), malposition (4%), instability (3%), iliopsoas impingement (2%), and periprosthetic fracture (1%). Major complications (instability, infection, aseptic loosening, and wound complications) were documented and included in the analysis. Minor postoperative complications such as urinary tract infection were excluded. Twenty-three of 114 procedures (20%) involved at least one early complication after revision of monoblock metal-on-metal THA with 18 (16%) undergoing at least one additional subsequent surgery. The most common complications included aseptic loosening (6%), deep infection (6%), dislocation (4%), and acetabular fracture (3%). Patients who sustained a complication after revision surgery were older on average than those who did not (66 years versus 58 years, p = 0.003). There were no differences in complication rate with respect to sex, time to revision, or revision diagnosis. Complications and reoperations occur frequently after revision for failed monoblock metal-on-metal THA (20% and 16%, respectively), and older patients appear to be at greater risk for complications after these revisions. Aseptic loosening, deep infection, and instability are all of great concern after revision and surgeons should be aware of these potential complications when undertaking revision of these THAs. Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background: Ankle arthrodesis has been the traditional surgical treatment for end-stage hindfoot arthritis. However, utilization of total ankle arthroplasty (TAA) is increasing as surgical techniques and implants have substantially improved. The purpose of this study was to compare the U.S. national rates of perioperative (in-hospital) complications between a statistically matched cohort of patients who underwent either an ankle arthrodesis or a TAA. Methods: Data from the 2002 to 2013 Nationwide Inpatient Sample releases were analyzed. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure codes were used to identify 4,192 patients treated with TAA (ICD 81.56) and 16,278 treated with ankle arthrodesis (ICD 81.11). ICD-9-CM diagnosis codes were utilized to identify major and minor in-hospital complications, and mortality was determined using the Uniform Bill patient disposition. The arthrodesis and TAA groups were matched with regard to age, sex, race, surgery year, hospital type, comorbidities, adjunctive procedures, and surgical indication. Unadjusted and adjusted in-hospital complication risks were compared between groups using the Fisher exact test and multiple logistic regression analysis. Results: We were able to statistically match 1,574 patients who underwent a TAA (37.5%) with a patient who underwent arthrodesis. A major in-hospital complication occurred in 8.5% (134) of the 1,574 patients in the ankle arthrodesis group compared with 5.3% (84) of the 1,574 in the TAA group (p < 0.001) whereas a minor complication was found in 4.7% (74) in the ankle arthrodesis group compared with 5.9% (93) in the TAA group (p = 0.14). There were no deaths in either group. After adjusting for case mix, we found that ankle arthrodesis was 1.8 times more likely to be followed by a major complication (odds ratio [OR] = 1.78, 95% confidence interval [CI] = 1.32 to 2.39) whereas the minor complication rate was 29% lower in that group (OR = 0.71, 95% CI = 0.45 to 1.13). Conclusions: In a matched cohort of 3,148 patients treated with either TAA or ankle arthrodesis, ankle arthrodesis was associated with a 1.8 times higher risk of a major complication but a 29% lower risk of a minor complication. Our findings are consistent with other studies that have shown TAA to be a safe procedure in the inpatient environment. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Extraction of implants because of periprosthetic infection (PJI) following complex revision total knee arthroplasty (rTKA) with extensive instrumentation is a daunting undertaking for surgeon and patient alike. The purpose of the present study was to evaluate whether infections following complex rTKA are better treated with 2-stage exchange or irrigation and debridement (I&D) with modular component exchange and antibiotic suppression in terms of infection control, reoperation, and function. Methods: We reviewed rTKAs that had been performed for the treatment of PJI from 2005 to 2016. Extensive instrumentation was defined as the presence ≥1 of the following: metaphyseal cones/sleeves, distal femoral replacement, periprosthetic fracture instrumentation, or fully cemented stems measuring >75 mm. Cases were categorized according to the initial treatment (I&D with antibiotic suppression or initiation of 2-stage exchange). Results: Eighty-seven patients with PJI and extensive instrumentation were identified: 56 patients who were managed with I&D with suppression and 31 who were managed with the initiation of 2-stage exchange. The rate of success (defined as no reoperation for infection) was similar for the 2 groups (62.5% the I&D group compared with 67.7% for the 2-stage group; p = 0.62). The rate of mortality was also similar (39.3% for the I&D group compared with 38.7% for the 2-stage group; p = 0.96). Of the 31 patients in the 2-stage group, 18 (58.1%) underwent reimplantation with a revision replacement. Of those 18 patients, 13 were still infection-free at the time of the most recent follow-up; however, when the analysis was expanded to all 31 patients in the 2-stage group, only 13 (41.9%) both had a successful reimplantation and did not require additional surgery for infection. Nine (29.0%) of the 31 patients in the 2-stage group never underwent the second stage, and 4 (12.9%) of the 31 required arthrodesis at the second stage. In contrast, 35 (62.5%) of the 56 patients in the I&D group were successfully managed, without additional surgery for the treatment of infection. At the time of the latest follow-up (mean, 3.2 years; range, 2 to 13 years), more patients in the I&D group were ambulatory (76.8% in the I&D group compared with 54.8% in the 2-stage group; p = 0.05) and maintained a functional bending knee joint (85.7% in the I&D group compared with 45.2% in the 2-stage group; p < 0.001). Conclusions: In the treatment of periprosthetic infection of rTKA with extensive instrumentation, I&D with chronic antibiotic suppression was as effective as 2-stage exchange in terms of preventing reoperation for infection and was more effective in terms of maintaining function. These data apply to rTKA with extensive periarticular instrumentation and should not be extrapolated to primary or simple revision implants. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinicians frequently assess asymmetry in strength, flexibility, and performance characteristics as a method of screening for potential musculoskeletal injury. The identification of asymmetry in countermovement jumps may be an ideal method to reveal asymmetry in other lower extremity characteristics such as strength that otherwise may require additional testing, potentially reducing the time and burden on both the athlete and clinicians. The present study aims to examine the ability of asymmetry in both the single-leg and two-leg countermovement jump tests to accurately detect hip abduction, hip adduction, and eccentric hamstring strength asymmetry. Fifty-eight young male elite soccer players from the same professional academy performed a full battery of functional performance tests which included an assessment of hip adductor and abductor strength profiles, eccentric hamstring strength profiles, and neuromuscular performance and asymmetries during countermovement jumps. Bilateral variables attained from both the single-leg and two-leg countermovement jump tests included concentric impulse (Ns), eccentric mean force (N), and concentric mean force (N) computed by the VALD ForceDecks software. Average maximal force (N) was calculated bilaterally for the strength assessments. Asymmetry was calculated for each variable using 100 × |(right leg − left leg)/(right leg)| and grouped into three categories: 0 to <10%, 10% to <20%, and 20% or greater. Analyses were performed for the two higher asymmetry groups. The accuracy to detect strength asymmetry was assessed as the sensitivity, specificity, and predictive values for positive and negative tests. The outcomes from the accuracy assessments suggest that the single-leg countermovement jump concentric impulse variable at the 20% threshold is indicative of a youth male soccer player having hip adduction strength asymmetry while also demonstrating more accuracy and applicability than the two-leg countermovement jump concentric impulse variable.