AdultHip Abstracts PDF

ADULT RECONSTRUCTION HIP
PAPERS this study was to determine the rate of DVT and PE after total knee
arthroplasty (TKA) and total hip arthroplasty (THA) in patients
with a diagnosis of varicose veins who have or have not had previous
PAPER NO. 31 varicose vein (VV) surgery, in an attempt to determine if prior VV
diagnosis or surgery alters the risk of DVT or PE after arthroplasty.
Is Inferior Vena Cava Filter Effective at Preventing METHODS: Data on 57,364 patients who had total hip
Pulmonary Embolism? arthroplasty (THA) and 51,859 patients who had total knee
Benjamin Zmistowski, BS, Philadelphia, PA arthroplasty (TKA) were identified from the Scottish Arthroplasty
Camilo Restrepo, MD, Philadelphia, PA Project (SAP) along with patients who had recorded DVT or
David Casper, MD, Philadelphia, PA PE events (Scottish Morbidity Database), varicose veins, and
varicose vein interventions. Statistical analysis was conducted
Ibrahim Raphael, MD, Philadelphia, PA
to determine a significant correlation between varicose
Matthew Austin, MD, Philadelphia, PA vein surgery and resulting DVT or PE post THA or TKA.
Javad Parvizi, MD, Philadelphia, PA RESULTS: Of the patient cohort that underwent THA, 462 (0.8%)
INTRODUCTION: Venous thromboembolism (VTE) is a had a diagnosed DVT within 90 days of orthopedic intervention.
common complication following total joint arthroplasty, ranging The DVT rate in patients who had previous VV surgery was 0.8%
from the frequently benign deep vein thrombosis (DVT) to the (27), and in those with no previous VV diagnosis or surgery was
distressing and at times fatal pulmonary embolism (PE). The aim 0.8% (428). In patients with a previous VV diagnosis but no VV
for prophylactic treatment of VTE is prevention of PE. However, surgery, the DVT rate was 3.1% (7) (Pearson Chi square test 14.8,
it has often been assumed that DVT is a proxy for PE. Based df 2, p=0.001). In the TKA cohort, 304 (0.6%) patients had a 90-
on this assumption, aggressive DVT prophylaxis is currently day DVT diagnoses. The DVT rate in patients who had previous VV
recommended at the expense of a higher proportion of bleeding surgery was 0.6% (22), and in those with no previous VV diagnosis
complications. This study investigates whether inferior vena cava or surgery was 0.6% (281). In patients with a previous VV diagnosis
(IVC) filter protects against PE. METHODS AND MATERIALS: We but no VV surgery, the DVT rate was 0.4% (1), a difference that did
identified 209 patients that underwent orthopaedic procedures not reach significance (Pearson Chi square test 0.1, df 2, p=0.95).
at a single institution with concurrent IVC filter placement Of the patient cohort that underwent THA, 403 (0.7%) had a
between 2004 and 2008. Fifty-one of these patients had an IVC diagnosed PE within 90 days of surgery. The PE rate in patients
filter placed following diagnosis of DVT to prevent “migration” who had previous VV surgery was 0.7% (26), and in those with no
of thrombus to the lungs and formation of PE. These patients previous VV diagnosis or surgery was 0.7% (376). In patients with
had an average age of 71.5 years and 30 (59%) were female. previous VV diagnosis but no VV surgery that PE rate was 0.4%
These patients were investigated for presence of DVT and PE. (1), a difference that did not reach statistical significance (Pearson
RESULTS: Two patients (3.9%) receiving IVC filter developed Chi square test 0.3, df2, p=0.85). In patients who had TKA, 411
PE after placement of the filter. There were no fatal PE in this (0.8%) had 90-day PE diagnoses. The PE rate in patients who had
cohort. One of these patients had concomitant atrial fibrillation. previous VV surgery was 0.9% (35), and in those who did not have
CONCLUSION This study identifies a high rate of PE despite IVC a VV diagnosis was 0.8% (374). In patients with a VV diagnosis
filter placement. This finding, once again, brings to question the but no surgery the PE rate was 0.9% (2), a difference that did not
“propagation theory” that assumes that PE arises from a thrombus reach significance (Pearson Chi square test 0.8, df 2, p=0.66).
in the extremity. Considering the fact that IVC filter has been shown CONCLUSION: DVT and PE is a major contributor worldwide to
to be very effective in prevention of migration of thrombus, our morbidity and mortality with one of the highest risk factors being
study demonstrates that a portion of PE may arise independently knee and hip surgery. Our study concluded that DVT and PE are
and as part of a hypercoagulable state. Thus, strategies that are major contributors worldwide to morbidity and mortality, with one
aimed at reducing DVT, by assuming DVT is a proxy for PE, needs of the highest risk factors being lower limb arthroplasty. Untreated
to be reexamined. We believe patients are placed at high risk of varicose veins are associated with an increased risk of DVT after
bleeding with administration of aggressive anticoagulation for hip arthroplasty, and it may be that patients with varicose veins
treatment of DVT and attempts to prevent its “propagation.” presenting for hip arthroplasty should consider treatment of
varicose veins prior to undergoing orthopaedic intervention. This
PAPER NO. 32 is the largest series of its kind reported to date. Further research
Is Previous Varicose Vein Surgery Associated with detailing relationships between known risk factors and the
decreased risk of DVT or PE post risk factor alleviation need to
Deep Vein Thrombosis within 90 Days of Hip and Knee be conducted in order to ascertain the best DVT/PE preventative
Replacement? approach.
Anahita Dua, MD, Brookfield, WI
Santiago S. Nieva, Edinburgh, United Kingdom
Alasdair G. Sutherland, MD, FRCS, Warrnambool, Australia
INTRODUCTION: Although varicose veins are an established risk
factor for deep vein thrombosis (DVT) there is a paucity of literature
detailing the association between prior varicose vein surgery and
DVT or pulmonary embolism (PE) in high-risk populations such
as patients undergoing knee or hip arthroplasty. The objective of
u The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use).
521 For full information refer to page 14. An alphabetical faculty financial disclosure list can be found starting on page 19.
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

PAPER NO. 33 undergoing elective total hip arthroplasty (THA) are also at a
particularly high risk for VTE. The purpose of our current prospective
Diagnosis of Periprosthetic Infection: Further Results study was to examine acute postoperative changes of SF and PAI-1,
on Leukocyte Esterase Dip Stick Test and the usefulness of assaying these markers as predictors for early
Elie S. Ghanem, MD, Philadelphia, PA VTE following THA was evaluated. MATERIALS AND METHODS:
Bahar Adeli, BA, Philadelphia, PA This study consisted of two groups including intermittent
Javad Parvizi, MD, Philadelphia, PA pneumatic compression (IPC) group (67 patients who underwent
only IPC as prophylaxis for VTE) and fondaparinux (FPX) group
INTRODUCTION: Synovial fluid leukocyte count and neutrophil
(103 patients who underwent IPC and FPX administration). Plasma
differential have been reported to have high sensitivity and specificity
levels of SF and PAI-1 were measured in the next early morning
in the diagnosis of infected total knee arthroplasty. We hypothesize
after THA. To diagnose postoperative VTE, multi-detector row CT
that neutrophils recruited into an infected joint secrete enzymes that
(MDCT) was performed for all patients at one week after surgery.
may be used as markers for infection. In this prospective study, we
RESULTS: Postoperative MDCT revealed 17 (25.3%) cases of
determined the sensitivity and specificity of one of these enzymes,
VTE in IPC group and 8 (5.8%) in FPX group. In IPC group,
leukocyte esterase, in diagnosing periprosthetic joint infection.
the plasma levels of SF and PAI-1 on the day after THA were
METHODS: From May 2007 to April 2010, knee synovial
significantly higher in patients with VTE (P<0.01). On the
fluid was obtained preoperatively from 108 patients being
other hand, no differences in both values were observed in FPX
investigated for possible joint infection or undergoing
group. Positive criterion of an increase in SF or PAI-1 above
revision knee arthroplasty. The aspirate fluid in all cases was
their cut-off levels (19.8µg/ml and 53.5ng/ml, respectively)
tested for the presence of leukocyte esterase using a simple
provided the sensitivity of 100% and specificity of 67% in IPC
colorimetric strip test. Color change (negative, trace, + or ++
group. In addition, when this criterion was applied to FPX
level of the enzyme) was noted within one or two minutes.
patients, 87.5% (7/8) of patients with VTE met the criterion,
RESULTS: According to clinical, serological and operative
and negative agreement rate of 98.0% (48/49) was observed.
criteria, 30 joints were deemed to be infected and 78 were
DISCUSSION AND CONCLUSION: Patients undergoing primary
determined to be uninfected. When a ++ leukocyte esterase
THA are at a high risk of VTE, which is possibly induced by a
result was considered positive, the test was 80.6 % (61.9-91.9,
hypercoagulable or regulated fibrinolytic state during the early
95% CI) sensitive and 100% (94.5-100.0, 95% CI) specific,
postoperative phase. Plasma SF and PAI-1 levels on day one
with a positive predictive value (PPV) of 100% (83.4-100.0,
after THA may provide an indication of the balance between
95% CI) and a negative predictive value (NPV) of 93.3% (85.4-
coagulation and fibrinolysis and be of value in predicting VTE
97.2, 95% CI). Leukocyte esterase correlated strongly with fluid
following THA. When high levels of SF or PAI-1 on the day after
polymorphonuclear counts (r=0.7769), as well as with total
surgery are observed, a higher risk for postoperative VTE might be
fluid cell count (r=0.5024) and serology including erythrocyte
considerable on the patients undergoing THA.
sedimentation rate (r=0.6188) and C-reactive protein (r=0.4719).
DISCUSSION AND CONCLUSION: It appears that the simple
PAPER NO. 35
colorimetric strip test that detects the presence of leukocyte esterase
in synovial fluid is an extremely valuable addition to the diagnostic Factors Associated with Infection in 30,491 Primary
armamentarium for prosthetic joint infection. The reagent strip Total Hip Arthroplasty Cases
has the advantage of real time, simple, and inexpensive testing Robert S. Namba, MD, Corona Del Mar, CA
with an ability both to rule out and to confirm periprosthetic joint
Maria CS Inacio, MS, San Diego, CA
infection. However, additional multicenter studies are required to
substantiate the results of our preliminary investigation before the
Liz Paxton, MA, San Diego, CA
reagent strip can be used in the clinic or intraoperative setting. INTRODUCTION: Total hip arthroplasty (THA) deep surgical site
infections (SSI) are devastating complications. Patient and surgical
PAPER NO. 34 risk factors of THA deep SSI have not been thoroughly examined.
The purpose of this study was to examine patient and surgical
Role of Coagulation and Fibrinolysis Markers in factors associated with THA deep SSI in a large, U.S. integrated
Screening for Venous Thromboembolism after Total Hip healthcare system. MATERIALS AND METHODS: A prospective
Arthroplasty cohort study of primary THA procedures performed between
Yohei Yukizawa, MD, Yokohama, Japan 2001 and 2009 was conducted. Patient characteristics, surgical
case details, surgeon and site case volumes were identified using a
Yutaka Inaba, MD, Yokohama, Japan
community-based Total Joint Replacement Registry (TJRR). Deep
Naomi Kobayashi, MD, Yokohama, Japan SSI was screened using a validated algorithm and adjudicated by
Kyohei Murakami, MD, PhD, Hiratuka, Japan chart review. Cox regression models were used to assess uni-variate
Takashi Ishida, MD, Yokohama, Japan and multivariable associations of possible risk factors for deep SSI.
Naoyuki Iwamoto, MD, Yokohama, Japan Hazard ratios (HR) and 95% confidence intervals (CI) are provided.
Hyonmin Choe, MD, Yokohama, Japan RESULTS: The study cohort consisted of 30,491 THA procedures,
Tomoyuki Saito, MD, Yokohama, Japan where 57% were women, the average age was 65.5 years (SD=11.8)
INTRODUCTION: Soluble fibrin (SF) - a composition of fibrin and mean BMI was 29.3 kg/m2 (SD=5.9). The incidence of
monomer and fibrinogen derivatives which are found in early-stage deep SSI was 0.51% (95%CI 0.43%-0.59%). In fully adjusted
thrombosis, and plasminogen-activator inhibitor 1(PAI-1) - a main regression models, patient factors associated with deep SSI
regulator of fibrinolysis system, have been developed to determine included: gender (females have an increased risk of infection)
thrombotic tendency. Highly invasive surgery has been shown to (HR=1.45, 95%CI 1.02-2.04); BMI (patients with BMI between
commonly result in a hypercoagulable state and to increase the 30 and 34 kg/m2 (HR=1.57, 95%CI 1.03-2.37) and >=35 kg/m 2
risk of postoperative venous thromboembolism (VTE). Patients (HR=2.37, 95%CI 1.56-3.61) have a higher risk than patients with
BMI between 18.5-30 kg/m2) ; and ASA (patients with ASA>=3

have higher risk than ASA<=2 (HR=2.20, 95%CI 1.55-3.13). PAPER NO. 37
Age, arthritis diagnoses, diabetes mellitus and race were not
associated with increased risk of THA SSI. The only surgical factor
Pulmonary Embolism Following Total Joint
associated with THA SSI was bilateral procedures which showed Arthroplasty: When Do They Occur?
a 5.32 (95%CI 2.45-11.56) increased risk of SSI than unilateral Javad Parvizi, MD, Philadelphia, PA
procedures. Surgeon and hospital case volumes, use of antibiotic William J. Hozack, MD, Philadelphia, PA
cement, fixation method, laminar flow, space suits, surgical William V. Arnold, MD, Jenkintown, PA
approach and fellowship training were not associated with SSI. Ronald Huang, Philadelphia, PA
CONCLUSION: A comprehensive infection surveillance system,
Ibrahim Raphael, MD, Philadelphia, PA
combined with a detailed TJR registry, identified patient and
surgical factors associated with THA infection. Obesity and
Richard H. Rothman, MD, Philadelphia, PA
chronic medical conditions should be optimized prior to THR. INTRODUCTION: The elevated risk of pulmonary embolism
The finding of increased infection risk with bilateral THA requires (PE) following total joint arthroplasty (TJA) has been well
further investigation. established, but little is known about the natural course of the
disease. Studies have shown an elevated risk of PE up to 90 days
PAPER NO. 36 postoperatively. Thus, anticoagulation is often continued for
many weeks postoperatively. However, chemical prophylaxis
An Evaluation of the Effect of Low Molecular Weight carries the risk of bleeding and associated periprosthetic joint
Heparin Versus Rivaroxaban on Complications After infection. Current guidelines for duration of prophylaxis are
Arthroplasty nonspecific. By determining when patients are at highest risk
Simon Jameson, Middlesbrough, United Kingdom for developing PE following TJA, we may be able to tailor
anticoagulation regimens to provide an ideal risk-benefit ratio.
Monika L. Rymaszewska, MB, ChB, Cleveland, United
METHODS: We retrospectively reviewed the records of 25,660
Kingdom consecutive patients that underwent primary TJA at our institution
Philip James, PhD, Alcester, Warwickshire, United Kingdom between January 2000 and December 2010. All patients were started
Ignacio Serrano-Pedraza, PhD, Madrid, Spain on warfarin the evening after surgery. Patients were investigated
Scott Muller, MBBS MD, FRCS, Northumberland, United only for symptomatic PE and were not screened. Pulmonary
Kingdom embolism that occurred within 90 days of TJA was documented.
Anthony Chi Wing Hui, MA, FRCS, Hurworth, Co. Durham, RESULTS: A total of 286 patients were diagnosed with PE
United Kingdom postoperatively by multidetector computed tomography (MDCT)
Mike R. Reed, MBBS MD, Northumberland, United Kingdom and/or ventilation-perfusion (VQ) scan. Median occurrence
of PE was two days postoperatively (range: 1 to 87 days), with
INTRODUCTION: The National Institute for Health and Clinical 254 of 286 PEs (88.8%) occurring within the first seven days
Effectiveness recommends both low molecular weight heparin after surgery. Average international normalized ration (INR) at
(LMWH) and rivaroxaban for venous thromboembolic (VTE) time of diagnosis of PE was 1.4 (range: 0.94 to 2.61). Multiple
prophylaxis following lower limb arthroplasty. Despite evidence regression analysis showed that cancer was associated with
in the literature that suggests rivaroxaban reduces VTE events, an earlier presentation of PE (p=0.013) whereas patients with
there are emerging concerns from the orthopaedic community obstructive lung disease presented with later PE (p=0.001).
regarding an increase in wound complications following its use. DISCUSSION AND CONCLUSION: Risk of PE appears to be
METHODS: Through the orthopaedic clinical directors forum, highest during the first week after TJA. Efforts must be made to
trusts replacing LMWH with rivaroxaban for lower limb arthroplasty minimize risk during this period. Furthermore, frequency of PE
thromboprophylaxis during 2009 were identified. Prospectively after the first postoperative week appears very low. Further studies
collected hospital episode statistics (HES) data was then analyzed must be done to evaluate the necessity of prolonged prophylaxis
for these units so as to determine rates of 90-day symptomatic deep following TJA.
venous thrombosis (DVT), pulmonary embolism (PE), major bleed
(cerebrovascular accident or gastrointestinal haemorrhage), all- PAPER NO. 38
cause mortality, and 30-day wound infection and readmission rates
before and after the change to rivaroxaban. A total of 2,752 patients uAugmentation of Vancomycin Elution from High Dose
prescribed rivaroxaban following total knee replacement (TKR) or Antibiotic Loaded Bone Cement
total hip replacement (THR) were compared to 10,358 patients Tanay J. Amin, MD, Kansas City, KS
prescribed LMWH. Data was analyzed using odds ratios (OR). Patrick G. Moodie, Overland Park, KS
RESULTS: There were significantly more wound infections in the
Kelly J. Hendricks, MD, Kansas City, KS
rivaroxaban group (3.85% vs. 2.81%, OR=0.72; 95% CI 0.58-0.90).
There were no significant differences between the two groups for PE
Terence McIff, PhD, Kansas City, KS
(OR=1.52; 0.77-2.97), major bleed (OR=0.73; 0.48-1.12), all-cause INTRODUCTION: Bone cement provides a medium for
mortality (OR=0.93; 0.46-1.87) and re-admission rate (OR=1.21; efficient delivery of antibiotics to eradicate and prevent local
0.88-1.67). There were significantly fewer symptomatic DVTs in infection. The application of antibiotic cement includes spacer
the rivaroxaban group (0.91% vs. 0.36%, OR=2.51; 1.30-4.82). treatment in staged procedures of revision arthroplasty and void
CONCLUSION: This study is the first to describe the real impact filling struts or bead pouches in treatment of open fractures.
of the use of rivaroxaban in the National Health Service. When This study specifically investigates the effect of two variables,
compared with LMWH in lower limb arthroplasty patients, wound quantity of liquid monomer and timing of vancomycin
infection rates were significantly higher following rivaroxaban addition, on ultimate elution of antibiotic from bone cement.
use while providing no reduction in symptomatic PE or all-cause METHODS: Two different types of commercially available bone
mortality. cement (Cement A and B) were prepared using three different
methods: a surgical control (standard preparation technique),

a mixture that doubled the standard amount of initial liquid respectively; however, this was not statistically significant (p=0.60).
monomer, and a novel technique that delayed antibiotic addition The risk of PE was 0.24%, 0.56%, and 0.18% for the respective
until after 30 seconds of polymerization elapsed. Pellets of a groups(p=0.51). The percent risk of MI or CVA was not statistically
standardized size were created from each preparation. The elution different between groups. Lastly, the risk of postoperative
profiles of five pellets from each preparation were measured over hematoma for the respective groups was 0.96%, 1.13%, and 0.54%.
six weeks utilizing high-performance liquid chromatography. CONCLUSION: Despite the use of less aggressive TE prophylaxis
RESULTS: Delayed antibiotic addition created significantly higher with aspirin, there was no statistically significant increase in TE
elution profiles than the surgical control and double liquid complications with intraoperative use of tranexamic acid. Risk of
monomer groups (p<0.0001). Vancomycin elution over six weeks hematoma postoperatively while on aspirin therapy, however, was
from Cement A was 52% greater in the delayed antibiotic group not statistically lower when compared to warfarin and dalteparin.
than in the standard surgical group, while Cement B demonstrated Physicians may consider the use of tranexamic acid to decreased
25% more elution within the delayed antibiotic group. Doubling blood loss and transfusion rates concomitantly with aspirin
the amount of liquid monomer led to a significantly lower elution therapy for TE prophylaxis after primary joint arthroplasty if the
profile (p<0.0001). Compared with the standard antibiotic patient has no other comorbidities necessitating the use of warfarin
technique, the use of double liquid monomer led to a 33% or low molecular weight heparin.
decrease in vancomycin elution over six weeks from Cement
A and a 35% decrease in vancomycin elution from Cement B. PAPER NO. 40
DISCUSSION AND CONCLUSION: High dose antibiotic bone Efficacy of Perioperative Irrigation and Debridement for
cement prepared utilizing the delayed antibiotic cement technique
increased vancomycin elution compared to the standard surgical Prosthetic Infection
preparation. Incorporation of additional liquid monomer Thomas K. Fehring, MD, Charlotte, NC
decreased vancomycin elution from high dose antibiotic bone Susan M. Odum, Charlotte, NC
cement. Keith R. Berend, MD, New Albany, OH
William A. Jiranek, MD, Richmond, VA
PAPER NO. 39 Javad Parvizi, MD, Philadelphia, PA
Thromboembolic Risk with Tranexamic Acid for Kevin J. Bozic, MD, MBA, San Francisco, CA
Primary Total Hip and Knee Arthroplasty: Three Craig J. Della Valle, MD, Chicago, IL
Prophylactic Regimens INTRODUCTION: The results of irrigation and debridement
Blake P. Gillette, MD, Rochester, MN for periprosthetic infection are mediocre at best with a failure
rate averaging 68%. Factors that may influence these results are
Lori J. Desimone, PA-C, Rochester, MN
organism type, host factors, and timing of intervention. While
Michael A. Kelm, MD, Rochester, MN the influence of organism type and host factors have been
Robert T. Trousdale, MD, Rochester, MN clarified, the timing of intervention remains an unresolved
Mark W. Pagnano, MD, Rochester, MN question. The purpose of this study was to determine the
Rafael J. Sierra, MD, Rochester, MN efficacy of irrigation and debridement (I&D) for periprosthetic
INTRODUCTION: The use of antifibrinolytics (i.e., tranexamic infection performed within the perioperative period.
acid) in total joint arthroplasty (TJA) has been shown to METHODS: A multi-center retrospective analysis of patients
reduce intraoperative blood loss and decrease transfusion rates undergoing irrigation and debridement for periprosthetic
postoperatively. Moreover, a recent clinical trial has shown infection within 90 days of primary surgery was performed.
decreased mortality and blood loss in trauma patients without Charlson Comorbidity Index (CCI) was used as a host factor
increased thromboembolic events. As orthopedic surgeons surrogate. A multiple logistic regression was conducted to
move to different thromboembolic (TE) prevention regimens, a determine the associations between CCI, age, sex, joint,
concern remains about their prothrombotic potential especially organism, timing between index and I&D (< 4 weeks,
when used with less aggressive TE prophylactic regimens. between 4 and 12 weeks) and repeat surgery due to infection.
METHODS: Patients undergoing primary total hip or knee RESULTS: Of the 82 patients who underwent I&D within
arthroplasty by three surgeons, each with a different postoperative three months of primary surgery, 51 failed (62%). Of the 56
TE prophylactic regimen, during 2008-2009 were retrospectively patients (29 hips/27 knees) who underwent I&D within four
reviewed. The three regimens included dalteparin, warfarin, weeks of primary surgery, 32 failed (57%). Eight of 11 patients
and aspirin. All patients received intraoperative tranexamic who underwent I&D within 10 days of surgery failed (73%).
acid. Patients were stratified based on their ASA physical status Nineteen of 26 patients (73%) who underwent I&D between one
score. Primary outcome measures were thromboembolic events and three months failed. Of the 40 staph organisms, 24 failed
including deep vein thrombosis (DVT), pulmonary embolism (60%). Of the seven strep organisms, five failed (71%). Of the
(PE), myocardial infarction (MI), and cerebrovascular accident 22 resistant organisms, 14 failed (64%). No covariates included
(CVA). Postoperative hematoma rates were also recorded. in the regression model were significantly associated with
RESULTS: A total of 1,497 patients were included in this study. revision surgery due to infection, with the numbers available.
The number of patients in each prophylactic regimen was 410, DISCUSSION AND CONCLUSION: I&D for prosthetic hip and
525, 547 for aspirin, warfarin, and dalteparin therapy respectively. knee infection is an attractive, frequently used procedure in the
Most patients were ASA score two or three, 1,039 and 378 patients perioperative period. It is assumed that early intervention will lead
respectively. The percent risk for any TE complication was 1.2%, to successful eradication of the offending organism in the majority
1.13%, and 0.73% for aspirin, warfarin, and dalteparin therapy of cases. Unfortunately the data presented here contradicts this
respectively (p=0.71). This did not significantly vary between assumption.
stratified groups. The risk for DVT was increased at 0.48% for
aspirin, and 0.19% and 0.18% for warfarin and dalteparin

PAPER NO. 41 to inform their patients and to focus measures for prevention.
METHODS: Data of hospitalizations for total hip arthroplasty
Renal Injury Due to Prophylactic Flucloxacillin and (THA) or total knee arthroplasty (TKA) were analyzed for each
Gentamicin in Hip and Knee Replacement (Protocols year between 1998 and 2007 from the National Inpatient Sample.
and Practice) Patients’ demographics, comorbidities, incidence of morbidity and
Sudhakar Rao R. Challagundla, MBBS, MRCS, Dumfries, mortality, length of hospitalization, and overall cost were compared
for infected and non-infected groups. Multivariate regression
United Kingdom
analysis was performed to determine independent risk factors for SSI.
David J. Knox, MB ChB, Glasgow, United Kingdom RESULTS: Perioperative SSI rate was 0.36% for THA and 0.31% for
Amanda Hawkins, FRCS, Dumfries, United Kingdom TKA (412,356 and 784,335 patient entries respectively). For both
David Hamilton, MB, ChB, BS, Dumfries, United Kingdom THA and TKA groups, patients with SSI had a significantly higher
Robert Flynn, PhD, Dundee, United Kingdom overall comorbidity burden (P<.0001) - reflected in the significantly
Sue Robertson, Dumfries, United Kingdom increased prevalence of alcoholism, chronic pulmonary disease,
Chris Isles, MD, Dumfries, United Kingdom congestive heart failure, cancer and complicated diabetes
Background: We switched our antibiotic prophylaxis for elective hip (P<0.0001), a considerably higher perioperative mortality rate
and knee surgery from cefuroxime to flucloxacillin with single dose (THA: 2.5% vs. 0.3%, TKA: 1.2% vs. 0.1%(P<.0001)) and a longer
gentamicin in order to reduce the incidence of C.Diff diarrhoea. More average length of hospital stay (THA: 13.4 vs. 4.2 days, TKA: 9.7 vs. 4
patients subsequently appeared to develop acute kidney injury (AKI). days (P<.0001)). Postoperative complications including deep vein
METHODS: During a twelve month period we examined thrombosis, acute respiratory distress syndrome, and pulmonary
the incidence of AKI sequentially in 198 patients undergoing embolism, and surgical site hematoma occurred more frequently in
elective hip or knee surgery: cefuroxime (n = 48); high dose SSI patients (P<.0001). Overall average cost of in-hospital care was
flucloxacillin (median 8g) (n = 52); low dose flucloxacillin approximately double for SSI patients (P<.0001). Independent risk
(median 4g) (n = 46); and cefuroxime again (n = 52). factors for perioperative SSI included male gender, minority race,
RESULTS: There were no statistically significant differences cancer, liver disease, coagulopathies, fluid and electrolyte disorders,
between the four groups by chi-square tests for age, gender, congestive heart failure, and pulmonary circulatory disease (table).
nature of operation (hip or knee surgery), American Society of CONCLUSION: Perioperative SSI after TJA is associated
Anaesthesia (ASA) grade, mode of anaesthesia (spinal ± general with increased morbidity, mortality, length of hospital stay
anaesthetic v GA), baseline serum creatinine, pre-operative co- and overall cost. Comorbidities subjecting patients to an
morbidity (hypertension, diabetes), pre-operative medication immunocompromized state or predisposing them to hematoma
(NSAIDs, ACEI/ARBs or betablockers) and post-operative formation were associated with the highest odds for SSI.
hypotension. Patients receiving high dose flucloxacillin required Table. Independent risk factors for surgical site infections after
more vasopressors during surgery (p = 0.02 by Kruskal-Wallis test). multivariate regression analysis
The proportion of patients in each antibiotic group with any form Risk Factors for SSI
of AKI by RIFLE criteria was: first cefuroxime group (8%), high 95% Wald
Odds
dose flucloxacillin (52%), low dose flucloxacillin (22%), second Variable Referent Confidence P-Value
Ratio
Limits
cefuroxime (14%) (p < 0.0001). Odds ratios (OR) for AKI derived
Procedure Type
from a multivariate logistic regression model and arbitrarily
THA TKA 1.03 0.96 1.10 0.3155
assigning an OR of 1 to first cefuroxime group, were: high dose
Age
flucloxacillin 14.5 (95% CI, 4.2-49.7); low dose flucloxacillin
45-64
3.0(0.8-10.8); cefuroxime again 2.0(0.5-7.7). Three patients 0-44 years 1.70 1.48 1.95 <.0001
years
required temporary haemodialysis. Biopsies in two of these showed 65-74 years 0.90 0.83 0.97 0.009
acute tubulo-interstitial nephritis. All three patients belonged to >/=75 years 0.98 0.90 1.06 0.6228
the high dose flucloxacillin group. None of the patients developed Gender
C Diff diarrhoea. Summary: We have shown a strong association Male Female 1.33 1.25 1.42 <.0001
between high dose flucloxacillin with single dose gentamicin Race
prophylaxis and subsequent development of AKI which was not Black 1.39 1.22 1.58 <.0001
confounded by any of the co-variates we measured White
Hispanic 1.50 1.28 1.75 <.0001
Race
Other 1.48 1.23 1.78 <.0001
PAPER NO. 42 Comorbidities
In-hospital Surgical Site Infections after Primary Hip Alcoholism 1.57 1.23 2.00 0.0003
Chronic Lung Disease 1.43 1.32 1.55 <.0001
and Knee Arthroplasty - Incidence and Risk Factors Congestive Heart Failure 2.10 1.85 2.38 <.0001
Lazaros Poultsides, MD, New York, NY Uncomplicated Diabetes 0.95 0.86 1.04 0.2795
Yan Ma, PhD, New York, NY Complicated Diabetes 1.54 1.22 1.94 0.0002
Alejandro Gonzalez Della Valle, MD, New York, NY Liver Disease 2.53 2.01 3.19 <.0001
Ya-Lin Chiu, MS, New York, NY Coagulopathy Absence 2.36 1.99 2.79 <.0001
Neurologic Disease of 1.29 1.08 1.54 0.0037
Licia Gaber-Baylis, Hillsborough, NJ
Obesity Disease 0.87 0.78 0.97 0.0143
Madhu Mazumdar, PhD Peripheral Vascular Disease 1.18 0.96 1.46 0.1079
Thomas Sculco, MD, New York, NY Renal Disease 1.75 1.45 2.10 <.0001
Stavros Memtsoudis, MD, PhD, New York, NY Cardiac Valvular Disease 1.12 0.96 1.30 0.1039
INTRODUCTION: Perioperative Surgical Site Infections (SSI) Electrolyte/Fluid Abnormalities 2.42 2.21 2.65 <.0001
after orthopedic surgeries have a great clinical and economic Oncologic Disease 1.99 1.69 2.35 <.0001
impact. Knowledge of risk factors for SSI can facilitate physicians Pulmonary Circulatory Disease 2.36 1.90 2.92 <.0001

PAPER NO. 43 thromboembolic and bleeding events in patients who received
rivaroxaban as the primary prophylaxis in clinical practice.
uEffect of Rivaroxaban on Return to Theatre Rates METHODS: Prospective, observational study of patients given oral
Following Total Hip and Knee Replacement Factor Xa inhibitor (rivaroxaban) following primary and revision
Cyrus D. Jensen, MB BS, MRCS, New Castle Upon Tyne, total hip arthroplasty (THA) and total knee arthroplasty (TKA).
United Kingdom All patients were approached to participate and consent obtained.
Rebecca L. Morrell, MBBS, Newcastle-upon-Tyne, United Patients treated with rivaroxaban 10 mg po daily starting post-
Kingdom operative day (POD) #1 and continued for 15 days. All participants
were followed up at six weeks and three months. Doppler
Andrew Steval, Newcastle Upon Tyne, United Kingdom
ultrasound or venograms used to diagnose proximal DVT. Spiral
Andy Sprowson, MD, Ashington, United Kingdom CT, CT Angio or V/Q scan were used to diagnose PE. Bleeding
Paul Partington, MD, Ashington, United Kingdom complications were documented as ‘on prophylaxis’ starting two
Mike R. Reed, MBBS MD, Northumberland, United Kingdom hours after first dose of anticoagulant therapy until 24 hours after
Scott Muller, MBBS MD, FRCS, Northumberland, United the 15th dose. Event rates are reported. Data reported on consented
Kingdom patients only. Research ethics approval was obtained for this study.
INTRODUCTION: Rivaroxaban has been recommended for RESULTS: From June to Dec. 2010, 1,010 patients underwent total
routine use as a thromboprophylactic agent in patients undergoing joint arthroplasty. Nine hundred and twenty-seven patients (92%)
lower limb arthroplasty. Trials supporting its use have not fully agreed to participate in the study. Nine hundred and ten patients
evaluated the risks of wound complications related to rivaroxaban. were followed up at three months (98%). Seventeen patients were
METHODS: A retrospective cohort analysis of 1,558 consecutive lost to follow-up. Complete data on 910 patients is reported: 378
patients who underwent total hip or knee replacements within men, 532 women with mean age 66 years. Total knees 517 (primary
the same hospital during a 19-month period (2009-2010) 477, revision 40). Total hips 393 (primary 358, revision 35). Eight
was performed. The first 489 patients (Group 1) were given hundred and sixty-one of these patients received rivaroxaban.
tinzaparin postoperatively as per NICE guidance. The following DVT: One in-hospital Doppler was indeterminate. One DVT was
559 patients (Group 2) were given rivaroxaban. Concerns reported at six weeks. Four DVTs were reported at three months: one
regarding wound complications prompted a change back to primary TKA and three Primary THAs. Total DVT= 5/861= 0.6%.
tinzaparin for the next 510 patients (Group 3.) Other than the PE: There were three confirmed PE during hospital stay: one revision
thromboprophylactic agent used, there were no other differences THA and two primary TKA. One confirmed PE occurred in primary
in the pre and postoperative treatments of all these patients. THA by six weeks. There was one case with an indeterminate
RESULTS: Nine of the 489 patients in Group 1 (tinzaparin) result. Two PEs reported at three months. Total PE 6/861=0.7%.
(1.8%, 95% CI 0.9-3.5%) returned to theatre (RTT) with wound Bleeding: Two major and six non-major surgical-site bleeds
complications within 30 days compared with 22 out of 559 patients occurred. One major and two non-major non-surgical site bleeds
in Group 2 (rivaroxaban) (3.94%, 95% CI 2.6-5.9%.) This increase occurred in patients who received rivaroxaban. Transfusion: Fifty
in RTT rate was statistically significant (p=0.046.) After reverting patients (5%) received blood transfusions with no difference
back to tinzaparin, eight out of 510 patients in Group 3 (tinzaparin) between patients who received rivaroxaban and those who did
(1.6% 95% CI 0.74-3.1%) returned to theatre. This reduction in not (Fisher’s exact test: 0.17, p=0.17). There was one perioperative
RTT rate was statistically significant (p=0.02.) Combining the death which was not related to surgery, DVT, pulmonary
tinzaparin groups (1 and 3) and comparing with the rivaroxaban embolism, bleeding or cardiovascular event by autopsy.
group (2) further increases the significance of our observations. DISCUSSION AND CONCLUSION: The incidence of
Tinzaparin RTT was 1.7% (95% CI 1.0-2.7%) compared with thromboembolic events within a period of three months was 5/861
rivaroxaban RTT of 3.94% (95% CI 2.6-5.9%) (p=0.01.) (0.6%) for DVT and 6/861 (0.7%) for PE. The incidence of major
DISCUSSION AND CONCLUSION: We observed a significant bleeding was 3/861 (0.3%). There were no deaths related to DVT,
rise in wound complication necessitating further surgery after PE or bleeding. Preliminary results are surprising for the number
a change in thromboprophylactic agent from tinzaparin to of pulmonary emboli which occurred while patients were still in
rivaroxaban, followed by a significant reduction after reverting hospital and for the number of DVT’s which occurred between six
back to tinzaparin. We call for further independent randomized weeks and three months. Further work is required to see if these
controlled clinical trials examining wound related complications trends are maintained. This study is ongoing.
with respect to new pharmacological treatments.
PAPER NO. 45
PAPER NO. 44 Periprosthetic Joint Infection Following Total Joint
uThromboembolic and Bleeding Events Following Arthroplasty
Elective Hip and Knee Arthroplasty Using Oral Factor Ronald Huang, Philadelphia, PA
Xa Inhibitor David Vegari, MD, Philadelphia, PA
John J. Murnaghan, MD, Toronto, ON, Canada Max Greenky, Philadelphia, PA
Jeffrey D. Gollish, MD, Toronto, ON, Canada Matthew Austin, MD, Philadelphia, PA
James Purtill, MD, Philadelphia, PA
INTRODUCTION: Rivoroxaban is an oral Factor Xa inhibitor
which is licensed in Canada for the prevention of thromboembolic Javad Parvizi, MD, Philadelphia, PA
events following total hip and total knee arthroplasties. INTRODUCTION: Periprosthetic joint infection (PJI) is one
Multicenter research trials have shown clinical efficacy for of the most devastating causes of implant failure following
prevention of deep venous thrombosis (DVT) and pulmonary total joint arthroplasty (TJA). Studies have found various
embolism (PE) and all cause perioperative mortality. The aim associations with development of PJI, such as poor nutritional
of this study was to prospectively document the incidence of status, diabetes, postoperative bleeding and hematoma, and

immunocompromised status. However, since infection is relatively on MARS MRI, an example of which is shown in Figures 1 and
rare with a reported incidence of around 1% following primary 2. However, there was no significant difference in prevalence
TJA, definitive risk factors have not been identified. The present when hip resurfacing was compared to LD MOM THA (p =
study utilizes prospective, single-institution, large database to 0.52). There were also no significant differences observed in
assess predisposing risk factors for PJI following modern TJA. whole blood metal ion levels, cup inclination and cup version.
METHODS: Records of 22,878 consecutive patients undergoing Patients with well-positioned hips demonstrated a similar
primary TJA at our institution between January 2000 through prevalence of pseudotumors as those with cup positions outside
February 2011 were reviewed. Patients operated on for acute of Lewinnek’s ‘safe zone’ (62% and 67% respectively, p = 0.69).
trauma were excluded, and patients that developed PJI on their DISCUSSION AND CONCLUSION: In symptomatic patients with
operated joint within 90 days following surgery were identified. MOM hips, the prevalence of pseudotumor was greater than 60%
Extensive number of patient related factors, preoperative blood and was neither restricted to any specific manufacturer (Figure 3)
test results, surgical factors, and postoperative parameters nor resurfacing or LD THA devices. Adverse soft tissue reactions
were evaluated to identify those predisposing the patients to were commonly associated but not synonymous with adverse cup
PJI. Univariate and multivariate regression analyses was used. position and raised blood metal ion levels.
RESULTS: Among all factors examined, history of diabetes,
smoking, and BMI were found to be important patient-related factors
predisposing them to PJI. Among laboratory tests, high perioperative
blood glucose above 126 mg/dL was found to be a significant risk
factor for PJI. Longer hospital stay and increased intraoperative
blood loss were found to be significant predisposing factors to PJI.
DISCUSSION AND CONCLUSION: This single institution study
utilizing prospective database has confirmed the importance of
some patient-related and surgical factors in increasing risk of PJI.
In addition, the study has identified a number of other unknown
factors which seem to be important risk factors for PJI. Better
knowledge of risk factors that result in increased incidence of
PJI enables surgeons to optimize patients and address some of
these reversible factors prior to elective arthroplasty. With the
Figure 1. Axial T2-weighted image of a pseudotumor surrounding a LD
increasing cost of health care and increasing burden of infection
THA.
on the society, we need to implement strategies that will reduce the
incidence of this dreaded complication.
PAPER NO. 211

Clinical and Radiological Features of 100 Painful Large
Diameter Metal-on-Metal Hip Arthroplasties
Ashley Matthies, BSc, London, United Kingdom
Figure 2. Coronal T2-weighted
Johann Henckel, BM, London, United Kingdom image of a pseudotumor
Shiraz Sabah, MD, London, United Kingdom surrounding a LD THA.
Barry Sampson, MD, London, United Kingdom
Keshthra Satchithananda, FRCR, London, United Kingdom Figure 3. Distribution of
Adam Mitchell, MD, London, United Kingdom pseudotumors according to hip
type (manufacturer)
Donald McRobbie, PhD, London, United Kingdom
John Skinner, FRCS, London, United Kingdom
PAPER NO. 212
Alister Hart, FRCS, London, United Kingdom
INTRODUCTION: Many studies now cite unacceptably Economic Burden of Periprosthetic Joint Infection in
high failure rates for large diameter metal-on-metal total hip the United States
arthroplasty (LD MOM THA) and surprisingly, higher than Steven M. Kurtz, PhD, Philadelphia, PA
MOM hip resurfacing. The mechanism of failure is uncertain, Edmund Lau, MS, Menlo Park, CA
but thought to involve surgical positioning, implant design Heather Watson, PhD, Menlo Park, CA
and a patient-specific response to metal wear debris. The aim Jordana K. Schmier, MA, Alexandria, VA
of this study was to compare clinical and radiological findings
Javad Parvizi, MD, Philadelphia, PA
between two groups of patients with painful MOM hips: hip
resurfacing and LD MOM THA. The primary outcome was the INTRODUCTION: Few studies consider the economic burden of
prevalence of pseudotumors (adverse soft tissue reactions). periprosthetic joint infection (PJI) to the inpatient health care
METHODS: We performed a well-powered matched case-control system. The purpose of this study was to characterize the patient and
study of 100 consecutively referred patients with painful MOM clinical factors influencing the economic burden of PJI in the US.
hips (sufficient to require revision). Cases were defined as patients METHODS: The 2001-08 Nationwide Inpatient Sample (NIS)
with LD THA and controls as hip resurfacings. We compared was employed to identify primary and revision total hip
whole blood metal ion levels, findings on metal artefact reduction (THA) and knee replacement (TKA) procedures using ICD-9
sequence (MARS) MRI, and cup position as measured from 3D-CT procedure codes (THA: 81.51 and 81.53, 00.70-00.73, 80.05;
scans. A logistic regression model was used to analyze the data. TKA: 00.80-00.84, 80.05, 81.54-81.55). Procedures with PJI
RESULTS: A total of 63% of patients demonstrated a pseudotumor were identified by the 996.96 ICD-9 diagnosis code. Hospital

charges were converted to costs using the NIS-supplied charge- METHODS: This study was a retrospective chart review of 424
to-cost ratio and inflation-adjusted to $2011 using the Medical primary knee and 346 primary hip arthroplasty patients at a
Care CPI. General linear modeling and paired t-tests were used single institution in 2009. Pre-operative labs were analyzed
to evaluate annual trends and differences in procedure cost and and patients were categorized as being anemic or non-anemic
length of stay (LOS) as a function of patient (e.g., age, gender, based on World Health Organization definitions (Hgb <12 in
comorbidities) and hospital factors (e.g., census region, bed size). females and <13 in males). The patient charts were reviewed
RESULTS: There were 137,400 infected revisions (47,100 THA; for post-operative blood transfusions, hospital length of stay
90,300 TKA) treated in U.S. hospitals between 2001-2008. The and incidence of readmission. There were no differences in
relative incidence of PJI ranged between 2.0 and 2.4% of THAs and transfusion indications or care pathways between the two groups.
TKAs and increased over time for THA (p=0.0248) but not for TKA The impact of anemia on the relative risk of each outcome was
(p=0.147). Overall, the mean cost to treat hip PJI was $6,376 greater determined while statistically controlling for other co-morbidities.
than the mean cost per knee PJI (p<0.0001, regression-adjusted for RESULTS: Anemia was present in 32% of patients undergoing
differences in age, gender, race, and region of the two populations, elective TJA, with a similar incidence among hip and knee
Table 1). Because of the growing incidence of PJI, the annual cost of patients. Females were statistically more likely to be anemic
infected revisions to US hospitals increased from $345M to $642M than males (37% vs 23%). Anemic patients, whether undergoing
during the study period and was projected to exceed $1B by 2020. hip or knee replacement, had a higher incidence of transfusion
DISCUSSION AND CONCLUSION: We estimated the national (49% vs. 25%), a longer average length of stay (4.3 vs. 3.8 days)
direct costs of PJI to the hospital health care system in the U.S. and a higher rate of readmission within 30 days (17% vs. 8%).
Although the costs per case of PJI were mitigated between 2001- DISCUSSION AND CONCLUSION: Anemia is common among
2008 by reducing the length of stay, the overall national burden of elective joint replacement patients and significantly increases a
PJI is increasing due to the expanding utilization of hip and knee patient’s risk of receiving an allogeneic blood transfusion. As post-
arthroplasty. The results of this study, though limited to treatments operative allogeneic blood transfusion may be associated with
and costs during hospitalization, will be useful for developing increased morbidity and cost, early identification and appropriate
policy related to PJI. As the demand for joint arthroplasty is treatment of pre-operative anemia may improve outcomes in these
expected to increase substantially over the coming two decades, so patients.
too will the burden of infections.
PAPER NO. 214
Table 1: Inpatient Cost and LOS for Infected THA and TKA in the US
Compliance with Surgical Care Improvement Project
Mean
Number of Cost Per Mean Cost Measures and Hospital-Associated Infections following
Mean Number of Mean
Infected Case of
LOS per Infected TKA
Per Case
LOS per THR
Year THA Infected of Infected
Procedures THA
Infected Procedures
TKA (2011
Infected Zhong Wang, PhD, Bethesda, MD
THA (d) in US TKA (d)
in US (2011 US$) Foster Chen, BS, San Diego, CA
US$) Michael M. Ward, MD, Bethesda, MD
2001 4,545 33,844 11.5 7,113 27,222 9.3 Timothy Bhattacharyya, MD, Bethesda, MD
2002 5,219 34,174 12.1 8,532 26,378 9.0 INTRODUCTION: Hospital compliance with Surgical Care
Improvement Project (SCIP) measures has increased recently
2003 5,271 36,846 12.5 9,936 29,871 9.0
for patients undergoing hip arthroplasty. However, reductions
2004 5,933 32,065 10.5 10,677 26,339 8.3 in postoperative infections were less than expected and concern
2005 5,634 32,982 10.8 12,113 26,302 7.9 remains about complications associated with prophylaxis against
2006 6,217 31,006 11.1 12,488 24,764 8.1
venous thromboembolism (VTE). We sought to examine the
association between hospital adherence to SCIP measures against
2007 6,931 31,586 10.5 13,424 24,511 7.8 infections or VTE and the outcomes of postoperative infections.
2008 7,380 31,788 9.5 15,983 26,300 7.4 METHODS: Observational study of 17,714 patients following hip
replacement in 2008 from 128 New York State hospitals. Facility-
PAPER NO. 213 and patient-level analyses were conducted using the New York
State Department of Health annual report and the State Inpatient
Preoperative Anemia in Joint Replacement Patients:
Database, respectively. Hospital-reported SCIP measures were used
Prevalence and Implications for Transfusion Risk and to dichotomize hospitals based on the median value of compliance.
Cost Outcomes were postoperative infections reported from each
Christopher J. Utz, MD, Rocky River, OH hospital and ascertained from individual patient’s discharge records.
Mary Lograsso, RN, Cleveland, OH RESULTS: During 2008, the mean hospital compliance increased
from 93.5% to 96.0% for the averaged infection prevention
Deanna Trihas, Cleveland, OH
measure (range: 80.2% -100%), and from 91.4% to 97.1% for the
Bernard N. Stulberg, MD, Cleveland, OH averaged VTE prevention measure (range: 67.3% to 100%). Higher
Mark I. Froimson, MD, Cleveland, OH adherence to any infection prevention measures was not associated
INTRODUCTION: Patients facing hip and knee arthroplasty with significant reduction in infection (all Ps >= 0.09). However,
may present with preoperative anemia that can increase the risk hospitals with greater than 99% of patients who had general VTE
of requiring post-operative blood transfusion. The prevalence of prophylaxis ordered (VTE-1), or at least 97% compliance with
anemia in this patient population varies widely in the literature. This timely VTE prophylaxis (VTE-2), reported significantly higher
study was undertaken to assess the prevalence of anemia in a tertiary infection rate compared to hospitals with lesser compliance (VTE-
referral center and its impact on the relative risk of post-operative 1, 1.52% vs. 1.00%, p=0.003; VTE-2, 1.60% vs. 0.98%, p<0.001).
transfusion, hospital length of stay and unplanned readmission. Based on patient-level analysis, hospitals highly compliant with

timely prophylaxis (VTE-2), but not with general prophylaxis clinically for a mean of 10 years. The mean age of the patients was
ordered (VTE-1), were found to be associated with increased risk 48.7 years and 74% were male. The ICS included two scores: an
of postoperative infection following hip replacement (adjusted Impact Score (IS) and a Hip Cycle Score (HCS). All patients were
odds ratio, 1.39; 95% confidence interval, 1.05-1.86, p=0.02). also evaluated with the UCLA activity score. Twenty-three patients
DISCUSSION AND CONCLUSION: Targeting complete (27 hips) underwent revision surgery after filling out the survey.
compliance with SCIP infection prevention measures was not RESULTS: The mean time of follow up at the time of survey data
linked to lower infectious outcomes following hip replacement. collection was 1.8 years (1.0 to 4.9) and the mean time of the
Increased adherence to timely VTE prophylaxis was associated follow-up period was 10.1 years (6.1 to 13.7). The mean IS was 28.1
with a higher risk of postoperative infections. Future trials of VTE (0 to 128) and the mean HCS 33.1 (0 to 144). Positive correlations
prophylactic agents should include infections as an outcome. were found between UCLA activity score and IS (r=0.535) or HCS
(r=0.497). After adjustment for femoral component size, body
PAPER NO. 215 mass index (BMI) and femoral defect size, a 10-point increment
Variables Influencing the Functional Outcome Scores in IS corresponded to a 37% (95% CI 1.18 to 1.59) increase in
the risk of revision while a 10-point increment in HCS increased
of the Hip the risk of revision by 22% (95% CI 1.06 to 1.41). Patients with
Kristoff Corten, MD, Pellenberg, Belgium an IS less than 50 had a risk of revision 3.8 times (95% CI 1.6 to
Marc L. Simoens, JR, Rijkevorsel, Belgium 8.9) lower than the patients with an IS of 50 or greater, with a
Katrien Cootjans, Mechelen, Belgium survivorship rate at eight years of 96.4% (95% CI 93.6% to 98.0%)
Johan Bellemans, MD, Langdorp, Belgium vs. 88.8% (95% CI 74.7% to 95.3%). No association was found
Jean-Pierre Simon, MD, Pellenberg, Belgium between UCLA activity score and survivorship of the procedure.
DISCUSSION AND CONCLUSION: High levels of sporting
INTRODUCTION: Functional outcome scores of the hip are often
activities can be detrimental to the long-term success of hip
used to assess the functional results of a hip procedure. However,
resurfacing arthroplasty, independently from other risk factors.
little is known about the variables that might influence these
Patients seeking hip resurfacing are usually young and should
functional outcomes. We aimed to (1) set up a baseline functional
limit their involvement in sports to levels that the construct will
score of 1.037 “healthy” subjects without any complaint of the hip
be able to sustain.
joint and (2) to assess whether age, musculoskeletal co-morbidities
or body mass index (BMI) would influence these outcome scores. PAPER NO. 217
METHODS: A total of 1,037 volunteers without any complaint
in the hip region were requested to fill in the modified Harris Predictors of Discordance in Expectations of Total Hip
Hip Score, the HOOS, the UCLA and the Tegner activity Arthroplasty between Patients and Surgeons
score. The subjects were assessed for age, BMI, pain in the Hassan Ghomrawi, PhD, New York, NY
knee, lower back or any other musculoskeletal pain. Forty- Carol A. Mancuso, MD, New York, NY
seven volunteers did not fill in the questionnaires completely.
Alejandro M. Gonzalez Della Valle, MD, New York, NY
The scores of in total 337 male and 653 female subjects were
collected and age categories of 10 years were sampled. Statistical Michael M. Alexiades, MD, Manhattan, NY
analysis with a two-way-ANOVA model and Mann-Whitney Charles N. Cornell, MD, New York, NY
U tests were used. P-values <0.05 were considered significant. Thomas P. Sculco, MD, New York, NY
RESULTS: All scores decreased significantly with increasing age Alvin I. Mushlin, MD, New York, NY
(p<0.001). Other significant negative correlations were found INTRODUCTION: Dissatisfaction with total hip arthroplasty (THA)
between hip scores and knee or lower back pain (p<0.001). No outcomes has been linked to unmet preoperative expectations.
significant correlation was found between the scores and BMI below Aligning patients’ expectations with their surgeon’s expectations
30. BMI above 30 was significantly associated with lower scores preoperatively may lead to better compliance with postoperative
(p<0.05). Gender was not a determinant variable for outcome score. medical and rehabilitation instructions and increase satisfaction.
DISCUSSION AND CONCLUSION: Outcome scores of the hip We compared preoperative patient and surgeon expectations and
should take age, knee or lower back pain and BMI into account. investigated predictors of discordantly high patient expectations.
This study presents baseline scores that can be used to compare METHODS: A total of 249 patients awaiting THA by seven
outcome scores following total hip arthroplasty (THA) with age specialized adult reconstruction surgeons in a single orthopedic
and co-morbidity matched cohorts. hospital completed a validated expectations questionnaire as
part of their preoperative assessment. The surgeon separately
PAPER NO. 216 completed the same expectations questionnaire preoperatively for
The Relationship of Sporting Activity and Survivorship each patient, blinded to their patient response. The questionnaire
addresses expectations of postoperative pain relief, function and
after Hip Resurfacing well-being (score range 0-100, 100 being highest expectation).
Harlan C. Amstutz, MD, Pacific Palisades, CA Using validated criteria, patients had discordantly high expectations
Michel J. Le Duff, Glendale, CA if their scores were ≥ 7 points higher than the surgeon. Using
Regina Woon, Los Angeles, CA generalized estimating equations (GEE), we estimated the effect
Alicia J. Johnson, BA, Los Angeles, CA on discordance of age, gender, education, comorbidity, BMI, and
INTRODUCTION: The effect of sports on the durability of the patient-reported SF-36 PCS and MCS scores, WOMAC function,
prosthesis after hip resurfacing has not yet been studied. This stiffness and pain subscale scores, preoperative assessments of
study correlates sporting activity levels computed as impact peri- and post-operative risk of complications. We also included
and cycle scores (ICS) with the survivorship of the procedure. an indicator for whether the patient expectations survey was
METHODS: A total of 445 patients filled out a sport-specific survey completed before or after a required preoperative educational class.
between one and five years after surgery and were then followed RESULTS: Patients (51.0% female, average age=62.1±11.8

yrs) had an average expectations score of 80.2±14.9. 34.5% PAPER NO. 219
of patient scores were ≥ 7 points higher than those of their
surgeon. GEE analysis showed that patients were more likely
Does the Use of Antidepressants Predict Outcomes
to have discordantly higher expectations if they had graduate Following Total Hip Replacement Surgery?
education vs. high school education or less (OR=2.57, CI [1.14, Meridith Greene, BA
5.80], p=0.02), perceived 0% peri- and post-operative risk of Ola Rolfson, MD, PhD, Gothenburg, Sweden
complications (OR=2.09, CI [1.12, 3.91], p=0.02), had higher Max Gordon, MD, Stockholm, Sweden
WOMAC stiffness scores (OR =1.32, CI [1.13, 1.55], p<0.01) Henrik Malchau, MD, Boston, MA
and filled out the expectations survey before the preoperative
Goran Garellick, MD, PHD, Goteborg, Sweden
educational class (OR =1.75, CI [1.21, 2.54], p<0.01). They were,
however, less likely to have discordantly higher expectations if INTRODUCTION: It is known that patients with anxiety and/
they had more comorbidities (OR =0.68, CI [0.49, 0.94], p=0.02). or depression before total hip replacement (THR) surgery tend to
DISCUSSION AND CONCLUSION: In this study, 34.5% of report less pain reduction and less satisfaction with their treatment.
patients had discordantly higher expectations than their surgeon. These analyses investigated if the use of antidepressants predicted
Multivariable analysis showed the importance of the educational patient reported outcome measures (PROMs) one year after THR.
class in aligning patient expectations and identified other METHODS: THR cases with a diagnosis of osteoarthritis
predictors of discordantly higher patient expectations that could performed from January 1, 2006 until December 31, 2007
be addressed through pre-operative patient education and patient- with complete preoperative and one-year postoperative PROM
physician dialogue. questionnaires were selected from a national joint replacement
registry (n=13,280, females n=7,593). Patients undergoing
PAPER NO. 218 reoperation within one year from surgery were excluded from the
analysis. The PROM protocol comprised the EuroQol group health
Incidence and Predictors of Unplanned Readmission related quality of life measure EQ-5D, a visual analog scale (VAS)
Following Total Joint Arthroplasty for pain, Charnley class survey and a VAS addressing satisfaction
Benjamin Zmistowski, BS, Philadelphia, PA after surgery. These cases were merged with a national database
Jordan A. Hess, BA, Philadelphia, PA covering all prescription purchases from 2005, to determine
Camilo Restrepo, MD, Philadelphia, PA the prevalence of purchase of prescribed antidepressants in this
group. Use of antidepressants was defined as the purchase of
antidepressant medications (ATC code N06A) up to three years
Richard H. Rothman, MD, Philadelphia, PA before surgery. Linear regression analyses were performed where
INTRODUCTION: Recent studies have exhibited an alarming outcome parameters were dependent variables and gender, age, co-
increase in national readmission rates following total hip morbidities defined by Charnley class and antidepressant use were
arthroplasty over the past decade. This increase is concerning independent variables. The percent change in VAS pain score was
for quality of patient care and clearly places a financial defined the preoperative score minus the one-year postoperative
burden on healthcare. This study aims to identify factors score divided by the patient’s capacity for change on the pain scale.
predicting readmission following total joint arthroplasty (TJA). RESULTS: Thirteen percent of the cases used antidepressants
METHODS: The institutional arthroplasty database was utilized to (n=1,657). The study group was representative of the hip replacement
identify those patients undergoing total knee or hip arthroplasty population in this country with respect to Charnley class and age.
from January 2004 to January 2009. A total of 10,641 patients After linear regression analysis, female gender, higher age, Charnley
were admitted for primary arthroplasty (5,212 knees and 5,432 C and antidepressant use were found to predict less patient
hips). From the same database, patients requiring unplanned satisfaction (p<0.001). Male gender, higher age and Charnley C
readmission within 90 days of discharge were identified. were associated with less improvement in EQ-5D index at 1 year
Multivariate logistic regression was utilized to determine (p<0.001). All variables, male gender, higher age, Charnley C and
the independent predictors of readmission within 90 days. antidepressant use were associated with less EQ VAS improvement
RESULTS: A total of 672 patients (6.3%; 672/10,641) were (p<0.001). When analyzing the percent change in VAS pain,
readmitted within 90 days during this time period. Age, gender lower age, Charnley A and B and the absence of antidepressant
and simultaneous bilateral versus unilateral replacement were not use predicted a better chance of pain reduction (p<0.001).
associated with early readmission. Charlson comorbidity index, DISCUSSION AND CONCLUSION: Controlling for the
ethnicity, discharge disposition, knee versus hip, and length-of- known confounders gender, age and co-morbidity, our
stay (LOS) were associated with readmission in univariate analysis analyses were done to find the influence of patient mental
and included in multivariate regression. Black race, discharge to status defined by preoperative antidepressant use on PROMs.
inpatient rehabilitation or skilled nursing facility, increased LOS and The use of antidepressants had a similar effect on patient
knee replacement were independent predictors of early readmission. satisfaction as gender, age and co-morbidities. While known
DISCUSSION AND CONCLUSION: This study identifies the risk factors of male gender, higher age and co-morbidities significantly
factors for unplanned readmission within 90 days of discharge influenced the change in EQ-5D index, antidepressants did not.
following arthroplasty at a high volume institution. It is likely that EQ-5D index improved similar amounts regardless of medication
an increased LOS is a reflection of postoperative complications that use, but those taking antidepressants started and ended with
increases the risk of readmission. As well, increased readmission lower scores than the patients not on these medications. Despite
following knee arthroplasty is likely a result of early return to similar EQ-5D change, all variables influenced the difference in
surgery for manipulation under anesthesia. These findings provide EQ VAS significantly. Gender no longer influenced the reduction
a path for understanding the etiology of readmission following TJA in pain, but antidepressant use did. These analyses suggest that
and can be used to direct future resources to prevent this costly the patient’s mental health status before surgery is as significant
problem and improve care. a factor in predicting PROMs as the patient’s gender, age and co-
morbidity status. Understanding a patient’s mental health status

before surgery may play a key role in management and education
of patients eligible for THR. Our findings add knowledge to
preoperative risk assessment. Cases at risk for poorer outcomes
may be identified through review of the patient’s medical record.
Antidepressant usage, gender, age and Charnley class could all play
a part in predicting PROMs after THR.
PAPER NO. 220

uUltrasound Screening of Periarticular Abnormalities
around Metal, Ceramic, and Polyethylene Bearings
Takashi Nishii, MD, Osaka, Japan
Takashi Sakai, MD, Suita, Japan
Masaki Takao, MD, Suita, Japan
Satoru Tamura, MD, Osaka, Japan
Hirohito Abe, MD, Osaka, Japan
Nobuhiko Sugano, MD, Suita, Japan
INTRODUCTION: There are concerns of soft-tissue reactions such
as metal hypersensitivity or pseudotumors for metal-on-metal
(MoM) bearings in hip arthroplasty, however, such reactions PAPER NO. 221
around ceramic or polyethylene bearings are incompletely
understood. The present study was conducted to examine the
Developing a Novel Risk Stratification Model to Predict
capabilities of ultrasound screening and to compare the prevalence Resource Utilization after Total Joint Replacement
of periarticular soft-tissue lesions among various types of bearings. Surgery
METHODS: Ultrasound examinations were conducted in David Kovacevic, MD, Cleveland, OH
171 hips (161 patients) with arthroplasty after mean follow-
Nathan W. Mesko, MD, Cleveland Heights, OH
up of 8.1 years (range, 1-22 years). This included 40 MoM hip
resurfacings (M-HR), 37 MoM total hip arthroplasties (M-THA) Keith Bachmann, MD, Shaker Heights, OH
with a large femoral head, 21 ceramic-on-ceramic total hip Deanna Trihas, Cleveland, OH
arthroplasties (THA) (C-THA), 25 THAs with a conventional Mary Lograsso, RN, BSN, Cleveland, OH
polyethylene liner (cPE-THA) and 48 THAs with a highly cross- Richard D. Parker, MD, Cleveland, OH
linked polyethylene liner (hxPE-THA). Periarticular soft-tissue Joseph P. Iannotti, MD, PhD, Cleveland, OH
reactions on ultrasound were classified into normal pattern, Mark I. Froimson, MD, Cleveland, OH
joint-expansion pattern, cystic pattern and large mass pattern
INTRODUCTION: Spending on healthcare continues to rise
(Fig 1). Magnetic resonance imaging (MRI) was subsequently
at a significant rate, stimulating renewed interest in providing
performed in 48 hips with high-frequency encoding bandwidths.
healthcare reform through the concept of value based purchasing.
Reliability of ultrasound screening for detection of periarticular
One key approach to offering value in healthcare delivery is the
abnormal reactions was estimated using the MRI findings as a
episode of care (EOC) model that identifies the resources required
reference. The frequencies of periarticular abnormal patterns
to manage a specific condition, for example lower extremity
on ultrasound were compared among the five bearing groups.
arthroplasty, over a finite period of time. Central to this approach
RESULTS: Periarticular abnormal lesions were detected in 26 hips
is the ability to clearly delineate the relationship between the input
(54%) on MRI. Using the abnormal lesions on MRI as a reference,
variables, including disease severity and comorbidities, which
positive predictive value, negative predictive value and the accuracy
influence the resources necessary to deliver desired outcomes.
of ultrasound examination for the detection of soft-tissue lesions
Although several studies have investigated the role of those various
were 84%, 78% and 85%, respectively. Abnormal ultrasound lesions
factors responsible for adverse outcomes following lower extremity
with joint expansion, cystic or mass patterns were most frequently
total joint replacement (TJR) surgery, we are unaware of any reports
observed in the cPE-THA group (48%), followed by the M-THA
examining the impact of such risk factors on resource utilization,
(24%), hxPE-THA (21%), M-HR (17%) and C-THA groups (14%).
cost and outcomes. The purpose of this study was to evaluate whether
Compared to the hxPE-THA group, the frequency of abnormal
increase in resource utilization was due to presence of comorbidities
patterns did not differ significantly in the two MoM groups. A
and whether this was correlated with impact on outcomes.
mass pattern was detected in three hips of the M-THA group and
METHODS: This study’s primary outcome, resource utilization and
one hip of the C-THA group. Abnormal ultrasound lesions were
outcomes following TJR surgery, was evaluated by investigating
significantly associated with the presence of symptoms (p<0.0001).
the effect of socioeconomic characteristics, comorbidities,
DISCUSSION AND CONCLUSION: Ultrasound examination
intraoperative factors and patient preferences. We utilized the
provides reliable screening of periarticular soft-tissue abnormalities
hospital system’s claims database to evaluate pertinent charges
in patients with hip resurfacing and THA. Various soft-tissue
and payments levied specific to our patient population of joint
reactions could be observed other than those for MoM bearings,
replacement patients during their EOC. Data was mined from the
and pseudotumors may not be a specific feature of MoM bearings.
claims database and this financial data for an episode was linked
to the specific medical information obtained from the electronic
medical record systems within our health system. Each patient
chart encounter for their EOC was reviewed for perioperative
complications, intraoperative factors, compliance with SCIP
measures, discharge disposition and interval changes in health

status. A multivariate analysis was utilized for all data elements (PT) seen in the MRI, or diagnosed in a revision operation.
to determine which potential outcome predictors were significant. RESULTS: To date, MARS MRI has been performed for 272
Using this approach, a risk stratification nomogram was patients (101 HR, 171 THA, 322 hips). Pseudotumour has been
developed to predict resource use and outcomes in prospectively found in 36 patients (43 hips, 13.2%). Further ARMeD has been
enrolled patients undergoing TJR surgery during their EOC. diagnosed in revision operation in five patients. One patient has
RESULTS: A total of 573 hospital system employees underwent a been revised due to aseptic loosening of the cup. Among those
total of 653 primary TJR surgeries from 2007 to 2010. The patients patients who have undergone our workup, incidence of ARMeDs
were grouped into the following categories based on procedure: has been 14.9% in HR patients and 15.2% in THA patients.
223 total hip arthroplasty (THA), 372 total knee arthroplasty ARMeD patients did not differ by age from non-ARMeD patients
(TKA), 53 unilateral knee arthroplasty (UKA), five with previous (p=0.4). The former group had significantly higher number of
hip surgery with conversion to THA. There was wide variability women (p=0.03). Preoperative range of motion or prosthesis type
in the resources required to complete an EOC among this cohort, did not differ between hips with ARMeD and hips without ARMeD
not all of which could be attributed to patient and process specific (p=0.36). Significantly higher inclination, however, was seen in
variables. Obesity was the most commonly occurring comorbidity hips with ARMeD (48.7 vs 51.3, p=0.02). Patients with ARMeD
followed by diabetes, hypertension and anemia. The presence had significantly higher metal ion levels compared to those
of multiple comorbidities yielded higher costs and increased without ARMeD (Cr: 16.0 µg/l vs 4.4 µg/l; Co: 38.7 µg/l vs 9.8 µg/l,
resource care without improving outcomes. Variability was found p<0.01). Ten (23.2%) ARMeD patients had both blood chrome
among surgeons’ use of resources. Variations in operating room and cobalt level lower than 7 µg/l. These patients had significantly
use, hospital length of stay and discharge disposition could not higher preoperative range of motion compared to other ARMeD
be explained by variance in patient or disease characteristics. patients (p<0.05). Nine PT patients (11 hips) reported no pain
DISCUSSION AND CONCLUSION: Although variability exists in the first question of the OHS. No difference was seen between
among EOC for the same disease and treatment dyad, only a these patients compared to other ARMeD patients in age, femoral
portion of the variability can be explained based on a model that diameter, preoperative ROM or AI. Cumulative survival rate for
accounts for patient specific comorbidities. This information is of ARMeD at six years was 70% (95% CI 66 to 74). When adjusted for
significant benefit to health systems and payers as they attempt to age, sex, AI, femoral diameter and preoperative range of motion in
predict the resources required to deliver care. Such modeling can Cox regression analysis, hips with THA had a 2.9-fold risk (95%
help manage expectations with regard to clinical course and cost, CI 1.5 to 5.9) of having an ARMeD as compared to hips with HR.
and can serve as a basis for discussions to eliminate variability in DISCUSSION AND CONCLUSION: With systematic screening
care pathways that are not reflective of underlying clinical need. protocol, ARMeD was found to be alarmingly common in
patients operated on with an ASR hip implant. The clinical picture
PAPER NO. 222 in ARMeD patients is variable. It must be considered a worry
Early Results of Systematic Screening for that relatively many of patients who developed ARMeD were
symptomless or had metal ion levels regarded as normal. Thus,
Complications in Patients Operated on with ASR Hip diagnosing ARMeD in metal-on-metal hip replacement patients
Replacements may require both clinical examination, measuring metal ion levels
Aleksi Reito, MB, Tampere, Finland in whole blood and cross-sectional imaging.
Timo JS Puolakka, MD, PhD, Tampere, Finland
Jorma Pajamaki, MD, PhD, Tampere, Finland PAPER NO. 223
Antti Eskelinen, MD, PhD, Tampere, Finland Smoking is a Harbinger of Early Failure with
INTRODUCTION: Both hip resurfacing arthroplasty (HR) and Ultraporous Metal Acetabular Reconstruction
conventional cementless total hip arthroplasty (THA) using Adolph V. Lombardi, Jr, MD, New Albany, OH
large-diameter head metal-on-metal bearing gained popularity Keith R. Berend, MD, New Albany, OH
in treatment of symptomatic osteoarthritis of the hip in young Michael J. Morris, MD, New Albany, OH
and active patients in the early 2000s. On September 7th, 2010 Joanne B. Adams, BFA, CMI, New Albany, OH
UK medicines and healthcare products (MHRA) announced a
Michael A. Sneller, BS, New Albany, OH
medical device alert regarding the ASR hip replacement implants
with metal-on-metal articulation. After this alert all such Tawnya Tucker, MT, New Albany, OH
patients operated on at our hospital were scheduled to undergo a INTRODUCTION: Acetabular reconstruction with newer
specific workup to reveal possible articulation-related problems. ultraporous metal in both complex primary and revision
We report the early results obtained thorough this protocol. total hip arthroplasty (THA) has increased survivorship with
METHODS: Between September 2004 and December 2009, 476 stable fixation and few failures. Smoking is considered a
patients (543 hips) underwent cementless THA using ASR cup, risk factor for surgical complications including transfusion,
and 408 patients (490 hips) HR arthroplasty with ASR resurfacing infection and cardiac. We hypothesized that the early results
implant. Five patients had received both implants. Informed of ultraporous metal acetabular reconstruction would be
consent was obtained from all patients. At a mean of 4.0 years unaffected by smoking in complex primary and revision THA.
postoperatively, all patients received an Oxford Hip Score (OHS) METHODS: Between 1999 and 2009, ultraporous acetabular
questionnaire and their whole blood chrome and cobalt levels components were used in 535 hips (500 patients) for 160
were analyzed. Further, all patients with femoral head size less complex primary and 375 revision cases. Of these patients 17%
than 50 mm, acetabular inclination >50 degrees, and patients with were smokers, 29.5% previous smokers, 49.0% non-smokers
elevated metal ion levels (>7 µg/l) were referred to magnetic artifact and 4.5% unknown. Early failures possibly related to negative
reduction sequence (MARS) MRI. We analyzed outcome of those effects of smoking were considered any infection, failure of
patients who have completed all these medical tests to date. Adverse in-growth or periacetabular fracture. Failures not considered
reaction to metal debris (ARMeD) was defined as pseudotumour related to smoking included dislocation and implant breakage.

RESULTS: There were 33 failures at an average of 18 months for routine follow up at regular intervals to monitor the
post-operative for a failure rate of 6.2%: 15 infections, 13 failure performance of the implant and bearing. The vast majority
of ingrowth, three dislocations, and one each liner fracture and of these follow-up clinic visits however are routine, with no
periacetabular fracture. The failure rate in smokers was 11%, in change in clinical outcomes. The technology and resources
non-smokers 3.8%, and in previous smokers 5.3% (Pearson’s now exist to enable follow-up assessment without the patient
6.5; p=0.01). With only smoking related failures included, the physically coming to see the surgeon. The purpose of this study
rate was 9% in smokers and 3.6% in non-smokers (4.6; p=0.03). was to measure the feasibility and costs associated with a web-
With previous smokers included as smokers failure is 9.2% based assessment compared to the usual method of follow up.
(6.2; p=0.01) and included as non-smokers 5.8% (3.7; p=0.05). METHODS: We randomized patients who were at least
DISCUSSION AND CONCLUSION: Even with ultraporous metal 12 months post-operative to either complete a web-based
technology, smoking is a significant risk factor for early failure in follow up (which included completion of an online form
complex primary and revision THA. Quitting smoking reduces the and an x-ray done at the nearest web-enabled facility) or to
inherent risk. Smoking cessation should be considered during pre- have their appointment at the clinic as usual. We recorded
operative education. travel distances, travel costs, time in x-ray, time in clinic and
time taken off paid employment to attend the appointment.
PAPER NO. 224 RESULTS: A total of 210 patients (96 THA, 114 TKA) completed
The Association of Socioeconomic Factors with the study with a mean age of 68.5 years. Patients in the web-
based group travelled less (29.1 km vs. 110.2 km, (p<0.01)),
Surgical Site Infection Following Total Hip Arthroplasty had lower associated travel costs ($4.00 vs. $21.41, (p<0.01))
Dave Warren, MD, MPH, St Louis, MO and reduced associated time (44.6 minutes for online form
Nupur D. Kittur, PhD, MPH, Saint Louis, MO completion vs. 55.6 minute clinic visit). Patients in the usual
Kathleen McMullen, MPH, Saint Louis, MO care group missed 5.7 hours from work and their caregivers
Ryan Nunley, MD, Saint Louis, MO missed 6.4 hours on average to attend the clinic appointment.
Robert L. Barrack, MD, Saint Louis, MO DISCUSSION AND CONCLUSION: There were significant time
and costs savings to patients in the web-based group compared to
INTRODUCTION: Several co-morbidities including diabetes and
those who had their appointment in person at the clinic. Other
rheumatoid arthritis (RA) are associated with an increased risk
potential advantages of web-based follow ups include decreased
of surgical site infection (SSI) following total hip arthroplasty
wait times in clinic for existing patients with problems, decreased
(THA) but the influence of socioeconomic factors such as
wait times for new patients waiting for surgery and reduced patient
race and household income on SSI is not fully understood.
and caregiver burden by decreasing travel distances, financial and
METHODS: We conducted a five-year retrospective cohort
time requirements.
study of hip arthroplasty patients using administrative records
at a 1,250 bed, teaching hospital. SSI cases were defined using PAPER NO. 301
National Healthcare Safety Network (NHSN) surveillance criteria.
RESULTS: A total of 3,490 procedures were identified between July Retrieval Analysis Reveals Damage Modes for Metal-
2005 and July 2010. Some 1,646 (47.2%) of patients were male, on-Metal Total Hip Replacements
439 (12.6%) were African-American, 1,126 (32.3%) had body mass Stefan Kinkel, Heidelberg, Germany
index (BMI) ≥ 30 kg/m2 [median BMI= 27.9, (range 10.1-62.4)], 359 Samantha M. Lee, BS, Philadelphia, PA
(10.3%) had diabetes, 113 (3.2%) had RA and median age = 58 years
Kirsten Stoner, M.S., New York, NY
(range 13-102). A total of 632 (18.1%) were revision cases; 38 (1.1%)
patients developed SSI. A nested case-control study compared 38 Timothy M. Wright, PhD, New York, NY
SSI cases to 114 randomly selected controls. Univariate risk factors Douglas E. Padgett, MD, New York, NY
for SSI included revision surgery [12 (31.6%) cases vs. 16 (14.0%) INTRODUCTION: Recent clinical concerns have arisen
controls, P=.018] and a patient home zipcode in the lowest quartile regarding metal-on-metal (MoM) total hip replacements. While
of median household income [16 (42.1%) vs. 22 (19.3%), P=0.028]. volumetric wear of MoM hip implants has been described, the
In a multivariate logistic regression model, African-American race damage modes accompanying in vivo use have not yet been
was significantly associated with SSI [21.1% of cases vs. 8.8% investigated. Such an investigation could suggest the source of
of controls; adjusted odds ratio = 5.8; 95% confidence interval, debris and identify damage modes unique to MoM bearings.
1.7-19.5] after adjusting for RA, ASA score and surgery duration. METHODS: Forty-six retrieved MoM total hip replacements
DISCUSSION AND CONCLUSION: Both socioeconomic and from 44 patients (19 females, 27 males) were obtained from an
patient factors significantly impact the incidence of SSI following Institutional Review Board-approved database. The average body
THA and both should be considered in risk adjusting THA SSI rates mass index (BMI) was 28.7 (range 16.5-47.6), average age at revision
between centers. was 55.2 (range 21-81 yrs) and average length of implantation was
36.2 (range 1.9-132 mos). The most common revision diagnoses
PAPER NO. 225 were wear-related clinical concerns, including osteolysis and
Web-Based Joint Replacement Follow Up pseudo-tumor like reactions (n=16), loosening (n=11), instability
(n=8) and infection (n=5). Each cup and head was represented by
Assessments: Are Routine Clinic Visits Necessary? a polar coordinate system on which surface damage characteristics
Steven J. MacDonald, MD, London, ON, Canada observed by light microscopy were mapped. The severity of
Jacquelyn Marsh, MSc, London, ON, Canada the damage was subjectively graded as mild, moderate and
Doug Naudie, MD, London, ON, Canada severe. Commonly observed modes were examined with SEM.
Dianne Bryant, PhD, London, ON, Canada RESULTS: Ninety-eight percent of the cups and 93% of the heads
showed moderate to severe scratching. When viewed under the
INTRODUCTION: It has been recommended that patients
light microscope, moderate to severe pitting was evident in 43%
undergoing total hip or total knee arthroplasty be seen
of the cups and 67% of the heads. SEM analysis showed evidence

of corrosion pits at the rim of three cups. A loss of the metallic need of revision surgery, due to wear debris induced osteolysis. It
sheen, termed wear patch, was found within 40º of the superior may also enable surgeons to use larger couples, thus reducing the
pole in 5% of the cups and 40% of the heads. Wear patches risk of impingement and dislocation. However, wear in standard
beyond 40º from the pole were seen in only 2% of the heads. polyethylene may be more sensitive to implant position than with
DISCUSSION AND CONCLUSION: Despite the claim that MoM HXLPE.
bearings are wear resistant, qualitative analysis of retrieved
femoral and acetabular MoM components showed considerable PAPER NO. 303
surface damage in terms of both extent and severity. Scratching One Third of Patients Diagnosed with Pseudotumors
is consistent with metal-on-metal articulations, in which carbides
serve as abrasive features whether fixed in the surface or released after Metal-on-Metal Total Hip Arthroplasty
as third bodies. The high occurrence of wear patches around Bart Bosker, MD, Zwolle, Netherlands Antilles
the pole is consistent with the location of the highest contact Harmen B. Ettema, Zwolle, Netherlands
force. The wear patches and severe scratching suggest boundary Martijn F. Boomsma, MD, Zwolle, Netherlands
lubrication conditions with little or no fluid between the MoM Boudewijn Kollen, Groningen, Netherlands
surfaces. Corrosive pitting located at the rim of three cups implies Mario Maas, Amsterdam, Netherlands
a corrosive, possibly galvanic process, that could result in direct Cees Verheyen, PhD, Zwolle, Netherlands
release of ionic metallic species. Though further investigation is
necessary to understand the clinical implications of these damage INTRODUCTION: Peri-articular tumors occur following large-size
modes, our findings suggest mechanisms for creation of substantial femoral head metal-on-metal resurfacing and conventional total hip
wear debris. replacement. Reports until now are based on symptomatic outcomes.
We intended to assess the true incidence of both symptomatic
PAPER NO. 302 and asymptomatic cases and to identify predicting factors for the
development of a pseudotumor. This is a design retrospective
The Eight Year Wear of Highly Cross-linked cohort study set in a teaching hospital in the Netherlands.
Polyethylene in Hip Arthroplasty: A Double Blind RCT METHODS: We included all patients who underwent hip arthroplasty
Geraint E. Thomas, MA, MBBS, MRCS, Oxford, United with large-size femoral head metal-on-metal conventional
Kingdom prostheses in our clinic (2005-2010). We collected data on hip
peter McLardy-Smith, FRCS, Oxford, United Kingdom outcome scores, metal ion levels and conventional pelvic and hip
radiographs. All patients were scheduled for CT scan examination.
Adrian Taylor, MBBS, FRCS, FRCS (Ortho), Oxford, United
RESULTS: Between January 2005 and July 2010, primary
Kingdom uncemented large-size femoral head total hip arthroplasties was
Harinderjit Gill, PhD, Oxford/Oxon, United Kingdom performed in 649 patients (732 hips). A total of 671 hips in 614
David W. Murray, MD, Oxford, United Kingdom patients were evaluated with a mean follow up of 2.7 years (range
Sion Glyn-Jones, MA MBBS, Oxford, United Kingdom 1-6.5 years). Pseudotumor was diagnosed in 207 hips (31%) in
INTRODUCTION: Highly cross-linked polyethylene (HXLPE) 202 patients (33%). To date, 39 (6%) of these hips were revised to
is commonly used in total hip arthroplasty; however there is a polyethylene acetabular component with small diameter metal
no long-term data to support its use. Hip simulator studies head. We identified the following risk factors for developing a
suggest that the wear rate of HXLPE is superior to conventional pseudotumor: female gender, swelling around the hip, discomfort
polyethylene (UHMWPE). The outcomes of hip simulator studies around the hip, clicking sensations and anterolateral surgical
are not always reproduced in vivo and there is some evidence approach. Patients with a pseudotumor had, on average, higher
that HXLPE wear may increase between five and seven years. In levels of cobalt and chromium in serum (10 µg/l vs 4 µg/l and 8 µg/l
addition the wear rate in relation to implant position is not known. vs 4 µg/l respectively). No difference in clinical outcome scores was
METHODS: A prospective double blind randomized control trial detected between the pseudotumour and non-pseudotumour group.
was conducted using radiostereometric analysis (RSA). Fifty-four No relation with component size or orientation could be identified.
subjects were randomized to receive hip replacements with either DISCUSSION AND CONCLUSION: This study showed a
UHMWPE liners or HXLPE liners. All subjects received a cemented substantial higher incidence of pseudotumors and subsequent
CPT stem and uncemented acetabular component. The 3D revisions in patients with metal on metal total hip arthroplasties
penetration of the head into the socket was determined to a minimum than previously reported. Because most revision (27 of 39) cases
of eight years. Implant position was determined using the RSA data. were identified only after applying an intensive screening protocol,
RESULTS: The total liner penetration was significantly different at we recommend close monitoring of patients with a metal on metal
eight years (p=0.005) with values of 0.33 mm (SE 0.05 mm) for hip arthroplasty.
the HXLPE group and 0.55 mm (SE 0.05 mm) for the UHMWPE
group. The steady state wear rate from one year onwards was PAPER NO. 304
significantly lower for HXLPE (0.005 mm/yr, SE 0.007 mm/yr) Pseudotumors are Common in Well Positioned, Low
than for UHMWPE (0.037 mm/yr, SE 0.009 mm/yr) (p=0.007).
The direction of wear was supero-lateral. Implant position was
Wearing Retrieved Metal-on-Metal Hip Arthroplasties
closely correlated to wear in standard polyethylene (p=0.002) Ashley Matthies, BSc, London, United Kingdom
DISCUSSION AND CONCLUSION: We have previously Johann Henckel, BM, London, United Kingdom
demonstrated that the penetration in the first year is creep- John Skinner, FRCS, London, United Kingdom
dominated; from one year onwards, the majority of penetration Alister Hart, FRCS, London, United Kingdom
is probably due to wear. This study confirms the predictions INTRODUCTION: Pseudotumors are sterile inflammatory
from hip simulator studies which suggest that the wear rate of lesions found in the soft tissues surrounding metal-on-metal
this HXLPE approaches that of metal-on-metal and ceramic-on- (MOM) hip arthroplasties. These lesions are thought to
ceramic articulations. HXLPE may have the potential to reduce the represent an adverse tissue response to metal wear debris and

may explain the high rates of failure widely cited in the current Table 2. Results for whole blood (WB) metal ion levels and component
literature. However, the etiology remains unclear, with recent wear rates for the matched case-control comparison.
studies suggesting that pseudotumors can occur in patients
No Pseudotumor Pseudotumor Sig.
with well functioning prostheses. We sought to investigate
further the relationship between pseudotumors, wear rate and WB Cobalt (ppb) 2.9 (0.5 to 162.3) 7.6 (1.4 to 88.0) p = 0.07
component orientation in a large series of retrieved MOM hips. WB Chromium (ppb) 3.2 (0.4 to 50.0) 4.7 (2.0 to 70.0) p = 0.07
METHODS: We performed a well-powered study of 105
Cup Wear Rate (μm/yr) 1.9 (0.0 to 31.5) 3.3 (0.0 to 31.2) p = 0.31
consecutively revised patients with current generation large
diameter MOM hip arthroplasties. We performed both cross- Head Wear Rate (μm/yr) 1.3 (0 to 62.12) 3.5 (0.0 to 22.6) p = 0.26
sectional and matched case-control analyses to compare component
position, pre-revision blood metal ion levels and component wear Figure 1. This shows the distribution of hips according to acetabular
rates between two groups of patients according to findings on orientation. Hips in red indicate those associated with a pseudotumor.
metal artefact reduction sequence (MARS) MRI scanning. Patients The blue box represents Lewinnek’s ‘safe zone’ for acetabular
demonstrating evidence of a pseudotumour were compared with orientation.
those that did not (Table 1). Component wear was measured in
our retrieval laboratory using a roundness measuring machine.
RESULTS: In this series, 69% of patients demonstrated a
pseudotumor on pre-revision MARS MRI. No significant
differences were observed for whole blood metal ion levels or
component wear rates when patients with pseudotumors were
compared to those without (Table 2). Additionally, patients
with well-positioned hips demonstrated a similar prevalence of
pseudotumors as those with cup positions outside of Lewinnek’s
‘safe zone’ (67% and 66% respectively, p = 0.64). The distribution
of pseudotumors according to cup position is shown in Figure 1.
DISCUSSION AND CONCLUSION: Pseudotumors were
commonly diagnosed prior to revision of current generation
MOM hip arthroplasties, but were not associated with component
malposition, raised blood metal ion levels or high component
wear rates. This would suggest that patient specific factors are likely
to be more influential in the etiology of adverse tissue reactions in
patients with MOM hip arthroplasty.
PAPER NO. 305
Table 1. Demographic and clinical data for each of the study groups: (1)
No Pseudotumor, (2) Pseudotumor, (3) Matched Pseudotumor Nine-Year Comparative Study of Highly Crosslinked and
No
Traditional Polyethylene in Total Hip Arthroplasty
Pseudotumor Pseudotumor Mark J. Jo, MD, Brentwood, MO
Pseudotumor
(Control (Case Group) Santiago Lozano Calderon, MD, Valhalla, NY
Group) Norman J. Roth, MS, Hawthorne, NY
Number of Patients 33 72 33 Steven B. Zelicof, MD, Harrison, NY
Number of Components 66 144 66 INTRODUCTION: To compare the linear penetration rates of a
Age (years) 51 (22 to 68) 58 (33 to 83) 58 (33 to 83)
highly cross-linked ultra-high-molecular weight polyethylene (PE)
to those in traditional polyethylene in total hip arthroplasty (THA).
Male / Female 8 M / 25 F 21 M / 51 F 8 M / 25 F METHODS: A total of 27 THA patients with highly cross-
Time Implanted (months) 37 (12 to 69) 40 (9 to 95) 35 (11 to 71) linked inserts were matched to 27 THA patients that
Femoral Diameter (mm) 46 (40 to 54) 46 (38 to 58) 46 (40 to 54) received traditional polyethylene inserts with respect to
age, gender, body mass index (BMI) and level of activity.
Implant Type Linear penetration for radiographs was measured using the
1 5 1
Adept (Finsbury Orthopaedics)
7 12 7 Martell’s computerized technique. Patients were evaluated at
ASR (DePuy)
13 38 17 follow up for pain, motion and function (Harris Hip Score).
BHR (Smith & Nephew)
5 10 3 RESULTS: Minimum follow up for inclusion in study was nine
Cormet (Corin Group Plc.)
5 2 3 years. Both groups were comparable in terms of demographics,
Durom (Zimmer)
2 5 2
M2a-Magnum (Biomet) preoperative pain, preoperative motion and motion as rated
Acetabular Inclination (°) 44 (27 to 63) 50 (33 to 78) 49 (32 to 63) per the Harris Hip Score. Postoperative penetration rate for the
traditional PE group was 0.098mm/yr. Penetration rate for the
Acetabular Version (°) 17 (-34 to 42) 19 (-14 to 45) 19.5 (-17 to 42)
highly cross-linked PE group was 0.037mm/yr. This represented
Clinical Cause of Failure a 62% decrease in wear which correlated with our previous data
0 2 1
Component Mismatch which showed a 59% decrease in wear at five years. There were
2 0 0
Fracture no catastrophic failures of the polyethylene in either group.
0 8 5
Infection
5 3 2 DISCUSSION AND CONCLUSION: This follow up study
Loosening (acetabular)
2 3 2 reinforces previous finding that highly cross-linked polyethylene
Loosening (femoral)
1 1 0 shows improved wear characteristics compared to traditional
Malalignment
23 48 20 polyethylene. This study also shows that the previous concerns
Unexplained Pain
regarding long term durability of highly cross-linked polyethylene

may not be clinically significant. materials, however, is formulation dependent. With respect
to oxidation, it is clear that sequential annealing reduced
PAPER NO. 306 oxidation when compared with first-generation annealing.
Oxidative and Mechanical Properties of Highly
Crosslinked Polyethylene in Total Hip Arthroplasty
Steven M. Kurtz, PhD, Philadelphia, PA
Daniel MacDonald, Philadelphia, PA
Gregg R. Klein, MD, Paramus, NJ
Amanda D. Marshall, MD, San Antonio, TX
Michael A. Mont, MD, Baltimore, MD
Matthew J. Kraay, MD, Cleveland, OH
Bernard N. Stulberg, MD, Cleveland, OH
Clare M. Rimnac, PhD, Cleveland, OH
INTRODUCTION: Highly crosslinked polyethylenes (HXLPEs)
have been in use in total hip arthroplasty (THA) for over a decade.
There is consensus in the literature that these materials show PAPER NO. 307
improved wear in vivo and significantly reduce osteolysis. However,
questions remain regarding the long-term oxidative stability of Proving Improvement of Wear Performance with Highly
HXLPEs and the influence of mechanical behavior on THA clinical Cross-Linked Polyethylene in Total Hip Arthroplasty
performance. The purpose of this multicenter study was to assess Koji Tsuji, MD, Kamakura, Kanagawa, Japan
the oxidative stability, mechanical behavior, wear and reasons Kazuo Hirakawa, MD, PhD, Kamakura, Japan
for revision of second generation HXLPEs and compare them to
Riichiro Tsukamoto, MD, Tokyo, Japan
our ongoing retrieval collection of first generation annealed and
remelted HXLPEs [5, 6]. We hypothesized the sequentially annealed Satoshi Takayanagi, MD, PhD, Kamakura, Japan
components would exhibit wear rates similar to first generation Takeaki Ueno, Kamakura-City, Japan
HXLPEs. We also hypothesized that the second generation HXLPEs Yoshiaki Itoh, MD, Kamakura, Kanagawa, Japan
would be more oxidatively stable than first generation HXLPEs. Akira Saito, MD, Kamakura, Japan
METHODS: Hip liners (n=376) were consecutively retrieved INTRODUCTION: Highly cross-linked polyethylene
during revision surgeries at seven surgical centers and have been (XLPE) was introduced to reduce polyethylene wear of total
continuously analyzed over the past 12 years in a prospective, hip arthroplasty (THA) based on in vitro improvement
multicenter study of THA revision and retrieval analysis. The of tribological properties. In this study, we evaluated the
liners were revised predominantly for loosening, instability in vivo wear rate of XLPE compared to conventional PE
and infection. Twenty-five liners were sterilized using non- (CPE) in primary THA at a minimum of five-year follow up.
ionizing methods (gas sterilized; implanted 8.1±3.5 years), 46 METHODS: Between March 2003 and March 2005, we enrolled
liners were sterilized in an inert environment (gamma inert; 148 hips in a prospective, randomized trial. All hips were
implanted 6.2±3.8 years), 177 were highly crosslinked and underwent primary THA with the same design acetabular liner,
remelted (remelted; implanted 1.8±2.1 years), 83 were highly cementless acetabular component and 26 mm CoCr femoral head
crosslinked and annealed (annealed 1; implanted 3.7±2.8 years) by single surgeon. At the surgery, either a CPE liner (sterilized
and 45 were highly crosslinked and annealed in three sequential with gamma radiation of 25kGy) or a XLPE liner (e-beam
steps (annealed 2; implanted 1.2±0.9 years). Oxidation was irradiation of 10Mrad) was chosen at random. Each radiograph
characterized in accordance with ASTM 2102 using transmission was analyzed with Martell computer method to assess for two-
FTIR performed on thin sections (~200µm). Mechanical dimensional vector and volumetric wear. The XLPE liners were
behavior was assessed via the small punch test (ASTM 2183). used for 83 cases and the CPE were 65 cases. The mean follow up
RESULTS: Oxidation was higher in the gamma inert and both was 70 months (range, 60 to 91 months). Mean age in the XLPE
annealed groups than the remelted and gas sterilization groups group and the CPE was 56±10 and 60±8, respectively (P<0.05).
(p<0.001), particularly at the rim. Oxidation significantly RESULTS: The mean 2-D vector wear was 0.101±0.30 mm
correlated with implantation time only at the rim of the annealed (0.02±0.05 mm/yr) in the XLPE group and 0.22±0.38 mm
1 liners (Rho=0.69; p<0.001) and the bearing surface of the (0.04±0.06 mm/yr) in the CPE group (P<0.05). The volumetric
remelted (Rho=0.28; p0.05). The annealed groups had the highest wear was 82.4±106.5 mm3 in the XLPE group and 118.9±106.1
ultimate load at the bearing surface (p<0.001). The gas sterilized mm3 in the CPE group (P<0.05). The annual penetration rate of
liners had the lowest superior surface ultimate load (p<0.01). the XLPE was 50% reduction compared to that of the CPE. The
Gas sterilized and gamma Inert liners had significantly higher mean bedding-in penetration for first year was 0.109±0.26 mm/
wear rates than all of the HXLPE cohorts (p≤0.01). No differences yr in the XLPE group and 0.09±0.40 mm/yr in the CPE group. The
were detected in wear rates among the HXLPE liners (p>0.66). subsequent penetration rate, with elimination of the bedding-in
DISCUSSION AND CONCLUSION: This ongoing study continues wear, resulted in the annual wear rate of -0.001±0.07 mm/yr in the
to evaluate the polyethylene properties and reasons for revision XLPE group and 0.03±0.08 mm/yr in the CPE group (P<0.05). Small
among clinically relevant HXLPEs used in total hip arthroplasty, localized osteolysis was recognized in the two cases of CPE group.
including second generation HXLPEs. All of the HXLPE materials DISCUSSION AND CONCLUSIONS: Several studies showed the
in this study have thus far proven effective at reducing wear percent reduction of XLPE in the rate of femoral head penetration
rates compared to the gamma inert and gas sterilized controls. have ranged from 30% to 90%, depending on which CPE was used
The oxidative stability and mechanical behavior of these as a control. The reduction rate of this study was rather little that

of the earlier studies. The CPE liners that were gamma-sterilized PAPER NO. 309
have a corresponding amount of cross-linking so that the liner
would result in wear rates that were lower than those of non-cross-
Metal Ion Analysis in Patients with Metal-on-Metal Hip
linked PE liners. And the total penetration of THA was due to a Replacements: Whole Blood vs. Serum
combination of creep (bedding-in penetration) and wear. In this Karren M. Takamura, BA, Los Angeles, CA
study, the XLPE liner showed distinctive improvement of wear Antoni Nargol, FRCS, Yarm, United Kingdom
performance, especially after bedding-in penetration, compared Andrew Taylor, MD, Surrey, United Kingdom
to the CPE liner at medium term. The reduction rate was estimated David Langton, Gateshead, United Kingdom
more than 95%. The effect may lead to better longevity of THA
as a result of less wear and osteolysis. We will continue to follow INTRODUCTION: Currently, there is no consensus as to whether
this cohort of patients, because long term in vivo mechanical serum, whole blood and/or red blood cell fraction should be
properties of the XLPE remain unknown. used to monitor the performance of the bearings. Therefore,
it is important to determine the appropriate sample collection
PAPER NO. 308 protocol to assess implant wear. This study’s aim was to determine
the distribution of chromium and cobalt in blood fractions.
Pseudotumour Following Metal on Metal Hip METHODS: The distribution of metal ions in the whole blood and
Replacement can Progress after Revision Surgery serum fractions: Whole blood Cr and Co samples were compared to the
Shahid Mehmood, MRCS, Banbury, United Kingdom corresponding serum Cr and Co samples in patients with unilateral
Hemant G. Pandit, FRCS, Oxford, United Kingdom hip resurfacings. Univariate linear regression was used to examine
the relationship between matched blood Cr and serum Cr samples.
George A. Grammatopoulos, MRCS, Oxford, United
In vitro study of chromium species distribution in human blood:
Kingdom Blood was collected from a healthy adult volunteer into (i) a
Nick Athanasou, MRCP, FRCPath, Oxford, United Kingdom container with EDTA as anticoagulant and (ii) a plain container.
Simon Ostlere, MD, Oxford, United Kingdom The anti-coagulated blood was divided into a series of portions
Harinderjit Gill, PhD, Oxford/Oxon, United Kingdom and each was spiked with solutions of Cr3+ or Cr6+ so as to
David W. Murray, MD, Oxford, United Kingdom increase the concentration by 0, 2, 5, 10 or 40µg/L. These samples
Sion Glyn-Jones, MA MBBS, Oxford, United Kingdom were further divided into four aliquots, which were separated into
INTRODUCTION: Solid or cystic pseudotumour is a potentially plasma and washed red blood cells (RBCs) after 45 min, four,
destructive complication of metal on metal (MoM) couples, usually 24 and 48 hours at room temperature. The non anti-coagulated
needing revision surgery to improve function and also to prevent blood was immediately divided into portions, similarly spiked
further soft tissue/bony damage. However, complete clearance of with Cr3+ or Cr6+, allowed to clot and the serum separated. The
the pseudotumour at the time of revision is unlikely at times. It concentrations of Cr were measured in RBCs and serum by ICPMS.
is not known whether the remnant pseudotumour will progress RESULTS: The distribution of metal ions in whole blood and
and cause further symptoms. This prospective case-controlled serum fractions: A total of 450 blood samples were sent for whole
study reports cases which had disease progression after revision blood and serum metal ion analysis. There was a highly significant
surgery for pseudotumour related to metal on metal hip couples. correlation between increasing whole blood Cr concentrations and
METHODS: A total of 37 hips (33 MoM hip resurfacing and four an increasing serum Cr to blood Cr ratio (r = -0.485, p < 0.001).
big head MoM total hip arthroplasty (THA)) were revised for Serum Co correlated well with blood Co (r = 0.953 p < 0.001) and
pseudotumour during the last 10 years. The patient demographics, the concentrations of Co in the two fractions showed less variability
time to revision, cup orientation, operative and histological than the Cr samples. Results of in vitro study: Blood samples spiked
findings were recorded for this cohort. Patients were divided into with Cr3+ showed preferential increase in Cr concentrations in
two groups - group R (needing re-revision for disease progression) the serum fractions. This was in contrast to blood samples spiked
and group C (control - no evidence of disease progression). with Cr6+, where there was a preferential increase in Cr in the
Oxford hip scores (OHS, 0-48, 48 best outcome) were used to RBCs. The time from sampling to removal of plasma cells had a
assess clinical outcome. The diagnosis of disease progression very small effect on overall measured Cr concentrations and the
was based on recurrence of clinical symptoms, cross-sectional distribution of the Cr species between the RBCs and plasma/serum.
imaging, operative and histological findings. The data was DISCUSSION AND CONCLUSION: The results suggest that as
analyzed using SPSS with statistical significance set at p < 0.05. wear increases, metal ions are taken preferentially into the serum
RESULTS: Nine of 37 (24%) patients identified with worsening fraction of blood. It has been shown that Cr6+ ions generated from
symptoms, eight underwent further re-revision surgery while one corrosion processes are preferentially taken into red blood cells, a
is awaiting revision surgery (group R). All patients were females result which was replicated in the current study. Cr3+ is believed
and the mean time to initial revision in group R was 34 months to have a greater affinity for serum proteins and is thought to be
(SD 21.8) and 60.5 months in group C (SD 27.5, p<0.01). The the predominant Cr species produced by mechanical wear. This
mean cup abduction angle and anteversion in group R were leads us to speculate that the increase of serum Cr concentrations
480 (SD 9.3) and 5.10 (SD 5.0), and 500 (SD 8.7) and 14.50 to levels greater than those found in whole blood is secondary to
(SD 8.5) respectively Re-revision surgery confirmed disease an increased rate of wear rather than corrosion processes.
progression in all cases. Oxford hip score was significantly worse
in group R 19 (SD 8.0) and 33 (SD14.2) (p=0.03). In all cases
needing re-revision, the pseudotumour was predominantly solid.
DISCUSSION AND CONCLUSION: This study demonstrates that
solid pseudotumours can progress following initial revision. This
is likely to be an ongoing reaction to retained metal debris despite
adequate clearance. All patients revised for pseudotumour should
be monitored using early ultrasound or MRI.

PAPER NO. 310 generation of contact stresses on both the cup liner and
femoral head, for four posterior-dislocation prone kinematic
Five-year Metal Ion Levels After Metal-on-Metal Total challenges and one anterior-dislocation challenge. Eighty-
Hip Arthroplasty (THA): A Prospective, Randomized one distinct cup orientations (radiographic definition) were
Trial investigated, with cup inclination varied between 25° and 65°
C. A. Engh, Jr, MD, Alexandria, VA in 5° increments and anteversion between 0° and 40°, again in
5° increments. Three values of femoral stem anteversion were
Steven J. MacDonald, MD, London, ON, Canada
considered: 0°, 12.5° and 25°. Stability and peak surface stresses
Supatra Sritulanondha, Alexandria, VA were reported for each of the 1,215 distinct FE simulations,
Abigail E. Thompson, BScN, London, ON, Canada with stability and avoidance of high edge loading being given
Doug Naudie, MD, London, ON, Canada identical weights for purposes of assessing overall performance.
Charles A. Engh, Sr, MD, Alexandria, VA RESULTS: With this equal weighting, cups oriented in approximately
INTRODUCTION: The FDA has requested post market surveillance 46° ± 10° inclination and 16° ± 5° anteversion were found to
data on metal-on-metal (MOM) modular total hip arthroplasty strike the ideal balance between stability and high contact stress
(THA) from multiple manufacturers. That request includes data avoidance (Fig. 2). Cup anteversion and femoral anteversion were
on metal ion levels. An analysis of five-year results of ion levels in found to independently influence predicted THA performance.
erythrocytes, serum and whole blood for 28-mm and 36-mm metal- DISCUSSION AND CONCLUSION: The optimal cup orientations
on-metal and metal-on-polyethylene (MOP) THA is presented. determined in the present study are similar to those which have
METHODS: Investigators enrolled 120 patients in a prospective trial, empirically evolved clinically. However, the present data for 36mm
105 of whom were eligible at the time of surgery and subsequently MoM implants suggests a tighter tolerance for cup anteversion (±
randomized into one of three groups. Group 1 received a MOP 5° vs. ± 10°), indicating the continued need for precise surgical
THA, Group 2 received a 28-mm MOM THA and Group 3 received positioning even with large head THAs. Additionally, the current
a 36-mm MOM THA. Patients were blinded to their treatment data challenge the notion of an equivalent summed (combined)
group. Blood samples were obtained preoperatively, at six-month, anteversion, as both the cup and stem anteversion independently
one-year, two-year, three-year and five-year follow-up visits. influenced stability and contact stress. Besides representing
RESULTS: At five-year follow up, the MOP ion levels were among the most comprehensive computational analyses of cup
significantly lower than each of the two MOM groups (p<.001) positioning effects on predicted THA outcomes, the present work is
for all blood samples tested for cobalt and chromium, with the notable in terms of being the first combined/concurrent balancing
exception of erythrocyte chromium (p=0.194). Serum and of considerations of stability and avoidance of adverse surface
erythrocyte cobalt showed significant increases (p=.029, p=.002) contact stress.
from two to five years in the 36-mm MOM group; similar
increases were not seen in the 28-mm MOM group. At six months,
one 36-mm MOM patient had serum or erythrocyte ion levels
greater than 7 ppb. At five years, there were five patients. None
of the patients in the 28-mm MOM group had ion levels greater
than 7 ppb. Correlations between cobalt serum, erythrocyte
and whole blood were stronger than in chromium. One 36-mm
MOM patient was revised due to an adverse local tissue reaction.
DISCUSSION AND CONCLUSION: Contrary to our hypothesis
that the larger 36-mm MOM group would have lower ion levels
compared to the 28-mm MOM group, our findings showed that
cobalt serum and erythrocyte ion levels leveled off in the 28mm
MOM group but continued to increase in the 36-mm MOM group.
PAPER NO. 311

Balancing Competing Considerations for Optimal
Orientation in 36-mm Metal-on-Metal Total Hips
Jacob Elkins, M.S., Iowa City, IA
Douglas R. Pedersen, PhD, Iowa City, IA
John J. Callaghan, MD, Iowa City, IA
Thomas D. Brown, PhD, Iowa City, IA
INTRODUCTION: Concerns have mounted regarding adverse
reactions to metal wear debris and ions in metal-on-metal
(MoM) total hip arthroplasty (THA), presumably associated with
excessive wear. However, positioning of MoM bearings involves
significant tradeoffs, as cup orientations most favorable in terms of
stability are not necessarily ideal in terms of reduction of contact
stress and wear potential. Therefore, investigation continues
to identify the optimal cup orientation for MoM implants.
METHODS: A physically and analytically validated THA
finite element (FE) model (Fig. 1) was used to identify optimal
cup orientations by assessing femoral head subluxation and

PAPER NO. 312 PAPER NO. 313
Cross-linked Polyethylene: Life Tested 13 Years and 37 Metal Ions and Chromosome Aberrations in Metal
Million Cycles Bearing Hip Arthroplasty: A Randomized Controlled
Jeffrey S. Hopkins, MD, Columbia, SC Trial
Andrew K. Battenberg, BS, Los Angeles, CA Jonathan Perera, BSc(Hons), MBBS, MRCS, London, United
Andrew Kupiec, Palos Verdes Estates, CA Kingdom
Thomas P. Schmalzried, MD, Los Angeles, CA Baljinder S. Dhinsa, MBBS, Kent, United Kingdom
INTRODUCTION: Cross-linked polyethylene (XL poly) is Kieran R. Gallagher, MRCS, Surrey, United Kingdom
intended to decrease wear and particle-induced osteolysis. Sammy A. Hanna, MRCS, London, United Kingdom
We have previously reported on a cohort of patients with a five Steve Tai, MBBS, Herts, United Kingdom
Mrad cross-linked polyethylene (re-melted and gas plasma Richard Carrington, MD, Herts, United Kingdom
sterilization) at a minimum of two and five years. The clinical
Jonathan Miles, FRCS (Ortho), Stanmore, United Kingdom
wear rates were similar to wear simulator studies. At five years,
osteolysis was not detected on plain radiographs. We have William Aston, FRCS, Stanmore, Middlesex, United Kingdom
reassessed this cohort at a minimum of 10 years post-op. Tim Briggs, FRCS, Middlesex, United Kingdom
METHODS: Thirty-four patients comprised the initial cohort. INTRODUCTION: The aim of this randomized controlled
Three patients are now deceased. Twenty-four patients from study is to investigate whether metal-on-metal (MoM)
the initial study group were available for 10-year radiographic implants result in increased blood metal ions and chromosome
follow up. We assessed an average of 6.5 films per patient (range aberrations post-operatively when compared to metal-on-
4-11). Quantitative activity data was obtained on 18 patients; polyethylene (MoP) implants. Resurgence of MoM arthroplasties
three patients were too disabled to participate and three refused. are being inserted into increasing numbers of younger
Activity was measured at a minimum of two years and again at patients due to the increased durability, stability and range
10 years postoperatively with a computerized two-dimensional of motion. Recent studies have raised multiple concerns over
accelerometer worn on the ankle. The two activity measures were possible genotoxicity and carcinogenicity of MoM implants.
averaged to determine total cycles at last follow up. Wear was METHODS: This is a randomized controlled, prospective study
measured using a validated, edge-detection based algorithm and of patients who have undergone elective total hip replacement.
wear rates were calculated by linear regression 1) as a function of After they were selected for total hip arthroplasty they were
time in vivo and 2) per million cycles of measured patient activity. then randomized into two groups: Group A received a MoP
Serial AP and lateral radiographs were reviewed independently by implant and Group B received a MoM implant. Patients were
three orthopaedic surgeons for presence and location of osteolysis. reviewed pre-operatively (control group) and at three, six, 12
RESULTS: At a minimum of 10 years (max. 13), linear and volumetric and 24 months post-operatively. On each occasion, blood tests
wear rates were 0.026mm/yr (-0.096-0.134) and 17.8mm3/yr (0.0- are taken to quantify metal ion levels (chromium (Cr), cobalt
78.8), respectively. As a function of activity, linear wear averaged (Co), titanium (Ti), nickel (Ni) and vanadium (V)) using a
-0.014mm/million cycles (-0.413-0.092) and 12.7mm3/million high-resolution inductively coupled plasma mass spectroscopy,
cycles (1.5-50.2). Osteolysis was not observed on any radiograph. and blood was also tested for chromosome aberrations in T
DISCUSSION AND CONCLUSION: At 10 years postoperative, this lymphocytes using 24-color fluorescent in situ hybridization.
five Mrad XL poly demonstrates a wear rate that is similar to pre- RESULTS: A total of 51 patients were recruited, 23 of whom had
clinical wear simulator studies. The wear rate at 10 years is slightly MoP prosthesis and 28 a MoM. Forty-nine of these had their two-
lower than that observed at five years, likely because patient year follow up with blood analysis, (22 MoP and 27 MoM). The
activity has declined. At a minimum of 10 years, this amount of metal ion analysis has shown that there was a statistically significant
polyethylene wear did not result in radiographically apparent difference between the chromium levels between the two groups,
osteolysis. This has favorable implications for bearings larger (P = 0.026), showing the MoM group to have higher chromium
than the 28 and 32mm diameters in this study. The occurrence of ion concentrations. Similarly with cobalt, the MoM group had
osteolysis also depends on the design of the modular acetabular a higher ion concentration, but this was only just statistically
component and CT scanning is more sensitive for the detection of insignificant, (P = 0.058). Titanium has also anecdotally shown
small lesions. If in vivo oxidation of the polyethylene has occurred higher ion levels in the MoM group at the two-year stage. The other
in any case, no adverse effect was detected by this longitudinal two ions, nickel and vanadium show no difference between the
study. Multiple hips in this series have been life tested to greater groups. These changes can be seen in graphs 1 to 7. Chromosome
than 25 million cycles (max. 37 million) without evidence of aberrations occurred in both groups. Both the MoM and MoP
impending failure. These observations are promising for the 20 groups showed increase frequency of aneuploidy aberrations and
year result in the average-activity patient. We will continue to structural damage, (figure 3). The greatest increase in metal ion
follow this cohort to assess the performance of this bearing over levels occurred at the one to two-year interval corresponding to
time and relative to patient activity. significant rise in chromosome aberrations. A comparison was
made between metal ion levels and chromosomal aberrations;
we found that the patients with higher metal ion levels, especially
chromium, cobalt and titanium, also demonstrated higher levels of
chromosomal aberrations, (translocations, breaks and aneuploidy).
DISCUSSION AND CONCLUSION: MoM bearings demonstrate
higher levels of blood metal ions, when compared with MoP
bearing. This study is only at the two-year stage and the data
points to a continued rise in the blood metal ion levels in the
MoM patients. We know that the patients with the highest

metal ion levels also have a higher number of chromosomal METHODS: A total of 218 (123M: 95F) consecutive patients with
aberrations; with time it is intuitive to believe that this trend minimum two serum ion measurements (ICPMS protocol) were
will continue and subsequently lead to a carcinogenic risk to the included. The mean age at surgery was 52.3 years (SD: 10), the
patient. The results of this study show that the levels of chromium, first assessment was made at a mean of 2.5 years (11 months to
cobalt and titanium are significantly higher in the MoM group eight years) and the last assessment at a mean of 4.6 years post
compared to the MoP group. This corresponds to increases resurfacing (two to 12 years). Ion level change was defined as
in chromosome aberrations in these groups with increases in ion level at last assessment minus ion level at first assessment.
structural chromosome damage particularly after two years. Ten different resurfacing designs were implanted, the majority
being BHR (n=104), Conserve plus (n=55) and ASR (n=25).
The median femoral component size was 50 mm (38 - 59mm).
Radiological assessment of acetabular component orientation was
made with EBRA. Optimum acetabular component orientation
was defined as ± 10° about an inclination/anteversion of 45°/20°.
RESULTS: For the whole cohort a significant reduction in chromium
(Cr) levels between initial [2.6 µg/ml (SD: 6.8)] and last assessment
[1.9 µg/ml (SD: 8.3)] was found (p= 0.004). Cobalt (Co) levels
were similar at initial [1.7 (SD: 7.7)] and last [1.8 (SD: 10.6)] follow
up (p=0.78). Cr levels increased in 31% and Co increased in 46%
of patients. There was a significant ion level increase (> 3 µg/ml
of both Cr and Co) in 5% of patients. There was no significant
difference in the change of ion levels between genders (p=0.4).
Although there was no significant difference between implant
designs (p = 0.07), there was a trend of higher ions being seen at
last follow up in patients with the ASR implants in comparison to
the BHR and the C+. Component size did not correlate with change
in ion levels (p=0.4). Acetabular component orientation did not
influence ion level change (p=0.46). However, a CPR distance
(contact patch-rim) of <10mm was associated with an increase
in Cr levels over time (p= 0.042). Patients whose ions increased
at follow up had significantly lower Harris Hip Scores (p=0.038).
DISCUSSION AND CONCLUSION: The analysis of the evolution
of ion levels in unilateral hip resurfacing after the run-in phase
demonstrates an overall decrease of Cr levels but no significant
change in Co levels. This in vivo finding is consistent with
tribocorrosion studies showing the formation of a passive
protective film on the articulating surfaces after the initial wear-in,
preventing further corrosion. From that point on, provided there
is no edge loading causing increased surface wear, ions are mainly
formed by corrosion of the particulate debris generated during the
run-in phase. In vitro studies have shown a higher dissolution of
the more soluble Co from the debris while Cr remains in solid form
PAPER NO. 314 with less ion formation. In a number of cases in our study, ion
levels continued to increase, indicating surface wear is probably
The Evolution of Ion Levels during Steady-state Wear in ongoing. These increasing ion levels were correlated with hip
Resurfaced Hips resurfacing designs with a lower coverage angle more prone to edge
Catherine Van Der Straeten, MD, St-Martens-Latem, loading and with the development of clinical symptoms. In well-
Belgium performing hip resurfacing, Cr ions are reduced with time while
George A. Grammatopoulos, MRCS, Oxford, United Co levels remain similar.
Kingdom
PAPER NO. 315
Harinderjit Gill, PhD, Oxford/Oxon, United Kingdom
Koen A. DeSmet, MD, Gent, Belgium High Serum Metal Ions (> 7µG/l) Cannot Be Used as an
INTRODUCTION: Tribological and clinical studies have described Indirect Screening Test in Metal on Metal Bearing Hip
a characteristic wear pattern of metal-on-metal hip resurfacings Surveillance
(MoMHRAs) with a run-in period followed by a lower-wear Ibrahim Malek, MD, Cardiff, United Kingdom
steady-state. The duration of the run-in period varies but is found Amanda King, Cardiff, United Kingdom
to be up to 1 million cycles in hip simulator studies. The steady-
Hemant Sharma, MRCS,MS, Neath, United Kingdom
state is followed by a ‘bedding-in’ phase minimizing wear or by an
increasing wear patch with edge loading. The use of metal ions as Sabur A. Malek, FRCS (Ortho), Cardiff, United Kingdom
surrogate markers of in-vivo wear is recommended as a screening Stephen A. Jones, MD, Vale Of Glamorgan, United Kingdom
tool for the in-vivo performance of MoMHRAs. The aims of this Alun John, MD, Caridd, United Kingdom
retrospective, single-surgeon study were to measure ion levels in INTRODUCTION: In the presence of emerging evidence about
unilateral MoMHRAs at different stages during the steady-state in adverse reaction to metal debris (ARMD), there is an urgent need
order to study the evolution of wear and describe factors affecting it. of an effective surveillance program. A threshold for further cross

section imaging in such patients based on raised serum metal ions 0.061 mm/year in the oxinium group versus 0.11 mm/year
remains an important issue due to implications of cost and resources. in the metal group (p = 0.23). Femoral head material did not
METHODS: A total of 209 consecutive, symptomatic significantly influence femoral head penetration in either group,
unilateral hips underwent Metal Artefact Reduction whereas highly cross linked polyethylene significantly reduced
Sequence (MARS) MRI scans and serology for cobalt and penetration when compared to EtO sterilized material (median
chromium levels between January 2009 and June 2011. of 0.036 versus 0.288 mm/year, Mann-Whitney test, p < 0.0001).
RESULTS: There was wide variation in serum cobalt and chromium DISCUSSION AND CONCLUSION: This study demonstrated that
levels in these patients with median serum cobalt value at 4.2µg/L up to five-year follow up, femoral head penetration was mainly
(Range: 0.4 -335.4 µg/L). Median serum chromium value was influenced by polyethylene processing method rather than femoral
4.9µg/L (Range: 0.2-163.0 µg/L). Thirty-six (40%) MARS-MRI scans head material. Although the reduction associated with oxinium in
were positive for ARMD. There was significant correlation between both study groups was not statistically significant, longer follow up
serum cobalt and chromium levels (Correlation coefficient: is necessary to evaluate the clinical significance of such a reduction.
0.775). There was also significant difference in serum metal ion
levels between two groups with positive and negative MARS-MRI PAPER NO. 347
scans for numbers available (p<0.001 and 0.001 for serum cobalt New Polyethylenes in Total Hip Replacement: A 10-12
and chromium respectively, Mann Whitney U test). Compared to
MARS-MRI as potential gold standard for the diagnosis of ARMD, Follow-up Study
the sensitivity of serology (>7µg/L) for serum cobalt and chromium Eduardo García-Rey, MD, Madrid, Spain
was 57%, specificity was 64%, positive predictor value was 52% Eduardo Garcia-Cimbrelo, MD, Madrid, Spain
and negative predictor value was 69% in symptomatic patients. A Ana Cruz-Pardos, Madrid, Spain
lowered threshold of >3.5 µg/L for serum cobalt and chromium INTRODUCTION: A significant reduction in wear using highly
levels improves the sensitivity and negative predictor value to cross-linked polyethylene (HXLPE) versus polyethylene sterilized
86% and 74% but at the expense of specificity (27%) and positive with nitrogen (PE) at five years was described previously. We ask if the
predictive value (44%). The receiver operating characteristic improvement observed at the earlier follow up continues at 10 years.
(ROC) curve analysis from our data suggests that serum cobalt METHODS: Between 1999 and 2001, 90 patients underwent
and chromium cut off level of >2 µg/L would give sensitivity of surgery using the same cementless cup and stem: 45 had cups with
90%. To achieve 90% specificity, serum cobalt and chromium PE liner and 45 with HXLPE liner, both associated with the same
cut off levels have to be >16 µg/L and >11 µg/L respectively. stem (28 mm metallic femoral head). This prospective randomized
DISCUSSION AND CONCLUSION: Compared to MARS MRI as study assessed 83 patients with a minimum follow up of 10 years.
potential gold standard for the diagnosis of ARMD, high serum The linear femoral head penetration was estimated at six weeks, at
metal ions had low sensitivity and positive predictor values; and six and 12 months and then annually thereafter, using the Dorr
moderate specificity and negative predictor values. We suggest method, given the nonspherical cup shape. All radiographs were
that, raised metal ion serology (>7µg/L) should not be used as a evaluated by the same author, who was not involved in surgery.
sole indirect screening test for surveillance of MoM bearings. The RESULTS: There was one hip in the PE group that showed proximal
investigating clinician should have a low threshold for obtaining femoral osteolysis. There was no loosening of any prosthetic
cross sectional imaging in symptomatic MoM bearing hips, even in component. Femoral head penetration in the early postoperative
the presence of low serum metal ions. radiographs was 0.16 mm (0.05-0.28) for the PE group and 0.08
mm (0.02-0.15) for the HXLPE group (p<0.001). The mean yearly
PAPER NO. 346 linear femoral head penetration was 64.8% lower for the HXLPE
Randomized Comparison of Oxinium Versus Metal group; 0.05 mm/year for the PE group and 0.02 mm for the
Against Conventional and Highly Cross-linked HXLPE group(p<0.001). Mean linear femoral head penetration at
10 years was 61% less in the HXLPE group than in the PE group.
Polyethylene in THA DISCUSSION AND CONCLUSION: There is a significant reduction
Moussa Hamadouche, PhD, Paris, France in yearly linear femoral head penetration with the HXLPE.
Jean-Pierre Courpied, PhD, Paris, France Confirmation that this reduction will result in less osteolysis
INTRODUCTION: The purpose of this study was to compare requires continued follow-up studies.
the effect of femoral head material (oxinium versus metal)
on polyethylene wear in two consecutive prospective PAPER NO. 348
randomized series of low friction total hip arthroplasty. uCementless Dual Mobility Sockets in Primary THA at
METHODS: A total of 100 patients (mean age 60.9 years) were
randomized to receive either oxinium (50 hips) or metal (50 hips)
a Mean Seven-Year Follow Up
femoral head. The polyethylene socket was EtO sterilized in the first Moussa Hamadouche, PhD, Paris, France
50 patients, whereas it was highly cross-linked and remelted (XLPE) Herve Arnould, MD, Bourg en Bresse, France
in the 50 following patients. All other parameters were identical in Bertand Bouxin, MD, Berck Sur Mer, France
both groups. The primary criterion for evaluation was linear head INTRODUCTION: Several designs based upon the dual
penetration measurement using the Martell system (Hip Suite). mobility (DM) concept have been recently FDA approved.
RESULTS: Complete data were available for analysis in 44 hips The aim of this retrospective study was to report on the
(22 in each study group) at a median follow up of 4.8 years minimal five-year follow-up results of a cementless DM socket.
(3.0 to 5.3), and in 43 hips (22 oxinium and 21 metal) at a METHODS: Between January 2000 and June 2002, 168 primary
median follow-up of 4.0 years (2.0 to 4.7) in the EtO sterilized consecutive non selected THAs were performed in 92 females
and XLPE series, respectively. In the EtO sterilized series, the and 76 males. The average age at surgery was 67.3 years. A single
median penetration rate was 0.25 mm/year in the oxinium DM socket design was used consisting of a Ti-sprayed and HA-
group versus 0.33 mm/year in the metal group (p = 0.20). In coated CoCr shell with a highly polished inner surface articulating
the highly cross-linked series, the median penetration rate was

with a mobile polyethylene component. The femoral head was bone. RSA examinations, Harris Hip, UCLA, WOMAC and
captured in the polyethylene component using a snap-fit type SF-12 scores were obtained at two weeks, six months and
mechanism, the latter acting as a large unconstrained head inside annually with the furthest patients evaluated through five years.
the metal cup. In 115 hips, the modular femoral head completely RESULTS: The randomized groups had comparable mean age
covered the Morse taper, whereas a long-neck option leaved the (58 +/- 7 years), preoperative UCLA activity score (5 +/- 2) and
base of the Morse taper uncovered in the remaining 53 hips. body mass index (BMI) (30 +/- 4). In evaluating cup stability,
RESULTS: At the minimum five-year follow up, 119 patients the tantalum and titanium shells demonstrated no statistically
were still alive and had not been revised at a mean of 7.2 years, significant difference in micro-motion at the bone-metal interface.
four hips were revised for dislocation between the femoral At six months median vertical translation of tantalum and
head and the mobile insert (intra-prosthetic dislocation) at titanium was -0.01mm and 0.04mm respectively, and reMEd
a mean of 5.9 years, 22 patients were deceased and 23 patients stable with median translation of -0.02mm and 0.04mm at four
were lost to follow up. Intra-prosthetic dislocation occurred years. Evaluation of polyethylene wear demonstrated statistically
in four of the 53 hips (7.5%) with an incompletely covered significant less femoral head penetration in the highly crosslinked
Morse taper, whereas no case of dislocation was reported in UHMWPE liners compared to the conventional group through five
the remaining 115 hips (Fisher exact probability, p = 0.009). years. At one year the femoral head penetration was 0.06mm for
DISCUSSION AND CONCLUSION: A current cementless DM the highly crosslinked UHMWPE and 0.16mm for the conventional
socket was highly effective in the prevention of dislocation liner. This difference reMEd at two years (0.08mm vs. 0.12mm),
following primary THA. However, fatigue damage and wear of three years (0.03mm vs. 0.32mm) and four years (0.08mm
the mobile insert at the capturing area can lead to intra-prosthetic vs. 0.34mm) (p<0.01 all four years). Mean UCLA, WOMAC,
dislocation requiring revision. Surgeons should be aware of this Harris Hip and SF-12 scores improved similarly in both groups.
specific complication and aggressive contact at the femoral neck to DISCUSSION AND CONCLUSIONS: Following THR, both cohorts
mobile insert articulation (“third articulation”) should be avoided. of patients have excellent clinical outcomes with statistically
significant improvements in function and pain relief with no
PAPER NO. 349 significant difference between the two groups. The femoral head
RSA Study of Tantalum vs. Titanium Acetabular Shells penetration rates were highest for both groups of liners in the first
six months, consistent with the “bedding-in” period. Thereafter,
and Crosslinked vs. Conventional Liners in Young THR the femoral head penetration was statistically significantly less in
Patients the cross-linked UHMWPE liners from one year through five years
David C. Ayers, MD, Worcester, MA of follow up. Highly cross-linked polyethylene liners are therefore
Marie E. Walcott, MD, Worcester, MA more capable of withstanding wear than conventional UHMWPE
Michelle Aubin, MD, Worcester, MA liners. There was no statistically significant differences in shell
migration between the titanium and tantalum shells with both
Jacob M. Drew, MD, Shrewsbury, MA
shells demonstrating excellent stability at the bone-metal interface
Peyton Hays, MD, Worcester, MA and exhibiting minimal micromotion at five years follow up.
Mark Eskander, MD, Pittsburgh, PA
Henrik Malchau, MD, Boston, MA PAPER NO. 350
Charles R. Bragdon, PhD, Boston, MA Long-term Comparative Survivorship of Uncemented
INTRODUCTION: In the active total hip replacement (THR)
population, maintaining acetabular component stability and
Acetabular Components in Revision Total Hip
limiting polyethylene wear are crucial components to preventing Arthroplasty
premature implant failure. Titanium with fiber metal coating Hilal Maradit-Kremers, MD, MSc, Rochester, MN
is among the most common materials used in cementless THR. James Howard, MD, London, ON, Canada
Trabecular metal, composed of porous tantalum, has a metallic Youlonda Loechler, Rochester, MN
strut design resembling trabecular bone, designed to improve Cathy D. Schleck, Rochester, MN
tissue infiltration and limit migration. It is unknown if tantalum William Harmsen, MS, Rochester, MN
offers an advantage over titanium in the biologic fixation of
Daniel J. Berry, MD, Rochester, MN
porous-coated acetabular shells. Highly cross-linked ultra high
molecular weight polyethylene (UHMWPE) liners were designed Miguel E. Cabanela, MD, Rochester, MN
to improve the durability of the weight bearing surface of total Arlen D. Hanssen, MD, Rochester, MN
hip replacements and prevent osteolysis, which can contribute to Mark W. Pagnano, MD, Rochester, MN
premature implant failure. Characterization of early wear patterns Robert T. Trousdale, MD, Rochester, MN
of commonly available acetabular liners in active THR patients David G. Lewallen, MD, Rochester, MN
with high functional demands is needed. Radiostereometric INTRODUCTION: It is unknown whether there are differences in
analysis (RSA) provides highly precise measurements of femoral long-term effectiveness of different types of uncemented acetabular
head penetration and micromotion at the bone-acetabular shell components in revision total hip arthroplasty (THA). The purpose of
interface that are otherwise not detectable by routine radiographs. this study was to compare the survivorship of historical and current
METHODS: In this Institutional Review Board-approved, uncemented acetabular components following revision THA.
prospective, randomized, blinded study, 46 patients received a METHODS: The study population included 3,236 patients with
primary THR by a single surgeon. Each patient was randomized 3,448 revision THA procedures with an uncemented acetabular
to receive a titanium (n=23) or tantalum (n=23) uncemented component performed at a large U.S. medical center between
hemispheric cup and a highly cross-linked (n=25) or conventional 1/1/1984 and 12/31/2004. Patients were actively followed
polyethylene liner (n=21). At the time of surgery, tantalum RSA up at regular intervals to ascertain details of subsequent
markers were implanted around the liner periphery and 12 revision surgeries, including cup (metal shell plus liner)
markers were implanted into the patient’s femur and periacetabular and liner only revisions. Overall and cause-specific (aseptic

loosening, wear/osteolysis, infection, instability) survival of op HHS leaving the insert material as the only variable. Patients
10 different acetabular components was compared using Cox were followed up using the Harris Hip score, anteroposterior (AP)
proportional hazards regression models adjusting for age and sex. radiographs and digital wear measurements using Roman V1.70
RESULTS: A total of 605 re-revisions, including 386 cup revisions [1, 2]. Wear and radiographic signs of osteolysis were analyzed at
were performed, corresponding to overall survival of 69% (CI: a mean follow up of 13.1 years (12.0-13.7). Groups were compared
67%, 72%) at 15 years. In comparison to titanium wire mesh using the t-test (means) or the Fisher Exact test (proportions).
designs, cup revisions for aseptic loosening were significantly RESULTS: Sixty-one patients (34 conventional, 27 Duration) were
more common with the beaded (HR 2.01, 95% CI: 1.44, 2.80) left for analysis (16 deaths and 18 lost to follow up). At 13yrs the
designs, but less common with trabecular metal designs (HR total linear head penetration was significantly lower with Duration
0.25, 95% CI: 0.06, 1.04). There were no liner revisions for wear (0.90 ±0.36mm, range: 0.3-1.7mm) than conventional PE (1.46
or osteolysis over a median 5.2 years of follow-up of 534 THA ±0.74, range: 0.4-3.3mm, p<0.001). Also the annual wear rate was
surgeries with crosslinked polyethylene liners, resulting in a significantly (p=0.005) lower for Duration (0.069 ±0.027mm/
significantly lower risk of wear-related revisions with crosslinked yr) than for conventional PE (0.112 ±0.058mm/yr, p<0.001).
polyethylene than with conventional liners. Head size and use of This reduction (-38%) compared well to the original simulator
elevated liners were not associated with the risk of re-revisions. prediction (-45%, [3]). In one center x-rays were available for wear
DISCUSSION AND CONCLUSIONS: In the setting of revision measurements also at 5yrs, 8yrs and 10yrs, the reduction in total
THA, cup survival is worse with beaded acetabular designs than wear and wear rate in this sub-group (n=31) increased with FU-time
with titanium wire mesh or highly porous designs. Crosslinked (-30% at 5yrs, -38% at 8yrs, -42% at 10yrs and -48% at 13yrs). In
polyethylene liners are associated with a reduced risk for wear- the Duration group only two patients (7%) had a wear rate above
related liner revisions. the >0.1mm/yr (osteolysis threshold) compared to 15 (44%) in
the Conventional group (p< 0.001). Patients with radiographic
signs of acetabular osteolysis (cysts) on the AP x-ray were less
frequent in the Duration (9/27= 33%) than in conventional
group (24/34= 71%, p<0.01). Only in the conventional group,
one revision was performed (cup for wear). Total wear, wear rates,
reductions and signs of osteolysis were similar for both centers.
DISCUSSION AND CONCLUSIONS: At long-term FU the annual
wear rate of Duration did not increase but in fact it decreased so that
the wear relative reduction over conventional (now ‘historic’) PE did
not deteriorate but increased. Also with Duration PE, the incidence
of osteolysis was significantly less. Thus no clinical evidence of PE
degradation or the elevated osteolytic potential of its wear debris was
found for this first generation moderately crosslinked and annealed
PE at 13yrs in-vivo. References [1] Geerdink et al. JBJS-B 2008
Jul;90(7):839-46 [2] http://www.eors.info/WearRomanManual.
pdf [3] Geerdink et al. Acta Orthop. 2006 Oct;77(5):719-25
PAPER NO. 351
Two-center RCT of Crosslinked vs. Conventional PE:
Sustained Wear Reduction and Less Osteolysis in the
Long Term?
Bernd P. Grimm, PhD, Aachen, Germany
Martijn Schotanus, Sittard-Geleen, Netherlands
Aart D. Verburg, MD, Sittard-Geleen, Netherlands
Nanne Kort, PhD, Roosteren, Netherlands
Ide C. Heyligers, MD, Heerlen, Netherlands
INTRODUCTION: Large wear rate reductions have been shown
for crosslinked polyethylene (PE) in simulators and short- to mid- PAPER NO. 352
term clinical wear studies. However, concerns persist about a) The Implant Designer Series: Are These Favorable
long-term in-vivo oxidation (especially with annealed PE), b) late
accelerating wear due to degradation and c) the possibly higher
Results Believable?
osteolytic potential of crosslinked PE particle debris. This is one of Hany Bedair, MD, Newton, MA
the longest follow up (FU) studies (13yrs) comparing conventional Bryan M. Lawless, MD, Manchester, NH
versus crosslinked PE to investigate whether the wear reduction is Henrik Malchau, MD, Boston, MA
maintained in the long-term and if reduced osteolysis becomes INTRODUCTION: The performance of hip and knee implants
evident METHODS: In a prospective two-center study 97 primary as reported by the designing surgeon or center is often felt to
THA patients (Stryker ABG-II, 28mm CoCr heads) were randomized be more optimistic than those observed in the orthopaedic
to either receive a first generation crosslinked PE (Stryker Duration: community at large. With the maturation of several national
30kGy, gamma irradiation in N2, annealed for free radical removal joint registries, these reported results can be compared to the
and crosslinking) or then conventional, now “historic“ PE (30kGy, experience of large numbers of surgeons. The purpose of this study
gamma irradiation in air). Both groups were statistically non- is to compare the survivorship results of different hip and knee
different (p>0.1) regarding age (64.0 years), gender, BMI, stem arthroplasty prostheses in case series reported by the designing
and cup size, cup inclination, liner thickness or pre- and post-

surgeon or center with those reported in national joint registries Table 1. Patient demographics
and to investigate any potential patterns within a reported series
Mean age at surgery, y (range) 61.2 (29-87)
that may lead towards a discrepancy with national registry data.
M/F 79/133
METHODS: Reported results of 16 different hip and knee arthroplasty
implants published by the designers of that implant were identified Mean follow-up, y (range) 11.1 (10-15)
and compared to results in four national registries (Swedish, BMI, (range) 26.2 (17.7 - 37.7)
Australian, New Zealand, England/Wales). The time to follow Osteoarthritis, 200; avascular necrosis, 19;
Diagnosis
up between the reports and registries was normalized. Revision rheumatoid arthritis, 10; other, 29
for any reason was considered a failure. Specifics of each study Mean annual wear rate, mm/y (range) 0.08 (0.0009-0.32)
design (number of patients, surgeons, centers, etc.) were compared Table 2. Annual wear rates and incidence of acetabular osteolysis for
to identify factors that led to higher correlation with registries. different noncemented acetabular components.
RESULTS: The study results of 11 hip implants were compared
to 28 registry reports and five knee implants to 12 registry Mean Acetabular Incidence of
THA Acetabular follow- Annual Wear Acetabular
reports. Three of 16 (19%) implants performed worse in three Investigator
Component Type up, years Rate, mm/y Osteolysis
of the four registries compared to the published study. Two (range) (range or SD) (%)
implants performed worse in one of the four registries. In
Monoblock Elliptical
addition, two implants performed better in the registries than 11.1 (10- 0.08 (0.0009 -
Present study (Implex, Allendale, 1.9
in the published study. There did not appear to be any consistent 15) 0.32)
NJ)
predictors of correlation. There were many implants that did Mayman et al
not have comparable data in the registries for comparison. Monoblock Elliptical
[JOA 2007,
DISCUSSION AND CONCLUSIONS: Contrary to popularly held (Implex, Allendale, 7.2 (5-9) 0.079 (0-0.31) 0
previous
NJ)
beliefs, reported results by the designers of an implant seem to study]
correlate favorably with the results of large numbers of surgeons. Young et al Monoblock Porous-
5.3 (3.8-
[JBJS Am coated (DePuy, 0.11 (±0.13) 0
6.8)
PAPER NO. 353 2002] Warsaw, IN)
Ten to 15 Year Clinical and Radiographic Results for a Della Valle
et al
Modular Trilogy
Compression Molded Monoblock Elliptical Acetabular [JBJS Am
(Zimmer, Warsaw,
IN)
5.3 (4-7) 0.09 (0-0.45) 1.7
2003]
Component
Modular
Lazaros A. Poultsides, MD, New York, NY
Chen et al Hemispheric Duraloc
Vasilis Sioros, Ioannina, Greece 6.8 (5-8.2) 0.10 (±0.14) 2.2
[CORR 2006] (DePuy, Warsaw,
Nikos Chatzoudis Ind)
John A. Anderson, MD, New York, NY Modular Omnifit
Danilo Bruni, MD Ito et al PSL(Howmedica 8.6 (5.2- 0.18 (0.02-
5
[CORR 2004] Osteonics,Allendale, 12.1) 0.42)
Robert L. Parisien, Med Student, Biddeford, ME NJ)
Burak Beksac, MD, Istanbul, Turkey Modular
Thomas P. Sculco, MD, New York, NY Kim et al
Hemispheric Duraloc
[JBJS Am 9.8 (8-11) 0.12 (0.01-0.24) 9
INTRODUCTION: Polyethylene wear rates correlate with osteolysis. (DePuy, Warsaw,
2003]
Modular acetabular components may fail because of backside Ind)
polyethylene wear or liner/shell dissociation. A monoblock Modular Anatomic
acetabular component avoids these problems, and we report the Udomkiat et al Porous Replacement
10.2 (7-
[JBJS Am (APR, Sulzer 0.16 (±0.13) 3.6
long-term results from previously published midterm follow up. 11.9)
2002] Orthopaedics,
METHODS: A total of 258 primary total hip arthroplasties Austin, Tex)
(212 patients) with a titanium monoblock, elliptical acetabular
Modular
component, performed by one surgeon, were followed up for a mean Young et al
Hemispheric Duraloc
period of 11.1 years (range, 10-15 years) (table 1). Radiographs [JBJS Am 5.5 (3.8-8) 0.16 (±0.08) 5
(DePuy, Warsaw,
were scanned, digitized and examined for acetabular osteolysis. 2002]
Ind)
Wear rates were determined with the Martell hip analysis software. Modular
RESULTS: Average yearly wear rate was 0.08 mm/yr (range, Archibeck et al
Hemispheric Harris-
[JBJS Am 10 (8-11) 0.16 (0-0.47) 16
0.0009-0.32 mm/yr) (table 2). Acetabular radiolucencies were 2001]
Galante II (Zimmer,
present in six hips (2.4%). All radiolucencies were non-progressive, Warsaw, Ind)
and were present in acetabular zone I. Acetabular osteolysis was Modular
present in five patients (five hips, 1.9%); all cups were stable. Four Hemispheric (CoCr)
acetabular components were revised, all for recurrent instability; Barrack et al Long-term Stable
6 (5-8) 0.10 (0-0.5) 11
[CORR 1997] Fixation (LSF,
no acetabular components were revised for polyethylene wear or
Implant Technology,
dissociation, acetabular osteolysis, loosening or deep infection. Secaucus,NJ)
Three femoral components were revised due to aseptic loosening.
Crowther et al Modular Harris-
DISCUSSION AND CONCLUSION: The monoblock titanium 0.15 (0.02-
[JBJS Am Galante I (Zimmer, 11 (9-14) 23
porous coated acetabular component has a very low complication 0.59)
2002] Warsaw, IN)
rate at minimum 10 years follow up. Furthermore, it is associated
with the lowest polyethylene wear rate reported in the current
literature, and a very low incidence of acetabular osteolysis, thus
demonstrating excellent long term survival.

PAPER NO. 354 resistance. There is consensus in the literature that these materials
show improved wear in vivo and significantly reduce osteolysis.
Prospective Randomized Multicentre Study of a “New” Due to the increased wear performance of HXLPE, heads larger
Approach to MIS THA: Stem Subsidence an Issue than 32 mm are now widely used. The goal of this prospective
Nelson V. Greidanus, MD, Vancouver, BC, Canada multicenter retrieval study was to investigate the wear performance
Samir Chihab, MD, Vancouver, BC, Canada of HXLPEs coupled with standard heads (≤28mm) and large
Donald S. Garbuz, MD, Vancouver, BC, Canada heads (≥32mm). We hypothesized that the large heads would
Bassam A. Masri, MD, Vancouver, BC, Canada have greater femoral penetration rates than the standard heads.
METHODS: Consecutively retrieved liners (n=376) were collected
Michael Tanzer, MD, Montreal, QC, Canada
during revision surgeries at seven surgical centers and continuously
Allan E. Gross, MD, Toronto, ON, Canada analyzed over the past 10 years in a prospective, multicenter study
Clive P. Duncan, MD, Vancouver, BC, Canada of THA revision and retrieval analysis. Loosening, infection
INTRODUCTION: This study examined the potential and instability were the primary reasons for revision for both
superiority of a “new” intermuscular surgical approach the ≤28mm heads and the ≥32mm heads (p>0.2). Of these, 219
to limited incision total hip replacement (THR). articulated against a large femoral head (≥32mm), while 158
METHODS: After a learning curve which included a hands-on articulated against standard heads (≤28mm). The femoral heads
course and a combined number of 95 cases (minimum 10 per articulated against five polyethylene formulations: 25 liners were
surgeon), five subspecialized hip surgeons, at three academic sterilized using non-ionizing methods (Gas Sterilized-control;
centers, participated in the study of a “new” anterolateral minimally Implanted 8.1±3.5 years), 46 liners were sterilized in an inert
invasive (MIS) approach to THR. It was a multicenter, prospective, environment (Gamma Inert-control; Implanted 6.2±3.8 years),
randomized trial, comparing it to the “standard” limited incision 177 were highly crosslinked and remelted (Remelted; Implanted
approaches already in use (direct lateral or posterolateral). 1.8±2.1 years), 83 were highly crosslinked and annealed (Annealed
HRQoL outcomes were assessed at baseline and intervals out to one; Implanted 3.7±2.8 years), and 45 were highly crosslinked
24 months. Detailed, blinded, radiographic measurements in a and annealed in three sequential steps (Annealed two; Implanted
subset of 98 cases at one center included cup alignment in two 1.2±0.9 years). Femoral penetration was assessed using a
planes, stem alignment, subsidence, loosening and fractures. calibrated micrometer (accuracy = 0.001 mm). We excluded liners
Parametric and nonparametric analyses were performed. that were in vivo for less than one year, where creep is expected
RESULTS: A total of 156 patients were recruited and the same to be dominant. The control groups had limited numbers of
implant system used in every case. There was no difference between large heads (n = 1 and 2; in the Gas Sterilized, and Gamma Inert,
groups at baseline (pre-op age, gender, BMI, comorbidity, WOMAC). respectively), while the Annealed two cohort had only one standard
Similarly, interval HRQoL outcomes out to 24 months were not head, thus they were eliminated from the head size analysis.
different (p>.05). Cup and stem alignment were satisfactory with RESULTS: Penetration rates were dependent upon polyethylene
no difference between the groups, but there was a highly significant formulation with the gas sterilized and gamma inert groups having
difference in stem subsidence (p = 0.007) with a mean migration the highest penetration rates (p≤0.005). Femoral head penetration
of 4.23mm in the “new” group. Two have already required rates were similar among the three different highly crosslinked
revision. Also there were four trochanteric fractures in this group. polyethylene formulations (p>0.05). In the first generation highly
DISCUSSION AND CONCLUSION: This study failed to crosslinked groups, femoral head penetration rates were similar
demonstrate superiority with the “new” anterolateral (so-called between the large diameter heads and the standard heads (p>0.29).
G3) approach. Furthermore the risk of painful stem subsidence and DISCUSSION AND CONCLUSION: We reject our hypothesis that
fracture was increased. Likely this is related to the greater technical larger heads would have increased penetration rates as compared
challenge of exposure with this approach in some patients, leading to 28mm head sizes. In fact, the HXLPE formulation was the most
to the risk of undersizing the stem in those cases. The authors have important factor in determining femoral head penetration rates.
returned to the standard surgical approaches in use before the trial. This supports the safety of use of larger femoral heads with highly
crosslinked polyethylene. This study is limited by insufficient
PAPER NO. 355 power (power = 0.25) and because we only measured linear
Retrieval Analysis on the Effects of Head Size on penetration into the liner, not volumetric penetration. Larger
head sizes that have similar linear penetrations should generate
Performance of Crosslinked Polyethylenes for Total Hip larger wear volumes. Further studies using volumetric methods
Replacement are warranted to investigate the effects of larger head sizes.
Steven M. Kurtz, PhD, Philadelphia, PA
Amanda D. Marshall, MD, San Antonio, TX
Aaron J. Johnson, MD, Baltimore, MD
Bernard N. Stulberg, MD, Cleveland, OH
INTRODUCTION: Larger diameter femoral heads provide
increased stability and range of motion. However, due to increased
surface area, larger heads also increase the risk of polyethylene
wear. Highly crosslinked polyethylenes (HXLPEs) were introduced
in total hip arthroplasty more than a decade ago to improve wear

Long-Term (20-25 Year) Results of an Uncemented A Study of Taper Corrosion in 111 Current Generation
Tapered Femoral Stem and Factors Affecting Large Diameter Metal-on-Metal Hip Components
Survivorship Alister Hart, FRCS, London, United Kingdom
Marcus Streit, MD, Dossenheim, Germany Adam Hexter, London, United Kingdom
Christian Merle, MD John Skinner, FRCS, London, United Kingdom
Moritz Innmann, MD, Heidelberg, Germany Johann Henckel, BM, London, United Kingdom
Tobias Gotterbarm, MD, Heidelberg, Germany Gordon W. Blunn, MD, Middlesex, United Kingdom
Peter Aldinger, MD, Stuttgart, Germany Ferdinand Lali, PhD
INTRODUCTION: Excellent intermediate-term results with Ashley Matthies, BSc, London, United Kingdom
use of uncemented tapered femoral components in primary INTRODUCTION: In 2009 it was reported that 35% of all hips in
total hip arthroplasty have been reported. Little is known about the United States were large diameter head metal-on-metal total
factors that influence the survival of uncemented stems in the hip replacements (LHMoM THR). However, there are several recent
long-term. Therefore we report the minimum 20-year (mean, 22 reports of unacceptably high rates of failure of this type of hip: up to
years; range, 20-25 years) results and analyzed the independent 49% at five years that have been attributed to corroded taper junctions.
effects of several factors on the long-term survivorship. There are no studies that have quantified the corrosion of the tapers
METHODS: We retrospectively evaluated the clinical and from current generation MoM hips. We aimed to characterize
radiographic results of a consecutive series of 354 total hip taper corrosion of the three most commonly used LHMoM THRs
arthroplasties using an uncemented grit-blasted, tapered femoral and investigate the influence of design and femoral diameter.
stem in 326 patients. Mean time of follow-up evaluation was METHODS: Corrosion was qualitatively assessed for 111 components
22 years (range, 20-25 years), mean age at surgery was 57 of three different designs; the ASR XL (DePuy), the BHR (Smith and
years (range, 13-81 years). Kaplan-Meier survivorship analysis Nephew) and Durom (Zimmer) devices. A peer-reviewed qualitative
was used to determine long-term survival rates for different grading system was used. An unanticipated finding was a ridged
end points. Multivariate survivorship analysis using Cox’s appearance on most female taper surfaces, which corresponded
regression model was performed with an end point of aseptic with the ridges of the trunnion surface. A subjective grading
loosening of the femoral component for the risk factors age system was devised to quantify this imprinting phenomenon.
(continuous variable), male gender, diagnosis, canal fill index RESULTS: We found that 92% of components were corroded to
(CFI) <80%, type of acetabular component and cup revision. some extent with at least moderate corrosion observed in 61%.
RESULTS: At final follow up, 126 patients (136 hips) had died, There was no significant difference in corrosion between the
and four patients (five hips) were lost to follow up. Forty-two different manufacturers both in terms of the head components
hips (12%) underwent femoral revision - 10 (3%) for infection, (p=0.52) and trunnions (p=0.20). Increasing head size showed a
12 (3%) for late periprosthetic fracture due to trauma, and 20 weak but significant positive correlation with corrosion (r=0.241,
(6%) for aseptic loosening of the stem. Kaplan-Meier analysis, p=0.02). The imprinting scores and corrosion scores showed a
with revision of the femoral component for any reason as the strong and significant positive correlation (r=0.776, p=0.01).
end point, revealed that the survival rate at 22 years was 85% DISCUSSION AND CONCLUSION: Corrosion was not
(95%-confidence limits, 80%-89%). The survival rate with manufacturer dependent, with no difference observed between the
femoral revision for aseptic loosening as the end point was 93% ASR XL device and other hip types. An unexpected finding was that
at 22 years (95%-confidence limits, 89% - 96%). No femoral the corrosion was strongly associated with the presence of ridges
component showed radiographic evidence of definite loosening. on the female taper surface. We believe the rough surface of the
Osteolysis was limited to Gruen zones 1 (8%, Ø 1.44 cm²) and trunnion is causing considerable mechanical wear at the female
7 (13%, Ø 0.97 cm²). Undersized stems (CFI <80%) and stems taper surface and creating an aggressive corrosive environment.
after previous cup revision were at higher risk for aseptic loosening Larger head diameters experienced greater corrosion, which is of
(relative risk 4.2 (p<0.01) and 4.3 (p=0.02), respectively). Age at clinical significance given the evolution towards larger femoral
time of surgery (p=0.91), male gender (p=0.42), type of acetabular head sizes. We recommend review of the use of ridged trunnions
component (p=0.88) and diagnosis (p=0.96) had no significant in combination with cobalt-chrome head components and believe
influence on the risk of long-term aseptic loosening in this cohort. large head diameters should be used with caution until greater
DISCUSSION AND CONCLUSION: The long-term results with understanding of the mechanical forces on the head-trunnion
this type of uncemented femoral component are encouraging and junction is achieved.
compare to the best reported series in primary cemented total hip
arthroplasty. Young age and male gender were not associated with
a higher risk of aseptic loosening in the long term.

PAPER NO. 358
Multi-Center Minimum Five-year Wear Analysis
of Large Femoral Heads on Highly-Crosslinked
Polyethylene
Michael Doerner, BA
John M. Martell, MD, Chicago, IL
Paul F. Lachiewicz, MD, Chapel Hill, NC
Kim C. Bertin, MD, North Salt Lake, UT
Charles R. Bragdon, PhD, Boston, MA
Henrik Malchau, MD, Boston, MA
INTRODUCTION: Large femoral head sizes provide an
increased range of motion, decreased implant impingement
and protection against dislocation. However, increased wear
with large diameter femoral heads against ultra-high molecular
weight polyethylene (UHMWPE), necessitated the use of femoral
heads of 32 mm diameter or less. The introduction of highly
cross-linked polyethylene (HXLPE) has shown improvement in
wear performance. This study combines data from three centers
to determine if the wear rates of HXLPE depend on head size.
METHODS: We identified 487 patients (534 hips) who underwent
primary total hip arthroplasty (THA) with radiographic follow up
at a minimum of five years. Martell Hip Analysis Suite was used
to analyze all pelvic radiographs resulting in head penetration
values. Linear and volumetric wear rates were calculated by
dividing the head penetration between the longest follow up
and the one-year film. Wear rates for the standard head sizes
(28-32mm) and large head sizes (36mm) were compared using
a Mann-Whitney U Test. A second analysis method used a group
regression to calculate the slope of the head penetration rates for
the different head sizes. The slopes were compared using a Zar test.
RESULTS: Radiographic follow up was gathered for THAs using
standard and large head sizes (238 hips and 296 hips). Standard
head sizes include 130 hips with 28mm femoral heads and 108
hips with 32mm femoral heads, while large head sizes included
296 hips with 36mm femoral heads. At longest follow up, there
was a significant difference in linear head penetration rates
between the standard and large head sizes (17.0±92.3 µm/year and
76.0±167.1µm/year, respectively, p<0.00005). There was also a
significant difference in volumetric head penetration rates between
standard and large head sizes (8.79±27.2 mm3/year and 51.8±81.9
mm3/year, respectively, p<0.00005). By the group regression, the
slope of the regression line for standard head sizes was 3.7 µm/year
and for large head sizes was 26.7 µm/year . There was not a significant
difference between these linear penetration rates (p=0.19). For
volumetric head penetration rates by the group regression, there
was no significant difference (p=0.51) between standard and
large heads (2.0 mm3/year and 15.2 mm3/year, respectively).
DISCUSSION AND CONCLUSION: The differing statistical
analysis for significant differences among the various methods
for calculating wear rates makes interpretation difficult. While
penetration rates should be lower with larger femoral heads, it is
important to note that the magnitude of penetration and volumetric
wear rates are much lower than reported for conventional
polyethylene and there have been no reported cases of osteolysis
with the use of large heads with highly cross-linked polyethylene.
Further studies of the creep behavior of this material, further
analysis of the direction of wear and volumetric calculations and
further clinical follow up is required.

PAPER NO. 359 6,659 conventional primary total hip procedures undertaken
for the treatment of osteoarthritis. Outcomes were compared to
uHip Resurfacing vs. Cementless Large Diameter Total almost 170,000 procedures using “fixed” neck femoral stems for
Hip Arthroplasty - Prospective, Randomized Clinical the same diagnosis. The cumulative percent revision (CPR) at
Trial seven years for exchangeable neck prostheses was 8.9% (7.9, 10.1)
Ville M. Remes, MD, Helsinki, Finland and this compared to 4.2% (4.1, 4.3) for “fixed” femoral stems
(HR 2.11 (1.90, 2.36) p<0.001). This difference was not affected by
Jukka Kettunen, MD, Kuopio, Finland
bearing surface. There were seven femoral stems with exchangeable
Keijo Makela, MD, Turku, Finland necks that had CPRs of at least three years. All had a high revision
Jukka Huopio, MD, PhD, Kuopio, Finland rate. The difference was due to an increased rate of revision
Hannu Miettinen, MD, Kuopio, Finland for loosening, dislocation and femoral prosthesis breakage.
Petri Virolainen, MD, Littoinen, Finland DISCUSSION AND CONCLUSION: The use of femoral stems
INTRODUCTION: Hip resurfacing arthroplasty (HRA) has gained with exchangeable necks in routine primary THA increases the
popularity during the last decade in treatment of symptomatic rate of revision by at least two fold. This appears to be true for all
hip osteoarthritis (OA) in young and active patients. Advocates of prostheses with longer than three years follow up.
hip resurfacing believe it has several theoretical advantages: bone
stock preservation on the femoral side, more physiological loading PAPER NO. 556
of the proximal femur, a low risk of dislocation due to large head Change in Serum Metal Ion Concentrations Following
and an easier revision operation than with conventional total hip
arthroplasty (THA). Most of these advantages of hip resurfacing
Revision of Metal on Metal Total Hip Arthroplasty
are theoretical and evidence from clinical trials is still lacking. Thomas E E. Brown, MD, Charlottesville, VA
METHODS: We randomized prospectively 152 consecutive Zhinian Wan, MD, Los Angeles, CA
patients (92 males, 60 females) aged 60 years of age or less Quanjun Cui, MD, Charlottesville, VA
undergoing surgery for severe hip OA in three university James A A. Browne, MD, Charlottesville, VA
hospitals to either cementless large diameter metal-on-metal INTRODUCTION: There has been growing concern regarding the
THA or HRA. Clinical, radiological and functional outcome was systemic and local effects of metal ions released from metal-on-metal
assessed pre-operatively, at three months, at one and two years. total hip replacements. There have been no studies comparing the
RESULTS: Between RHA and THA groups there were no difference serum levels of metal ions after converting metal-on-metal (MOM)
in Harris hip score preoperatively (62.7 (SD, 14.2) vs. 60.1 (SD, 11.4) to metal-on-polyethylene (MOP) total hip arthroplasty (THA). The
(ns)) or at the final follow up (96.3 (SD, 8.8) vs. 97.8 (SD, 4.5)) (ns). purpose of this study was to evaluate the change in serum metal ion
Corresponding numbers of UCLA activity score were preoperatively concentration following the conversion of MOM THA to MOP THA.
5.7 (SD 1.5) and 5.2 (SD 1.7) (ns) and postoperatively 7.2 (SD METHODS: From September 2010 to April 2011, 16 patients with
1.5) and 6.7 (SD 1.6) (ns) for RHA and THA groups respectively. symptomatic MOM THA were revised to a metal-on-polyethylene
DISCUSSION AND CONCLUSION: Outcome after large diameter bearing couple. Of these 16 patients, nine patients had bilateral
THA and RHA was similar in this prospective randomized MOM THAs and seven patients had unilateral MOM THAs. The nine
controlled trial. It is unclear if HRA have any benefits over patients with bilateral MOM had revision of the more symptomatic
conventional cementless large diameter THA. side, with retention of the other MOM THA. All patients had normal
renal function, based on blood chemistry. Serum levels of cobalt
PAPER NO. 360 and chromium were tested prior to the revision, and were repeated
The Use of Femoral Stems with Modular Necks in Total between six weeks to three months postoperatively. Changes in
Hip Replacement Increases the Risk of Revision levels of cobalt and chromium were analyzed with the paired t test.
RESULTS: The average blood levels of cobalt were 28.7 µg/L
Stephen Graves, MD, Adelaide, Australia preoperatively and 6.4 µg/L postoperatively (p=0.004). The average
Richard de Steiger, MD, Richmond, Australia blood levels of chromium were 16.9 µg/L preoperatively and 12.2
David Davidson, MD, University Of Adelaide, Australia µg/L postoperatively (p=0.009). Following revision, levels of
Kara Cashman, BSc (HONS), Adelaide, Australia both cobalt and chromium were decreased in all patients. The
Yen-Liang Liu, Adelaide, Australia concentration of cobalt decreased greater than that of chromium.
Philip Ryan, FAFPHM, Adelaide, Australia Prior to revision, patients with bilateral MOM THA exhibited higher
INTRODUCTION: Femoral stems with modular (exchangeable) blood levels of cobalt and chromium (43.5 and 23.9, respectively);
necks were introduced to enable surgeons to have increased choice patients with a unilateral metal-on-metal bearing surfaces had lower
with respect to determining femoral neck version, offset and length blood levels of cobalt and chromium (15.3 and 10.7, respectively).
during total hip arthroplasty (THA). It was hoped that this would Postoperatively, patients with bilateral metal-on-metal THA still
reduce complications in particular dislocation. There has, however, possessed elevated levels of cobalt and chromium (9.2 and 15.4,
been little published on the impact of introducing this new technology. respectively); the patients with a unilateral metal-on-metal cup had
METHODS: The data was obtained from a comprehensive national lower levels of cobalt and chromium (2.2 and 6.5, respectively).
database that prospectively recorded procedures using a range of Two patients had a normal metal ion level postoperatively.
prostheses with exchangeable femoral necks. Only procedures DISCUSSION AND CONCLUSION: Serum levels of cobalt and
with a primary diagnosis of osteoarthritis were included. Analyses chromium rapidly decreased following the conversion of metal-
were undertaken to examine the impact of age, gender, articulation on-metal to metal-on-polyethylene bearing surface in revision
bearing and the type of prosthesis used. The reasons for revision total hip arthroplasty. The pre-revision blood levels of cobalt
were also determined. The principal outcome measure was time and chromium were higher in patients with bilateral MOM THA.
to first revision using Kaplan-Meier estimates of survivorship. Following revision, levels of metal ions in the patients with
RESULTS: Femoral stems with exchangeable necks were used in bilateral MOM THA (and one side revised) were still higher than
in patients with revised unilateral THA. Following revision, Cobalt

levels decreased more than chromium levels in both groups. 67.2μg/L
Serum metal ion levels decreased rapidly following the conversion serum Co 2.74μg/L (0.8-21.2) 89.70% 7.4μg/L/month
(2.1-228)
of MOM to MOP THA. The significance of cobalt declining more
60.5μg/L
rapidly in both groups remains to be determined. Longer follow whole blood Co 3.0μg/L (0.3-26.4) 87.30% 8.9μg/L/month
(1.5-271)
up is warranted in order to evaluate the clearance of serum cobalt
and chromium ions following conversion of MOM to MOP THA. *all values reported are medians
DISCUSSION AND CONCLUSION: Metal ion levels come down
PAPER NO. 557 relatively quickly after revision of a malfunctioning implant,
especially if metal ion levels are high. This is consistent with
Metal Ion Levels after Revision of Large Head Metal- reports in the literature where symptoms associated with elevated
on-Metal Hip Replacements with Abnormal Wear metal ions subsided after removal of the metal implant prosthesis,
Karren M. Takamura, BA, Los Angeles, CA but this is the first to report on large group of large-head (>36mm)
Raghu P. Sidaginamale, Shrewsbury, United Kingdom MOM prosthesis.
Jamshid N. Gandhi, MBBS, Coxhoe, Durham, United
Kingdom PAPER NO. 558
Antoni Nargol, FRCS, Yarm, United Kingdom Are Metal Ion Levels a Useful Trigger for Surgical
David Langton, Gateshead, United Kingdom Intervention?
INTRODUCTION: Cobalt and chromium metal ion levels William L. Griffin, MD, Charlotte, NC
significantly decrease after revision of an abnormally wearing Thomas K. Fehring, MD, Charlotte, NC
metal-on-metal hip replacement (patients with metal ion levels James C. Kudrna, MD, Glenview, IL
above 7µg/L). There have been recent concerns regarding high Robert H. Schmidt, MD, Fort Worth, TX
metal ion levels and adverse reaction to metal debris (ARMD)
Michael J. Christie, MD, Nashville, TN
in patients with metal-on-metal (MOM) hip replacements.
Both the Medicines and Heathcare products Regulatory Agency
Susan M. Odum, Charlotte, NC
(MHRA) in the United Kingdom and the Food and Drug Anne C. Dennos, BS, Charlotte, NC
Administration (FDA) in the United States released warnings, INTRODUCTION: Adverse local tissue reactions have been reported
and metal ion testing has been recommended to monitor patients with a variety of metal on metal (MOM) implants. These reactions
with MOM hip replacements. Studies have shown metal ions to range from metallic staining of tissues to pseudotumors with peri-
correlate with component wear, and can be used as a diagnostic articular necrosis. It has been suggested that metal ion levels may
tool for monitoring bearing wear. High metal ions have been have prognostic value in determining timing or need for surgical
associated with the presence of pseudotumors, gross metallosis, intervention. The British Orthopedic Association’s alert concerning
and reports of cobalt toxicity have been reported. Currently, MOM implants chose ion levels of 7ppb as a threshold for concern.
it is unknown whether revising patients with high metal ions The purpose of this study was to determine if cobalt and chromium
and its associated problems return to normal after revision. ion levels can predict soft tissue damage at the time of revision.
METHODS: Twenty-eight patients with large-head MOM hip METHODS: This study included patients undergoing revision of a
replacements (average femoral size 44mm) were included in MOM hip and who had pre-operative Co and Cr ion levels. Tissue
the study. The study cohort included 24 female and four male damage noted at the time of revision surgery was graded on a four-
patients, whose metal ion levels were above 7µg/L in at least point scale. Damage scores were compared to ion levels and time in
one blood fraction. The 7µg/L was chosen as the cut-off, as this situ independently and in combination to determine a time/dose
was the suggested level by the MHRA where the patient may correlation. The data were also analyzed to determine an ion level
have problems associated with abnormal wear. There were 21 threshold that could serve as a trigger for surgical intervention.
unilateral patients and seven bilateral MOM patients. Eleven RESULTS: Eighty-four patients had Co and Cr ion levels obtained
were total hip replacements and 17 were hip resurfacings. Serum prior to revision of a symptomatic MOM hip. Ion levels ranged
and whole blood metal ion levels were taken pre-revision and from 0.8- 236ppb for Co, and 0-112ppb for Cr. There was a trend
post-revision. Statistical analysis was performed using SPSS. toward higher ion levels in cases with more severe tissue damage
RESULTS: Cobalt and chromium in both serum and whole blood (Co p=0.50, Cr p=0.99). Both Co and Cr ion levels had poor
decreased significantly post-revision (table 1) (all p<0.0001) after sensitivity and specificity values as predictors of soft tissue damage
an average time of 4.3 months post-revision (range: 1-41mos). (Co- 60%, 62%; Cr- 36%, 80%). The positive predictive values for
Pre-revision metal ion levels significantly correlated with the rate Co and Cr were only 46%, and 26% respectively. The length of time
of cobalt and chromium ion level decrease in all blood fractions to revision significantly correlated with tissue damage (p=.05).
(all p<0.0001). Whole blood cobalt decreased significantly faster DISCUSSION AND CONCLUSION: Co and Cr ion levels are
compared to whole blood chromium (p=0.03); however, there not reliable predictors of peri-articular soft tissue damage and
was no significant difference in the rate of change between serum should not be used in isolation as surgical intervention triggers.
cobalt and chromium (p=0.24). Furthermore, the 7ppb threshold was not a useful predictor of
damage.
Table 1.
pre %
post revision rate of change
revision change
43.4μg/L
serum Cr 9.5μg/L (3.3-41.5) 65.70% 5.6μg/L/month
(5.6-115)
30.6μg/L
whole blood Cr 8.48μg/L (4.3-28.8) 59.50% 3.5μg/L/month
(7.7-75.5)

PAPER NO. 559 hip replacement. The authors evaluated the results of a consecutive
non-selected series of revision cementless acetabular components
Survivorship and Revision Analysis Among Primary and compared these results to the same surgeon’s consecutive non-
Metal on Metal Total Hip Arthroplasty Using 36 mm selected series of cemented revision acetabular components at a
Diameter Heads comparable minimum 20-year follow up to determine whether
Kevin B. Fricka, MD, Alexandria, VA cementless fixation was more durable than cemented fixation.
METHODS: Sixty-one consecutive non-selected revision total hip
C. A. Engh, Jr, MD, Alexandria, VA
replacements were performed using a single cementless acetabular
William G. Hamilton, MD, Alexandria, VA component and a cemented femoral component, and followed
Henry Ho, MSc, Alexandria, VA for a minimum of 20 years. These results were compared to a
INTRODUCTION: It has been estimated that 35% of total hip consecutive non-selected revision series of 83 hips performed by
arthroplasty (THA) in the United States during the last decade the same surgeon using all cemented components and followed for
used metal on metal (MOM) bearings. However, there has a minimum of 20 years. Hips were evaluated for revision related
been a sharp decline in its use recently due to implant recalls, to loosening or wear, and radiographic evidence of loosening.
FDA surveillance and increasing reports of adverse local tissue RESULTS: At minimum 20-year follow up, the prevalence of
reactions (ALTR) which can present with elevated ion levels, revision of the acetabular component for aseptic loosening was
soft tissue/muscle damage, large fluid collections around the 0% in the cementless group and 18% in the cemented group
hip and pseudotumors. We report on the survivorship and (p = 0.0003). The radiographic loosening prevalence was 3.3%
reasons for revision among MOM bearings using a 36 mm head. in the cementless group and 32% in the cemented group (p =
METHODS: We reviewed our institutional database and 0.0001). In the cementless group, 11.5% required reoperation for
we performed 1,073 THAs using 36 mm MOM bearings wear of the liner (average wear 0.18 mm/yr in the revised group)
since 2001. We collected data on patient demographics, and the overall linear wear rate was 0.09 mm/yr for all cases.
presence of osteolysis, dislocation rates and reason for DISCUSSION AND CONCLUSION: This study demonstrates
revision. From this we calculated survivorship curves. a marked improvement with cementless fixation compared to
RESULTS: The follow up averaged 3.4 years with 24% of patients cemented fixation on the acetabular side of the construct in
having > five years follow up and 1% deceased. The average age revision total hip replacement at minimum 20-year follow up.
was 55.1 years with a body mass index of 28.9. Males accounted
for 50% of the patients. Osteoarthritis was the primary diagnosis PAPER NO. 561
in 83% of patients. The survivorship at three years with revision
Causes of Revision of Hip Resurfacings from a
as the end point was 98.6% and with reason secondary to ALTR
the rate was 99.5%. At six years, the survivorship rate was 96.7% European Specialist Independent Center
and 97.7% respectively. There were 21 (2%) revision surgeries Koen A. DeSmet, MD, Gent, Belgium
with 13/21 (62%) secondary to an ALTR. The remaining revisions Catherine Van Der Straeten, MD, St-Martens-Latem,
were for infection (2/21), aseptic loosening (5/21) and stem Belgium
fracture (1/21). Osteolysis was present in 30 (2.8%) patients, 27 George A. Grammatopoulos, MRCS, Oxford, United
had femoral lysis and three had pelvic lysis. There were seven Kingdom
dislocations with a mean time to dislocation of 1.58 years. The
dislocation rate was 0.65% and none of these patients required INTRODUCTION: Metal-on-metal hip resurfacing arthroplasty
revision surgery. In this series, the incidence of ALTR was 1.21% (HRA) has been used in increasing numbers to treat hip
and the mean time to revision secondary to ALTR was 5.1 years. pathologies in young and active patients. The reasons for HRA
DISCUSSION AND CONCLUSION: The 36 mm MOM THA revision have evolved with improving surgical experience
demonstrated good early survivorship with reoperations for and techniques. The aim of this study was to investigate the
dislocation reduced. Osteolysis was not eliminated with this causes of failure and the operative findings in all consecutive
bearing and over 60% of the revisions were MOM bearing HRA revisions performed at an independent specialist center.
complications secondary to the presence of an ALTR. Given the METHODS: Since 2001, 113 consecutive HRA revisions were
preponderance of early revisions secondary to metal bearing performed in 110 patients. Forty-three primary surgeries were done
complications and the absence of these types of revisions with at our center (43/113, revision rate: 1.3%), the remaining elsewhere.
cross-linked polyethylene bearings, we no longer recommend the Eight different HRA designs were revised mainly in females (60%).
use of metal bearings in THA. The mean time to revision was 31 months (0-101). Ion levels were
used as diagnostic tool since 2006. Components’ orientation
PAPER NO. 560 was measured from radiographs using EBRA. Histological
evaluation was performed at an independent specialist laboratory.
Cementless Acetabular Component Revision at RESULTS: All patients presented with some pain/discomfort.
Minimum 20-year Follow Up: Are We Improving Versus Mean time to revision was 31 months (0-101). Six HRAs were
Cemented Fixation? revised for fracture. The most common pre-operative reason for
revision included cup malpositioning (50%), usually excessive
Bryan N. Trumm, DPT, BS, Iowa City, IA abduction or anteversion. The most common intra-operative
John J. Callaghan, MD, Iowa City, IA finding was a bursa (44%) followed by impingement (34%)
Christopher A. George, MD, Chicago, IL and metallosis (31%) usually correlated with high metal ions.
Steve S. Liu, MD, Iowa City, IA There were gender-specific differences in component sizes
Devon D. Goetz, MD, West Des Moines, Iowa and causes of failure, with a higher incidence of component
Richard C. Johnston, MD, Iowa City, IA malpositioning, osteolysis, elevated metal ions, and metal
INTRODUCTION: Loosening of the acetabular component has sensitivity in women. Time to revision in patients with high
been the long-term problem associated with cemented revision total metal ion levels was shorter in patients with the ASR (21 months,
SD:10) in comparison to the BHR (38 months, SD: 25) (p=0.05).

DISCUSSION AND CONCLUSION: Component malpositioning pseudotumors in patients with painful metal-on-metal (MOM)
is the most common cause of HRA failure. Metal ion measurements hip arthroplasties. Pseudotumors are thought to indicate need for
are an excellent tool to detect wear at an early stage. The revision revision however they have also been reported in well-functioning
analysis highlights the importance of surgical experience, MOM hips. Comparing MRI findings of well functioning MOM
indications and prosthesis design. with ceramic-on-ceramic (COC) hips will help interpret the
significance of psuedotumors but there is currently no report of
PAPER NO. 562 such a study. Therefore, we aimed to compare COC with MOM hips
The Main Issue of Large Diameter MoM Total Hip for: (1) the prevalence of pseudotumors; and (2) muscle changes.
METHODS: We performed a case-control study to compare the
Arthroplasty: The Taper Junction MRI findings in MOM and COC hips. We defined cases as well-
Karren M. Takamura, BA, Los Angeles, CA functioning COC hip replacements and controls as well-functioning
David Langton, Gateshead, United Kingdom MOM hips. All primary hip replacements were performed using
Jamshid N. Gandhi, MBBS, Coxhoe, Durham, United posterior approach. Fifteen cases and 28 controls were recruited.
Kingdom All recruited patients underwent metal artefact reduction sequence
Antoni Nargol, FRCS, Yarm, United Kingdom (MARS) MRI. The Bal system was used to score the muscle atrophy.
Thomas Joyce, PhD, Newcastle Upon Tyne, United Kingdom RESULTS: We found 18 pseudotumours in this series. There
was no difference in age, gender, cup position, and Oxford Hip
James Lord, MSc, Newcastle Upon Tyne, United Kingdom
Score between controls and cases (Table 1). The prevalence of
Raghavendra P. Sidaginamale, Shrewsbury, United Kingdom pseudotumours in cases (1 hip; 6.7%) and in controls (17 hips;
INTRODUCTION: The modular junction of metal on metal (MoM) 60.7%) were significantly different (chi square p < 0.001). Glutei
total hip replacements (THR) is an important source of metallic debris. muscles were mostly normal or showed mild atrophy in both
This metallic debris can precipitate an immune response leading to groups (figures 1 & 2) while moderate to severe muscle atrophy
potentially catastrophic soft tissue damage as well as osteolysis. were common in obturator internus. There were no differences
METHODS: We carried out a prospective study using custom between MOM and COC in all muscle groups except piriformis.
techniques to analyze one of the largest collections of failed DISCUSSION AND CONCLUSION: This study has increased our
MoM THRs in the world. All explants from patients who understanding of the clinical relevance of MRI findings in patients
had suffered adverse reactions to metal debris (ARMD) were with hip replacements. The higher prevalence of pseudotumours
included in this study. These explants included: 40 36mm in MOM hips, when compared to COC hips, suggests that they
THRs (one manufacturer), and 90 resurfacing head THRs from are caused by either metal wear debris or large head size. Muscle
several manufacturers. Volumetric wear analysis of the bearing atrophy was uncommon in the glutei but common in obturator
surfaces and taper junctions was carried out using a coordinate internus in patients with well-functioning MOM and COC hips.
measuring machine. These values were compared to serum
and whole blood prerevision metal ion concentrations from
the corresponding patients. Scanning electron microscopy was
used to assess the chemical composition of the wear debris.
RESULTS: All explants retrieved from ARMD patients were found
to have abnormal areas of wear either at the bearing surface,
the taper junction or both. Characteristic patterns of wear were
identified on the internal surfaces of the tapers which appeared
to reflect exactly the morphology of the mated stems. Taper wear
depths reached in excess of 100 microns however rarely did
taper material loss exceed a volume of 4mm3. In only 50% of
patients with extensive taper damage were blood/serum metal ion
concentrations greater than the threshold suggested by the MHRA.
DISCUSSION AND CONCLUSION: Taper wear is a major cause of
concern for large head MoM THRs. It does not appear to be limited
to specific designs.
PAPER NO. 563

MRI of Well Functioning Hip Arthroplasties: Ceramic-
on-Ceramic vs. Metal-on-Metal
Ee Kew, London, United Kingdom
Shiraz Sabah, MD, London, United Kingdom
Donald Mcrobbie, PhD, London, United Kingdom
Keshthra Satchithananda, FRCR, London, United Kingdom
Adam Mitchell, MD, London, United Kingdom
Johann Henckel, BM, London, United Kingdom
Alexander D. Liddle, MBBS, London, United Kingdom
INTRODUCTION: Surgeons use magnetic resonance imaging
(MRI) to assess periprosthetic soft tissue changes, including

PAPER NO. 565
uCeramic-on-Metal Bearings in Total Hip Arthroplasty
can be Expected to Squeak: A Biomechanical Study
James Browne, MD, Charlottesville, VA
Qingshan Chen, Rochester, MN
Robert Trousdale, MD, Rochester, MN
INTRODUCTION: Ceramic-on-metal (COM) is a bearing couple that
has received recent attention for use in total hip arthroplasty. Among
other potential benefits, the differential hardness of this bearing
couple has been theorized to reduce or eliminate the potential for
squeaking, although no data exists to support or refute this claim.
METHODS: A custom-made hip simulator was used to examine
the COM articulation under different environmental and
clinical situations in vitro. The COM bearing consisted of a 36-
mm zirconia-toughened alumina ceramic head coupled with
PAPER NO. 564 a 56-mm acetabular component and a 36-mm metal insert.
Conditions for testing included normal gait, high load, and
Early Periprosthetic Fracture after Operation with an metal transfer, with each condition tested in both dry and
Uncemented Femoral Stem lubricated conditions. Results were compared to metal-on-metal
Truike M. Thien, MD, Mölndal, Sweden (MOM) and COC couples tested under the same conditions.
Göran Garellick, MD, PHD, Goteborg, Sweden RESULTS: Squeaking was reproduced in all dry conditions with
Leif I. Havelin, MD, Bergen, Norway COM and disappeared when a small amount of lubricant was added.
COM showed no difference in squeaking properties compared
Soeren Overgaard, Odense, Denmark
with MOM. Unlike a COC articulation, COM squeaking could not
Ove N. Furnes, MD, Bergen, Norway be reproduced with metal transfer in a lubricated environment.
Johan N. Karrholm, MD, Molndal, Sweden DISCUSSION AND CONCLUSION: Our observations suggest
INTRODUCTION: The survival of uncemented stems squeaking is a problem of lubrication in all hard-on-hard bearings.
has been inferior to cemented fixation in the Swedish The COM articulation should not be expected to eliminate
Hip Arthroplasty Register due to the occurrence of early squeaking in vivo. However, this biomechanical study suggests
periprosthetic femoral fracture. However, the incidence of COM squeaks more like a MOM articulation than a COC bearing.
periprosthetic femoral fractures is low and therefore large patient
cohorts are needed to study and evaluate probable causes. PAPER NO. 566
METHODS: We used the NARA-database, a collaboration of Revision for Failed Metal on Metal Hip Replacement
the Arthroplasty Registries in Denmark, Norway and Sweden
to evaluate whether age (<50, 50-59, 60-69, 70-79, >=80 years),
Brad L. Penenberg, MD, Beverly Hills, CA
gender, preoperative diagnosis and fixation play any role in the risk Michelle Riley, PA, Beverly Hills, CA
of periprosthetic fracture within two years from operation using William J. Maloney, MD, Redwood City, CA
Cox regression model. A total of 293,577 cemented (C) and 72,774 INTRODUCTION: Large head, metal on metal bearings in total hip
uncemented (UC) stems operated between 1995 and 2009 were replacement were introduced into the U.S. market in the late 1990s.
included. We used revision due to periprosthetic fracture as endpoint. This technology was of interest because of the reported very low
RESULTS: Uncemented stems were in general used at a lower wear rates. The hope was that with low wear, osteolysis, loosening
age, more frequently in males and in cases with secondary and revision surgery would be reduced. In addition, the large
osteoarthritis. The crude revision rate for cemented stems was femoral heads were attractive to surgeons because of the improved
0.03% and 0.07% and for uncemented stems 0.39 and 0.40% at hip stability associated with big heads. Over the last three years,
six months and two years, respectively. The Kaplan-Meier survival there has been increasing concern with adverse tissue reactions
rate at two years with use of revision due to periprosthetic fracture around these metal bearings associated with socket loosening and
as endpoint was 99.9% ± 0.01% for cemented and 99.5% ± 0.05% the need for revision surgery. The purpose of this study is to report
for uncemented femoral stems. Compared to the oldest age group on the pre-operative and intra-operative findings in a large series of
(=>80 years) the risk for revision due to periprosthetic fracture up revisions for failed large head, metal on metal total hip replacements.
to two years was decreased in the age groups 0 - 49 and 50 - 59 METHODS: Fifty-two patients underwent revision for failed metal
years (RR 0.40, 95% confidence limits: 0.25 - 0.66; 0.60 0.42 - 0.86, on metal total hip replacement. In all 52 cases, the patients had
p<=0.005, Cox regression). It was not influenced by gender, but a mono-block acetabular component. The pre-operative work-up
increased (compared to the group with primary OA) in patients for these patients evolved over time. All patients had pre-operative
operated because of hip fracture and non-traumatic femoral head x-rays. CBC, ESR and CRP were routinely checked. If there were
necrosis (RR 2.87, 2.23 - 3.67; 2.18 1.41 - 3.38, p<=0.001). Use of any concerns for infection, a hip aspiration was done and sent for
uncemented stem increased the risk for this early complication cell count and culture. At revision surgery, the character of the joint
(RR uncemented/cemented: 9.17, 7.35 - 11.49, p<0.0005). fluid was noted. More recently, serum cobalt and chromium levels
DISCUSSION AND CONCLUSION: Older patients and especially were checked. Histology was performed in all cases. Socket fixation
those operated with hip replacement due to hip fracture and non- was noted. Intra-operative cultures we routinely performed.
traumatic femoral head necrosis run an increased risk for early RESULTS: Fifty-one of 52 patients had pain which varied in
periprosthetic fracture. Even if the incidence of this complication intensity from mild to moderate. Although groin pain was the
is low, uncemented stems should be used with care in patients with most common presenting symptom, peri-trochanteric and buttock
these diagnoses. pain were also presenting symptoms. Socket fixation was often

difficult to assess radiographically. Serial x-rays were helpful in 45.5±17.9 [range = 9-86] preoperatively to 81.1±16.5 [range =32-
detecting subtle acetabular migration, obvious migration, gross 100] postoperatively [p <.05]. The mean follow up was 41 months
shift, or frank shell dislocation. Only 70% of symptomatic patients [range= 24-52 months] for conversion THRs. The average Harris
showed abnormal radiographs. Twenty-eight patients underwent Hip Score for patients with conversion THRs improved from
pre-operative aspiration. The WBC count was less than 3000/UL 40.0±11.3 [range = 28-57] preoperatively to 85.0±12.8 [range
in 23 patients. However, in five patients the cell count ranged from =66-97] postoperatively [p <.05]. The mean follow up was 45
3200 to 20400/UL despite being culture negative. Twenty-one months [range= 24-120] for primary THRs. The average Harris Hip
patients had pre-operative serum ion levels. Cobalt was elevated Score for patients with primary THRs improved from 42.3±14.9
in all but one with a range of 0.8 to 60.4mcg/L. The appearance [range = 9-77] preoperatively to 85.0±12.0 [range =51-100]
of the peri-articular tissues varied from normal appearing to postoperatively [p <.05]. All impaction grafted bone (allograft,
frankly necrotic. The joint fluid was cloudy in 31 of the cases autograft or a combination) incorporated radiographically, thus
and could easily be mistaken for pus. The socket was loose in restoring bone stock. Complications included one early infection
46 of the 52 cases. Histologic findings ranged from nonspecific which was managed successfully with debridement and liner
findings of chronic inflammation (giant cell reaction, histiocytic exchange; two late infections were managed successfully with
aggregates, and amorphous debris) to pulverized bone, necrosis staged revision. Two revisions required subsequent re-revision
and infiltration of lymphocytes, plasma cells and histiocytes for late loosening. There were two hip dislocations, one of
comparable to that of “ALVAL” or “pseudotumor” patients. which required surgical treatment to place a constrained liner.
DISCUSSION AND CONCLUSION: In this series of mono-block DISCUSSION AND CONCLUSION: Impaction bone grafting in
metal on metal hip replacements, the most common reason for primary, conversion and revision total hip replacement is a reliable
revision was pain associated with socket loosening. Given the surgical technique that restores bone stock in cases of major
likelihood of symptom persistence or progression, as well as the acetabular bone deficiency. When autograft bone is unavailable or
potential for adverse bone or soft tissue destruction, it seems insufficient in volume to fill the defect, the technique of impaction
appropriate to recommend early revision rather than observation. bone grafting using cancellous allograft bone croutons with or
It is not possible to tell whether the loose sockets were fixed at without autograft is highly successful, safe and reliable.
some point in time and then loosened as a part of the biologic
response to metallic wear products. The time to revision overall PAPER NO. 568
was quite short and it is likely that most of these sockets were Revision Total Hip Arthroplasty: Can Previous Operative
never integrated. There was no correlation between extent of tissue
damage and ion levels. Reports Be Relied on for Planning Purposes?
Nitin Goyal, MD, Arlington, VA
PAPER NO. 567 Mohan S. Tripathi, BA, Philadelphia, PA
Impaction Bone Grafting in Acetabular Reconstruction Claudio Diaz, MD, Philadelphia, PA
Matthew Austin, MD, Philadelphia, PA
for Complex Primary and Revision Hip Arthroplasty
Nilesh K. Patil, MD, State College, PA
Katherine Hwang, MS, Redwood City, CA INTRODUCTION: The need for revision total hip arthroplasty
(THA) as a growing population of patients outlives their prosthesis
Stuart B. Goodman, MD, Redwood City, CA
cannot be ignored. Component documentation during primary hip
INTRODUCTION: The reconstruction of major acetabular bone replacement is vital to the revision surgeon for preoperative planning.
defects during revision, conversion and primary total hip replacement In this study, we reviewed operative reports from the primary
(THR) is challenging. We reviewed a consecutive series of 168 hip operation in patients undergoing revision THA to determine if these
arthroplasties (108 revisions, eight conversions, and 52 primary reports contained complete information related to components.
total hip arthroplasties) performed by one surgeon between 1997- METHODS: All patients who underwent revision hip surgery
2008 using impaction bone grafting for acetabular reconstruction. at our center by one surgeon between January 2008 and May
METHODS: Autograft, cancellous allograft croutons, and 2011 were reviewed. Operative reports from previous hip
demineralized bone matrix were used to fill bone defects as arthroplasty performed at both our institution and outside
needed. Clinical data was gathered prospectively on standardized institutions were retrospectively reviewed for completeness
forms. The radiographs were reviewed by an independent with regard to details of components utilized. Operative reports
blinded orthopaedic surgeon. The acetabular bone deficiency was were considered complete if manufacturer, product and all
classified according to the American Academy of Orthopaedic pertinent dimensions of cup, liner, stem, and head were recorded.
Surgeons: Type I: segmental deficiency with significant rim RESULTS: Ninety-two patients who underwent revision surgery
defect; Type II: cavitary defects either medially or posteriorly; had operative reports from the primary surgery that were available
Type III: combined cavitary and segmental deficiency; Type IV: for review. Forty-seven of these patients had primary THA
pelvic discontinuity; and Type V: arthrodesis. This classification performed by 32 different outside hospitals/surgeons, while 45
was based on the pre-operative radiographs and intra-operative had the primary THA performed at our institution. Of 83 patients
findings after removal of the cup. According to this method, 56 requiring liner exchange, only 10 (12%) reports contained the
hips had Type I, 31 hips had Type II, 48 hips had Type III, and required information. Some 40% (47/92) of operative reports
27 patients had Type IV deficiencies. An additional six hips lacked information regarding the cup manufacturer, product or
had bone grafting of defects without removal of the stable cup. dimensions, while 28% (26/92) did not report cup manufacturer
RESULTS: Of the 168 patients, 19 subsequently died of causes and product name. A total of 18% of reports (17/92) failed to report
unrelated to the hip surgery, and 11 patients refused to return the femoral stem manufacturer and product name. One report
for clinical follow up and could not be contacted. All cases incorrectly recorded the product as a knee implant instead of a hip
had at least two years of follow up. The mean follow up was 43 implant while one did not record any implant characteristics at all.
months [range= 24-110 months] for revision THRs. The average DISCUSSION AND CONCLUSION: This study reveals the dismal
Harris Hip Score for patients with revision THRs improved from nature of component documentation during primary THA. As more

patients and younger patients are considered for joint replacement, METHODS: The Medicare 5% sample claims database was used
surgeons performing primary THA must be cognizant of recording to calculate the relative risk of PJI and mortality within 180
detailed implant characteristics to ensure that the future revision days post-operatively as a function of clinical and demographic
surgeon has all the pertinent information required to optimally characteristics in 53,252 primary THA patients between 1998
treat each patient. and 2009. Logistic regression using 29 comorbid conditions,
age, gender, race, and socioeconomic status (SES) were used as
PAPER NO. 569 inputs to estimate the probability of mortality and infection.
The Clinical Implications of an Elevated Blood Metal Ion RESULTS: The overall risk of PJI and mortality within 180 days
post-operatively was 1.31% and 2.2%, respectively. White
Result post MoM Hip Resurfacing women with hepatic and renal comorbidities, coagulopathy, and
David Langton, Gateshead, United Kingdom diabetes were at highest risk for PJI. White men with pulmonary
Jamshid N. Gandhi, MBBS, Coxhoe, Durham, United comorbidities, renal disease, dementia, and metastatic tumors
Kingdom were at highest risk for mortality. Low SES was associated with
Raghavendra P. Sidaginamale, Shrewsbury, United Kingdom increased risk of PJI and mortality. An electronic risk calculator
Karren M. Takamura, BA, Los Angeles, CA was developed to estimate the risk of PJI and mortality in Medicare
Antoni Nargol, FRCS, Yarm, United Kingdom THA patients based on their individual demographic and clinical
characteristics, compared with the rates for the entire Medicare
INTRODUCTION: Recent Medicines and Healthcare Products THA population and patients with similar demographics.
Regulatory Agency (MHRA) guidance suggests only patients DISCUSSION AND CONCLUSION: This information is important
with painful metal-on-metal (MoM) hip arthroplasties or when counseling elderly patients regarding the risks of PJI and
patients who have certain prostheses should undergo blood mortality following THA and for risk-adjusting publicly reported
metal ion testing. There is currently a lack of data describing the THA outcomes.
outcome of asymptomatic patients with elevated metal ion levels.
METHODS: In 2007, following unusual soft tissue reactions in PAPER NO. 811
patients with MoM hip resurfacings, routine blood chromium (Cr)
cobalt (Co) analysis was carried out in all senior author’s patients. uMid-Term Survival of Head and Liner Exchange
Patients who gave blood samples between 2007 and 2010 who Revision for Well-Fixed Acetabular Components
had no or “slight” pain were included in this study. Patients were Nathan A. Mall, MD, Oak Park, IL
assessed using the Harris hip and UCLA activity scores. Kaplan Muyibat A. Adelani, MD, Saint Louis, MO
Meier survival analysis was performed with patients censored if John C. Clohisy, MD, Saint Louis, MO
they had undergone revision or had been listed for revision prior
Robert L. Barrack, MD, Saint Louis, MO
to March 2011. Our previous work has shown a Co concentration
> 5µ/L to be highly sensitive and specific for abnormal wear. Ryan Nunley, MD, Saint Louis, MO
Patients were therefore subdivided according to Co: “Low” <2; INTRODUCTION: Aseptic loosening and osteolysis are common
“equivocal” 2 - 5; “increased” 5 - 10; “excessive” >10 (all µg/l). The problems. Performing a head and liner exchange (HLE) rather than
survivorship of these groups was compared using the log-rank test. full acetabular revision (AR) provides multiple advantages. We
RESULTS: There were 297 patients in total. At time of writing, determined the importance of acetabular component position and
25 joints had failed. All but one failure was attributed to adverse the type of polyethylene (conventional or highly crosslinked) liner
reaction to metal debris. Kaplan Meier survival analysis showed a used at the time of revision on mid- to long-term survival of HLE.
significant, sequential decrease in joint survivorship in the patient METHODS: A total of 144 patients underwent HLE for
groups progressing from “low” wear (99% at 80 months) compared aseptic loosening, osteolysis, or polyethylene wear with
to 32% at 80 months for the patients in the “excess” group. All patients minimum three-year follow-up (avg 6.3 years). Anteversion
in the “excess” group were found to have some degree of osteolysis. and inclination of the acetabular component were measured
DISCUSSION AND CONCLUSION: Elevated metal ion levels are on pre-revision radiographs. Implant records were reviewed to
associated with early joint failure even in asymptomatic patients. determine if conventional or HXLPE polyethylene liners were
used at the time of revision. All dislocations were recorded and
PAPER NO. 570 patients requiring additional revisions were deemed failures.
RESULTS: Average Harris Hip Score (81.4) and UCLA score (5.4)
Identifying the High Risk Total Hip Arthroplasty Patient were both significantly improved from pre-operative values
Kevin J. Bozic, MD, MBA, San Francisco, CA (p<0.05). There were 42 (30%) and 64 (46%) hips outside of the
Edmund Lau, MS, Menlo Park, CA safe zones for inclination and anteversion, respectively. Nineteen
Kevin Ong, PhD, PE, Philadelphia, PA of 144 hips (13%) were outside of the safe zone in both planes,
Steven M. Kurtz, PhD, Philadelphia, PA six of which required a repeat revision (32%). Fifty-two hips were
Thomas P. Vail, MD, San Francisco, CA inside both safe zones, only two of which required repeat revisions
Harry E. Rubash, MD, Boston, MA (4%).There were 13 (9%) repeat revisions; five for instability,
Daniel J. Berry, MD, Rochester, MN seven for progression of lysis, and one for infection. Seven hips
that were originally revised with conventional polyethylene
INTRODUCTION: Although individual patient risk factors
required additional revision surgery for progression of lysis.
have been identified for periprosthetic joint infection (PJI)
DISCUSSION AND CONCLUSION: Patients with appropriately
and postoperative mortality in total hip arthroplasty (THA)
positioned, well-fixed acetabular components can be treated with
patients, the interactions between those risk factors are poorly
an isolated HLE rather than AR with good long term outcomes
understood. The purpose of this study was to evaluate which
and survival. Acetabular components placed outside the safe zone
combinations of risk factors are associated with the highest
for inclination and anteversion were at highest risk for failure
risk of PJI and mortality, and to develop an electronic risk
and should be an indication for complete acetabular revision
calculator for PJI and mortality in Medicare THA patients.
regardless of fixation. Highly-crosslinked liners when compared to

conventional liners seem to halt or at least markedly slow the lytic
process following HLE.
PAPER NO. 646

uTopical Bisphosphonate Augments Fixation of Bone-
grafted Implants, BMP-2 causes Resorption-based
Instability
Jorgen Baas, MD, PhD, Aarhus C, Denmark
Marianne T. Vestermark, MD, PhD, Aarhus C, Denmark
Thomas Jakobsen, Aarhus, Denmark
Thomas H. Jensen, MD, Frederiksberg C, Denmark
Joan E. Bechtold, PhD, Minneapolis, MN
Kjeld Soballe, MD, Aarhus, Denmark
INTRODUCTION: Revision arthroplasties in osteopenic bone
may need bone-grafting, but healing is inconsistent. rhBMP-2
(BMP) is a potent stimulator of new bone formation, but also
accelerates bone resorption. The bisphosphonate (BP) zolendronate
induces osteoclastic apotosis and slows down bone resorption.
METHODS: In the present study the two drugs in combination PAPER NO. 647
and alone were studied in our canine model of impaction bone Pseudotumor in Metal-on-Metal Hips: Can a Blood
grafting. Cancellous bone grafts were soaked in either saline
or zolendronate solution and then added vehicle or rhBMP-2 Metal Ion Cut-off Level Indicate When to Perform MRI?
giving four treatment groups: A) control B) BMP C) BP and D) John Skinner, FRCS, London, United Kingdom
BMP+BP. The allograft treated with A,B,C or D was impacted into Shiraz Sabah, MD, London, United Kingdom
a circumferential defect of 2.5 mm around plasmaspray HA on Johann Henckel, BM, London, United Kingdom
Ti PoroCoat implants. Forty implants in 10 dogs were included. Keshthra Satchithananda, FRCR, London, United Kingdom
RESULTS: The group with allograft soaked in zolendronate only Adam Mitchell, MD, London, United Kingdom
was biomechanically better than all other groups (p<0.05). It had
less allograft resorption compared to all other groups (p<0.005)
without any statistically significant change in new bone formation. INTRODUCTION: The Medicines and Healthcare Regulatory
The addition of BMP-2 to the allograft did not increase new bone Authority (MHRA) in the U.K. recommends that patients
formation significantly, but allograft resorption was accelerated. with unexplained, painful metal-on-metal hip replacements
This was also the case were the allograft was treated with BMP-2 and (MOM-HR) be investigated with MRI if they have whole
zolendronate in combination. This caused a decrease in mechanical blood metal ion levels above 7ppb. However, diagnostic
implant fixation in both these groups compared to the control group, test characteristics for blood metal ion levels in the
however it was only statistically significant in the BMP-2 group. diagnosis of pseudotumor on MRI have not been reported.
DISCUSSION AND CONCLUSION: The study shows that topical METHODS: Fifty-one patients with unilateral, unexplained,
zolendronate can be a valuable tool for augmenting bone grafts painful MOM-HR were prospectively imaged using metal-artifact
when administered correctly. The use of BMP-2 in bone grafting reduction sequence MRI. Whole blood metal ions were measured
procedures seems associated with a high risk of bone resorption using inductively-coupled plasma mass spectrometry. Cases were
and mechanical weakening. defined as patients with pseudotumor on MRI, while controls had
no pseudotumor. Sensitivity, specificity and receiver operating
characteristic (ROC) curve analyses were performed for cobalt,
chromium and the maximum of either value (Max Co-Cr).
RESULTS: Thirty-four patients (67%) were diagnosed with
pseudotumor. Max Co-Cr in cases was median 7.3 (range 0.6-
386.5) parts per billion (ppb) and controls 3.2 (range 0.6-73.5)
ppb (p<0.05). The area under the curve (AUC) was 67% (52-
82%, 95% confidence intervals) for Max Co-Cr. The MHRA
cut-off had sensitivity 50% (33-67%), specificity 94% (69-
100%), positive predictive value 94% (71-100%) and negative
predictive value 48% (31-66%) for detection of pseudotumor.
DISCUSSION AND CONCLUSION: Pseudotumor was a common
diagnosis on MRI in unexplained, painful MOM-HR and was
associated with high blood metal ion levels. The MHRA blood
metal ion cut-off level of 7ppb increased the diagnosis rate of
MRI but missed half of all pseudotumors. Further research on
blood metal ion cut-off levels is needed to determine their role in
monitoring of MOM-HR.

PAPER NO. 648 between the LIA and saline control groups. Our multimodal
analgesia protocol provides satisfactory pain control with minimal
Evaluation of the Efficacy of Local Infiltration and side effects, and the addition of the LIA technique appears to
Infusion Analgesia for Total Hip Arthroplasty provide no further benefit.
Olga Solovyova, BS, Cromwell, CT
Sanjay Sinha, MBBS, Hartford, CT PAPER NO. 649
Stephanie Caminiti, APRN, Farmington, CT 2D Measurements of Cup Orientation in MoM Hips are
Courtland G. Lewis, MD, Farmington, CT Highly Inaccurate Compared to 3D-CT
INTRODUCTION: New techniques in postoperative analgesia, Kinner Davda, MD, London, United Kingdom
including local infiltration analgesia (LIA), aim to provide good Niall A. Smyth, MD, New York, NY
pain management and maximum muscle control while reducing
side effects. The objective of this study was to investigate the
use of intraarticular injections of RKA (0.2% ropivacaine, 15mg
Justin P. Cobb, MD, London, United Kingdom
ketorolac, and 0.5mg epinephrine) mixture and continuous Alister Hart, FRCS, London, United Kingdom
catheter infusions of ropivacaine as a method of postoperative INTRODUCTION: Cup malorientation in metal on metal hip
pain control for total hip arthroplasty (THA) patients. The arthroplasty (MoM HA) has been reported to cause significant
hypothesis was that, following surgery, continuous catheter complications associated with suboptimal outcome and
infusion of ropivacaine in addition to infiltration with RKA bearing failure. Several highly cited studies have assessed two
would result in lower pain scores and less narcotic consumption dimensional (2D) pelvic radiographs with one commercial
than infiltration with RKA alone, and both of these techniques software package to examine these relationships. To our
would be superior to patient controlled analgesia (PCA) alone. knowledge, there is no comparison between 2D and three
METHODS: In this prospective, double-blinded study, 105 patients dimensional (3D) computed tomography (CT) analysis for
were randomized into three groups, and surgeries were performed MoM HA. We aimed to establish the intra and inter observer
by three high volume arthroplasty surgeons. All patients received the reliability of each, and to compare the accuracy of cup orientation.
standard perioperative multimodal analgesia protocol consisting METHODS: Cup position was measured on the standardized
of celecoxib, pregabalin, acetaminophen, and a scopolamine patch. antero-posterior pelvic radiograph and low dose CT scans of
General laryngeal mask anesthesia was used for surgery. Before 100 consecutive patients from our MoM HA clinic. Ninety-
wound closure, the surgeon infiltrated the intraarticular space and six hips (92 patients) consisting of 93 resurfacings, and three
tunneled a catheter into the joint. The experimental treatment modular components were included; four radiographs were
protocol for the three groups was as follows: 1) Control group: inadequate and excluded. For reliability tests, 30 randomly
50cc infiltration of saline and a 5cc/hr catheter infusion of saline selected hips were measured by independent observers using
for 48 hours postoperatively; 2) RKA infiltration + saline infusion both imaging modalities, three times at two weekly intervals.
group: 50cc infiltration of RKA mixture and a 5cc/hr catheter RESULTS: Results of intra and inter observer reliability are
infusion of saline for 48 hours postoperatively; 3) RKA infiltration presented in Table 1. Bland Altman analysis demonstrated that the
+ ropivacaine infusion group: 50cc infiltration of the RKA mixture mean difference in inclination values between imaging modalities
and a 5cc/hr catheter infusion of 0.2% ropivacaine for 48 hours was 0.3°, with up to a 9° error. The difference in version was much
postoperatively. All patients were placed on a PCA pump which greater at 8°; 2D underestimates version by 21° or overestimates by
had 0.2mg of hydromorphone available to them every 10 minutes 5.2°. A significantly greater number of hips fell within a 10° safe zone
(no basal rate), for a maximum of 1.2mg/hr. Rescue medication of 45° inclination and 20° version, if cup orientation was measured
and epidural analgesia were available for breakthrough pain. by 3D CT rather than 2D (65% vs 24 % p<0.0001, Fisher’s exact test).
A power analysis (80% power) of data presented in previously DISCUSSION AND CONCLUSION: Inter and intra observer
published studies indicated that at a 95% confidence interval, 26 observations of inclination showed excellent reliability for both
subjects per group and one standard deviation of difference would modalities, suggesting the superior and inferior apices of a metal
provide statistically significant results. Primary outcome measures cup are readily identifiable for making this measurement. The 9°
were pain scores (scale of 0 to 10) and narcotic consumption, difference between the two may arise from errors in pelvic tilt,
assessed every four hours. Secondary outcome measures were rotation and obliquity known to occur in radiographs. Using 3D-
adverse side effects and patient satisfaction regarding the CT, pelvic orientation can be fixed and components analyzed from
analgesic protocol (poor, fair, good, or excellent). Analysis of a standard frame of reference regardless of patient position at the
Variance (ANOVA) was used to analyze group means using SPSS. time of scanning. Inter and intra observer reliability of cup version
RESULTS: The groups were demographically similar. There is poorer using 2D analysis than 3D-CT. Retroversion was evident
was no statistically significant difference in the administration in three hips on 3D CT, but not on plain radiographs (Figure
of intraoperative narcotics between the groups, nor in PACU 1). Errors in 2D version were likely to be due to the difficulty of
hydromorphone consumption. The pain scores upon PACU delineating the cup rim, obscured by a large diameter metal head
admission and discharge were comparable between groups. of same radio opacity. Scatter plots, such as Figure 1, have been
Furthermore, there was no significant difference between used extensively in the MoM HA literature. Such graphs may greatly
groups in the pain scores and hydromorphone consumption misrepresent the performance of a device, or surgeon if utilizing
on the floor. There were two to four adverse effects noted 2D values. Studies investigating the effects of cup malorientation
in each group, all of which were minor (nausea, vomiting, may be under or over reporting associations with pseudotumour,
lightheadedness, heartburn). The pain management metal ion levels and modes of failure. We do not advocate 2D
protocol was rated good or excellent by >95% of patients. assessment of cup orientation. The recently published analysis of
DISCUSSION AND CONCLUSION: Current literature suggests over 5,000 MoM hips using the software tested in this study needs
that LIA reduces postoperative pain and narcotic consumption. to be interpreted carefully. We suggest 3D-CT is a more effective
However, the results of this study indicate that there is no difference tool for this purpose with greater accuracy and reliability.

anteversion angles and in the anteversion error (p = 0.001) between
the imageless navigation and ultrasound-based navigation groups.
In addition, we observed a significant correlation between the body
mass index and the anteversion imageless navigation system group.
DISCUSSION AND CONCLUSION: Ultrasound-based navigation
improves cup positioning in total hip arthroplasty better than
imageless navigation system with surface registration by reducing
the percentage of outliers, achieving a higher accuracy of
anteversion, reducing the mean and the range anteversion error
between intraoperative displayed and postoperative measured cup
orientation. The higher precision seemed to be dependent on the
correctness of evaluation of landmAK, and is therefore influenced
by thickness of soft tissues.
PAPER NO. 651

The Outcome of Extensively Porous Coated Stems for
Revision Total Hip Arthroplasty
William J. Peace, MD, Denver, CO
Henry Ho, MSc, Alexandria, VA
Robert Hopper, PhD, Alexandria, VA
C. A. Engh, Jr, MD, Alexandria, VA
INTRODUCTION: As the number of total hip arthroplasties
(THA) performed continues to increase, so do the numbers of
revisions. Common diagnoses for femoral revision THA include
aseptic loosening, osteolysis, and periprosthetic fractures. The
tenants of revision femoral arthroplasty include obtaining
rotational stability, inhibiting axial implant migration implant
and restoration of hip biomechanics. The procedure of choice
at our institution has been the use of extensively porous coated
stems in revision THA; we have previously reported a 95%
survivorship at 10 years with this type of implant. The purpose
of this study was to review our institutional experience to date
PAPER NO. 650 and evaluate the longterm survivorship of femoral revision
THA using extensively porous coated cylindrical prostheses.
Use of an Ultrasound Based Navigation System METHODS: In order to identify our study population, we
for an Acurrate Acetabular Positioning in Total Hip queried our institutional database for all femoral revisions
Arthroplasty using extensively porous-coated stems with a cylindrical distal
geometry. Patient demographics, including gender, age at the
Georgi Wassilew, MD, Berlin, Germany time of revision and the original THA diagnosis were queried
Olaf Hasart, MD from our database. At the time of revision surgery, any cement
Carsten Perka, MD, Berlin, Germany residue if present was removed with curettage or high speed
Viktor Janz, MD, Berlin, Germany drill. When necessary, a trochanteric osteotomy was employed in
INTRODUCTION: Precise identification of bony landmAK order to gain adequate access to the femoral canal. The femoral
by use of pointer based navigation systems is influenced by the canal was prepared with sequentially larger cylindrical reamers
thickness of soft tissue. Ultrasound-based navigation systems prior to introduction of the revision stem. The surgical goal was
try to overcome the problems of positional deviation associated to obtain scratch fit over at least a 5 to 7cm segment of healthy
with soft tissue. The purpose of this study was to compare an diaphyseal bone. Stem fixation was assessed radiographically
ultrasound-based navigation system with an imageless navigation and classified as bone ingrown, fibrous stable, or loose according
system with surface registration in the postoperative acetabular to previously published criteria. Kaplan-Meier survivorship was
cup position. Additionally, we investigated the influence of the evaluated using femoral rerevision for any reason as an endpoint.
body mass index on the accuracy of both navigations systems RESULTS: The mean follow up among all 1,000 cases was 6.9 ±
METHODS: A prospective randomized controlled study of two 5.5 years (range, 0 to 26.8) years. Five-hundred-forty of the stem
groups of 40 patients each was performed. In the first group, revisions were followed less than five years, 218 were followed
cup positioning was assisted by an ultrasound-based navigation five to 10 years, 160 were followed 10-15 years, and 82 were
system and the second group, the cup was assisted by imageless followed 15 years or longer. Radiographically, 5% of the stems
navigation system with surface registration. Cup abduction were graded as loose, 7% were fibrous stable, and the remaining
and anteversion angles were measured on three-dimensional stems were bone ingrown. Kaplan-Meier survivorship using
computed tomography reconstructions postoperatively. stem rerevision for any reason as an endpoint was 98.6± 0.8%
RESULTS: One of the 40 cups (2.5%) in the ultrasound-based group at two years, 97.0 ± 1.3% at five years, 95.6 ± 1.8% at 10 years,
and 12 of the 40 cups (30%) in the imageless navigation group and 94.5 ± 2.3% at 15 years. There were no rerevisions after 12
were outside of the defined safe zone (outlier). This was statistically years. We have had 27 stems undergo rerevision: 14 for aseptic
significant (p = 0.001). We observed a statistical significance in the loosening, seven for implant fracture, four for infection and
two in conjunction with periprosthetic femoral shaft fractures.

DISCUSSION AND CONCLUSION: Mechanical loosening rates old or more (as compared with those who were less than 80 years
have been reported to be less than 5% at nominal 10-year follow old) was 1.5. Two underlying diagnoses occurring during follow
up when the level of femoral bone damage does not extend more up, cognitively impaired patients or neurologic disease, were
than 10 cm below the lesser trochanter prior to revision. When the also associated with a significantly greater risk of dislocation.
femoral bone damage extends more than 10 cm below the lesser DISCUSSION AND CONCLUSION: The cumulative long-term
trochanter, revision becomes more challenging. Prerevision bone risk of dislocation for patients with hip fractures is greater than has
stock is a factor affecting femoral fixation. We have documented been reported in short-term studies. The incidence of dislocation
lower survivorship when the femoral bone damage extends more is highest in the first year after arthroplasty and then continues at
than 10 cm below the lesser trochanter, but the overall survivorship a relatively constant rate for the life of the arthroplasty. Patients at
for these types of cases is 89% at 10-year follow up. Consistent highest risk are old female patients and those with a diagnosis of
with prior reports, failure to achieve bone ingrowth occurs in 10% neurologic desease. Dual mobility or constrained liners in these
to 20% of cases but the decision to rerevise a stem is typically patients is an efffective technique to prevent post-operative hip
driven by patient symptoms rather than radiographic appearance. dislocation.
Extensively porous-coated, cylindrical stems offer a straight-
forward surgical technique that can be used to address the full PAPER NO. 653
spectrum of femoral bone defects that are typically encountered at Gait Analysis after Total Hip Arthroplasty - Minimally
revision. We regard the use of cementless fixation with extensively
porous-coated cylindrical stems as the gold standard in the femoral Invasive Anterolateral vs. Conventional Lateral
revision setting. Approach
Stefan Landgraeber, MD, Essen, Germany
PAPER NO. 652 Henning Quitmann, MD, Essen, Germany
uCumulative Risk of Dislocation after THA for Sebastian Güth, MD, Freiburg, Germany
Fractures Decreased with Dual Mobility or Constrained Dominik Raab, PhD, Duisburg, Germany
Liners Wojciech Kowalczyk, Duisburg, Germany
Philippe Hernigou, PhD, Creteil France, France Andrés Kecskeméthy, PhD, Duisburg, Germany
Alexandre poignard, MD, Creteil, France INTRODUCTION: Minimally invasive (MIS) total hip
Charles- Henri Flouzat-lachaniette, MD, Creteil, France arthroplasty is claimed to be superior to the standard
technique because it reduces operative trauma. But there is
INTRODUCTION: Total hip arthroplasty (THA) has been still controversy as to whether minimally invasive total hip
efficacious for treating hip fractures in healthy older patients. arthroplasty enhances the postoperative outcome. The aim of
However, in these patients with fractures a widely variable this study, therefore, was to compare the outcome of patients
prevalence of dislocation has been reported, partly because of who underwent total hip replacement through an anterolateral
varying durations of follow up for this specific end-point. The minimally invasive approach or a conventional lateral approach.
purpose of the present study was to determine the cumulative risk METHODS: We performed a prospective study of 76 patients with
of dislocation in these patients with fractures and to investigate if primary hip arthritis. Only patients aged between 65 and 75 were
dual mobility or constrained liners decrease the risk of dislocation. included. Patients with a body mass index (BMI) of > 30 kg/m2
METHODS: Between 2000 and 2005, 125 patients with neck or severe concomitant diseases (tumor, neuronal disease) were
fracture underwent primary THA using a dual mobility (50 hips) excluded, as were patients who had arthritis or had undergone
or a constrained (75 hips) liner. The results of these 125 dual arthroplasty of other joints. Patients underwent unilateral total
mobility acetabular liners were compared with 180 THA without hip arthroplasty with an uncemented acetabular cup and a
dual mobility or without constrained liners performed for neck cemented stem either through a minimally invasive anterolateral
fractures in the same hospital between 1995 and 2000 by the same approach (n = 38) or a direct lateral approach (n = 38). Patients
surgical team. The mean age of the 305 patients was 75 years (65 were evaluated clinically using the WOMAC and Harris Hip
to 85). All patients were followed for a minimum of five years score and underwent motion capturing preoperatively and at 12
for radiographic evidence of implant failure. The patients were days, six and 12 weeks postoperatively. Gait analysis was carried
followed at routine intervals and were specifically queried about out using the three-dimensional eight-camera system. Typical
dislocation. The cumulative risk of dislocation and reccurent gait parameters, e.g. cadence, walking speed and step length, as
dislocation was calculated with use of the Kaplan-Meier method. well as diagrams with the characteristic of the angles, e.g. knee
RESULTS: For patients without dual mobility or without flexion/extension, hip flexion/extension and hip ab/adduction,
constrained liners, the cumulative risk of a first-time dislocation were taken into account. Additionally, a three-dimensional
was 5% at one month and 12% at one year and then rose at a force plate was applied to estimate ground reaction forces. A
constant rate of approximately 1% every year to 16% at five years. set of markers for the standard plug-in-gait marker placement
For patients with dual mobility liners, the cumulative risk of a for lower extremities was used for all measurements. During a
first-time dislocation was 1% at one month, 2% at one year and single session each subject walked over the measuring path (6
then did not change at five years. There were no differences in the m) five times. The data was processed using the manufacturer’s
mortality rates or in loosening rates among the treatment groups. reporting software and the object-oriented gait modeling software.
The rate of secondary surgery was highest in the group without RESULTS: Postoperative gait analysis showed significantly
constrained or dual mobility (10% for recurrent dislocation) better results in comparison to the preoperative measurements.
compared with 1% in the group treated with constrained or However, the mean difference between pre- and postoperative
dual mobility liners. In absence of constrained or dual mobility analysis was not significantly better in MIS than in the
liners, multivariate analysis revealed that the relative risk of conventional group. Physical examination also revealed
dislocation for female patients (as compared with male patients) no significant differences between the two groups.
was 2.1 and that the relative risk for patients who were 80 years DISCUSSION AND CONCLUSION: Both physical examination

and gait analysis showed that the conventional approach and the PAPER NO. 655
minimally invasive approach led to equally good operation results.
Therefore, both approaches can be equally recommended for hip
Prospective Randomized Study of Anterior vs. Postero-
replacement surgery. Gait analysis is a suitable method for hip lateral Approach for Total Hip Arthroplasty
research as it yields results which are equivalent to those obtained William P. Barrett, MD, Renton, WA
from physical examination. Shelly Turner, Renton, WA
INTRODUCTION: Proponents of direct anterior approach
PAPER NO. 654 total hip arthroplasty (THA) propose that the muscle sparing
Examination of an Accelerated Total Hip Arthroplasty nature of this procedure results in less postoperative pain, earlier
Protocol: Does the Patient Benefit? functional gains and the use of intraoperative fluoroscopy
results in reduced variability of acetabular cup position. We
Daniel M. Casey, PT, Boston, MA
conducted a prospective, randomized Institutional Review
Claire E. Robbins, PT, DPT, MS, GCS, Franklin, MA Board-approved clinical study comparing direct anterior THA
Stephen B. Murphy, MD, Boston, MA to a contemporary posterolateral THA to test these claims.
Daniel M. Ward, MD, Chestnut Hill, MA METHODS: The surgeon performed 43 direct anterior approach
David A. Mattingly, MD, Chestnut Hill, MA and 45 posterior approach THAs over a 16-month period.
Geoffrey J. Van Flandern, MD, Chestnut Hill, MA Standardized pre-op and post-op treatment protocols were
Carl T. Talmo, MD, Boston, MA utilized. Operative time, blood loss, analgesia use and length of
James V. Bono, MD, Boston, MA stay were recorded. The same acetabular and femoral components
Carla S. Hill, Needham, MA were used in all cases. Postoperative radiographs were reviewed
to assess cup orientation. Harris Hip, HOOS, UCLA Scores and a
INTRODUCTION: Since its debut over 10 years ago, minimally timed six-minute walk test captured pain and functional outcomes
invasive total hip arthroplasty (THA) has often been associated pre/post operatively. Osteoarthritis was the primary diagnosis
with accelerated and improved postoperative rehabilitation when in 95% of the procedures. Age and body mass index (BMI) did
compared to THA performed with a traditional surgical approach. not differ statistically between groups. Significantly more men
In recent years, some surgeons have taken the association to another were randomly assigned to the anterior approach (p=0.020).
level and introduced the “fast track” or “same day total hip.” The RESULTS: The operative time was longer and blood loss higher
success of these programs continues to be debated. The objective of in the anterior cohort (p<0.05). Pain medication usage was
this study was to investigate the effect of accelerated postoperative significantly lower in the anterior cohort during the hospital stay
rehabilitation and early mobilization on length of stay and hospital (p<0.05). At one month post-operatively the anterior cohort had
readmissions in patients undergoing THA at one institution. higher Harris Hip Function, Harris Hip Total, HOOS Sports and
METHODS: We retrospectively reviewed a consecutive series of 593 UCLA scores (p<0.03 for all). Three month scores also favored
patients who underwent THA at one institution between January the anterior cohort. Patients receiving the anterior approach were
31, 2011 and April 30, 2011. Six arthroplasty surgeons using varying discharged significantly sooner (2.3 vs. 2.7 days, p=0.0004).
surgical techniques participated. A total of 191 patients received Mean anteversion angles significantly differed between surgical
accelerated rehabilitation and were mobilized on the day of surgery approaches with a mean of 20.4° in the anterior approach and a
by physical therapy and nursing. The remaining 402 patients mean of 25.3° in the posterior approach (p=0.0353). Anteversion
were mobilized on postoperative day one, which is standard standard deviation was also reduced in the anterior cohort (4.5° vs.
protocol for the institution. Length of stay, discharge disposition 7.3°, p=0.0836). Abducation angles did not significantly differ with
and hospital readmission were assessed. Statistical analyses were respect to mean or standard deviation (45.4°+3.1 in the anterior
performed using t-test for means and Z-test for two proportions. cohort and 45.8°+4.3 in the posterior cohort). Anterior approach
RESULTS: Distribution of patients among the six surgeons was complications included one patient with severe pain and one with
similar. Length of stay for the accelerated rehabilitation group was delayed wound healing. Posterior approach complications included
2.16 days and for the standard group was 3.38 days. The difference one operative calcar fracture, one dislocation and one trochanteric
was statistically significant with a confidence level of 95%. One bursitis. DISCUSSION AND CONCLUSION: The direct anterior
patient was readmitted to the hospital within 30 days (.52%) in approach THA cohort required less post-op pain medication, half-
the early mobilization group compared to 19 re-hospitalizations day shorter hospitalization and patients had higher functional
(4.72%) in the postoperative day #1 mobilization group. Discharge scores at one and three months. There was less variability in the
disposition was similar for both groups with 78% being discharged acetabular cup anteversion. There were no functional differences
to home versus 22% discharged to a rehabilitation facility. at one year between the anterior and posterior cohort.
DISCUSSION AND CONCLUSION: This study highlights the
benefit of early mobilization in THA patients independent of the PAPER NO. 656
surgical technique used in influencing length of stay, hospital
readmission and discharge disposition. Our results support the uWhat are Safe Upper Limits in Well Functioning
use of an accelerated rehabilitation protocol at one institution Resurfaced Hips?
following total hip replacement surgery. George A. Grammatopoulos, MRCS, Oxford, United
Kingdom
Catherine Van Der Straeten, MD, St-Martens-Latem,
Belgium
Harinderjit Gill, PhD, Oxford/Oxon, United Kingdom
Koen A. DeSmet, MD, Gent, Belgium
INTRODUCTION: Metal-on-metal hip resurfacing arthroplasty
(MoMHRA) is a surgical option in the treatment of end-stage hip

disease. The measurement of systemic levels of metal ions gives PAPER NO. 657
an insight into the wear occurring (i.e. state of the bearing couple)
and is advocated by regulatory bodies as routine practice in the
Hip Resurfacing Arthroplasty Enables Faster Walking
assessment of resurfaced hips. However, there is still considerable and Longer Stride Length than Total Hip Arthroplasty
debate regarding the interpretation of measured metal ion values Justin P. Cobb, MD, London, United Kingdom
after MoM implantation. A fundamental question is “what are Anatole V. Wiik, MBBS, London, United Kingdom
the acceptable upper levels of chromium (Cr) and cobalt (Co) Angus Lewis, FRCS, London, United Kingdom
ions concentration beyond which the measurements become Andrew A. Amis, London, United Kingdom
clinically significant?”. The aim of this study is to address
this question in both unilateral and bilateral resurfaced hips. INTRODUCTION: Hip resurfacing arthroplasty (HRA) has been
METHODS: A total of 453 patients with unilaterally MoMHRA promoted as an alternative to standard total hip arthroplasty
and 139 patients with bilateral MoMHRA (assessment: >12 (THA), enabling patients with coxarthrosis to pursue higher
months post last surgery) were retrospectively identified from levels of function. However, patient reported outcome measures
an independent specialist hip center’s database. Routine metal and gait analysis have failed to distinguish between them at
ion levels were measured at last follow up (ICPMS protocol). normal walking speeds. Our null hypothesis was that the type of
Radiological assessment included measurement of acetabular arthroplasty would not predict postoperative top walking speed,
component orientation using EBRA, calculation of the contact and that there would be no difference between the operated and
patch to rim (CPR) distance, and evaluation for any adverse X-ray un-operated hip. The study was powered to detect a 5% difference.
findings. The cohort was divided into the well functioning group METHODS: A case control study was performed using 63
(Group A) and the non-well functioning group (Group B). In order subjects (21 THA , 21 HRA, 21 healthy controls, all matched for
for a resurfacing to be well functioning, all of the following criteria age and gender.) The experimental groups were a minimum of
had to be fulfilled (bilateral patients had to fulfill criteria for 24 months after their hip arthroplasty. All had been performed
both hips): 1. No patient reported hip complaints, 2. No surgeon through a posterior approach, and had been discharged from
detected clinical findings, 3. HHS> 95, 4. CPR distance> 10mm, routine follow up by the two senior authors, one who performs
5. No abnormal radiological findings and 6. No further operation HRA when appropriate, and the other who has always used THA.
scheduled. Upper levels (acceptable limits) of Cr/Co were considered On an instrumented treadmill, each subject was measured by a
to be represented by the top margin of the box-whisker plot [upper researcher blinded to which procedure the patient had undergone.
limit = 75th quartile value + (1.5 x interquartile range)] in Group A. After a six-minute acclimatization period at 4km/hr, the speed
RESULTS: A total of 251 unilateral MoMHRAs patients (55%) and was then increased incrementally until either the subject felt
58 patients with bilateral MoMHRAs (42%) comprised Group A. uncomfortable, or gait symmetry had deteriorated. At all intervals,
The majority of males were in Group A compared to the majority of measurements were taken for both limbs including: speed,
females who belonged in Group B (p<0.001); subsequently Group cadence, stride length, step length, impulse, progression angle,
A patients had bigger size components (p<0.001). Unilateral base of support, maximum forces at heel strike, mid-stance and
Group A [Cr: 2.0 µg/l (SD: 1.5)/ Co: 1.8µg/l (SD: 1.2)] patients push off. The procedure generally took 12 minutes of continuous
had significantly lower ions than Group B [Cr: 7.3µg/l (SD: 17.3)/ walking and was completed without difficulty by all subjects.
Co: 6.6µg/l (SD: 18.1)] patients (p <0.001). Similarly, Group A RESULTS: The two experimental groups were well matched for
bilateral patients [Cr: 3.8µg/l (SD: 2.7)/ Co: 2.8µg/l (SD: 1.9)] had age, sex, Oxford Hip Score (HRA 45 vs. THA 46), BMI (29.4 vs.
significantly lower ions that Group B [Cr: 10.7µg/l (SD: 16)/ Co: 29.5), leg length (91.7 vs. 91.5cm) and at preferred walking speeds
8.5µg/l (SD: 15.8)]. The upper levels (safe were: Cr: 4.6µg/l / Co: were indistinguishable. However at top walking speed (TWS)
4.0µg/l for unilateral MoMHRAs and Cr: 7.4µg/l / Co: 5.0µg/l for the HRA group were able to walk significantly faster, achieving a
bilateral MoMHRAs). Unilateral MoMHRAs had significantly higher mean of 2.08m/sec (range 1.39 -2.50) compared to THA with a
ion levels compared to bilateral patients (p <0.001). Sensitivity mean of 1.89m/sec, (range 1.53-2.22 p=0.01). This 9% difference
and specificity of these upper levels in predicting poor function appears to be due to a longer stride length at higher speeds (173
were respectively 25% and 95% for Cr and 22% and 96% for Co. vs. 163 cm) and higher cadence (141 vs. 136 steps/min). Of the
DISCUSSION AND CONCLUSION: The findings of this study other variables, the peak force asymmetry recorded in the THA
suggest that both unilaterally and bilaterally resurfaced patients group at heel strike did not reach significance. The mean gait
with well functioning implants have low metal ion levels with upper cycle at top speed of the two groups is illustrated (Figure 1).
levels of Cr: 4.6µg/l / Co: 4.0µg/l for unilateral MoMHRAs and Cr: DISCUSSION AND CONCLUSION: This small, blinded, case
7.4µg/l / Co: 5.0µg/l for bilateral MoMHRAs These results indicate control study is the first to focus on high end performance following
that the upper acceptable limit of metal ion levels in resurfaced hip arthroplasty, encouraging patients to achieve as high a speed
hips is lower than the previously MHRA recommended threshold, as they comfortably could. The THA group in this study walked
however the study was conducted with very low tolerance for what 9% faster than the previously published top speed of 1.73m/sec,
was considered a clinically problematic hip. Well-functioning however the HRA group still walked 9% faster again, matching
bilateral resurfacing have higher ion levels compared to well- the normal controls for speed and stride length. At higher speeds,
functioning unilateral resurfacing. in the THA group, the operated leg was spared peak loads at heel
strike, while the HRA and control groups reMEd symmetric (figure
1). This is not randomized data, but the use of age and sex matched
patients and a control group allow some tentative conclusions to
be drawn. The use of an instrumented treadmill has been shown
to be a useful tool, providing reliable continuous data at higher
speeds than can be achieved in a conventional gait lab. For patients
who are interested in higher performance, this data suggests
that an HRA may enable a more normal gait at higher speeds.

Patients with solid pseudotumors and extensive soft tissue
destruction should be revised.
Table 1. Comparison of factors that may be linked to pseudotumor in 149
patients with MOM-HR that had MARS MRI performed at our centre.
Control
Case group
group (No p Value
(Pseudotumor)
Pseudotumor)
Study number 81 patients 68 patients -
Age at primary surgery
54 (28-74) years 52 (21-66) years p=0.088
[median (range)]
Duration from primary surgery
32 (5-93)
to MRI 27 (3-64) months p=0.536
months
[median (range)]
Gender 29M:52F 20M:48F p=0.485
Bilateral? 28/81 patients 32/68 patients p=0.134
PAPER NO. 658 Oxford Hip Score/48 30 (2-48) 29 (4-45) p=0.186
uRisk Factors for Pseudotumor in Metal-on-Metal Hip Maximum of either cobalt or

chromium in whole blood
5.3 (0.6-386.5) 4.6 (0.6-162.3)
p=0.145
Replacements [median (range)]
ppb ppb
Shiraz Sabah, MD, London, United Kingdom 63 Resurfacing 57 Resurfacing

Karuniyan V. Vipulendran, Haverfordwest, United Kingdom Implant Type 17 Modular 6 Modular p=0.069
Johann Henckel, BM, London, United Kingdom 1 No data 5 No data
Keshthra Satchithananda, FRCR, London, United Kingdom 5 Adept 3 Adept
Adam Mitchell, MD, London, United Kingdom 9 ASR 10 ASR
28 BHR 26 BHR
Anastasia Papadaki, MSc, London, United Kingdom Manufacturer 4 Biomet 3 Biomet
Donald McRobbie, PhD, London, United Kingdom 15 Cormet 13 Cormet
John Skinner, FRCS, London, United Kingdom 5 Durom 4 Durom
Alister Hart, FRCS, London, United Kingdom 15 Other/No Data 9 Other/No Data
INTRODUCTION: Pseudotumors are sterile, inflammatory Inclination

49 (31-78) deg 49 (13-66) deg p=0.467
lesions associated with large-diameter metal-on-metal hip [median (range)]
replacements (MOM-HR). They may be diagnosed using cross- Version
20 (-22-47) deg 25 (-47-51) deg p=0.399
sectional imaging during the investigation of an unexplained, [median (range)]
painful MOM-HR. Pseudotumors are an important clinical 35 Malpositioned
problem due to their association with unexplained hip pain 29 Malpositioned
Malposition? 18 Well- p=0.493
10 Well-positioned
and rare reports of devastating periprosthetic tissue damage. positioned
We aimed to investigate risk factors for pseudotumor and Head size
to determine which were associated with poor prognosis. 48 (38-58) mm 46 (40-58) mm p=0.457
[median (range)]
METHODS: We conducted a case-control study in 149
CRP 5.0 (0.4-236.0) 2.0 (0.4-159.0)
consecutive patients that had metal artifact-reduction sequence p=0.355
[median (range)] mg/L mg/L
MRI performed at our center. We identified 81 cases with
pseudotumor (three solid, 78 fluid-filled) and 68 controls Table 2. Comparison of 81 patients with pseudotumor on MARS MRI to
without pseudotumor. We analyzed demographic, prosthesis, determine factors that may be associated with poor prognosis.
positioning and serological data. We performed subset analyses Painful Well-functioning p Value
in the pseudotumor group to compare well-functioning
patients (n=21) with patients with unexplained pain (n=60). Study number 60 21 -
RESULTS: Solid pseudotumors were all painful, but were Age at primary surgery
54 (28-73) years 56 (33-74) years p=0.302
uncommon when compared to fluid-filled pseudotumors. [median (range)]
Distributions of risk factors for pseudotumor are presented in Table Duration from primary
1. No significant differences between groups were found for any surgery to MRI 28 (5-78) months 32 (8-93) months p=0.072
risk factor. Risk factors that may be important in prognostication [median (range)]
in pseudotumor patients are presented in Table 2. Female sex Gender 15M:45F 14M:7F p=0.001
(p=0.001), raised blood metal ion levels (p=0.003) and small
Bilateral? 22/60 patients 6/21 patients p=0.599
head size (p=0.027) were associated with painful pseudotumor.
DISCUSSION AND CONCLUSION: There are currently no obvious Oxford Hip Score/48 25 (2-45) 39 (24-48) p=0.000
risk factors for pseudotumor in MOM-HR. All common implant Maximum of either cobalt or
types are affected, whether they are well-functioning or painful. 3.2 (1.2-41.0)
chromium in whole blood 8.7 (0.6-386.5) ppb p=0.003
ppb
Our data agrees with published studies in that female sex, raised [median (range)]
blood metal ion levels and small head size were associated with 18 Resurfacing
poor clinical status. However, we found the presence of a fluid- 45 Resurfacing
Implant Type 2 Modular p=0.214
filled pseudotumor was not and provide this new information. 15 Modular
1 No data

5 Adept 0 Adept section of the exposed population. Although the medium term
9 ASR 0 ASR results of MoMHA appear good this sensitization causes concern
23 BHR 5 BHR for the long term survivorship prospects of these bearings.
Manufacturer 4 Biomet 0 Biomet
8 Cormet 7 Cormet
4 Durom 1 Durom
7 Other/No Data 8 Other/No Data
Inclination
49 (31-78) deg 48 (39-62) deg p=0.970
[median (range)]
Version
20 (-22-46) deg 21 (0-47) deg p=0.323
[median (range)]
26 Malpositioned 9 Malpositioned
Malposition? p=0.552
14 Well-positioned 4 Well-positioned
Head size
46 (38-58) mm 49 (44-58) mm p=0.027
[median (range)]
CRP 5.0 (0.4-236.0) 2.0 (0.8-73.0)
p=0.503
[median (range)] mg/L mg/L
PAPER NO. 659

uHigh Incidence of Nickel Sensitization at 10-Year
Review of Metal-on-Metal Arthroplasty
Hena Ziaee, Birmingham, United Kingdom PAPER NO. 660
Joseph Daniel, FRCS, Birmingham, United Kingdom Do Ceramic on Polyethelene or Ceramic on Ceramic Hip
Chandra Pradhan, FRCS, Brinmginham, United Kingdom Implants Add Value?
Derek McMinn, FRCS, Birmingham, United Kingdom
Thomas K. Comfort, MD, Stillwater, MN
INTRODUCTION: Metal-on-metal hip arthroplasties (MoMHA) Penny Tatman, MPH, Saint Paul, MN
have been shown to fail through a unique macrophage and
Susan C. Mehle, Saint Paul, MN
lymphocytic vasculitis dominated pattern which has been
variously described as pseudotumours, adverse reactions
Kathleen Killeen, OT, Woodbury, MN
to metal debris, etc. The underlying reason for this is often INTRODUCTION: Surgeon preference for choice of bearing
related to excessive metal debris released from the device in surface in total hip arthroplasty (THA) has changed over time.
most cases. In some patients these reactions are found even Traditional metal on polyethelene (MOP) THAs have known
in the presence of low metal ion levels, indicating an immune shortcomings so alternative bearing surfaces have been developed
hypersensitivity type of reaction. A histological ALVAL score has to solve these problems. Recent failures of metal on metal have
been used to differentiate the two types of reactions. Lymphocyte made ceramic on poly (COP) and ceramic on ceramic (COC)
transformation test (LTT) is one means of assessing the sensitivity bearing surfaces more popular. However, recent studies have
of a patient to metals although its reliability is clinically unproven. failed to show significant differences in survival of these THAs.
METHODS: This is a minimum 10-year review of the first 350 METHODS: All COP (n=609) and COC (n=168) THAs performed
consecutive patients (402 hips) who had been treated with MoMHA in our community registry between 2002 and 2010 were compared
including all ages and diagnoses. Mean age of the patients is 53 years to a group of MOP THAs (n=1196) done in the same time frame.
and mean body mass index (BMI) 26.3. Twenty-five patients (30 Analysis was performed to compare cumulative revision rates
hips) died during the 10 years, 23 hips (22 patients) were revised (CRR) and the risk of revision (RR) for the three groups. Analysis
and 12 patients (13 hips) were lost to follow up. A total of 241 was done using Kaplan Meier methods and Cox regression.
patients (277 hips) attended the review and consented to donate RESULTS: COC/COP THAs were done in younger patients,
blood for the test. Blood was drawn in sodium citrate cuvettes were more expensive, had a shorter follow-up period, were
and transported to the laboratory within 24 hours. Testing was more often diagnosed with aseptic necrosis, and more often
performed by a technique called memory lymphocyte immuno- had a smaller head size than the MOP THAs. There was no
stimulation assay against cobalt, chromium, molybdenum, nickel, significant difference in the CRRs between the COP (3.0%),
titanium and aluminium at two concentrations for each metal. COC (5.6%), or MOP (3.3%) THAs (p=0.17). There was also no
RESULTS: The reactivity rate in the patient population using difference in the RR between COP and MOP THAs (hr = 0.97,
this technique is low against aluminium (1.1%), cobalt (1.1%) p=0.95) or between COC and MOXP THAs (hr=1.32, p=0.53)
and chromium (0.4%), moderate against molybdenum after adjusting for age, year of index procedure, and head size.
(8.3%) and titanium (3.6%) and high against nickel (52%). DISCUSSION AND CONCLUSION: Alternative bearing surfaces
DISCUSSION AND CONCLUSION: The limitation of this for THA has been pursued because of component loosening /
study is the absence of a control group of patients without osteolysis in MOPs. Most of the evidence supporting the use of
metal implants. However on comparison of these results to these alternative surfaces has been from laboratory performance
published figures from non-exposed population, it is evident data. Our study showed no difference in the survival of COP or
that patients with modern metal-on-metal hip arthroplasty COC THAs over traditional MOP THAs. Although longer term
are being sensitized to nickel. Nickel constitutes only a small follow up may demonstrate lower rates of wear/osteolysis for
percentage (<1%) of the cobalt-chrome alloy used in MoMHA COC/COP THAs, currently we cannot justify the additional cost
and is present only as a contaminant. However the small of these components.
amounts released from the bearing appear to sensitize a large

PAPER NO. 766 large cyst; AVN > 50%; LLD > 1cm). Patients wore the AM on their
ankle for one week pre-operatively and at one year postoperatively.
THR Compared to IF for Femoral Neck Fractures: A RESULTS: Both groups showed statistically significant
Randomized, Controlled Trial with a Seventeen Year improvement in activity after surgery for the average number of
Follow Up steps per day (p=0.003) and percentage of time at high levels of
Ghazi Chammout, SR, Stockholm, Sweden activity (p=0.0066). There was also a decrease in the percentage
of inactivity for both groups (p=0.0157). Additionally, the THA
Sebastian S. Mukka, MD, FRCS, Sundsvall, Sweden
group significantly increased the percentage of time at medium
Andreas Stark, JR, Stockholm, Sweden (p=0.0018) and low (p=0.0013) levels of activity. The only
Olof Skoldenberg, MD, Stockholm, Sweden significant difference between the two groups was change in
INTRODUCTION: The aim of this trial was to compare inactivity after surgery that favored the THA group (p=0.0496).
total hip replacement (THR) and internal fixation (IF) over DISCUSSION AND CONCLUSION: Step activity monitoring data
a long-term follow up of 17 years with regards to hip function, indicates that both SRA and THA patients increase activity levels
mortality, re-operation rate and clinical outcome for elderly, following surgery, but we found no objective evidence to support
healthy patients with a displaced femoral neck fracture (FNF). the claim that SRA patients are more active than THA patients.
METHODS: We enrolled 100 patients; 79 women, 21 men,
median 79 (range 65-90) years, with a pre-injury healthy hip, PAPER NO. 768
in a single-center, randomized controlled trial. Subjects were
Labral Tears Seen in MRI: What is the Significance?
randomly assigned to surgery with THR (n=43) or IF (n=57).
The primary end point was hip function, evaluated with Harris
Ronald Huang, Philadelphia, PA
hip score (HHS). Secondary end points included mortality, re- Kurt Yusi, MD, Waynesville, NC
operation, gait speed and activities of daily life (ADL). Follow-up Fiona Carty, MD, Castleknock, Ireland
was done after three months and one, two, four, 11 and 17 years. William Morrison, MD, Philadelphia, PA
RESULTS: HHS was significantly higher in the THR group with a Javad Parvizi, MD, Philadelphia, PA
mean difference throughout the study period of 14.3 points (95% CI INTRODUCTION: Acetabular labral tear is becoming an
8.7 to 19.9,p<0.001, ANOVA]). There was no difference in mortality increasingly common diagnosis with orthopedic surgeons
between two groups. After 17 years, 10 (23%) patients in the THR facing patients who have been given an MRI diagnosis of labral
group and 27 (53%) in the IF group had been re-operated (relative tear. The significance of labral tear seen on the MRI is still
risk with IF 2.3; 95% confidence interval [CI], 1.3 to 4.1; P=0.003). not well understood. It has been our experience that a large
DISCUSSION AND CONCLUSION: In healthy, elderly patients number of patients presenting with labral tear in a symptomatic
with a displaced FNF, THR yields, without increasing mortality, hip also have evidence of labral tear in the contralateral and
a better hip function and significantly fewer re-operations over a often asymptomatic hip. The intention of this study was to
long term period. determine the incidence of labral tear in asymptomatic hips.
METHODS: Patients undergoing MR arthrogram for unilateral hip
PAPER NO. 767 or pain were included in this study. Patients were excluded if they
Step Activity Levels after Surface Replacement and had documented bilateral hip pain, no labral pathology was present
Total Hip Arthroplasty in a Young Active Population on the affected side, or if patients had recent hip or pelvic surgery. A
total of 176 studies met the inclusion criteria. Radiologist readings
Ryan Nunley, MD, Saint Louis, MO of both the affected and asymptomatic sides were compared. This
Erin Ruh, MS, Saint Louis, MO study is ongoing with a plan to include a total of 777 MR arthrograms
Robert L. Barrack, MD, Saint Louis, MO of the hip done within the past three years at our institution.
INTRODUCTION: There has been recent interest in surface RESULTS: Labral tear was seen in 158 of 176 symptomatic hips. Of the
replacement arthroplasty (SRA) as an alternative to total hip 158 patients with a labral tear on their symptomatic side, 20 patients
arthroplasty (THA), although there is limited objective data (12.7%) also had a contralateral labral tear that was asymptomatic.
to support claims that SRA allows patients to be more active DISCUSSION AND CONCLUSION: The relatively high presence of
postoperatively. Rating scales for THA were developed in the 1960s, labral pathology in contralateral and asymptomatic hip reinforces
and, consistent with indications at that time, excellent score required the notion that presence of a labral tear on cross sectional imaging
only pain relief, normal walking, and successful basic activities of may not be a clinically significant finding and certainly does not
daily living. Despite the application of hip arthroplasty procedures warrant surgical intervention in all. Even in the presence of labral
to a younger, more active, more demanding patient population, pathology (tear, cyst, detachment, and so on) meticulous clinical
these same subjective rating scales are still utilized. If no difference evaluation should be performed to determine the exact cause of
in any objective clinical measure can be demonstrated, continued hip pain. This study is most likely underreporting the incidence
support for SRA will be difficult to justify given the rising concerns of labral pathology in asymptomatic hips, as arthrogram of the
over metal on metal articulations. The purpose of this study asymptomatic hips were not performed.
was to objectively determine the functional outcomes following
SRA compared to THA using a step activity monitoring device.
METHODS: We prospectively enrolled 64 young, active patients
(35 SRA and 29 THA) to wear an activity monitor (AM), which
measures duration and level of activity, total number of steps
taken per day, and distinguishes between patterns of activity and
inactivity. Inclusion criteria: Males age ≤ 65 and females age ≤ 55, pre-
symptomatic UCLA score ≥ 6, BMI ≤ 35, and a desire to return to high
impact activities. The THA group consisted of patients meeting the
inclusion criteria but with a contraindication precluding SRA (e.g.,

Does Periacetabular Osteotomy Modulate Hip Cartilage Medical Complications and Mortality Following Lower
Biochemistry? A Prospective dGEMRIC Study Limb Arthroplasty in the English NHS
David Stelzeneder, MD, Boston, MA Simon Jameson, Middlesbrough, United Kingdom
Tallal C. Mamisch, MD, Bern, Switzerland Axel Weusten, MD, Newcastle Upon Tyne, United Kingdom
Nitya Krishnan, MS, Singapore, Singapore Philip James, PhD, Alcester, Warwickshire, United Kingdom
Jenny Chan, BS, Boston, MA Ignacio Serrano-Pedraza, PhD, Madrid, Spain
Michael B. Millis, MD, Boston, MA Robert Sanders, MBBS, London, United Kingdom
Young Jo Kim, MD, Boston, MA Mike R. Reed, MBBS MD, Northumberland, United Kingdom
INTRODUCTION: The aim of this study was to prospectively assess INTRODUCTION: Medical complications and death are rare
proteoglycan content in patients with developmental dysplasia events following elective orthopaedic surgery. Diagnostic
of the hip (DDH) undergoing periacetabular osteotomy (PAO). and operative codes are routinely collected on every patient
METHODS: Thirty-six hips of 36 patients (mean age 25.5±8.9 admitted to hospital in the English NHS (hospital episode
years, range 13-45) undergoing PAO were included in this statistics, HES). This is the first study investigating rates of these
prospective cohort study. Patients with DDH and a lateral center events following lower limb arthroplasty in the English NHS.
edge angle < 16 degrees were included. Patients with more METHODS: All patients (559,017 patients) who underwent
severe osteoarthritis (Tönnis grade greater or equal to II) and hip (THR) or knee arthroplasty (TKR) between March 2005
neuro-muscular disorders were not eligible. To assess cartilage and February 2010 were analyzed. Patients were subdivided
proteoglycan content delayed Gadolinium Enhanced MRI of based on Charlson co-morbidity score. Ninety-day medical
Cartilage (dGEMRIC), scans were performed pre-operatively and complications - myocardial infarction (MI), cerebrovascular event
one year post-operatively for each patient. A 1.5T MR system and (CVA), chest infection (LRTI), acute renal failure (ARF), and
a fast 3D isotropic T1 mapping sequence (four minutes scan time) pulmonary embolus (PE) - and inpatient mortality were extracted.
were used. The regions of interest (ROIs) were selected on five RESULTS: The overall 90-day in-hospital MR after THR was
radial reformats along the acetabulum: anterior, anterior-superior, 0.44% (1130 of 256350 patients) and 0.34% (1034 of 302667)
superior-anterior, superior, and superior-posterior radial slices after TKR. MI rate was 0.43-0.52%. Of these 14.3% died. LRTI
were generated in 30 degree steps. Anatomic landmAK around rate was 0.72-0.74%. Of these 12.2% died. RF rate was 0.42-
the acetabulum were used to register the pre and post-operative 0.48%. Of these 14.1% died. PE rate was 0.65-0.80%. Of these
scans. On each of the five radial reformats, the acetabular cartilage 3.9% died. Patients were more likely to die following LRTI than
was evaluated. Pre-operative x-rays were evaluated for Tönnis PE (Odds ratio 3.40 [95% confidence intervals 2.82-4.08]). TKR
osteoarthritis grade. In addition to a global analysis, the data were patients with chronic obstructive pulmonary disease (COPD)
subdivided into tertiles (thirds) of pre-op dGEMRIC index (12 were more likely to have a post-operative LRTI than patients
per group) to assess the dGEMRIC changes in patients with a low, without COPD (OR 3.92 [3.36-4.58]). For THR patients, this was
intermediate, and high dGEMRIC index. Paired t-tests were used. higher (OR 4.96 [4.28-5.75]). In patients with no co-morbidities,
RESULTS: The pre-operative Tönnis grade was 0 (normal) in 23 no personal history of venous thromboembolism, and no
and I (minimal OA changes) in 13 patients. The dGEMRIC index post-operative complications (47% of all patients in this study,
of the total cohort decreased from 575.8±139.8 milliseconds 261,222 of 559,017), mortality was only 0.1% (257 patients).
(ms) pre-op to 520.3±130.3 ms one-year post-op; however, DISCUSSION AND CONCLUSION: This national data analysis
these values are within the normal range for healthy subjects allows a greater understanding of mortality risk following post-
(570±90 ms). The tertile cohort of low pre-op dGEMRIC index operative complications, and provides robust information for the
showed a significant increase in dGEMRIC index: 430.4±74.5 vs. consenting process. Despite the concerns regarding VTE and the
456.8±118.8 ms (pre-op vs. post-op; p=0.02). On the other hand high investment in prevention, fatal PE is in fact far less common
the intermediate and high pre-op dGEMRIC cohorts showed a than mortality after MI, LRTI and RF. This data also shows that
decrease (within the normal range): 576.9±31.4 vs. 515.0±117.8 the risk of mortality for fit patients without post-operative
and 717.7±103.1 vs. 587.9±120.6 ms (p<0.001 for both). complications was very low.
DISCUSSION AND CONCLUSION: In vitro and in vivo studies
have shown that cartilage proteoglycan content can be modulated PAPER NO. 771
by mechanical stress and furthermore, in vivo dGEMRIC studies Total Hip Arthroplasty for Femoral Neck Fracture:
have shown that physical activity can modulate knee cartilage
proteoglycan content (Tiderius et al, Magn Reson Med. 2004). Comparing Outcomes to an Elective Patient Population
Our results demonstrate an increase in proteoglycan concentration Adam Sassoon, MD, Rochester, MN
after osteotomy in cartilage areas with low pre-op dGEMRIC index Michele R. D’Apuzzo, MD, Charlottesville, VA
(mild degenerative changes). In areas with normal and higher than Stephen A. Sems, MD, Rochester, MN
normal pre-op dGEMRIC index (intermediate and high dGEMRIC Joseph R. Cass, MD, Rochester, MN
cohorts), the proteoglycan content decreased to normal range after Tad M. Mabry, MD, Rochester, MN
osteotomy. It can be assumed that this decrease in proteoglycan
INTRODUCTION: Total hip arthroplasty (THA) remains a
content is related to decreased mechanical loading resultant from
treatment option for femoral neck fractures. In an elective setting,
increased femoral head coverage after osteotomy. Hence, PAO
THA is a successful procedure and can be used as a benchmark
for hip dysplasia appears to modulate cartilage proteoglycan
with which to compare the results of THA following a fracture.
concentration into a more normal range after surgery. A “healing
METHODS: Patients from the National Hospital Discharge
response” of mildly degenerated acetabular hip cartilage after PAO
Survey treated with a THA for osteoarthritis (OA) and femoral
is suggested by these data.
neck fracture (FNF) between 1990-2007 were selected for
comparative analysis. The age, pre-operative health, post-

operative complication rate, post-operative disposition, points) to a post-operative mean of 86 points (range, 55 to 100
and mortality rate were examined and compared between points). Of the 44 hips who had previous resurfacing arthroplasty,
groups at six-year intervals (‘90-‘95, ‘96-‘01, ‘02-’07). there were four revisions for aseptic reasons (91% survivorship);
RESULTS: A total of 2,160,061 primary THA procedures were there were two aseptic revisions in 48 hips that had a history
performed for OA, while 174,641 were performed for FNF. of core decompression (96% survivorship); and three aseptic
There was a difference in the mean age between the two groups, revisions in 121 hips that had no history of prior surgical treatment
which was 68 and 79, respectively. The peri-operative mortality (98% survivorship). Although the survivorship was higher in the
rates following elective and post-traumatic THA were 0.2% cohort of patients who did not undergo prior surgical procedures,
and 1.7% for the first interval, 0.1% and 2.9% for the second there was no difference when compared to either patients who had
interval, and 0.3% and 0.8% for the third interval (p<0.001). The prior resurfacing (p=0.08), or prior core decompression (p=0.62).
percentage of patients with diabetes, the length of stay, and the DISCUSSION AND CONCLUSION: This study reports excellent
percentage of patients discharging to a rehab facility were higher overall survivorship of 96% in this difficult patient population
in the FNF group at each time interval. Acute dislocations were at mid-term follow up. Although patients who had prior surgical
more frequent in the FNF patients during the first and second interventions, especially those who had undergone resurfacing
intervals, but this was not observed during the last time interval. arthroplasty, had slightly lower survivorship when compared to
DISCUSSION AND CONCLUSION: In comparison to primary those who had not, there was no statistical difference in the results.
elective THA for OA, THAs performed in patients with a FNF result This indicates that joint preserving procedures, including core
in higher peri-operative mortality rates, longer hospital stays, and decompression and bone grafting procedures, do not adversely
a greater need for post-operative inpatient rehabilitation. While affect the outcomes of later total hip arthroplasty. In light of
once greater in the FNF population, dislocations between the this, it is the opinion of the senior authors that joint preserving
elective and FNF groups have recently equilibrated. This may be procedures should be attempted whenever appropriate, taking
due to increased use of larger femoral heads. into account the level of collapse and stage of disease at time of
presentation, prior to total hip arthroplasty. When arthroplasty is
PAPER NO. 772 ultimately required, it is encouraging that the overall survivorship
Total Hip Arthroplasty in Osteonecrosis: Does Prior is high in this difficult to treat young patient population.
Treatment Affect Long Term Outcome? PAPER NO. 773

uDoes the Patient Know Best? Sports and Satisfaction
Qais Naziri, MD, Baltimore, MD
Harpal S. Khanuja, MD, Cockeysville, MD after Total Hip Arthroplasty
Aaron J. Johnson, MD, Baltimore, MD Andrew S. Parker, MD, Houston, TX
Adam Brekke, San Antonio, TX
INTRODUCTION: Osteonecrosis can be a challenging disease
for the orthopaedist to treat, especially since these are young Kenneth B. Mathis, MD, Houston, TX
patients who present with end stage hip disease. Consequently, Gregory W. Stocks, MD, Houston, TX
many joint preserving procedures, such as core decompression, Robert L. Barrack, MD, Saint Louis, MO
bone grafting, or bone sparing procedures such as resurfacing Ryan Nunley, MD, Saint Louis, MO
arthroplasty are utilized in an attempt to preserve as much Andrew J. Shimmin, MD, Windsor, Australia
femoral bone stock as possible in these patients. Historically, Philip C. Noble, PhD, Houston, TX
total hip arthroplasty has been considered a last resort for these
INTRODUCTION: Many patients expect to recover normal hip
patients after all other treatment options have been exhausted,
function after total hip arthroplasty (THA), and often return to the
mainly due to historically poor reported implant survivorship.
sports they enjoyed prior to surgery. Surgeons have recommended
The purpose of this study was to assess the clinical and
against participation in many of these demanding activities because
radiographic outcomes of standard total hip arthroplasty in all
of their risk to the patient and to implant survival. The purpose of
patients who were treated by a single surgeon for osteonecrosis
the study was to determine if participation in demanding activities
to determine if prior surgical treatments affected outcomes.
after THA causes an increase in pain, symptoms, or dissatisfaction.
METHODS: Between 2001 and 2010, 213 total hip arthroplasty
METHODS: A total of 143 patients (51% male, avg. age 62.9)
procedures were performed in 192 patients who had a primary
were enrolled in the study with IRB approval. All patients
diagnosis of osteonecrosis. There were 125 men and 88 women
underwent primary, unilateral THA and had no co-morbidities.
who had a mean age of 41 years (range, 13 to 81 years) at time
At a minimum of one-year post-op, each patient completed a
of total hip arthroplasty, a mean body mass index of 27 kg/m2
self-administered Hip Function Questionnaire, consisting of an
(range, 15 to 46 kg/m2), and a mean follow up of 75 months
inventory of 124 activities and a survey of the patients’ symptoms,
(range, 24 to 125 months). Patients were stratified according
pain and satisfaction. An activity score was also calculated for
to prior surgical intervention for osteonecrosis: there were 42
each patient, based on their frequency of participation and the
patients (44 hips) who had a prior resurfacing arthroplasty, 45
demand level of each activity. Patients were separated into high,
patients (48 hips) who had prior core decompressions or bone
medium, and low demand groups and compared statistically.
grafting procedures performed, and 105 patients (121 hips) who
RESULTS: A total of 31% of patients were classified as high-demand
had no prior surgical intervention. Additionally, there were nine
(HD), 31% as medium-demand (MD), and 38% as low-demand
patients who had failed hemiresurfacing artrhoplasty procedures.
(LD). There was no significant difference between groups in terms
All hips were graded according to the Ficat and Arlet classification
of: frequency of hip pain (23% ; p=0.89), hip stiffness (18%;
system. Outcomes were assessed to determine overall implant
p=0.95), or use of pain medications (5%; p=0.98). Fewer HD
survivorship, time to revision surgery, and Harris hip scores.
patients reported that their hip feels normal (81%) compared to MD
RESULTS: There were nine revisions for aseptic reasons, for an
(95%; p=.02) and LD patients (89%; p=.03). However, more high-
overall implant survivorship of 96%. The mean Harris hip scores
demand patients were extremely satisfied (86%) than medium-
improved from a pre-operative mean of 45 points (range, 30 to 60

demand (64%; p=.007) or low-demand patients (71%; p=0.03). PAPER NO. 775
DISCUSSION AND CONCLUSION: Despite the risk of
participation in sports and other high-demand activities, patients
Real Time Visualization of Femoroacetabular
do not seem to experience increased incidence of pain or symptoms Impingement and Subluxation Using 320-slice
compared to those who are sedentary. High-demand patients seem Computed Tomography
to be aware of persistent symptoms yet are satisfied to maintain an Georgi Wassilew, MD, Berlin, Germany
active lifestyle.
Viktor Janz, MD, Berlin, Germany
PAPER NO. 774 Carsten Perka, MD, Berlin, Germany
INTRODUCTION: Femoroacetabular impingement results from
Spinal vs. General Anesthesia in THA: An Analysis unphysiological femoroacetabular contact and causes hip pain as
using Prospectively Collected Clinical Patient Data well as premature hip osteoarthritis. As the symptoms are related
Steven J. MacDonald, MD, London, ON, Canada to function, it may be difficult to identify a femoroacetabular
Matt C. Lyons, MD, Mosman, Australia impingement (FAI) on standard radiographs. The purpose of the
Lyndsay Somerville, PhD, London, ON, Canada present study was to identify anatomical factors predisposing a
James Howard, MD, London, ON, Canada femoroacetabular impingement and assess the diagnostic accuracy
of dynamic four-dimensional volume computed tomography in
Doug Naudie, MD, London, ON, Canada
the preoperative diagnosis of femoroacetabular impingement.
James P. McAuley, MD, London, ON, Canada METHODS: On dynamic four-dimensional volume computed
Richard W. McCalden, MD, London, ON, Canada tomography (CT) 30 patients with hip pain (> 3 months)
Robert B. Bourne, MD, London, ON, Canada and positive clinical and radiological impingement signs
INTRODUCTION: The pros and cons of general anesthesia were prospectively analyzed. The dynamic investigations
versus spinal anesthesia in total hip arthroplasty (THA) has been were performed in flexion, as well as in abduction and
a long debated topic. The purpose of this study was to compare external rotation. The accuracy of the computed tomography
the surgical times, blood loss and transfusion requirements measurement was tested by comparison of the preoperatively
between anesthetic types in patients undergoing primary THA. evaluated impingement with the intraoperative findings during
METHODS: A consecutive series of 1,600 THA procedures surgical dislocation, which were defined as the gold standard.
with complete preoperative and postoperative data were RESULTS: The rate of anterior and posterior impingement as
evaluated. Twenty-eight percent of procedures were performed noted at the time of surgical dislocation was 90% (27 of 30)
with a general anesthetic (GA), 67% with a spinal anesthetic and 70% (21 of 30). Compared to the intraoperative findings,
(SP) and 5% with a combination of the two. Outcomes were the dynamic CT images showed a high agreement. Additionally
compared and tested for significance using the Independent significant correlations were found between decreased hip
Samples Kruskal Wallis or Pearson Chi-Square analysis. flexion and a decreased acetabular anteversion and between a
RESULTS: Comparing GA and SP respectively, there was a decreased external rotation and an increased beta and combined
statistically significant difference in patient age between the groups posterior angle. On four-dimensional computed tomography a
(age 63.73 ± 14.5 vs. 66.6 ± 12.8, p<0.05), but not in ASA scores posterior-caudal subluxation was observed in 12 patients and
and distribution, or preoperative hemoglobin levels (131.74 ± 32.5 an anterior subluxation was found in 21 patients DISCUSSION
vs. 133.21 ± 28.9). There was a statistically significant difference AND CONCLUSION: Four-dimensional computed tomography
in length of time proceeding surgical procedure favoring Generals is a suitable method to dynamically visualize the functional
(SP: 35 mins (10 - 72) vs. GA: 30 mins (8 - 65), p<0.05), however consequences of anatomical FAI pathologies. The location of the
overall time in room was longer in Generals (GA: 132.83 ± 29.0 vs. impingement can be accurately determined and, when combined
SP: 127.15 ± 22.5). There was a statistically significant difference in with information about possible chondral damage supplied by
discharge hemoglobin favoring Spinals (SP: 97.9 ± 14.2 vs. GA: 94.9 magnetic resonance arthrography, allows the surgeon to select
± 16.4, p<0.05), lower transfusion rates (SP: 8.4% vs. GA: 14.0%, the optimal surgical access and plan the required operation for
p<0.05) and shorter length of stay (SP: 4.9 days vs. GA: 5.3 days, minimal invasiveness.
p<0.05). The patients receiving a combination of anesthetic had
a significantly greater length of time until surgical procedure (43
mins (20 - 145)) and overall time in room (142.85 ±27.2) compared
to both GA and SP, however were similar in all other outcomes.
DISCUSSION AND CONCLUSION: In this consecutive series of
patients undergoing general anesthesia, spinal anesthesia and
a combination for total hip arthroplasty, the general anesthesia
cohort demonstrated advantages in statistically significantly
shorter time proceeding the surgical procedure, however the overall
procedure time was significantly longer. The spinal group had less
blood loss and lower transfusion rates and the combination group
had statistically longer procedure times compared to both GA and
SP.

PAPER NO. 777
Patient-rated Expectations of Surgery for
Femoroacetabular Impingement
Anne F. Mannion, PhD, Zurich, Switzerland
Franco M. Impellizzeri, PhD, Zurich, Switzerland
Florian D. Naal, MD, Zurich, Switzerland
Otmar Hersche, MD, Fribourg, Switzerland
Michael Leunig, MD, Zurich, Switzerland
INTRODUCTION: Patients’ expectations are an important
determinant of their subsequent assessment of treatment
outcome. To date, no studies have been carried out
investigating expectations in relation to minimal invasive
hip preservation surgery for femoroacetabular impingement
(FAI); this was the aim of the present prospective study.
METHODS: Before surgery, 127 patients completed a
PAPER NO. 776 questionnaire booklet containing the Oxford Hip Score (OHS),
their motivation for undergoing surgery, and Likert-scales rating
Impingement-free Hip Range of Motion in the degree of improvement that they expected in various domains
Asymptomatic Young Adult Males (pain, general function, sport, walking capacity, independence,
Brian Larkin, MD, University City, MO social function, mental well-being). Twelve months post-
Marnix Van Holsbeeck, MD, Detroit, MI operatively, 84 patients answered questions regarding the actual
perceived improvement in each of these domains, the global
Ira Zaltz, MD, Royal Oak, MI
outcome of surgery (5-point Likert-scale: operation “helped
INTRODUCTION: Femoroacetabular impingement is an a lot” through to “made things worse”) and the OHS again.
identifiable mechanical cause of chondrolabral injury that can RESULTS: The alleviation of pain was the most common reason
lead to end stage hip arthritis. There is very little normative data for deciding on surgery, being the top or second-top reason in 61%
published on dynamic hip range of motion and the degree of patients. Further, 58% patients declared that an improvement in
impingement-free hip flexion in asymptomatic people. Dynamic hip pain would be the single most important change leading them
ultrasonography can demonstrate labral anatomy and femoral to declare the operation had helped; for 24%, it was the ability
morphology in multiple positions. The purpose of this study is to do sport, and for 15%, an improvement in general function.
to define (1) impingement-free hip range of motion until labral Compared with the actual improvement recorded at 12 months,
deflection and (2) the maximum degree of hip flexion when prior expectations had been overly optimistic in more than 50%
further flexion is limited by femoroacetabular impingement. of patients for hip pain, sport, and general function, and in 33-
METHODS: Forty asymptomatic adult male volunteers (80 hips) 48% patients for mental well-being, independence, and walking
between the ages of 21 and 35 underwent bilateral hip ultrasound capacity. There was no significant relationship between baseline
static and dynamic examination. Femoral morphology was expectations per se and global outcome. In multiple regression the
characterized and mid-sagittal flexion range of motion was measured significant unique predictors of a good global outcome were: higher
at two points: (1) when labral deformation was identified and (2) 12-month OHS (=better pain and function), and expectations
maximum flexion when the femur impinged upon the acetabular rim. being fulfilled for pain, mental well-being and sport (each p<0.05).
RESULTS: The mean age of the subjects was 27.9 ± 3.1 years and DISCUSSION AND CONCLUSION: In this patient group,
the mean body mass index (BMI) was 25.2 ± 3.8. All femoral expectations of surgery were overly optimistic. Having one’s
heads were found to be spherical. Thirteen subjects were identified expectations fulfilled was important for a good outcome. The
with varying degrees of anterolateral head-neck junction CAM results emphasize the benefit of assessing patient-orientated
morphology, bilateral in three and unilateral in 10 individuals. outcome in routine practice and the factors that might influence
The overall incidence of CAM findings in the study was 16/80 it, such that realistic expectations can be established for patients
hips (20%). Soft tissue impingement occurred prior to bony prior to surgery.
impingement in all hips. Average impingement-free hip flexion
measured from full extension to initial labral deflection was PAPER NO. 778
comparable side to side: right 68.3 ± 17.2 degrees and left 68.3 ±
16.2 degrees. Maximum mid-sagittal flexion, measured at the time The Validity of Using Administratively Coded
of bony impingement was 97.0 ± 5.9 degrees on the right and 95.9 ± Complication and Comorbidity Data in TJA
6.4 degrees on the left. Subjects with CAM morphology impinged Kevin J. Bozic, MD, MBA, San Francisco, CA
at lower degrees of flexion than morphologically normal hips. Ravi Bashyal, MD, Oak Park, IL
DISCUSSION AND CONCLUSION: The surgical alteration of hip Shawn G. Anthony, MD, MBA, Boston, MA
anatomy for the purpose of increasing impingement-free range
Brandon Shulman
of motion requires knowledge of normative data. This study
demonstrates that labral deflection occurs at less flexion than bony
Vanessa Chiu, MPH, San Francisco, CA
impingement in asymptomatic young adult males. Maximum Harry E. Rubash, MD, Boston, MA
hip flexion in asymptomatic males is approximately 95 degrees, INTRODUCTION: Administrative claims data have increasingly
significantly less flexion than previously considered normal. been used in public reporting of total joint arthroplasty (TJA)
outcomes and ’value-based’ physician and hospital payment
strategies. However, the accuracy and validity of administrative
claims data, particularly with respect to revision TJA procedures, is

unknown. The purpose of this study was to evaluate the concordance (49%), however it was relatively rare in the knees (14%), in
between administrative claims and the clinical record for 13 the shoulders (7%) and ankles (4%). Surgical treatment was
commonly reported comorbidities and complications in TJA patients. required in 221 hips (37%), 17 knees (3%), and four ankles (1%).
METHODS: Administratively coded diagnosis and procedure DISCUSSION AND CONCLUSION: From our investigation, it
codes obtained from hospital billing records from 1,350 was evident that steroid-induced multiple necroses occurs in high
consecutive primary and revision TJA procedures performed at frequency. We believe that systemic damage of the terminal vessels
three high volume institutions during 2009 were compared with in bone marrow is the cause of steroid-induced ON.
corresponding clinical documentation, including operative notes
and discharge summaries. Administratively coded comorbidities PAPER NO. 780
and complications derived from hospital billing records were Characterization of Patient Expectations and
compared with clinical documentation from. Concordance between
the administrative and clinical records was determined for each Satisfaction Following Total Hip Arthroplasty (THA)
revision TJA-related ICD-9 comorbidity and complication code. Robert J. Krushell, MD, Springfield, MA
RESULTS: Concordance was excellent for diabetes and post- Mary I. O’Connor, MD, Jacksonville, FL
op MI (K>0.80), very good for chronic lung disease, coronary R. Scott S. Oliver, MD, Duxbury, MA
artery disease, and post-operative DVT/PE (K=0.60-0.79), and Manoshi Bhowmik-Stoker, PhD, Mahwah, NJ
moderate for congestive heart failure, obesity, prior MI, peripheral
INTRODUCTION: Given the growing focus on patient centered
arterial disease, bleeding complications, history of DVT/PE,
care, research on the individual goals of patients who choose to
prosthetic-related complications, and post-op renal failure
undergo total hip arthroplasty (THA) and the degree to which their
(K=0.40-0.59). All comorbidities and complications had a high
expectations are met, becomes increasingly important. The purpose
degree of specificity (>92%), but lower sensitivity (29-100%),
of this study was to prospectively study individual patient’s activity
indicating that comorbidities and complications coded in the
expectations preoperatively in comparison with their subjective
administrative record were highly accurate, but often incomplete.
outcome postoperatively. This type of individualized data is an
DISCUSSION AND CONCLUSION: Administratively coded
important addition to traditional clinical outcome measures.
comorbidities and complications have moderate to excellent
METHODS: The Patient Expectation Questionnaire (PEQ) was
correlation with the clinical record. However, the specificity of
administered to 236 patients prior to primary THA, prospectively
administrative claims is much higher than the sensitivity. These
enrolled from multiple centers. Preoperatively, patients were asked
findings underscore the need for improved, unambiguous clinical
to select three of 12 possible types of desired activity that were
documentation related to TJA procedures.
most important in their decision to undergo THA. At six months,
one and two years postoperatively, patients rated the extent of their
PAPER NO. 779
ability to carry out those same activities and their satisfaction.
Multiple Osteonecroses (ON) in Patients with Steroid- Traditional clinical outcome measures were also collected.
induced ON of the Femoral Head - Analysis of 2,400 RESULTS: At one year, 82.6% of all identified pre-operative
expectations were achieved ‘most of the time’ (≥75%) with a
Joints high level of satisfaction (89.3%). Top two expectations from
Koh Shimizu, MD, Chiba, Japan the preoperative PEQ were ‘recreational activities’ (50.42%)
Sara Shimizu, MD, Chiba, Japan and ‘return to sports’ (39.41%), highlighting the significance of
Junichi Iwasaki, MD, Ichihara City, Chiba, Japan return to “nonessential” activities. Younger, patients were more
Masatsugu Yamagata, MD, Ichihara, Japan likely to expect the surgery to benefit ‘return to work’ and ‘sexual
INTRODUCTION: Multiple bone necroses occurring in patients function’ (p<0.0001) while older (p<0.0001) and heavier patients
with osteonecrosis (ON) of the femoral head has been reported (p=0.001), often selected ‘elimination of assistive devices’ and
to be relatively rare by radiographic analysis. However, many ‘independence in daily activities’ in their preop expectations.
cases of multiple bone necroses were revealed by MRI. A detailed DISCUSSION AND CONCLUSION: Characterization of patient
investigation into multiple bone necroses was conducted in expectations is essential in providing patient centered healthcare
order to contribute to the understanding of the etiology of bone with positive clinical outcomes.
necrosis. This research was performed in order to investigate the
incidence, common sites of occurrence, and clinical symptoms and
surgical treatment of the steroid-induced multiple bone necroses.
METHODS: The subjects of this study consisted of 300 patients
POSTERS
with steroid-induced ON of the femoral head. There were
57 male and 243 female patients with an average age of 37 POSTER NO. P001
years. An analysis was made of the hips, knees, shoulders, and A Comparison of Metal on Metal to Metal on Highly
ankles of each patient. MRI and radiography were performed
in all 2,400 joints, and RI (99mTc-MDP) in 1,272 joints. Cross-linked Polyethylene Total Hip Replacements
RESULTS: Multiple bone necroses were observed in 203 of Monti Khatod, MD, Santa Monica, CA
300 patients (67%). Through an analysis of occurence by site Christopher F. Ake, PhD, San Diego, CA
in the 1,800 joints (600 knees, 600 shoulders, 600 ankles), Liz Paxton, MA, San Diego, CA
the most common site was the lateral femoral condyle (49%), Cunlin Wang, Silver Spring, MD
followed by the distal femoral meta-diaphysis (37%), medial Art Sedrakyan, PhD, MD, New York, NY
femoral condyle (32%), humeral head (24%). The occurrence of
necrosis was classified into two areas: articular areas in contact INTRODUCTION: Concern regarding increased revision rates of
with cartilage and meta-diaphyseal areas not in contact with metal on metal bearings has led to caution in their use. While used
bone endosteum. Collapse was revealed in 292 of 600 hips for many years now, their current status remains questionable. We
aimed to provide clinical data from a large prospectively collected

total joint registry on the short- and mid-term results of total hip Femoral Components maintained femoral BMD better than the
replacements (THR) comparing metal on metal (MOM) to metal alloy based components used for comparison. Based on these
on highly cross-linked polyethylene (XLPE) bearing surfaces. early results, the Epoch Femoral Components for primary THA are
METHODS: A contemporary total joint registry was reviewed justified for continuance of further prospective study.
from 2001 to 2009. A total of 18,050 primary THR were evaluated.
Metal on metal accounted for 20.4% of these cases while metal POSTER NO. P003
on highly cross-linked polyethylene accounted for the remainder, ALTERNATE PAPER: ADULT RECONSTRUCTION HIP II
79.6%. Failure was defined as aseptic revision for any reason. KM
survivorship curves were created. A propensity score analysis was
Inpatient Pulmonary Embolism in Elective Primary Hip
performed to evaluate factors associated with revision surgery and Knee Arthroplasty Patients
including bearing surface. The propensity score model was a Usman Zahir, MD, Baltimore, MD
logistic regression run as generalized linear mixed model with Robert Sterling, MD, Owings Mills, MD
random effects for surgeon and site. It included BMI, age, gender, Vincent Pellegrini, MD, Baltimore, MD
diagnosis, diabetes, race (black, Hispanic, Asian, white, other), Mary Forte, PhD, RN, Baltimore, MD
operative time, surgeon and site annual volumes, surgical approach,
INTRODUCTION: The incidence of inpatient pulmonary
femoral head size, fixation (hybrid, cemented, uncemented),
embolism (PE) in elective primary arthroplasty patients in
antibiotics in cement, and surgeon fellowship as predictors.
the United States is unknown. Prior studies have included
RESULTS: At five-year follow up, cumulative implant survival was
patients with cancer, trauma, revisions or patients under age
97.5%. For XLPE it was 97.4% and for MOM it was 98.2%. The
60. The goals of this study were to determine the incidence
stratified Cox regression model yielded a hazard ratio for aseptic
and adjusted odds of inpatient PE by procedure in elective
revision among MOM vs. XLPE of 1.07 (95% CI 0.84, 1.37) p=0.581.
primary hip and knee arthroplasty patients in the U.S.
DISCUSSION AND CONCLUSION: A contemporary United States
METHODS: The 1998-2007 Nationwide Inpatient Sample (NIS),
based total joint registry found excellent five-year survivorship for
Healthcare Cost and Utilization Project of the Agency for Healthcare
total hip replacements utilizing both metal on metal and metal
Research and Quality (AHRQ) provided a national stratified
on highly cross-linked polyethylene bearing surfaces. In a multiple
probability sample of all-payer hospital discharge data for this
variable model, no difference in survivorship was discovered
retrospective cohort study. Patients age 60 years or older who had
between the two bearing surfaces examined.
an inpatient stay for at least one total hip (THA) or total knee (TKA)
POSTER NO. P002 arthroplasty were included (ICD-9-CM 81.51, 81.54). Patients with
cancer, infection, trauma or revisions were excluded. The outcome
Five-Year Results of a Prospective, Randomized, was inpatient PE (ICD-9 diagnosis 415.1x). We determined
Controlled Study of a Composite Femoral Component descriptive statistics and 95% confidence limits (CL) on the estimates
from SAS® SURVEYFREQ and the adjusted odds of inpatient PE by
for THA procedure from SAS® SURVEYLOGISTIC, controlling for patient
Russell G. Cohen, MD, Tucson, AZ age, sex, Charlson comorbidity score and surgical indication.
Nebojsa V. Skrepnik, MD, Tucson, AZ RESULTS: The sample included 796,121 discharge abstracts
Lawrence R. Housman, MD, Tucson, AZ representing 3,893,472 patients with inpatient hospital stays
Scott V. Slagis, MD, Tucson, AZ for primary THA or TKA. Women comprised 63.7% of patients.
John A. Maltry, MD, Tucson, AZ Two-thirds of patients were under age 75. Osteoarthritis was
Jay A. Katz, MD, Tucson, AZ the primary diagnosis in 95.6% of patients. Most patients
Brad Askam, Tucson, AZ had few comorbidities (Charlson score=0 in 68.5%). Patients
Robert W. Eberle, Pleasanton, CA with unilateral TKA comprised 65.36% of admissions; two-
joint admissions were 4.59% (95.4% were bilateral TKA). The
INTRODUCTION: The purpose of this prospective, randomized overall unadjusted PE incidence was 0.362% (95% CL: 0.339%,
controlled study was to compare the five-year clinical, 0.384%). PE differed by procedure with unilateral THA patients
radiographic, and DEXA results of a Composite Femoral having the lowest PE incidence. Multiple-procedure patients
Component for primary THA with other non-cemented had the highest PE incidence, especially bilateral THA. The
femoral components of varying design and surface preparation. adjusted odds of PE showed a similar pattern by procedure.
METHODS: The Epoch® Hip Prosthesis Components were DISCUSSION AND CONCLUSION: Elective TKA is associated
studied in conjunction with the VerSys® Fiber Metal Taper, with higher incidence of inpatient PE than THA in the U.S. Multiple
Fiber Metal Midcoat, and Beaded Fullcoat components. All 227 procedures are associated with a higher incidence of PE than
patients were randomized into one of five groups and followed unilateral procedures, especially in bilateral THA. Our results can
prospectively for five years. All patients were assessed using the assist surgeons in patient education and perioperative planning.
Harris Hip Score, SF-36 and WOMAC. Radiographic analysis was Further research identifying ways to decrease PE in elective TKA
performed to assess differences using the various components. and multi-procedure patients is warranted.
DEXA was used to determine changes in peri-prosthetic BMD.
RESULTS: There were differences between groups for the HHS, SF-36
and WOMAC scores. The Epoch Components showed better results
for relief of pain and restoration of function. Radiographs revealed
no difference in the incidence of assessment criteria. Serial DEXA
results showed better maintenance of BMD for the Epoch Components.
DISCUSSION AND CONCLUSION: The results from this trial
showed that a Composite Femoral Component for primary THA
can achieve clinical and radiographic results equal to standard
alloy components of varying design. Additionally, the Composite

POSTER NO. P004
uMRI Reveals a High Prevalence of Pseudotumours
Adjacent to Well Functioning Metal-on-metal Hip
Arthroplasties
Keshtra Satchithananda, FRCR, London, United Kingdom
Donald McRobbie, PhD, London, United Kingdom
INTRODUCTION: Pseudotumors are sterile, inflammatory
periprosthetic lesions found adjacent to painful metal-on-
metal hip replacements (MOM-HR). They are thought to
represent an adverse response to implant-derived metal wear
particles and may be diagnosed using cross-sectional imaging.
Their incidence in well-functioning MOM-HR is not known.
METHODS: We performed a case-control study comparing findings
on magnetic resonance imaging (MRI) of patients with unilateral
MOM-HR. We defined cases as patients with unexplained, painful
MOM-HR (intention to revise due to pain or Oxford Hip Score (OHS)
<30 out of 48). We defined controls as patients with well-functioning
MOM-HR. Thirty cases and 28 controls were consecutively
recruited. Incidence and appearances of pseudotumours were
recorded. All patients underwent computerized tomography
(CT) for acetabular component position measurement.
RESULTS: We diagnosed 34 pseudotumors in this series. The
OHS of cases (mean 20.2, 95% confidence interval (CI) 12.7-
45.8) was significantly poorer than controls (mean 41.2, 95%
CI 18.5-45.8, p=<0.0001). The prevalence of pseudotumor
in cases (17 of 30 patients [61%]) versus controls (17 of 28
patients [57%]) was not significantly different. No objective
differences in pseudotumor characteristics were identified
between groups. No correlation between the presence of
a pseudotumor and component position was identified.
DISCUSSION AND CONCLUSION: Periprosthetic cystic
pseudotumours were found commonly in both groups, with
no significant difference between case and control groups.
Pseudotumor was also commonly found in patients with well
positioned acetabular components, measured by CT. While MARS
MRI is useful for surgical planning, the presence of a pseudotumor
POSTER NO. P005
may not necessarily indicate the need for revision surgery. Retrieval Analysis of 130 Metal-on-Metal Hips Showed
that the ASR is Higher Wearing when Compared to the
BHR
Ashley Matthies, BSc, London, United Kingdom
Kevin Ilo, MBBS, London, United Kingdom
INTRODUCTION: The National Joint Registry for England and Wales
report a five-year clinical failure rate of 12% for the DePuy ASR. This
compares to 4.3% for the Smith and Nephew BHR. Subsequently
this has led to the recall of the ASR resurfacing and XL hip systems.
However, the mechanisms responsible for the high failure rate of the
ASR compared to other current generation metal-on-metal (MOM)
hip arthroplasties remain unclear. We compared clinical data and
wear performance for a large series of retrieved ASR and BHR hips.
METHODS: This was a well-powered study of 130 consecutively

revised large diameter MOM hip arthroplasties, comparing the POSTER NO. P006
DePuy ASR (n = 66) with the Smith and Nephew BHR (n = 64). Pre-
, intra- and post-operative clinical data was collected prospectively
Survivorship Analysis of Mayo Conservative Hip versus
for all patients to establish the clinical cause of failure. This included the Versys Hips
pre-revision radiographs and blood metal ion analysis. Linear David A. Kummerfeld, MD, Temple, TX
wear rates were measured for all explanted components using a Christopher D. Chaput, MD, Temple, TX
roundness measuring machine according to a published protocol. Kirby Hitt, MD, Temple, TX
RESULTS: The two groups had comparable clinical variables Bryce C. Allen, MD, Temple, TX
(Table 1), including the clinical cause of failure. The ASR group
Kindyle L. Brennan, PhD, Temple, TX
demonstrated higher levels of whole blood cobalt and chromium,
although this trend was not statistically significant. Wear analysis
George W. Brindley, MD, Lubbock, TX
(Table 2) showed that the acetabular components of the ASR, INTRODUCTION: Conventional primary hip prostheses employ
when compared to the BHR, were significantly higher wearing cemented or proximal press fit, metaphyseal filling designs, both
(p = 0.03) and more likely to be edge worn (p < 0.01). However, options available in the Versys system. Both have reliable long-
there was no difference in the femoral head wear rate (p = 0.14). term survivorship. One shortfall of these designs is destruction
DISCUSSION AND CONCLUSION: We attribute our findings to of proximal bone stock. Short stem hip prostheses have been
specific design differences between the two prostheses. The ASR designed for younger patients in an attempt to save bone stock
has a lower clearance and reduced cup articular arc angle when for future revision. One such design, the Mayo Conservative Hip
compared to the BHR. Both of these factors increase the likelihood utilizes a tight proximal interference fit to achieve stability. The
of edge contact and are likely to lead to increased wear, particularly purpose of this study is to compare the rate of revision between
of the cup. This may explain why the ASR appears to be more the Mayo Conservative Hip and the Versys Hip prosthesis.
sensitive to sub-optimal position. METHODS: Retrospective chart review identified 156 Mayo hips
placed between 1999 and 2005 and 119 Versys Press Fit and
Table 1. Summary of patient and clinical data for the ASR and BHR hips cemented hips placed between 1997 and 2004 by a single surgeon at
in this study. this institution. Demographic variables, and radiographic outcomes
ASR BHR including the presence of revision were recorded at five and 10 year
follow-up intervals. All modes of prosthesis failure were identified.
Number of hips 66 64
Failures were divided into two groups: aseptic femoral loosening
Female / Male 42 Females / 24 Males 42 Females / 22 Males and all other modes of failure. Kaplan-meier survivorship curves
Age at primary 56 (23 to 78) 56 (23 to 68) were constructed for the two groups using time of failure, measured
in number of months to revision, as endpoints. Those who did
Time implanted (months) 35 (7 to 59) 49 (10 to 121)
not have revision were considered survivors and survivorship
Femoral diameter (mm) 47 (35 to 55) 46 (38 to 58) was based on the last follow-up date. SAS version 9.2 was used to
Cup inclination (°) 51 (15 to 82) 51 (24 to 73) calculate univariate and multivariable Cox Proportional hazards
Cup version (°) 15 (-8 to 48) 23 (-47 to 50)
regression models to compare the two types of hip prosthesis.
P-value of less than 0.05 indicated a statistical significance.
WB Chromium (ppb) 9.8 (0.2 to 119.0) 4.8 (0.4 to 183.0) RESULTS: Two-hundred-seventy-five patients met inclusion criteria
WB Cobalt (ppb) 13.5 (0.5 to 167.0) 10.2 (0.0 to 167.0) for analysis, and patients were followed up to 154 months (mean
Cause of failure:
follow up=63 months, SD=46 months), from initial surgery.
1. Unexplained pain 46 43 Average patient age for the total sample was 64 years. Average age
2. Acetabular loosening 10 6 of patients in the Mayo and Versys groups were 51 and 71 years,
3. Femoral Loosening 3 5 respectively (P<.0001). A total of 22 patients were revised due to
4. Infection 1 3 any reasons. Five patients were revised due to infection or acetabular
5. Fracture 2 1 loosening only. There were 19 (12%) revisions in the Mayo group;
6. Malalignment 4 5 15 (10%) for aseptic loosening. There were three (3%) revisions
7. Component mismatch 0 1
in the Versys group, 1(1%) for aseptic loosening. Over roughly
Table 2. Comparison of linear wear rates between the ASR and BHR a 10-year span, the Mayo group had significantly more revisions
hips. overall (p=.0034) and due to femoral aseptic loosening (p=.0021).
DISCUSSION AND CONCLUSION: The use of the short stem Mayo
ASR BHR P
hip in a single surgeon experience resulted in a higher failure rate
Acetabular Cup: than the more conventional implant design of the Versys system.
21.99 (1.3 to 651.8) 14.9 (2.0 to 740.4) p = 0.646
Linear wear depth (μm) Previous case series have documented a low revision rate for this
Acetabular Cup: prosthesis; however, this is not supported by the current study.
9.2 (0.0 to 245.6) 4.2 (0.0 to 153.8) p = 0.032
Linear wear rate (μm/yr)
Femoral Head:
13.14 (0.0 to 315.3) 15.07 (1.5 to 234.4) p = 0.779
Linear wear depth (μm)
Femoral Head:
6.0 (0.0 to 84.7) 3.5 (0.7 to 52.4) p = 0.143
Linear wear rate (μm/yr)
Edge Loading 85% (n = 56) 63% (n = 40) p = 0.005

POSTER NO. P007 POSTER NO. P008
Hepatitis C Patients Do Not Show Worse Outcomes Development and Validation of Ranawat Orthopaedic
Compared to Controls After Elective Joint Arthroplasty Patient Administered Questionnaire (PAQ)
Omkar Baxi, BS, Lumberton, NJ Carol A. Mancuso, MD, New York, NY
Fabio Orozco, MD, Egg Hbr Twp, NJ Amar S. Ranawat, MD, New York, NY
Adam Miller, MD, Philadelphia, PA Morteza Meftah, MD, New York, NY
Michael J. Bercik, MD, Philadelphia, PA Chitranjan S. Ranawat, MD, New York, NY
Alvin C. Ong, MD, Linwood, NJ INTRODUCTION: In the current available questionnaires for
INTRODUCTION: Hepatitis C affects 1-2% of the general patients undergoing hip and knee arthroplasty, there is no
population and up to 5% of orthopedic patients. Despite comprehensive survey that includes location of pain (separately
this high prevalence, the effects of Hepatitis C on total for hip and knee), incorporated patient’s emotional status, sense
joint arthroplasty outcomes have not been studied. of well being, overall satisfaction and frequency and functionality
METHODS: Eighty-two patients undergoing 95 surgeries patients. Our hypothesis was that PAQ for patients undergoing
between 2006 and 2011 were identified as Hepatitis C patients hip and knee arthroplasty is valid (as compared to WOMAC),
by the inclusion of ICD-9 codes 70.51, 70.54, or 70.7 in their concise, simple to understand, clinically relevant and easy to score.
charts. The study obtained demographic and surgical data for METHODS: Between January 2009 and March 2010, a total of 100
these patients through a chart review and focused on length of pre-operative hip patients and 100 pre-operative knee patients
hospital stay, blood loss, and hemoglobin loss as outcomes of were included in this study. All patients completed the PAQ as
the surgery. The study values were compared to control values well as WOMAC. Development of PAQ was done according to the
from PubMed-indexed literature between 2008 and 2011. principles described by Irrgang and Anderson in ‘Development and
RESULTS: There were no statistically significant differences Validation of Health Related Quality of Life.’ All questionnaires
in demographics between the study and control samples. In were administrated prior to patient evaluation by the physician.
addition, there were no significant differences in outcomes RESULTS: The internal consistency (Cronbach alpha) of the PAQ
between the acute and chronic/unspecified Hepatitis C samples. was 0.8 and 0.87 for knee and hip respectively, compared to WOMAC
The study found that Hepatitis C patients undergoing joint (p < 0.0001). The strongest correlation was for function subscale.
arthroplasties had a shorter hospital stay (3.18+1.4 days) and a DISCUSSION AND CONCLUSION: The hip and knee PAQ are
smaller hemoglobin drop (3.67+1.9 g/dL) compared to controls internally consistent and valid compared to the WOMAC, and
(3.7 days and a drop of 4.75 g/dL). These findings were significant responsive to change in clinical status. PAQ has unique features
at the p<0.001 level. In addition, the subsample of Hepatitis C for time frame for pain, psychosocial and satisfaction components.
patients undergoing hip arthroplasty had a significantly shorter
hospital stay (3.1+1.26d), smaller blood loss (164.7+111.5mL) POSTER NO. P009
and hemoglobin loss (4.14+1.82g/dL) than their controls Synovial Fluid Analysis for Select Cytokines May Assist
(3.7+0.02d, 368.5+277.8mL, and 5.3+1.8g/dL, respectively).
DISCUSSION AND CONCLUSION: These results indicate
in Stratifying the Severity of ALTR in Failed MoM Hips
that Hepatitis C patients performed just as well as the general Scott T. Ball, MD, San Diego, CA
population. Surgeons may be especially careful with Hepatitis C Amir Misaghi, MD, San Diego, CA
patients due to the risk of infection spread with blood contact. This Robert S. Meyer, MD, San Diego, CA
prudence may result in more successful surgeries with attendant F. C. Swenson, MD, La Jolla, CA
smaller blood losses and shorter hospital stays. In addition, David Boyle, MS, La Jolla, CA
it is possible that the patients in this study represent a well- Patricia A. Campbell, PhD, Los Angeles, CA
controlled Hepatitis C population with liver function similar to
INTRODUCTION: The clinical features of patients experiencing
the normal population. In that case, orthopedic outcomes would
adverse local tissue reactions (ALTR) related to metal-on-
be predicted to be normal, similar to the results of the study.
metal (MoM) bearings in the hip can be variable, making the
The study has some limitations - the study and control surgeries
indications for revision ambiguous at times. In the current
were performed by different surgeons at different locations. This
study, synovial fluid analysis is being explored as a potential
disparity may lead in part to the outcome differences noted in
diagnostic and prognostic tool in the work-up and treatment of
the study. Further investigation of the surgery time for Hepatitis
patients experiencing ALTR related to MoM hip replacements.
C patients, suggesting surgical caution, is warranted. Overall, this
METHODS: In this case control study, 24 patients were identified
study finds that Hepatitis C does not have a negative impact on
with suspected ALTR from MoM implants. At revision, soft
orthopedic surgeries, as measured by length of stay, blood loss,
tissue specimens were analyzed histologically for cell types
and hemoglobin loss. As a result, a diagnosis of Hepatitis C should
and wear debris and cases were graded for severity using
not be a contraindication to elective joint replacement surgery
the ALVAL scoring system. Synovial fluid was obtained and
since these patients do not appear to have increased complications
profiled for cytokine expression by Luminex assay. Correlations
compared to normal population. Instead, a thorough assessment
were sought between histologic severity (ALVAL score) and
of the patient’s disease process may be a better indicator for
cytokine levels. Synovial fluid from the hip in 10 patients with
predicting surgical complications.
osteoarthritis (OA) served as a control for cytokine expression.
RESULTS: In the ALTR cases, levels of select cytokines (IL-1ra, IL-
6, IL-8, IL-10, TNF-α, VEGF, IP-10 and MCP-1) were significantly
elevated (p < 0.001) when compared to the OA controls. Of these
cytokines, IL-8, IP-10 and TNF-α demonstrated the most profound
and specific elevation. The level of expression of these cytokines
correlates with the histologic severity of the reaction with the

lowest ALVAL scores demonstrating lower cytokine levels and the POSTER NO. P011
highest ALVAL scores demonstrating the highest cytokine levels.
DISCUSSION AND CONCLUSION: In patients experiencing
uTwo-year Follow Up of Pseudotumor Diagnosed in
ALTR to MoM implants, there is a severe inflammatory response Metal-on-Metal Hip Arthroplasties
with the cytokines, IL-8, IP-10 and TNF-α, playing a central role. Shiraz Sabah, MD, London, United Kingdom
The expression of these cytokines correlates with the histologic Karuniyan V. Vipulendran, Haverfordwest, United Kingdom
severity of the reaction. Pre-operative synovial fluid analysis of Johann Henckel, BM, London, United Kingdom
select cytokine levels may provide useful diagnostic and prognostic Keshthra Satchithananda, FRCR, London, United Kingdom
information in determining the necessity and urgency of revision
surgery.
Anastasia Papadaki, MSc, London, United Kingdom
POSTER NO. P010 Donald McRobbie, PhD, London, United Kingdom
ALTERNATE PAPER: ADULT RECONSTRUCTION HIP VII John Skinner, FRCS, London, United Kingdom
Abnormal VEGF Expression in Mesenchymal Stem Cells
INTRODUCTION: Cross-sectional imaging of patients with
from Osteonecrotic Hips painful metal-on-metal hip arthroplasties (MOM-HA) frequently
Michael A. Mont, MD, Baltimore, MD identifies a pseudotumor, which is thought to represent a sterile,
Fackson Mwale, PhD, Montreal, QC, Canada inflammatory reaction. However, the clinical significance
Aaron J. Johnson, MD, Baltimore, MD of pseudotumor is uncertain following recent evidence that
John Antoniou, MD, Montreal, QC, Canada they are commonly present in well functioning MOM-HA.
INTRODUCTION: In osteonecrosis (ON) of the hip, We aimed to investigate prognosis following diagnosis of
interruption of angiogenesis is a pathological process that pseudotumor on metal-artifact reduction sequence MRI.
may lead to impairment of the nutrient supply, cell death, and METHODS: We performed a prospective cohort study to follow 81
the collapse of bone. However, the process of angiogenesis in patients with MOM-HA diagnosed with pseudotumor. We recorded
ON is not well understood. The purpose of this study was to demographic data,Oxfordhip score(OHS),3D computedtomography
investigate the expression of vascular endothelial growth factor assessment of component position (n=58) and blood metal ion
(VEGF) in human mesenchymal stem cells (MSCs) in vitro. levels (n=70) at the time of MARS MRI. We performed longitudinal
METHODS: MSCs from osteonecrosis patients were obtained follow up with clinical scores and recording of revision procedures.
from 15 milliliter aspirates from the intramedullary canal of RESULTS: Fifty-six patients met follow-up criteria. At a median
donors undergoing total hip arthroplasty for osteoarthritis. of 27 months follow up, 42 patients had undergone revision
Salt-free primers for target genes VEGFA, VEGFB, VEGFC, surgery. Of the remaining 14 patients, only two had deterioration
VEGFD and PGF as well as for housekeeping gene GAPDH in OHS. Follow-up results are presented in Table 1. A Kaplan-
were generated. Real time PCR conditions included one cycle Meier curve to demonstrate survival of prostheses following
of denaturation (95°C for 15 min), 45 cycles of amplification diagnosis of pseudotumor on MARS MRI is presented in Figure 1.
and quantification (95°C for 15 sec, 58°C for 15 sec, and 72°C Demographic data for our study population are presented in Table 2.
for 15 sec with a single fluorescence measurement), melting DISCUSSION AND CONCLUSION: Early revision surgery
curve (65-95°C with a heating rate of 0.1°C per sec and a was common following diagnosis of pseudotumor. However,
continuous fluorescence measurement), and finally a cooling a proportion of patients showed a clinical improvement for
step to 40°C. After real-time PCR, the samples were collected by reasons that were not clear. Follow-up MARS MRI may provide
centrifugation and the gene size was analyzed on 2.0% agarose gel. useful information in this population. Further research is needed
RESULTS: Cultured MSCs obtained from the hips of normal, to determine the natural history of pseudotumor and factors
ON, and osteoarthritic (OA) patients all expressed VEGF-A. associated with poor prognosis.
Furthermore, MSCs from normal stem cells also expressed Table 1. Follow-up of 81 patients diagnosed with pseudotumor on MARS
VEGF-B, but its expression had a tendency to increase in stem MRI.
cells from ON and OA patients while VEGF-C was absent in any Study number 81 patients
of the stem cells. However, VEGF-D expression was consistently 25 patients
decreased in MSCs from ON, but increased in stem cells from OA • moved away [n=21]
donors than in controls. In addition, placental growth factor (PGF) Lost to follow-up • died [n=2]
which has a similar function as VEGF, was expressed in MSCs and • dementia [n=1]
the levels were similar in MSCS from normal, ON, and OA donors. • did not wish to participate [n=1]
DISCUSSION AND CONCLUSION: The results suggest that ON Number surveyed 56 patients
and OA are associated with aberrant VEGF-D expression. Our data Duration from MARS MRI to follow-up
27 (6-43) months
further defines the complex changes and interrelationships in the [median (range)]
VEGF family gene expression in stem cells from ON and OA donors Duration from primary surgery to
54 (28-127) months
that may occur in the course of vascular invasion and cell death. follow-up [median (range)]
This investigation draws attention to these VEGF molecules and 42 patients
their relationships to the physiological and pathological events • unexplained pain [n=38]
Number revised
• aseptic loosening [n=3]
that are part of angiogenesis. • size-mismatch [n=1]
Duration to revision surgery from
4 (0-22) months
MARS MRI [median (range)]

14 patients POSTER NO. P012
• unchanged [n=2]
• improved [n=8]
Have Fretting and Corrosion Been Reduced in
Oxford Hip Score at follow-up
• deteriorated [n=2] Contemporary Head/Neck Modular Junctions?
• well-functioning, no initial score [n=1] Robert M. Urban, Chicago, IL
• poor-functioning, no initial score [n=1]
Deborah J. Hall, Chicago, IL
Table 2. Demographic data for 81 patients diagnosed with pseudotumor Jeremy Gilbert, PhD, Syracuse, NY
on MARS MRI. Craig J. Della Valle, MD, Chicago, IL
Oxford Hip Score at MARS MRI
26 (2-48) Jorge O. Galante, MD, Chicago, IL
[median (range)] Joshua J. Jacobs, MD, Chicago, IL
Age at primary surgery
55 (28-73) years INTRODUCTION: Contemporary femoral component head/
[median (range)]
Gender 16 male : 40 female
neck junctions with 12-14, 14-16 or similar taper geometries
are now in wide use. These junctions are of larger diameter
Bilateral 28/81 patients
to increase flexural rigidity and have improved tolerances
Maximum of either cobalt or chromium in whole blood
8.8 (1.0-386.5) ppb and enhanced surfaces relative to earlier designs in which
[median (range)]
42 Resurfacing
mechanically-assisted crevice corrosion was problematic.
Implant Type 13 Modular Although contemporary modular head/neck junctions promise
1 No data improved resistance to fretting and corrosion, there is a paucity
5 Adept of data on the actual prevalence of fretting and corrosion in
8 ASR retrieved devices. We asked whether fretting and corrosion had
22 BHR in fact been reduced in contemporary head/neck junctions.
Manufacturer 4 Biomet METHODS: A total of 246 consecutively retrieved femoral hip
6 Cormet stems with 12-14, 14-16 or similar geometry head/neck junctions
4 Durom
from 12 different manufacturers were examined using a reflected
7 Other/No Data
light stereo microscope. The mean duration of implantation was 36
Inclination
50 (31-78) deg months. The devices included 141 CoCr/CoCr junctions and 105
[median (range)]
CoCr/Ti-alloy junctions. The neck tapers were scored for the degree
Version
19 (-22-43) deg of fretting and corrosion damage (minimal=1, mild=2, moderate=3
[median (range)]
22 Malpositioned
or severe=4). Selected femoral necks were studied using a scanning
Component position? electron microscope to determine the mechanisms of corrosion.
14 Well-positioned
Head size Scores for fretting and corrosion damage were compared between
46 (38-58) mm the different head/neck couples using the Mann-Whitney test.
[median (range)]
RESULTS: Overall, the mean scores for fretting and corrosion were
Figure 1. Kaplan Meier survival curve demonstrating survival of
relatively low and were similar for CoCr/CoCr (1.4±0.8) and CoCr/
prostheses following diagnosis of pseudotumor on MARS MRI.
Ti-alloy (1.5±0.7) couples (p=0.056). Mild to moderate fretting
and/or corrosion were observed in 42% of CoCr/Ti-alloy couples
and 22% of CoCr/CoCr couples (p= 0.042). Severe intergranular
corrosion over the majority of the femoral neck taper occurred in
5% of all CoCr/CoCr couples (p=0.000). Intergranular corrosion
was limited to the area of the neck within the head/neck junction
and occurred exclusively in CoCr stems that had undergone
sintering to bond their metallic bead porous coating. The prevalence
of intergranular corrosion in the 79 CoCr stems with bead coating
from three different manufacturers was 9%. Intergranular
corrosion was not present in any of the CoCr stems for cement
fixation. Severe corrosion was not observed in any of the Ti-alloy
neck tapers, whether they had a sintered porous coating or not.
DISCUSSION AND CONCLUSION: Fretting and corrosion do
occur in contemporary femoral tapers, but appear to be reduced
both in prevalence and severity compared to previous studies of
earlier designs. This was especially so for CoCr/Ti-alloy couples.
The prevalence of intergranular corrosion of the neck in CoCr stems
with a sintered bead porous coating was greater than anticipated.
This suggests that some CoCr stems that have undergone sintering
to bond their bead coatings may be more susceptible to corrosion
attack at the head/neck junction. Additionally, the presence of
intergranular corrosion implies that fretting, while necessary to
initiate the corrosion process, is not required to continue corrosion
within the grain boundaries. Clearly, the solution conditions
within the intergranular regions and the electrochemical status
of the interface result in continued attack. Severe intergranular
corrosion of the femoral necks of CoCr stems with sintered bead
porous coating can increase the particulate and metal ion burdens

and increase the potential for component failure. endplates was graded on a scale of 0 to 4, on a continuum
from no arthritis to ankylosis using the Eubanks modification
POSTER NO. P013 of the Kettler classification. The hips for each specimen were
Ellipsoidal Wear Zones on MoM Heads Show Distinct also graded for degeneration on a scale from 0-3, as per the
Abdulian modification of the Cooperman classification for
Damage Patterns hip degeneration. Linear regression was used to analyze the
John H. Currier, MS, Hanover, NH relationship between hip OA and lumbar endplate degeneration.
John P. Collier, DE, Hanover, NH Fisher exact tests were performed with subjects grouped by
Barbara H. Currier, MChE, Hanover, NH decade of age, and to identify differences in each age group.
Stephen R. Kantor, MD, Lebanon, NH RESULTS: Hip OA is significantly associated with endplate
Steve D. Reinitz, BA, Hanover, NH degeneration at L1, L3 and L5 levels (p < 0.02). In the age group of
Douglas Van Citters, PhD, Hanover, NH 20 to 29 years, 35% specimens had evidence DDD in at least one
lumbar level as compared to only 17% with hip OA changes. At
INTRODUCTION: Clinical results for current generation metal 70 yrs 100% specimens had evidence of DDD in lumbar vertebrae
on metal (MoM) devices are mixed, with adverse local tissue while hip OA changes were present in only 50%. Fisher exact tests
reaction commonly reported. The recall of a widely used MoM demonstrated significant differences in each age group (p<0.01).
system has heightened interest and scrutiny of devices. This DISCUSSION AND CONCLUSION: Based on our study of a large
study uses high resolution imaging of bearing surfaces to identify population of adult skeletal specimens, it appears that there is
and compare wear features across a variety of MoM designs. significant association between degenerative disc disease of lumbar
METHODS: Ten retrieved current-generation MoM hip devices spine and hip osteoarthritis. Lumbar DDD changes precede hip
were studied, representing eight different hip systems: six total hip OA with one third of the population in their 20s showing evidence
arthroplasty (THA) designs and two resurfacings. Head diameters of early DDD of lumbar spine as compared to only 17% with OA
were 36 - 54 mm; in vivo duration 13.8 -56.7 mos. Bearing surfaces changes in hip. Lumbar DDD changes were seen in all subjects over
were imaged using standard stereo microscopy, 3-D digital imaging 70 years of age while only 50% population over 70 years shows OA
at resolution to 1000x, and white light surface profilometry. changes in hip. These findings suggest that lumbar degeneration
RESULTS: All 10 femoral heads (eight designs) display ellipsoidal may precede hip degeneration, and that lumbar degenerative
articulation zones defined by linear boundaries. The boundaries disease may lead to the development of hip osteoarthritis.
are areas of relatively intense scratching and changes in scratch
alignment. Although there is notable lighter scratching (depth POSTER NO. P015
0.01 - 0.05 µm) inside the ellipsoidal areas, the heavier or more
intense scratching, (depth 0.1 - 0.2 µm) generally lies outward of Does Native Hip Anatomy Fit Recommendations for
the linear boundary the eye perceives, rather than inward of it. Safe Component Orientation in THA?
DISCUSSION AND CONCLUSION: The ellipsoidal boundaries Christian Merle, MD
appear to have undergone extensive metal-metal contact and George A. Grammatopoulos, MRCS, Oxford, United
resultant scratching, with less severe scratching within the Kingdom
ellipsoid. The alignment of the ellipsoid boundaries along great-
Wenzel Waldstein, MD, Heidelberg, Germany
circle lines on the head indicates repetitive contact between the
head and the rim of the cup. The presence of ellipsoids across the Elise Pegg, PhD, Oxford, United Kingdom
range of sizes and in all device designs studied demonstrates that Hemant G. Pandit, FRCS, Oxford, United Kingdom
metal-metal contact at the rim of the cup is routine. Peter R. Aldinger, MD, Stuttgart, Germany
David W. Murray, MD, Oxford, United Kingdom
POSTER NO. P014 Harinderjit Gill, PhD, Oxford/Oxon, United Kingdom
Disc Degeneration in Lumbar Spine Precedes INTRODUCTION: The introduction of hard-on-hard bearings and
Osteoarthritic Changes in the Hip: A Postmortem Study the possible consequences of edge-loading and impingement have
stimulated increasing interest in the importance of component
of 350 specimens orientation in total hip arthroplasty and hip resurfacing.
Navkirat Bajwa, Cleveland, OH Recommended “safe zones,” such as Lewinnek’s, have been
Ernest Young, MS, Cleveland Heights, OH described for optimum acetabular component orientation in
Nicholas U. Ahn, MD, Shaker Heights, OH order to prevent impingement, dislocation and excessive wear.
INTRODUCTION: The relationship between hip and spine Furthermore, the concept of a “safe” combined anteversion has
degeneration was first described by MacNab. It was hypothesized gained popularity. The aims of this study were (1) to define the native
that degeneration in one area could lead to decompensation anatomy in a cohort of patients with primary hip osteoarthritis and
in the other; which preceded the other however, was unclear. (2) to determine whether native anatomy corresponds to surgical
WA Saunders studied 150 patients and found that lumbar recommendations of acetabular and femoral component orientation.
degenerative disc disease (DDD) was three times more common METHODS: We retrospectively reviewed a consecutive series of
in patients with hip osteoarthritis (OA). However it was not clear 131 CT scans performed pre-operatively in patients with primary
whether the spinal degeneration led to hip arthritis or if the hip end-stage hip osteoarthritis (131 patients, 57 males, 74 females,
degeneration led to spinal decompensation. The aim of this sudy mean age 60 (range: 42- 79) years, mean body-mass-index (BMI)
is to determine which degenerative process precedes the other. 27 (range: 19-45) kg/m²). Patients were positioned according to
METHODS: A total of 350 cadaveric human specimens from a standardized protocol as confirmed by scout views. Acetabular
the Hamann-Todd osteological collection in Cleveland, OH orientation was determined from axial images by selecting points of
were examined for evidence of endplate arthrosis in lumbar the acetabular rim included. Using validated programmes, a plane
spine and OA changes in the hip. Baseline data of age, sex and was fitted to the vertices along the rim, and a sphere was fitted to the
race of the specimen were collected. Degeneration of the lumbar native acetabulum. The diameter of the sphere represented the size

of the native acetabulum, while the abduction and anteversion of identified additional organisms not present within the joint.
the acetabulum were defined by the relationship of the acetabular RESULTS: Skin cultures correctly identified the same organism(s)
rim relative to the co-ordinate system of the CT scanner, accounting as the deep cultures in 15 cases (48.4%). The mean accuracy of
for the amount of pelvic flexion for each individual case. Moreover, skin cultures compared to intraarticular controls was 59.7%. Skin
femoral anteversion was determined as the angle between the cultures identified additional organisms in 10 cases and did not
femoral neck axis and the posterior condylar line of the knee. recognize all infecting organisms in two cases that would have led to
Combined anteversion was calculated as the sum of acetabular and an unnecessary change in the choice of antibiotic treatment (38.7%).
femoral anteversion. Native anatomy was evaluated with reference In one case, the skin cultures were positive, while the joint cultures
to the “safe zone” as described by Lewinnek (inclination: 35-55°, did not suggest a deep infection. In five cases (16.1%), the skin
anteversion: 5-25°) and to a “safe combined anteversion” of 20-40°. cultures were negative while the joint cultures suggested infection.
RESULTS: The mean acetabular rim diameter was 54 mm (SD: 6 DISCUSSION AND CONCLUSION: Cultures taken from a
mm, range: 41-71 mm). The mean acetabular anteversion was 18° sinus tract or draining wound often contain contaminants that
(SD: 6°, range: 1-33°). Females had a greater amount of acetabular may potentially impact management. Based on these findings,
anteversion (16°, range: 3-32°) compared to males (12°, range: 3-23°, obtaining skin culture from a draining wound or sinus does not
p< 0.001). A total of 90% of native acetabulae classified as being with seem to have any value in the management of patients with total
the ‘safe’ anteversion zone. The mean acetabular inclination was joint arthroplasty (TJA), and may further confuse the choice of
62° (SD: 7°, range: 30-76°). There was no difference in acetabular antibiotic treatment.
inclination between females (62°, range: 30-75°) and males (62°,
range: 37-76°, p=0.57). Twenty-one percent of native acetabulae POSTER NO. P017
classified as being withing the safe inclination zone. There was no Do We Need Pedometer Data to Differentiate Long-
difference in combined anteversion between females (34°, range:
7-70°) and males (30°, range: 2 - 55°) (p=0.1). Some 60% of Term Function Following Total Hip Replacement?
patients had a native combined anteversion with the “safe” limits. Ryan K. Takenaga, MD, Iowa City, IA
DISCUSSION AND CONCLUSION: There is still debate if Nicholas Bedard, BS, Iowa City, IA
acetabular and femoral implants should be orientated in such a Steve S. Liu, MD, Iowa City, IA
way to reconstruct individual anatomy or fit within a safe zone. Alison L. Klaassen, MA, Iowa City, IA
This study highlights the great variability in native hip anatomy. Douglas R. Pedersen, PhD, Iowa City, IA
If individual patient anatomy was reconstructed, only 14 cases John J. Callaghan, MD, Iowa City, IA
(11%) of the present cohort with primary osteoarthritis would
have component orientation that met the criteria of both “safe INTRODUCTION: As more and more total hip replacement
zone” definitions. The major difference between native anatomy implant designs and bearing surface options have become
and “safe” component orientation was observed for acetabular available and as the cost associated with the procedure is
inclination. Reduction of native acetabular inclination by escalating (because of the increased numbers being performed),
15° during cup implantation would result in safe component it is prudent to differentiate the results between designs long
inclination in 84% of cases, however only 47% of cases would term. The purpose of this study was to evaluate a group of active
meet criteria for both “safe zones.” patients (less than 50 years of age at the time of surgery) who
were still actively functioning 10 years following their total hip
POSTER NO. P016 replacement surgery. These patients were evaluated with activity
monitors, self administered rating scales, and six-minute walks.
Should Draining Wounds Be Cultured Prior to Revision METHODS: A consecutive series of 50 patients who underwent
Hip and Knee Arthroplasty? total hip replacement when they were under 50 years of age and who
Nathan Wetters, BS, Chicago, IL were followed for at least 10 years were included. In this consecutive
Javad Parvizi, MD, Philadelphia, PA group, all patients wore activity monitors (accelerometers worn
James I. Huddleston, III, MD, Redwood City, CA around the ankle, similar to a pedometer) for up to 14 days,
performed a six-minute walk, and completed SF-36, WOMAC,
Matthew Tetreault, BA, Chicago, IL
Tegner, and UCLA questionnaires. In addition, every patient had a
John Segreti, Chicago, IL minimum 10-year radiograph along with sequential radiographs.
Stuart B. Goodman, MD, Redwood City, CA RESULTS: Mean age at surgery and BMI were 39.3 years and 29.1,
Craig J. Della Valle, MD, Chicago, IL respectively. Mean 6-MW distance was 335 meters and pedometer
INTRODUCTION: Obtaining cultures from draining wounds data equaled 1.59 million steps per year. Average UCLA and Tegner
or a sinus tract is controversial. While some believe that Scores were 6.1 and 3.0 respectively. The mean linear wear rate was
valuable information can be obtained, others think that 0.263 mm/yr; the mean volumetric wear rate was 82.6 mm3/yr.
such cultures lead to confusion and the treatment of non- The average daily steps were significantly related to linear wear per
pathogenic bacteria obtained from the skin. The purpose of year (p = 0.0002) and volumetric wear per year (p = 0.002). 6-MW,
this study is to evaluate the value of superficial wound cultures Tegner, and UCLA Scores did not correlate with wear (p > 0.05).
compared to deep cultures obtained from within the joint. DISCUSSION AND CONCLUSION: Using acetabular liner wear as
METHODS: Thirty-one patients with a draining wound or sinus the best surrogate for activity, only pedometer activity correlated
tract after 16 total hips and 15 total knees were prospectively with wear. Hence, obtaining pedometer data should be considered
studied at three centers. Aerobic, anaerobic and fungal cultures when trying to distinguish differences in various hip arthroplasty
were taken from around the draining sinus or wound and a designs and techniques long term.
second set were obtained at the time of revision surgery. Culture
results were then compared to determine how frequently and
accurately the superficial cultures identified the same organism(s)
as those from within the joint and how often the skin cultures

POSTER NO. P018 POSTER NO. P019
Variation in Blood Utilization after Total Hip Lateral Center Edge Angle is Predictive of Acetabular
Arthroplasty (THA) in a Regional Hospital Network Overcoverage in Femoroacetabular Impingement
Antonia Chen, MD, Pittsburgh, PA Gregory R. Boone, JD, Rochester, MN
Brian A. Klatt, MD, Pittsburgh, PA Michael R. Pagnotto, MD, Wexford, PA
Mark Yazer, MD, Pittsburgh, PA Justin A. Walker, MD, Rochester, MN
Jonathan Waters, MD, Pittsburgh, PA Robert T. Trousdale, MD, Rochester, MN
INTRODUCTION: The practice of red blood cell (RBC) transfusion Rafael J. Sierra, MD, Rochester, MN
following total hip arthroplasty (THA) has changed over time. INTRODUCTION: Lateral center edge angle of Wiberg greater than
Previously, pre-operative autologous RBC donation (PAD) was or equal to 40º accurately predicts acetabular overcoverage and
pervasive. However, PAD as a blood conservation technique has the need for rim trimming for the treatment of femoroacetabular
been on the decline in recent years as pre-operative hemoglobin impingement. Surgical treatment options for femoroacetabular
optimization and intra- and post-operative shed blood recovery impingement (FAI) include both arthroscopic and open
techniques have become more widely employed. Although blood techniques. Coxa profunda, defined as the medial wall of the
conservation has improved, the administration of perioperative acetabulum at or medial to Kohler’s line, is commonly seen in
blood transfusions may be overutilized. The goal of this study was patients with FAI. However, the implications of coxa profunda in
to examine the current blood utilization patterns among individual management and choice of surgical technique have not been fully
surgeons performing THA within our large regional hospital network. elucidated. The objective of this study is to report the prevalence
METHODS: A retrospective cohort study was conducted that of coxa profunda in patients undergoing surgical hip dislocation
investigated blood utilization after primary THA throughout (SHD) for FAI and to report the operative findings radiographic
a large hospital system. Using our regional hospital network’s results METHODS: Seventy-five patients (85 hips) who were
electronic database, transfusion and patient outcome information treated with SHD for FAI with concurrent coxa profunda, as
on all orthopaedic surgeons who performed a minimum of 10 previously defined, were identified from 155 patients (178 hips)
THAs annually in the two years spanning 2009-2010 was extracted. treated with SHD between 8/2002 and 2/2011. There were 32 men
Peri-operative RBC transfusion rates, average hospital length of (35 hips) and 43 women (50 hips) with an average age of 28.3
stay (LOS), and charges for hospital stay were obtained for each years (17-50). Pre and post-operative radiographs were reviewed to
surgeon. The t-test was used to analyze differences in continuous determine radiographic criteria consistent with the deformity and
variables. Statistical significance was defined as p < 0.05. correction. Operative reports were reviewed to assess intraoperative
RESULTS: There were 33 surgeons who met the inclusion criteria. correction. The results were evaluated using Fisher’s Exact Test.
During the study period, 2,070 patients underwent THA; 1,927 RESULTS: The prevalence of radiographic coxa profunda was
had a primary diagnosis of osteoarthritis, 115 had a diagnosis of 48% (85/178). Four hips were lost to follow up in the immediate
avascular necrosis, 16 patients had congenital dysplasia, and 12 post-operative period. Nineteen patients had failed previous hip
had rheumatoid arthritis. Overall, 38.5% (796/2070) of these arthroscopy (22%). Overall the average pre-op lateral center edge
patients received at least one unit of allogeneic or autologous (LCE) was 35º (17-51) and the average post-op LCE was 31º (10-
RBCs in the peri-operative period. The transfusion rates varied 46). Eighty-two hips (96%) required osteochondroplasty of the
widely between the surgeons and ranged from 4.3% of patients femoral head/neck junction, and 41 (48%) required acetabular
transfused for one surgeon to 86.8% for another surgeon. Some rim trimming. Labral pathology was present in 74% of the hips
10.4% (83/796) of the transfusions received were with autologous and of these, 36 hips (42%) underwent labral debridement,
blood. An average of 1.97 units were transfused to these 796 15 (18%) underwent labral repair, and 12 (14%) underwent
patients during their hospitalization. The average length of stay for labral reconstruction. A pre-op LCE angle greater than or equal
patients who received an RBC transfusion was slightly longer (3.5 to 40º was seen in 24 hips, between 30º and 40º in 39 hips,
± 0.2 days) compared to those who did not receive a transfusion and less than or equal 30º in 21 hips (pre-op radiographs
(3.2 ± 0.2 days) (p=0.013). The average hospital charges for were unavailable in one hip). Of the 24 hips with a pre-op
patients who received an RBC transfusion were also significantly LCE greater than 40º, 20 hips (83%) required acetabular rim
higher ($82,588.60 ± $4,968.29) than the charges for patients who trimming compared to only 33% (13/39) in the 30-40º group (p
did not receive transfusions ($64,845.60 ± $2,384,73) (p=0.002). = 0.00011), and to 33% (7/21) in the less than 30º group (p =
DISCUSSION AND CONCLUSION: There is a large variation 0.00079). In the LCE over 40º subgroup, the average pre-op LCE
in blood utilization among orthopaedic surgeons performing was 43º (40-51) and the average post-op LCE was 36º (23-46).
THA, indicating a possible misallocation of resources. This study DISCUSSION AND CONCLUSION: Coxa profunda, defined as
demonstrates the need to establish systemic criteria to standardize the medial wall of the acetabulum at or medial to Kohler’s line, was
and reduce blood transfusions in this population, to reduce the risk present in 48% of all hips undergoing SHD for the treatment of FAI.
of infection after blood transfusion. Blood conservation protocols However, only 48% of those patients with traditionally defined
may reduce hospital costs and charges. coxa profunda required acetabular rim trimming. By contrast
83% of patients with an LCE angle greater than or equal to 40º
had significant acetabular overcoverage requiring rim trimming.
The traditional radiographic definition of coxa profunda did not
provide useful clinical information in the present series. LCE
values in patients with FAI may have unique implications for
management and choice of surgical technique. Further studies are
needed to better identify the patients who will benefit more from
SHD than from arthroscopic treatment.

POSTER NO. P020 was that there exists a disproportionate concentration
ALTERNATE PAPER: ADULT RECONSTRUCTION HIP V of high complexity cases in teaching hospital settings.
METHODS: Over 1.3 million joint replacement procedures,
A Clinico-Pathological Study of 60 Revised Metal-on- reported in the National Inpatient Sample were examined for years
Metal Hip Arthroplasties 2000-2008. Complex revision procedures were defined as those
Gulraj Matharu, BSc, Walsall, United Kingdom involving infection or peri-prosthetic fracture (n=15,961, 9.3% of all
Matthew Revell, FRCS (ORTHO), MBBS, Birmingham, revisions). Logistic regression was used to define patient, surgeon and
United Kingdom hospital characteristics associated with revision or complex revision.
RESULTS: The number of revision knee cases per year doubled
Vaiyapuri P. Sumathi, BIRMINGHAM, United Kingdom
from 7,785 cases in 2000 to 16,012 in 2008, while the number
Paul Pynsent, PhD of hip revision cases increased from 6,864 to 8,252. Although
Peter A. Revell, PhD, MBBS, Birmingham, United Kingdom teaching hospitals performed 42% of primary hip and knee
INTRODUCTION: Adverse reaction to metal debris (ARMD) is a cases, 52% of revision and 54% of complex revision hip and knee
mode of failure for metal-on-metal (MoM) bearings. It has been cases were performed at teaching hospitals. For hip procedures,
used as an inclusive term and can imply “pseudotumour,” aseptic the proportion revised was highest in patients older than 75
lymphocytic vasculitis and associated lesions (ALVAL), macroscopic (19 vs. 13% younger than 75, p<0.001). For knee cases, those
tissue necrosis, large periprosthetic effusions, or metallosis. Such younger than 50 were at highest risk for revision (29 vs. 10%,
a broad classification does little to clarify the aetiology or to guide p<0.001). The proportion of revision cases was also higher for
clinicians as to potential risk factors that might lead to suboptimal Medicaid patients (19% vs. 12% other insurance, p<0.001).
performance in MoM hips. The aim of the present study was to DISCUSSION AND CONCLUSION: Revision procedures,
characterize the nature of the histopathological response in treatment of periprosthetic infections and fractures are performed
patients with failed MoM bearings seeking evidence for ARMD. more often in teaching hospitals than in urban and rural settings
METHODS: Patients undergoing revision arthroplasty of MoM combined.
bearings were retrospectively identified from our institution’s
clinical database. This included MoM hip resurfacings and MoM POSTER NO. P022
total hip arthroplasties where a reaction to metal was feasible
uContemporary Cementless Anatomic THA with
from the clinical picture. Cases referred from other centers were
also included. Clear cases of infection or acute fractures were Ceramic-on-Ceramic Bearing in Patients < 30 Years of
excluded. Clinical data were obtained from patient notes. Two Age
histopathologists, blinded to all clinical data, examined histological Young-Hoo Kim, MD, Seoul, Republic of Korea
sections using light microscopy. A diagnostic category was assigned Jun-Shik S. Kim, MD, Seoul, Republic of Korea
using a systematic method of recording the features present.
Jin-Woo Choe, Seoul, Republic of Korea
RESULTS: There were 60 MoM hip arthroplasty revisions
performed between 1998 and 2010 which met the selection
Hyoung-Jin Kim, MD, Seoul, Republic of Korea
criteria. Of these 80% (n=48) were hip resurfacings and 20% INTRODUCTION: Reports with contemporary cementless
(n=12) total hip arthroplasties. The prospective clinical indications total hip arthroplasty (THA) with alumina-on-alumina
for revision included aseptic component loosening (32%; n=19), ceramic bearings in patients aged 30 years or younger are
component malposition (27%; n=16), and unexplained pain limited. We evaluated the long-term clinical and radiographic
(27%; n=16). Histological analysis demonstrated the features results, rates of revision, and survival of the cementless
of ALVAL to be present in 8% (n=5) of cases, while a further metaphyseal-fitting anatomic THA with ceramic-on-ceramic
12% (n=7) showed marked lymphocytic infiltration without bearing in consecutive 93 patients 30 years of age or younger.
lymphoid follicles or plasma cells. The remaining patients METHODS: We prospectively reviewed 93 patients (124 hips)
demonstrated features of a low-grade chronic inflammatory who had cementless THA when they were 30 years or younger
reaction (12%; n=7), infection (5%; n=3), or no evidence at surgery. The most common diagnosis was osteonecrosis
of an immunological or infectious process (63%; n=38). (55.6%) and developmental dysplastic hip (21%). Demographic
DISCUSSION AND CONCLUSION: The present study data, Harris hip score, Western ON and McMaster Universities
demonstrates that tissue responses in revised MoM hips are Osteoarthritis (WOMAC) score and University of CA, Los
diverse. Where there is clinical suspicion of ARMD only a small Angeles (UCLA) activity scores were recorded. Radiographic
proportion showed true features of ALVAL. In light of this, a more evaluation was used to determine implant fixation. The minimum
robust classification should be devised for adverse reactions to follow up was 10 years (mean, 14.6 years; range, 10 to 16 years).
metal debris. RESULTS: The mean preoperative Harris hip score, WOMAC
score and UCLA activity score were 41.6 points, 65 points and 3.4
POSTER NO. P021 points, respectively. At final follow up, the mean Harris hip score,
WOMAC score and UCLA activity score were 96 points, 14 points
Where Do Infections, Periprosthetic Fractures and and 8.1 points, respectively. One hundred percent of femoral
Revisions Get Treated? stems and 99% of acetabular components were well-fixed at final
Thomas Vail, MD, San Francisco, CA follow up. No hip had squeaking or osteolysis at final follow up.
C. Barnes, MD, Little Rock, AK DISCUSSION AND CONCLUSION: Our results in patients 30
Steven Takemoto, PhD, San Francisco, CA years of age or younger suggest that cementless acetabular and
femoral components provide outstanding long-term fixation and
INTRODUCTION: Complicated revision procedures require
significant pain relief well into the second decade. Moreover,
specific expertise that may not be available across the healthcare
alumina matrix composite femoral head on an alumina liner
network. The specific aim of this study was to examine the
provided high survivorship without osteolysis.
location of care and payer status for total joint infections,
periprosthetic fractures, and revision procedures. The hypothesis

POSTER NO. P023 There was no difference in outcome between modified and
standard polyethylene when a ceramic head was used (CPR at 10
Retrieved Metal on Metal Heads Convey Details of In years for COMP 6.3% (4.8, 8.1), COSP 8.2% (6.6, 10.3)). There
Vivo Articulation and Bearing Contact was a significant difference between modified and standard
John H. Currier, MS, Hanover, NH polyethylene when metal heads were used (CPR at 10 years for
Douglas Van Citters, PhD, Hanover, NH MOMP 4.7% (4.3, 5.1) and MOSP 7.1% (6.5, 7.8), HR=1.27 (1.13,
Michael B. Mayor, MD, Hanover, NH 1.44) between 3 months and 3.5 years, p<0.001, HR=1.88 (1.62,
Dermott J. McHugh, BA, BS, Hanover, NH 2.17) after 3.5 years, p<0.001). In the MOMP group head sizes less
than or equal to 28mm had a higher CPR than head sizes greater
Barbara H. Currier, MChE, Hanover, NH
than 28mm (CPR at 7 years for less than or equal to 28mm head
John P. Collier, DE, Hanover, NH size 3.7 (3.5, 3.9), CPR at 7 years for greater than 28mm head size
INTRODUCTION: Clinical results for current generation metal 3.2 (2.8, 3.7), HR=1.18 (1.03, 1.36) after 3 months, p=0.014).
on metal (MoM) devices are mixed, with adverse local tissue DISCUSSION AND CONCLUSION: At 10 years metal on modified
reaction commonly reported. The recall of a widely used MoM polyethylene had the lowest cumulative percent revision of the
system has heightened interest and scrutiny of the devices. This four bearing surfaces. In addition, larger head sizes had a lower
study uses high resolution imaging of bearing surfaces to identify rate of revision in this group.
and compare wear features across a variety of MoM designs.
METHODS: Ten retrieved current-generation MoM hip devices POSTER NO. P025
were studied, representing eight different hip systems: six total hip
arthroplasty (THA) designs and two resurfacings. Head diameters
Outcome at Fifteen Years for Cemented Total Hip
were 36 - 54 mm; in vivo duration 13.8 -56.7 mos. Bearing surfaces Arthroplasty and Revisions in Patients under 30 Years
were imaged using standard stereo microscopy, 3-D digital imaging Marloes W.J.L. Schmitz, MD, Nijmegen, Netherlands
at resolution to 1000x, and white light surface profilometry. Vincent Busch, MD, Nijmegen, Netherlands
RESULTS: All MoM designs in this study showed extensive scratching Jean W M Gardeniers, MD, MX Nijmegen, Netherlands
(depth 0.01 - 0.05 µm) consistent with third body debris, arrays of Jan Hendriks, PhD, Nijmegen, Netherlands
parallel scratches that change direction in echelon, and gouging
Rene PM Veth, Nijmegen, Netherlands
(depth 0.2 - 0.5 µm) with plastic deformation of the alloy evident.
DISCUSSION AND CONCLUSION: These results show that
Berend W. Schreurs, MD, Malden, Netherlands
the desired lubrication layer between MoM surfaces is often not INTRODUCTION: Especially in young patients, total hip implants
operative. The ubiquity of scratches on bearing surfaces indicate with proven long-term follow-up data should be used. Despite
hard debris particles are widespread. The alignment of scratches this, almost all patients under 30 years old will face a revision
throughout a change in direction indicates that dry contact is of their hip prosthesis during their life time because of their life
occurring during low-velocity articulation and reversal. Gouging expectancy. Therefore, the used implants should be revisable
is consistent with head-to-rim contact upon subluxation. The with reliable outcome. So far, several studies have evaluated the
occurrence of these phenomena on all the designs studied indicate outcome of total hip arthroplasty (THA) in patients under 30.
that they impact performance of all contemporary MoM hips. However, only few report the long term follow up of 10 years
or more and none present the outcome of the revised total hips.
POSTER NO. P024 METHODS: We retrospectively reviewed prospectively collected
data of 48 consecutive patients (69 hips), all received a cemented
Cross-linked Polyethylene in Primary Total Hip implant and in case of acetabular bonestock deficiency, a
Replacement: Analysis of Over 84,000 Procedures reconstruction with bone impaction grafting was performed.
Richard de Steiger, MD, Richmond, Australia Mean age at surgery was 24.6 years (range, 16.0-29.0 years).
Stephen Graves, MD, Adelaide, Australia Two patients were lost to follow up. All failed hips, again, were
David Davidson, MD, University Of Adelaide, Australia revised with cemented implants and, if needed, bone impaction
Kara Cashman, BSc (HONS), Adelaide, Australia grafting. For the primary THA Kaplan-Meier survival curves at
10- and 15-year endpoint revision for any reason and revision
Yen Liu, Adelaide, Australia
for aseptic loosening were calculated. The outcome of the revised
Philip Ryan, FAFPHM, Adelaide, Australia hips was studied and reported with re-revision as the endpoint.
INTRODUCTION: Concerns regarding wear and peri-prosthetic RESULTS: Mean follow up of all 69 hips was 11.5 years (range
lysis with standard polyethylene led to the development of highly 2-23.4 years). During follow-up 13 revisions were performed.
cross linked (modified) polyethylene. This has demonstrated less No stem revisions occurred, except in three septic failures. The
wear both in vitro and in vivo compared to standard polyethylene. 10- and 15-year survival rates with endpoint revision for any
This study compares the results of the use of standard or modified reason were 86% (95%-CI: 74-92%) and 75% (95%-CI:59-86%),
polyethylene with either metal or ceramic femoral heads. the same endpoints revision for aseptic loosening were 90%
METHODS: The data was obtained from a comprehensive national (95%-CI: 79-96%) and 82% (95%-CI: 65-92%), respectively.
database that prospectively recorded these procedures over a 10- None of the 13 revisions needed a re-revision within 10 years
year period. Analyses were undertaken to examine the impact of after re-implantation; however one cup failed after 13 years.
age, gender, femoral head size and prostheses as well as determining DISCUSSION AND CONCLUSION: This study shows that
the reasons for revisions. The principal outcome measure was time cemented primary total hip implants in patients under 30 years
to first revision using Kaplan-Meier estimates of survivorship. have acceptable outcomes at 10 and 15 years after surgery.
RESULTS: In the metal femoral head group 72,128 were used However, the most interesting part of the study is that the revised
with modified polyethylene (MOMP) and 21,841 used standard hips, all again re-cemented and, if needed, reconstructed with
polyethylene (MOSP). There were 12,143 procedures reported bone impaction grafting were performing well with no re-revisions
using ceramic on modified polyethylene (COMP) and 4,352 within 10 years after surgery.
procedures using ceramic on standard polyethylene (COSP).

POSTER NO. P026 METHODS: We evaluated the survival of 408 fluted and tapered
ALTERNATE PAPER: ADULT RECONSTRUCITON HIP I modular distal fixation stems in revision THA and factors
associated with survival using data from a nationwide arthroplasty
To Bridge or Not to Bridge? register. Indication for revision was aseptic loosening of the femoral
Awad A. Ahmed, BA, Philadelphia, PA component in 39%, followed by periprosthetic femoral fracture
Pekka A. Mooar, MD, Philadelphia, PA (21%), dislocation (16%), femoral revision in conjunction with
Matthew Kleiner, MD, Philadelphia, PA revision of aseptic loosening of the socket (6%), periprosthetic
Joseph S Torg, MD, Saint Davids, PA joint infection (PJI; 5%) fracture of the prosthesis (2%), and other
INTRODUCTION: Anticoagulation bridges are commonly indications including conversion of a hemiarthroplasty performed
used in orthopaedic procedures as chemoprophylaxis against for femoral neck fracture with acetabular erosion into a THA
thromboembolic disease. For some patients, these bridges result (10%). In 7%, the indication was incompletely recorded. In 18
in wound healing complications. We compared a cohort of of the 21 revisions for PJI, the exchange was performed as a II-
patients that received subcutaneous enoxaparin and oral dosed stage revision. Kaplan-Meier survival data were used to construct
warfarin as bridged chemoprophylaxis with those that received the survival probabilities of implants and the Cox multiple-
only warfarin during total hip arthroplasty (THA) procedures. regression model was used to study differences between revision
METHODS: A total of 120 patients were evaluated after primary hip indications and to adjust for potential confounding factors.
arthroplasty from 2008-2009. Sixty-three patients were given both RESULTS: The mean age of the patients was 72.5 years. Aseptic
enoxaparin and warfarin after THA, and 58 patients received only loosening was rare; the nine-year revision rate for aseptic
warfarin after THA. The two groups were statistically matched with loosening was only 3%. The nine-year overall survivorship for
respect to various comorbidities that might influence outcomes. In the stem was 75% (95% CI 70 - 80). The most common reason
particular, BMI, age, gender, hypertension, and history of diabetes for re-revision was dislocation of the prosthesis with or without
were variables that were standardized. The outcomes of interest malposition of the socket (67%). Indication for revision strongly
were the number of days to dry wound and length of hospital stay. affected the survival rate. Revisions for both dislocation and
RESULTS: On continuous days of drainage, a greater number of infection had an over three-fold relative risk for re-revision
days was required for healing wound endpoint to be observed compared to revisions for aseptic loosening. Increasing age slightly
for patients placed on warfarin-enoxaparin anticoagulation decreased the risk of re-revision but sex did not affect the survival.
bridges when compared to patients only given warfarin DISCUSSION AND CONCLUSION: We found that a fluted and
(odds ratio=2.39, p<0.05). Additionally, patients placed tapered modular distal fixation stem showed successful mid-term
on anticoagulation bridges had longer hospital stays (odds survivorship in femoral revisions at a nationwide level. Aseptic
ratio=1.27, p<0.05) than their warfarin-only counterparts. The loosening of this stem was rare; the nine-year survival rate was
mean hemoglobin drops for the two groups did not show any 97% (95% CI 95 - 99) using revision for aseptic loosening of the
statistically significant difference (2.74 mg/dL, 2.83 mg/dL). stem as the end-point. Revision for both dislocation and PJI had
DISCUSSION AND CONCLUSION: Use of warfarin bridged with an increased risk for re-revision compared to revisions for aseptic
enoxaparin as chemoprophylaxis for thromboembolic disease loosening. Majority of the re-revisions (67%) were performed due
places the patient at a greater risk for prolonged healing, and to prosthesis dislocations.
subsequent infection, as compared to warfarin-only treatment.
Additionally, the cost to our healthcare system associated with
POSTER NO. P028
these bridges is an additional $480 per patient as compared to Cerebral Blood Flow Velocity is Preserved during
their non-bridged counterpart. Further studies should examine the Total Hip Arthroplasty under Hypotensive Epidural
risks versus benefit of these bridges in reducing thromboembolic
disease. Anesthesia
Edwin P. Su, MD, New York, NY
POSTER NO. P027 Anna Maria Bombardieri, III, MD, PhD, New York, NY
Successful Use of a Fluted and Tapered Modular Distal George Go, New York, NY
Thomas P. Sculco, MD, New York, NY
Fixation Stem in Revision Total Hip Arthroplasty (THA)
Nigel E. Sharrock, MD, New York, NY
Eerik T. Skytta, MD, PhD, Tampere, Finland
INTRODUCTION: Hypotensive epidural anesthesia (HEA)
Antti Eskelinen, MD, PhD, Tampere, Finland
reduces blood loss, thromboembolism and is associated with low
Ville M. Remes, MD, Helsinki, Finland perioperative mortality.1 Furthermore, studies have demonstrated
INTRODUCTION: Modular femoral components with grit-blasted preservation of postoperative cognitive function and absence of
fluted and tapered distal fixation appear suitable tools in femoral stroke following HEA for total hip arthroplasty (THA).2 However,
reconstruction in revision total hip arthroplasty (THA) with the technique is not widely used in part because of concern
femoral bone loss and in treatment of periprosthetic fractures. that it may result in a reduction in cerebral blood flow (CBF).
There have been some reports with significant postoperative stem Therefore the present study sought to investigate cerebral blood
migration but otherwise the published series have been very flow velocity (CBFV) with transcranial Doppler under HEA.
promising. However, as with other hip revision arthroplasty, the METHODS: Fifty-nine patients undergoing THA with HEA were
risk of dislocation may be over 10%. Rate of stem re-revision for enrolled in this prospective observational study. The study was
aseptic loosening has varied between 1.4% to 7.3% at <5 years. completed in fifty patients: nine patients could not be included
Majority of the previous studies report results after short to mid- due to difficulty obtaining transcranial Doppler signals. HEA
term follow up, with number of patients varying between (n=62 to was induced by injection of 25-30 mL of a mixture of 2%
129) and/or are from specialized centers. Purpose of this study was lidocaine and 0.75% bupivacaine at the L1-L2 interspace and
to analyze its survival rate in femoral revision and factors affecting infusion of epinephrine (3-5 µg/min) to achieve a mean arterial
the survival rate using data from a nationwide arthroplasty register. pressure (MAP) of 40 to 50 mmHg. Sedation was maintained

with intravenous propofol infusion (mean rate 130 µg/kg/min). POSTER NO. P029
Continuous arterial blood pressure, heart rate, ECG, central venous
pressure and end-tidal pCO2 (through a nasopharyngeal airway)
Adiponectin Influences Particle-induced Osteolysis and
were monitored. Peak blood flow velocity in the middle cerebral Apoptosis in a Wear Particle-associated Murine Model
artery were measured by transcranial Doppler ultrasonography Stefan Landgraeber, MD, Essen, Germany
with a 2-MHz probe using a transtemporal window. Cerebral Sebastian Putz, Essen, Germany
hemodynamics were recorded with the patients awake and after Florian Grabellus, MD, Essen, Germany
propofol-induced sedation in the supine position. Patients were Marcus Jager, MD, PhD, Essen, Germany
then placed in the lateral decubitus and reMEd in this position
throughout surgery. CBFV was measured continuously throughout INTRODUCTION: The development of periprosthetic osteolysis
surgery. Data were analyzed at specific time points prior and during caused by cellular reactions to wear debris from artificial joints
HEA and following ephedrine injection at the end of surgery. is a decisive factor in the etiology of aseptic loosening of total
RESULTS: Clinical characteristics of patients are shown in Table arthroplasties. Particularly macrophages and foreign-body giant
1. Changes in MAP and peak CBFV are shown in figure 1. MAP cells show an increased rate of apoptosis. We have already shown
declined by 40% after the induction of HEA (from 84 ± 12 to 50 that inhibition of apoptosis leads to a significant reduction in
± 7 mmHg, p<0.0001) whereas peak CBFV increased by a 10% osteolysis. It is assumed that this is a so-called pathological type
(from 71 ± 19 to 80 ± 26 cm/sec, p=0.0003). This trend in MAP of apoptosis which causes cell death of such a massive extent
and peak CBFV reMEd constant throughout HEA. EtCO2 (mean 40 that not all resulting cell fragments can be completely removed.
mmHg), CVP (mean 4 cmH2O), SpO2 and HR reMEd unchanged. This leads to increased release of inflammatory cytokines and
DISCUSSION AND CONCLUSION: To our knowledge, this is thus to the activation of osteoclasts. As well as modulating a
the first study that demonstrates preservation of CBFV during number of metabolic processes, the hormone adiponectin also
HEA explaining in part why the technique is safe. Reference: inhibits apoptosis and promotes degeneration of apoptotic cell
1. Gonzalez Della Valle, A.; Serota, A.; Go, G.; Sorriaux, G.; remains. With our serological investigation of patients with
Sculco, T. P.; Sharrock, N. E.; and Salvati, E. A.: Venous thrombo- aseptic prosthesis loosening we showed that the survival of joint
embolism is rare with a multimodal prophylaxis protocol after replacements was significantly shorter in patients with lower serum
total hip arthroplasty. Clin Orthop Relat Res, 444: 146-53, 2006. levels of adiponectin. The aim of this study using a murine particle-
2. Williams-Russo, P. et al.: Randomized trial of hypotensive associated in vivo osteolysis model was to investigate if the degree
epidural anesthesia in older adults. Anesthesiology, 91(4): 926-935, of severity of particle-induced osteolysis can be influenced by
1999. deliberately increasing or reducing the serum level of adiponectin.
METHODS: Surgery was performed on 14 wild-type mice to
Table 1: Clinical characteristics of patients (N=50) implant polyethylene particles close to the midline suture of the
Sex (F/M) 18/32 calvaria. Seven of these mice (Group 1) were given daily peritoneal
Age 54 ± 18 injections of adiponectin (2µg/g KG) for 12 days. The other seven
Height (cm) 173 ± 12 mice (Group 2) received no adiponectin injections. Further
Weight (Kg) 87 ± 24
control groups of 14 wild-type mice also underwent surgery,
but no particles were implanted. Of these, seven mice received
Mean arterial pressure prior to anesthesia 105 ± 14
adiponectin injections (Group 3) and seven no adiponectin
Cardiovascular Risk Factors (N)
(Group 4). After 12 days the mice were sacrificed. The murine
Hypertension 17
tissues were then investigated to detect evidence of apoptotic
S/P myocardial infarction and stent 4
reactions using a TUNEL analysis. Moreover histomorphometry
Atrial Fibrillation 4 was performed to evaluate the bone destruction.
ASA Classification: I/II/III 7/30/13 RESULTS: The mice in Group 1, which received adiponectin
injections daily, showed less osteolysis and bone destruction after
particle implantation than the wild-type mice of Group 2. As far
as apoptotic reactions were concerned, there were practically none
in the control groups without particle implantation. In contrast,
apoptosis in the mice with particle implantation was significantly
increased, although the apoptotic reactions in the Group 1 mice,
which received adiponectin injections, were clearly smaller.
DISCUSSION AND CONCLUSION: These results show that
adiponectin influences the degree of severity of particle-induced
osteolysis. We hypothesize that adiponectin has a positive effect
on the development of particle-induced osteolysis by supporting
degeneration of apoptotic cell remains and also due to its anti-
inflammatory properties. This is especially interesting because the
serum level of adiponectin can be raised by a fiber-rich diet, weight
reduction and increased physical activity.

POSTER NO. P030
The Surgical Anatomy of the Piriformis Tendon, with
Particular Reference to Total Hip Replacement
James Roche, MD, Nottingham, United Kingdom
Chris Jones, PhD, Adelaide, Australia
Riaz Khan, FRCS, Cottesloe, WA, Australia
Piers Yates, MD, Fremantle, WA, Australia
INTRODUCTION: The piriformis muscle is an important landmark
in the surgical anatomy of the hip, particularly when using the
posterior approach for total hip replacement (THR). Standard
orthopaedic teaching dictates that the tendon must be cut in order
to allow adequate access to the superior part of the acetabulum and
the femoral medullary canal for implantation of a THR through
this approach. However, in our experience a routine THR can be
easily performed through a posterior approach without sacrificing
this tendon. Current surgical literature regarding the femoral
attachment of piriformis is inconsistent and confused; this seems to
have come about through repeated inaccuracies in the nomenclature
and the description of landmAK, particularly in the literature
relating to the entry point for anterograde nailing of the femur.
METHODS: We dissected a series of 22 cadaveric proximal
femora in order to clearly define the morphological anatomy
of the piriformis tendon. To illustrate the variation in
the attachment site of the piriformis tendon, the method
of shape coordinates (Bookstein orange) was used.
RESULTS: We confirmed that the tendon attaches on
the crest of the greater trochanter, in a position typically
superior to the trochanteric fossa, well away from the
entry point for broaching the intramedullary canal during
THR. Overall, the tendon attachment site encompassed the
summit and medial aspect of the greater trochanter as well
as a variable attachment to the fibrous capsule of the hip joint.
DISCUSSION AND CONCLUSION: The piriform fossa is a term
used by orthopaedic surgeons to refer the trochanteric fossa and
normally has no relation to the attachment site of the piriformis
tendon. We conclude that the anatomy of the piriformis muscle
is usually implied imprecisely in the current surgical literature
and terms are mis-used and interchanged inappropriately. The POSTER NO. P031
insertion of the piriformis muscle is well away from the entry The Morbidity and Mortality Acute Predictor for Hip
point for femoral broaching in total hip replacement.
and Knee Arthroplasty (arthro-MAP)
Thomas H. Wuerz, MD, Cleveland Heights, OH
David M. Kent, MD, MSc, Boston, MA
Harry E. Rubash, MD, Boston, MA
INTRODUCTION: We aimed to develop a comprehensive
predictive tool for immediate postoperative complications after hip
and knee arthroplasty based on pre- and intraoperative variables.
METHODS: Data on procedures, comorbidities and immediate
outcomes during hospitalization were collected from all patients
undergoing primary and revision hip and knee arthroplasty from
March 2003 to March 2006 (N=3511). Logistic multivariable
regression analysis was performed to serve as basis for a nomogram.
The following eight variables were used in the model: lowest heart rate,
estimated blood loss, blood urea nitrogen, primary versus revision
procedure, race, American Society of Anesthesiologists (ASA) score,
comorbidities, and the presence/absence of fracture. Bootstrapping
was used to correct for overfitting bias for both discrimination
and calibration. Net reclassification improvement (NRI) was
used to compare model performance to the Surgical Apgar Score.
RESULTS: All variables included in the multivariable logistic
regression model were found to be statistically significant predictors

of post-operative complications except race and lowest heart rate. other than anterolateral (88% vs. 63%, p=0.002). All other
The nomogram based on this model had a concordance index variables had no significant effect on component placement.
(bootstrap-corrected) of 0.757, which compared favorably to that DISCUSSION AND CONCLUSION: Increased odds of correct
of the Surgical Apgar Score (0.612), and also was well calibrated. implant position were found with higher surgeon volume and lower
Compared to the Surgical Apgar Score, the NRI was 71.5%, 18.4% BMI. High-volume surgeons had higher risk of malposition using
and 53% among patients with or without complication respectively. an anterolateral approach. All other variables had no significant
DISCUSSION AND CONCLUSION: We developed an easy to use effect on component placement.
novel clinical prediction tool, the morbidity and mortality acute
predictor for arthroplasty (arthro-MAP), that might be useful for POSTER NO. P033
immediate postoperative risk stratification for major complications A Biomechanical Model of Acetabular Cup Deformation
in hip and knee arthroplasty, or for longitudinally assessing quality
and safety improvement interventions in this population. Future in Metal-on-Metal Designs
testing in heterogeneous populations and settings is needed. John B. Meding, MD, Mooresville, IN
Scott R. Small, MS, Terre Haute, IN
POSTER NO. P032 Mary E. Jones, Brownsburg, IN
Accuracy of Acetabular Component Positioning in Hip Merrill A. Ritter, MD, Indianapolis, IN
Arthroplasty INTRODUCTION: Press-fit acetabular components are susceptible
Jeffery Krempec, MD to deformation following implantation in an under-reamed
socket. Clinical and cadaveric investigations have described
Ryan Nunley, MD, Saint Louis, MO
this deformation mechanism as component pinching between
John C. Clohisy, MD, Saint Louis, MO the ischial and ilial columns following press-fit implantation.
Douglas J. McDonald, MD, Saint Louis, MO Excessive deformation, particularly in metal-on-metal (MOM)
Robert L. Barrack, MD, Saint Louis, MO components, may potentially lead to increased torsional friction,
INTRODUCTION: Acetabular component malposition is component micromotion, degradation of fluid-film lubrication,
linked to higher bearing surface wear and instability. This and implant loosening. The purpose of this study was to evaluate
study examines the frequency in which acetabular components the effect of design and material considerations on induced
are placed within a predetermined target range. Surgeon deformation in metal-on-metal as well as conventional metal-
and patient factors were analyzed for risk associated with backed acetabular components. Understanding of the overall
placing the acetabular component outside the target range. effect of implant design on acetabular cup deformation is critical
METHODS: We evaluated postoperative anteroposterior (AP) to the prevention of deformation-related clinical complications.
pelvis radiographs for every consecutive primary total hip METHODS: Utilizing an automated reaming and implantation
arthroplasty (THA), complex THA, and surface replacement process, metal-on-metal and metal-backed modular acetabular
arthroplasty (SRA) completed from 2004 to 2009 from a single cups were press-fit into a worst-case pinching model in polyurethane
institution. Cross table radiographs confirmed anteversion foam with a 1 mm under-reamed interference fit. The experimental
vs. retroversion of the components. Hips without adequate setup closely follows a previously validated model from separate
radiographs were excluded. Acetabular component abduction investigators which generated acetabular component deformation
and anteversion angles were determined. We defined acceptable closely matching those observed in cadaveric pelvic specimens.
ranges for abduction and anteversion for both THA (30o-55o Digital image correlation was used to quantify diametral cup
and 5o-35o, respectively) and for SRA (30o-50oand 5o-25o, deformations caused by press-fit implantation in cups and
respectively). The results were compared to a previously published polyethylene liners from 0 to 120 hours following implantation
range of abduction (30o-45o) and anteversion (5o-25o) ranges. with an accuracy of +/- 2 microns. Experimental groups (n=6 per
RESULTS: From 1753 THA, 1628 (93%) components met our group) consisted of 48, 54, 60 and 66 mm MOM cups with a 6
abduction target, 1666 (95%) components met our anteversion mm wall thickness, 58 mm cups with a 20 mm wall thickness, and
target, and 1547 (88%) simultaneously met both targets. both CoCrMo and Ti6Al4V 58 mm metal-backed modular cups.
From 299 SRA, 265 (87%) components met our abduction RESULTS: Full results are shown in Table 1. Increased deformation
target, 277 (93%) components met our anteversion target, and was correlated with increased cup diameter, thinner wall
246 (83%) simultaneously met both targets. When using a construction, and Ti6Al4V metal-backed designs (p<0.0001).
previously published range of abduction and anteversion angles, The greatest diametral deformation within the MOM subset of
lower percentages fell within the target ranges. From 1,753 cups tested was 104 +/- 8 microns, measured in 66 mm diameter
THA, 776 (44%) components met the abduction target, 1494 thin-walled MOM cups. Significantly higher, yet potentially less
(85%) components met the anteversion target, and 650 (37%) clinically significant, deformations were measured up to 267
simultaneously met both targets. From 299 SRA, 208 (70%) +/- 14 microns in titanium metal-backed modular cup designs.
components met the abduction target, 277 (93%) components met DISCUSSION AND CONCLUSION: The role of clearance in
the anteversion target, and 194 (65%) simultaneously met both THA lies in the establishment of elastohydrodynamic lubrication
targets. Through multivariate logistic regression, we examined if between the femoral head and acetabular bearing surface in metal-
component head size, surgical approach, surgeon experience (>5 on-metal device designs. However, too tight of clearance paired
yrs in practice), surgeon volume (>100 cases/year), BMI, gender, with a large component deformation from press-fit implantation
or age had an impact on component placement. The odds ratio for and gait loading could potentially increase early component
high-volume surgeons was 1.99 (p=0.002) compared to that of the loosening or wear. While the specific designs tested deformed
low-volume surgeons for accurately implanting the component. to a magnitude less than the manufacturer-specified diametral
The odds of successful implantation decreased by 0.2 (p<0.001) clearance, the results of this study reiterate the need for careful
for every 5kg/m2 increase in BMI. Low-volume surgeons were design planning encompassing deformation in thin walled and
consistent with placement using all surgical approaches. High- conventional metal-backed acetabular component designs.
volume surgeons were significantly better with all approaches

dislocation/ revision rates, nor improve patient reported outcome
(OHS). Cup orientation alone, should not be considered predictive
of patients’ early/mid-term outcome following THA.
Figure 1. Scatter graph of acetabular component orientations of all THA
in study.
POSTER NO. P034

Factors Influencing Acetabular Component Orientation
in Total Hip Arthroplasty and the Effect on Outcome References: 1. Lewinnek G et al,. Dislocations after total hip replacement
Geraint E. Thomas, MA, MBBS, MRCS, Oxford, United arthroplasties. JBJS(Am) 60;217-220, 1978 2. Callanan M et al,. An analysis of
cup positioning in total hip arthroplasty: Quality improvement by use of a local
Kingdom joint registry. ORS 2010, New Orleans.
George A. Grammatopoulos, MRCS, Oxford, United
Kingdom POSTER NO. P035
Hemant G. Pandit, FRCS, Oxford, United Kingdom
Sion Glyn-Jones, MA MBBS, Oxford, United Kingdom
Autogenous Femoral Head for Uncemented Acetabular
Harinderjit Gill, PhD, Oxford/Oxon, United Kingdom THA Reconstruction in DDH: 20 Year Results
David J. Beard, DPhil, Oxford, United Kingdom Matthew P. Abdel, MD, Rochester, MN
David W. Murray, MD, Oxford, United Kingdom Louis S. Stryker, MD, Rochester, MN
INTRODUCTION: The introduction of hard-on-hard bearings and Robert T. Trousdale, MD, Rochester, MN
the consequences of increased wear due to edge-loading renewed Daniel J. Berry, MD, Rochester, MN
interest in the importance of cup orientation for implant/outcome Miguel E. Cabanela, MD, Rochester, MN
following hip arthroplasty. Studies have shown increased dislocation INTRODUCTION: Anterolateral bone deficiency in total hip
risk when the cup is mal-oriented which has led to identification of arthroplasties (THA) completed for developmental dysplasia of
safe-zones. The aims of this study of primary total hip arthroplasty the hip (DDH) oftentimes compromises acetabular component
(THA) were to identify factors that influence cup orientation coverage and stability. Earlier reports on the fate of autogenous
and describe the effect of cup orientation on clinical outcome. femoral head bone grafts have varied. Few studies have investigated
METHODS: In a prospective study involving seven centers, patients the mid-term results of uncemented acetabular components with
undergoing primary THA between 1999 and 2002 were recruited. autogenous femoral heads for acetabular reconstruction in DDH.
All patients underwent detailed assessment pre-operatively and However, there is minimal literature on long-term outcomes.
at regular post-operative intervals. A total of 1,077 had adequate As such, the purpose of the current study was to determine
radiographs for inclusion. This study’s primary outcome measure the 20-year survivorship of THAs with an uncemented socket
was the change between pre-operative and latest follow up Oxford- used in conjugation with a bulk femoral head autograft in
Hip-Score(OHS), (ΔOHS). Secondary outcome measures included patients with anterolateral bone deficiency secondary to DDH.
dislocation/revision rates. Cup orientation was measured with METHODS: We prospectively followed 33 patients (38 hips) at a
EBRA. The influence of patient’s gender/BMI/operative-position/ single, tertiary care academic institution who underwent THA for
surgeon grade/approach on cup orientation was examined. degenerative joint disease secondary to DDH with bulk femoral
Zones tested as possibly ‘safe’/’optimum’ included Lewinnek’s head autograft and an uncemented acetabular component. Five
(inclination: 35 - 55 °, anteversion: 5 - 25°), Callanan’s (inclination: patients had bilateral involvement. The average age at the time
30 - 45°, anteversion: 5 - 25°) and a zone ± 10°about the study’s of index surgical intervention was 42 years (range, 12 - 67 years),
mean orientation (inclination: 35 - 55°, anteversion: 0 - 20°). with 85% of the patients being female. Average operative and
RESULTS: There were 22 dislocations (2%) and 11 revisions anesthesia times were 216 and 280 minutes, respectively. The
(1%) at a mean follow up of seven years. None of factors tested operative approach was anterolateral in 24 hips, transtrochanteric
(Gender/ BMI/ Patient Position/ Surgical-experience) had an in 10, and posterior in four. Mean follow-up was 19.1 years.
effect on cup placement within any of the zones tested (χ2>0.47). RESULTS: The survivorship free of acetabular revision was 79%
There was no difference in dislocation rate between the posterior at 15 years. At 20 years, the survivorship free from acetabular
and anterio-lateral approaches (χ2=0.9). Cups implanted via the revision was 66%. Only one autogenous femoral head had
posterior approach had greater anteversion (p0.56), than THAs of not united at the time of revision surgery. An additional two
either approach (χ2>0.39). ΔOHS was not different for patients patients underwent liner and head exchanges, while two patients
with cups within or outside any of the zones tested (p=0.32). underwent femoral revisions, resulting in a survivorship free
DISCUSSION AND CONCLUSION: Despite the wide scatter in from any revision of 55% at 20 years. Two additional patients
cup orientation, no safe zone could be identified that would reduce experienced Vancouver B1 periprosthetic femoral fractures

after trauma at an average of 11 years post-operatively. Both POSTER NO. P037
were treated with retention of components and plating.
DISCUSSION AND CONCLUSION: Anterolateral acetabular bone
The Use of Performance-Based Tests for the
deficiency is present in most patients with acetabular dysplasia. Preoperative Evaluation of Total Hip Arthroplasty
Managing this deficiency is one of the technical problems that must Aasis Unnanuntana, MD, Bangkok, Thailand
be overcome when total hip arthroplasty is used to treat DDH. This Jeffrey E. Mait, MD, Brooklyn, NY
study demonstrated acceptable long-term results after use of an Andre D. Shaffer, BS, New York, NY
uncemented porous-coated socket fixed with screws in conjunction Joseph M. Lane, MD, New York, NY
with a bulk femoral head autograft. This method of reconstruction
Carol A. Mancuso, MD, New York, NY
provided reliable acetabular fixation. More importantly, it appeared
to restore acetabular bone stock in patients with DDH since many INTRODUCTION: Preoperative functional evaluation of patients
patients with hip dysplasia are young and require additional hip undergoing total hip arthroplasty (THA) is commonly assessed
operations. We continue to consider this technique for young by using self-reported questionnaires such as the Western ON
patients with moderate anterolateral acetabular bone deficiency McMasters Universities Osteoarthritis Index (WOMAC) and
requiring total hip arthroplasty. the Short Form-36 (SF-36). Performance-based tests such as
the two-minute walk test and the timed get-up-and-go test are
POSTER NO. P036 simple maneuvers to evaluate actual physical function and
have been advocated as an essential part of preoperative THA
Significance of Preoperative 3D-CT Angiography for evaluation. To the best of our knowledge, this is the first study
Localization of the Femoral Artery in Complicated THA to demonstrate the relationship between the shorter and more
Shigeo Fukunishi, MD, Nishinomiya, Japan clinically practical two-minute walk test and self-reported
Tomokazu Fukui, MD, Nishinomiya City, Hyogo, Japan questionnaires in preoperative THA patients. The objectives of
Shoji Nishio, Nishinomiya, Japan this study were to assess the relationship between self-reported
questionnaires (WOMAC and SF-36) and performance-based tests
Yuuki Fujihara, Nishinomiya-City, Hyogo, Japan, Japan
(two-minute walk test and timed get-up-and-go test) in patients
Shohei Okahisa, MD, Hyogo, Japan scheduled for THA, and to identify clinical variables associated
Shinichi Yoshiya, MD, Nishinomiya, Hyogo, Japan with the two-minute walk test and the timed get-up-and-go test.
INTRODUCTION: Major vascular injury is one of the most METHODS: We prospectively collected data from a cohort of
devastating intraoperative complications in total hip arthroplasty patients scheduled for primary THA from April 2010 to January
(THA). Although the rate of this complication is low, the risk is 2011. Each patient was asked to complete the WOMAC and SF-36
increased when the normal anatomy is distorted by previous and to perform the two tests (two-minute walk test, timed get-
surgery or original morbidities. We have performed 3D-CT up-and-go test) at the time of a preoperative evaluation. For the
angiography in patients with potential risk for this complication. two-minute walk test, patients were asked to walk up and down a
In this study, we review our clinical experiences and examine the designated corridor and the distance walked in two minutes was
significance and the need for the preoperative vascular survey. recorded. For the timed get-up-and-go test, patients were asked to
METHODS: Preoperative 3D-CT angiography was performed for get up from a chair, walk for three meters, and return to the original
20 hips undergoing THAs. These include five primary THAs (three position. Pearson’s correlation coefficients and Spearman’s rho
hips with Crowe type IV and two hips with ankylosis) and 15 were used to determine the association between the self-reported
revision THAs. Prior to the index THA, the patients had undergone questionnaires and performance-based tests. Multivariable
zero to nine previous surgical procedures (average: 3.5). In each linear regression models were created to evaluate independent
of the patients, we evaluated the preoperative angiographic associations between clinical variable and preoperative
images and assessed the amount of migration of the femoral head. two-minute walk test and timed get-up-and-go test results.
RESULTS: Altered anatomic location and route of the deep RESULTS: A total of 162 patients completed the WOMAC and SF-36
femoral artery was identified in all patients. Especially, in and performed two-minute walk test and timed get-up-and-go test.
revision cases with proximal migration of the femoral head of 5 The correlation between preoperative self-reported questionnaires
cm or more, the deep femoral artery was shown to be shifted to and two-minute walk test and timed get-up-and-go test was only
upper, posterior and lateral direction and adjacent to lower part mild to moderate, ranging from 0.16 to 0.58, thus indicating
of the original acetabulum. In addition to the distorted location, these measures are not equivalent or interchangeable. The highest
it was shown that numerous twisted co-lateral circulatory correlation was found between performance-based tests and the
vessels developed and grew into the original acetabulum. SF-36 physical function subscale (r=0.58, p<0.001 and r=0.52,
DISCUSSION AND CONCLUSION: The preoperative 3D-CT p<0.001 respectively). The use of a walking aid, female sex and the
angiography revealed altered anatomy of the femoral artery as well presence of other painful lower extremity joints were significantly
as the presence of unusually developed co-lateral vessels in and associated with two-minute walk test (r2=0.51, p<0.001) while age
around the original acetabulum. Preoperative identification of this and additional painful lower extremity joints were significantly
anatomical variation is thought to be of great help to reduce the associated with timed get-up-and-go test (r2=0.10, p<0.001).
risk of inadvertent vascular injury during the complicated THA. DISCUSSION AND CONCLUSION: Our study demonstrates that
there are mild to moderate correlations between preoperative
self-reported questionnaires and performance-based tests.
This indicates that performance-based tests and self-reported
questionnaires are not interchangeable and provide distinct
information about different aspects of physical function. Thus, a
comprehensive preoperative evaluation for THA patients should
include a combination of self-reported and performance-based
tests in order to better assess the level of disability prior to surgery.

Given that performance-based tests are simple to efficiently
perform in clinical practice, they should be integrated into
routine preoperative evaluation and, in addition to self-reported
questionnaires, might be important patient-centered outcomes
during post-operative evaluation.
POSTER NO. P038

Results in the Midterm of Arthroscopic Assisted Mini-
open Technique for Femoroacetabular Impingement
Manuel Ribas, MD, Bacelona, Spain
Carlomagno A. Cardenas Nylander, MD, Barcelona, Spain
Ruben E. Ledesma, MD, Barcelona, Spain
Vittorio Bellotti, BARCELONA, Spain
Oliver Marin-Pena, MD, Tres Cantos (Madrid), Spain
INTRODUCTION: Surgical treatment of femoroacetabular
impingement (FAI) is becoming accepted worldwide, mainly
because of improvement in clinical results and quality of POSTER NO. P039
life in preliminary studies. In addition, the arthroscopy Achieving Clinically Adequate Stem Fixation Despite
assisted direct anterior mini-open approach has provided
an excellent way to treat this condition in different FAI
Severe Proximal Femoral Bone Loss
presentations. The aim of the study is to verify if satisfactory Sophia Sangiorgio, PhD, Los Angeles, CA
short-term clinical-functional results prevail at the midterm Edward Ebramzadeh, PhD, Los Angeles, CA
and if they differ according to preoperative degenerative stage. Sean L. Borkowski, MS, Los Angeles, CA
METHODS: A cohort of 296 hips in 278 patients operated Daniel A. Oakes, MD, Pasadena, CA
between 2003 and 2008 (mean follow up 5,2 years, range 2 - 8 Jeremy Reid, MD, Culver City, CA
years) have been included in the study. Data of Merle D’Aubigné Benjamin C. Bengs, MD, Santa Monica, CA
and WOMAC scores and UCLA activity level preoperative and
INTRODUCTION: Revision hip arthroplasty often presents
at the latest follow up (FU) have been obtained from clinical
with severe proximal femoral bone loss. A non-cemented,
records. A Kaplan-Meier survivorship curve has been established
grit-blasted dual tapered stem designed to achieve diaphyseal
considering endpoint those patients who either were lost
fixation was evaluated under aggressive physiological loads,
from FU or who underwent hip replacement. Chi-Squared
simulating extreme activity, in a cadaver model for potential
and Wilcoxon tests have been used for comparisons between
use in revision cases. We then measured the effect of simulated
groups according to Tönnis radiological preoperative stage.
sequential proximal femoral bone loss on interfacial micromotion.
RESULTS: Overall results show mean improvement in MDA,
METHODS: Ten cadaveric femurs were implanted with non-
WOMAC and UCLA activity level from preoperative values of
cemented tapered titanium femoral stems by an orthopaedic
15,7 , 59,7 and 7,3 to 17,4 , 93,3 and 8,7, respectively at the latest
surgeon, familiar with the instrumentation. Dynamic axial
FU (p<0,01). Global survivorship was at eight years 88,8% (CI
compression increasing from 300N-1000N, and biaxial torque
95%). However when suvirvorship was divided according to
(±1Nm to ±15Nm) were applied using an MTS 858 servohydraulic
radiological degenerative stages: 98,77% was obtained for Tönnis
load frame. Sequential, transverse cuts were performed in 1-cm
0 , 92,8% for Tönnis 1 and 62,3% in Tönnis 2 (p<0,01, CI 95%).
increments from proximal to distal. Motion detector transducers
DISCUSSION AND CONCLUSION: Overall clinical and
measured AP and ML interface micromotion at the stem tip
functional improvement in FAI symptomatic operated patients
and 1cm below the level of the last cut, with an accuracy of one
prevails in the midterm with encouraging susrvivorship in patients
micron. Following intact testing, sequential transverse cuts in
with preoperative stages Tönnis 0 and Tönnis 1. According to
1-cm increments were made, with loading repeated after each cut
our experience it should be recommended to this population to
until failure, or the sixth cut. An additional specimen was loaded
undergo surgical procedure with onset of clinical symptoms.
intact seven times, without any sequential cuts, as a control.
RESULTS: Three specimens reMEd stable throughout testing,
with initial and peak per-cycle motions of less than 50 µm. Six
specimens destabilized under loading with higher per-cycle
motions, specifically at the distal stem tip during peak loading in the
anterior-posterior direction, with motions of 78±69 µm, compared
to 12±9 µm in the stable specimens (P<0.05). Total migration of the
destabilized specimens was also significantly higher, specifically at
the proximal stem tip in the medial-lateral direction, with migrations
of 101±34 µm (P<0.05) and at the distal stem tip in the anterior-
posterior direction, with migrations of 155±179 µm (P<0.05),
compared to 33±12 µm and 13±11 µm for the stable specimens.
DISCUSSION AND CONCLUSION: For implants with good bone
quality, interfacial micromotion measured using an extreme
biomechanical model reMEd below the previously reported initial
stability ingrowth threshold of 50µm, even after severe bone loss.
With severe proximal bone loss, a non-cemented tapered stem

that achieves sufficient meta-diaphyseal fixation may be a more cementless acetabular component and a cemented femoral
desirable option than a larger, distal diaphyseal-fit revision stem. component, and followed for a minimum of 20 years. They were
Therefore, the results indicate that when a strong initial fixation compared to a similar series performed by the same surgeon using
is achieved, long term success is possible in the face of substantial a cemented acetabular and cemented femoral component that had
proximal femoral bone loss. also been followed for a minimum of 20 years. Hips were evaluated
for revision for loosening and wear, and radiographic loosening.
POSTER NO. P040 RESULTS: At minimum 20-year follow up, the prevalence of
Achieving Expectations Predicts Satisfaction After Hip revision of the acetabular component for aseptic loosening was
0.8% in the cementless group and 6% in the cemented group (p =
and Knee Arthroplasty 0.008). In the cementless group, 4.2% of cases required reoperation
Ian Harris, MBBS, FRACS, PhD, Caringbah, Australia for wear of the liner (linear wear rate revised group 0.241 mm/yr).
INTRODUCTION: Patient satisfaction after total hip Radiographic acetabular component loosening occurred in 2% in
and knee replacement has been linked to pre-operative the cementless group and 21% in the cemented group (p = 0.0009).
expectations and whether or not those expectations were DISCUSSION AND CONCLUSION: This study demonstrates
met. This study aims to determine which expectations best a marked improvement with cementless fixation compared to
predict patient satisfaction after elective total knee and total cemented fixation in primary total hip arthroplasty at minimum
hip replacement, using a validated 19-item expectation tool. 20-year follow up. Bearing surface wear was the major cause
METHODS: All patients undergoing elective hip and knee of failure (gamma in air polyethylene) and is currently being
arthroplasty in four metropolitan hospitals (two public and addressed by better polyethylene and better acetabular component
two private) were approached to participate. Patients were locking mechanisms.
recruited pre-operatively and followed at six and 12 months
post-operatively. Data collected were: demographic data, pre- POSTER NO. P042
operative expectations, pre and post operative SF-36 general uInhibition of the MCP-1-CCR2 Ligand-receptor
health survey, pre and post operative Oxford hip or knee scores,
patient satisfaction, and a post-operative expectation survey to Axis Decreases Systemic Macrophage Trafficking to
determine which expectations were met. Multivariate analysis UHMWPE Particles
was performed to determine significant predictors of satisfaction. Emmanuel Gibon, MD, Stanford, CA
RESULTS: A total of 331 patients were recruited, and follow up Ting Ma, MS, Stanford, CA
was 89% at 12 months. Satisfaction was strongly correlated with Pei-Gen Ren, Shenzhen, China
SF-36 scores and Oxford outcome scores. Unmet expectations Kate Fritton, BS, MS, Stanford, CA
was the strongest predictor of dissatisfaction at six and 12 months
Sandip Biswal, MD, Stanford, CA
post-operatively. Of the 19 expectation items measured, the
strongest predictors of dissatisfaction were unmet expectations of: Stuart B. Goodman, MD, Redwood City, CA
“improvement in walking”; “relief of pain during the day” and “using INTRODUCTION: Macrophages are the key cells in the
public transport.” Meeting expectations of sexual function was not inflammatory response to wear particles. Production of
associated with satisfaction at six or 12 months. Patient age and wear particles leads to a non-specific macrophage-mediated
gender, surgeon and hospital were not associated with satisfaction. foreign body reaction that can lead to high local levels of pro-
DISCUSSION AND CONCLUSION: Patient satisfaction after hip inflammatory cytokines and chemokines. Moreover, polyethylene
and knee arthroplasty is strongly associated with meeting pre- particles induce systemic macrophage recruitment and pro-
operative expectations. Expectations of pain relief and walking are inflammatory cytokine release resulting in osteolysis. Monocyte
the strongest predictors. chemoattractant protein-1 (MCP-1) is one of the most abundantly
released chemokines and acts through its cell receptor CCR2.
POSTER NO. P041 In this study, we show that interruption of the MCP-1 ligand-
receptor axis is a viable strategy to mitigate systemic trafficking of
Primary Cementless Acetabular Fixation at Minimum macrophages and osteolysis in the presence of clinically relevant
20-year Follow-up: Are We Improving Versus to ultrahigh molecular weight polyethylene (UHMWPE) particles.
Cemented Fixation? METHODS: Fifty-six, eight to nine week old nude mice were
Michael Stefl, Grundy Center, IA divided into six groups. Group 1 animals had UHMWPE particles
John J. Callaghan, MD, Iowa City, IA infused into the distal femur via a minipump; the animals were
also injected intraperitoneally with 0.1 mL of RS102895 (a soluble
Steve S. Liu, MD, Iowa City, IA
competitive CCR2B receptor inhibitor). Group 2 had infused
Devon D. Goetz, MD, West Des Moines, IA UHMWPE particles; the animals were injected intraperitoneally
Richard C. Johnston, MD, Iowa City, IA twice a week with 0.1 mL of the carrier solution. Group 3 and 4
INTRODUCTION: Loosening of the acetabular component had infused UHMWPE particles and were injected via the tail
has been the long term problem associated with cemented vein with either CCR2 -/- or wild type reporter macrophages.
total hip replacement. The authors evaluated the results of Group 5 had a single injection of sterile saline solution into the
a consecutive, non-selected series of cementless acetabular femoral marrow space. Group 6 had a single injection of MCP-
components at minimum 20-year follow up and compared 1 into the femoral marrow space to confirm the localization of
these results to the same surgeon’s consecutive non-selective migrated reporter macrophages induced by MCP-1. For Groups 1,
series of cemented acetabular components at a comparable 2, 5 and 6, tail vein injections were performed with the reporter
minimum 20-year follow-up to determine whether cementless macrophage cell line RAW264.7 that was transfected with the
acetabular fixation was more durable than cemented fixation. lentiviral vector to express the bioluminescent optical reporter
METHODS: A total of 120 consecutive non-selected total hip gene firefly luciferase (fluc), and a fluorescence reporter gene green
replacements were performed by a single surgeon using a single fluorescent protein (gfp). Animals underwent bioluminescent

imaging and microCT scanning at periodic intervals and needs to recognize that not all of these patients do well following
immunohistological staining of retrieved specimens at sacrifice. surgery. Based on the findings of this study patients who are older
RESULTS: Local injection of MCP-1 into the distal femoral canal and those with more advanced arthritis are less likely to do well
induced systemic recruitment of intravenously injected reporter with surgical intervention. In addition patients with increased
macrophages. When RS102895, the CCR2B antagonist was shaft-neck angle, which we believe is a proxy for developmental
injected, we observed a significant decrease of systemic migration dysplasia of the hip (DDH), are also at increased risk of failure.
of macrophages using bioluminescence and immunohistology. Recognition of prognostic factors may allow surgeons to better
The same trend was observed using macrophages deficient in identify appropriate candidates for surgery and/or counsel these
the CCR2 receptor. MicroCT analysis confirmed the protective patients better with regard to their expectations for outcome.
effect of the MCP-1 receptor antagonist on particle-induced
bone loss. Total bone mineral density was significantly POSTER NO. P044
decreased for Group 2 (receiving particles but no antagonist) Results of a Two-Year, Prospective, Randomized,
compared to Group 1 (receiving particles plus the antagonist).
DISCUSSION AND CONCLUSION: Previously, it was assumed Controlled Study of Metal-Ion Release following MoM
that the reaction to wear particles for joint replacements was a THA
localized event. The current study provides strong experimental Scott V. Slagis, MD, Tucson, AZ
evidence of a direct relationship between the chemokine MCP- Nebojsa V. Skrepnik, MD, Tucson, AZ
1 and systemic macrophage recruitment in the presence of John J. Wild, Jr, MD, Tucson, AZ
UHWMPE particles. When the MCP-1 ligand-CCR2 receptor axis
Brian B. Nielsen, MD, Tucson, AZ
was interrupted by two interventions, macrophage trafficking was
mitigated. Furthermore, disruption of the chemokine-receptor Murray F. Robertson, MD, Tucson, AZ
axis was associated with a decrease in the particle-associated Robert W. Eberle, Pleasanton, CA
adverse effects on bone mineral density. Thus, modulation of this INTRODUCTION: Metal ion levels have been measured to estimate
chemokine-receptor axis may provide a therapeutic strategy to their release after primary total hip arthroplasty (THA). Metallic
diminish particle-associated periprosthetic osteolysis. ion release may be related to bearing surface wear and thus serve as
an indicator of the in-vivo performance of metal-on-metal (MoM)
POSTER NO. P043 articulations. The purpose of this prospective, randomized,
Femoroacetabular Impingement: Predictors of Surgical controlled study was to compare a new MoM hip component with
established MoM and metal-on-polyethylene (MoP) components.
Failure METHODS: We designed and implemented a multi-surgeon,
Ronald Huang, Philadelphia, PA prospective, randomized controlled trial to compare clinical,
Christopher L. Peters, MD, Salt Lake City, UT radiographic and ion concentration in serum (cobalt and chrome)
Jill Erickson, PA, Salt Lake City, UT results across multiple devices including the Large Head ASRTM XL
Rob Stewart, Philadelphia, PA System (MoM-1) the UltametTM Advanced Modularity System (MoM-
Javad Parvizi, MD, Philadelphia, PA 2), and, as the control, the Pinacle TM Acetabular Cup System with
Marathon cross-linked polyethylene liner (MoP) (DePuy, Warsaw, IN,
INTRODUCTION: It is not infrequent to encounter patients
USA). One-hundred and fifty-one consecutive patients undergoing
presenting with femoroacetabular impingement (FAI) and
THA were included for study: MoM-1 n=97; MoM-2 n=22; MoP
labral tear. Currently various surgical procedures are available
n=32. Clinical, radiographic, and venous whole blood assessments
to treat these patients with arthroscopy of the hip being most
were preformed pre-operatively, and post-operatively at six
popular in North America. The challenges that surgeons face
months, one year, and two years, with further assessments planned
relate to appropriate patient selection, as not every patient
yearly thereafter through five years. All serum ion concentrations
with this condition requires surgical intervention. Further, it
are reported in nmol/L. Complications were recorded both intra-
is not known what factors influence the outcome of surgery for
operatively and post-operatively. Five patients from the ASR group
these patients. The objective of this study is to determine the
had six revisions performed (one bilateral) we collected blood
prognostic factors for surgical treatment of patients with FAI.
samples at one, three and six months after revision for ion levels.
METHODS: All patients undergoing mini-open femoroacetabular
RESULTS: MoM-1 patients had significantly increased average Co
osteoplasty (FAO) are followed prospectively at our institution.
and Cr levels at all post-operative periods (Table 1). Clinical scores
Among 320 patients undergoing this procedure between 2006
improved after surgery in all groups and continued to improve in
and 2010, 109 hips (101 patients) have reached the minimum
MoM-2 and MoP patients after two years but, decreased slightly in
follow up of two years (average: 2.6 years (range 2.0 to 4.2
MoM-1 patients at two years. Acetabular abduction angle for MoM-
years). The outcome of surgery was evaluated in these patients
1 was 50.2°, MoM-2 was 47.8°, and MoP was 51.7°. In the MoM-1
using WOMAC, modified Harris Hip Score, and UCLA activity
group, 12 (13%) hips (11 patients) had significantly elevated ion
scores. The influence of numerous patient related, clinical, and
levels at all post-operative time periods (MoM-1 Outliers). Six
radiographic variables on the functional outcome of FAO was
hips (6%) in five MoM-1 outlier patients required revision THA.
evaluated. Failure was defined as Modified HHS <80, UCLA
DISCUSSION AND CONCLUSION: We report two-year follow-up
activity score 20. Univariate regression analysis was performed to
results of a prospective, randomized, controlled trial comparing
detect statistically significant variables. Multivariate analysis was
clinical radiographic and serum metal ion levels for ASR MoM,
then performed to identify independent risk factors for failure.
Ultimet MoM and Pinnacle MoP articulations. Clinical and
RESULTS: Among 30 variables examined, advanced
radiographic outcomes through two years were similar for all
age (p<0.001), higher Tonnis stage (p<0.042), and
groups, with a slight drop in clinical outcome in the ASR (MoM-
increased neck shaft angle (p<0.03) were found to be
1) group at two years. High metal ion levels (greater than 1000)
main determinants of failure at surgical intervention.
are an indicator of failure of large head metal on metal implants.
DISCUSSION AND CONCLUSION: Although surgical
Average serum CO and Cr ion levels were elevated at all post-
intervention for patients with FAI is reasonable option, one

operative follow-ups for the ASR (MoM-1) group only. Alarmingly POSTER NO. P046
high serum metal ion levels were observed in the ASR (MoM-1)
group in 12 hips (11 patients) with six hips (five patients) requiring
Rate of Surgical Site Infections in Joint Replacement
revision THA. All revisions were in the ASR group and may have Surgery: One Versus Two Prophylactic Antibiotics
caused the dip in clinical outcome scores at two years. However, Amy Sewick, MD, Philadelphia, PA
in the ASR (MoM-1) outlier patients, there was no radiographic Amun Makani, MD, Philadelphia, PA
evidence of component malposition or aseptic loosening. The Gwo-Chin Lee, MD, Philadelphia, PA
Ultamet (MoM-2) articulations performed comparatively across
INTRODUCTION: A surgical site infection (SSI) is an infection
all variables to the Pinnacle (MoP) articulation. Because of the
that develops before 30 days after an operation or within
alarmingly high serum ion levels in the ASR (MoM-1) group,
one year if an implant was placed and the infection appears
continuation of this study through five years is warranted.
related to surgery. It is estimated that 2.6% of 30 million
surgical procedures annually are complicated by SSI and these
complications can cause significant morbidity and increased
healthcare costs. While timely and appropriate administration
of preoperative antibiotics can significantly reduce the risk
of infection, due to the increasing prevalence of MRSA in the
community, it is unclear which antibiotic(s) provides optimum
prophylaxis for patients undergoing hip and knee procedures.
Therefore the purpose of this study is to evaluate the effect of dual
antibiotic prophylaxis compared to single antibiotic prophylaxis
POSTER NO. P045 in patients undergoing elective hip and knee procedures.
Early Complications of Total Hip Arthroplasty Using the METHODS: We reviewed the institutional records of prospective
outcomes data from 7/31/2008 to 1/31/2011. During this period,
Anterior Supine Approach on the Orthopaedic Table a total of 2,890 hip and knee replacement procedures including
Chengla Yi, MD, Hubei, China revisions were performed by four arthroplasty surgeons in a single
Juan F. Agudelo, MD, Orlando, CO urban academic center. Three surgeons adopted a dual prophylactic
Michael R. Dayton, MD, Aurora, CO antibiotic regimen of Cefazolin and Vancomycin (unless allergy)
Steven J. Morgan, MD, Denver, CO administered one hour prior to incision, while one surgeon used
INTRODUCTION: Anterior supine intermuscular (ASI) total hip Cefazolin (unless allergy) as the sole prophylactic antibiotic.
arthroplasty performed on a fracture table has been increasingly During this period, there were 34 surgical site infections identified
used for primary total hip arthroplasty (THA). Accurate placement based on institutional guidelines and reported to CMS. There were
of the cup, low incidence of dislocation, a shorter hospital stay 16 men and 18 women with an average age of 59. The average ASA
and faster return of function and unassisted gait are potential classification for these patients was 2.32 (range 2-4) in the group
benefits. However, a high complication rate, particularly during with dual prophylaxis compared to 2.87 (range 2-4) for patients
a surgeon’s learning curve, has been reported. In the present receiving single antibiotic prophylaxis. The data was blinded
study, we reviewed the complications and short-term results of and independently reviewed by the chief of infection control.
the ASI THA using an orthopaedic table in an academic center. RESULTS: The overall rate of SSI during this period at our
METHODS: Sixty-one consecutive primary total hip replacements institution was 1.2%. Comparing surgeons who elected dual
in 54 patients with at least three-month follow up were included antibiotic prophylaxis compared to a single antibiotic regimen,
in the present analysis. All procedures were performed using the the infection rate was 1.1% vs. 1.3% (p=0.56). Of the 25 patients
anterior supine intermuscular approach in the fracture table and with SSI treated with dual antibiotic prophylaxis, three (12%) were
cementless implants under fluoroscopic guidance. A retrospective culture positive for MRSA while six out of nine patients (67%) with
review was performed to evaluate the early complication rate Cefazolin only prophylaxis had culture positive MRSA infection
and radiographic accuracy of implant placement. Additional at the time of reoperation (p<0.01). Use of Cefazolin as the sole
analyses were performed to establish the learning curve for agent for antibiotic prophylaxis was associated with a 12 times
the ASI approach for primary THA in an academic setting. increased likelihood of developing a MRSA SSI (Odds Ratio=12, CI
RESULTS: Intraoperative complications included three 2.5-60, p=0.0004). There were no known complications associated
trochanteric fractures and two calcar fractures, four of which with the use of dual antibiotic prophylaxis during this period.
required cable fixation during the original operation. One non DISCUSSION AND CONCLUSION: The addition of Vancomycin
displaced trochanteric fracture was treated conservatively. One as a prophylactic antibiotic agent does not significantly reduce
patient sustained an injury of the lateral femoral cutaneous the rate of SSI compared to Cefazolin alone. However, use of
nerve. There were no other ipsilateral fractures. Postoperative Vancomycin does appear to change the microbiology of SSI and
complications included one anterior dislocation during reduce the prevalence of MRSA infections.
irrigation and debridement of a wound hematoma; one infected
superficial hematoma that was treated with irrigation, retention POSTER NO. P047
of the implants and antibiotics; one stem subsidence presenting as Treatment of Corticosteroid Hip Osteonecrosis with
increasing pain three months after surgery, requiring stem revision. Stem Cells
The overall complication rate was 16.39%. Overall, three patients
(three hips; 4.92%) required reoperation. All the intraoperative
Philippe Hernigou, PhD, Creteil France, France
fractures occurred during the first 32 cases performed. Alexandre Poignard, MD, Creteil, France
DISCUSSION AND CONCLUSION: There is a high incidence Charles-Henri Flouzat-Lachaniette, MD, Creteil, France
of complications during the early learning curve of the anterior INTRODUCTION: This study reports the results of percutaneous
supine THA using the fracture table in an academic setting. autologous bone marrow grafting in 62 patients with

corticosteroids treatment who had bilateral osteonecroses. procedures performed at the senior author’s institution on patients
One hip osteonecrosis was treated with bone marrow (BM) who were undergoing staged revision for deep periprosthetic
injection and the other contralateral hip osteonecrosis with infection as confirmed by previously-published criteria. During
core decompression (CD) alone. Only patients with bilateral each procedure, between two and five tissue samples were sent
symptomatic osteonecrosis and patients with hips at stage for intra-operative histopathologic analysis, with unused tissue
I or II (as defined by Steinberg) were included in this study. fixed in formalin for a later final histopathological reading.
METHODS: Between 1990 and 1995, 62 consecutive patients (28 Frozen sections were evaluated from multiple slices from each
males and 34 females) were included in this study. These patients sample with greater than 40 high powered fields scanned per
had a mean age of 31 years (range 18 to 34 years) at the time of slice. A positive section was considered to have greater than five
the onset of symptoms. The average follow up was 17 years (range, polymorphonucleocytes per high-powered field. Indeterminate
15 to 20 years). An average of 152 + 16 milliliters of marrow was sections contained between one and five cells per high-powered
aspirated from the iliac crest. The number of stroma progenitor field. Negative sections averaged less than one cell per high-
that was transplanted was estimated by counting the Fibroblast powered field, with no sections containing five PMNs. A frozen
Colony Forming Units which express type I and type III collagen. section diagnosis was considered a false negative or positive if there
The bone marrow graft obtained after concentration contained was a discrepancy with the final histopathological diagnosis made
average 4889 + 716 progenitors per cubic centimeter (range 3515 upon review of the permanent section. Evaluations were performed
to 6293 per cubic centimeter). Each hip received a mean number of on individual samples as well as individual surgical episodes.
thirty cubic centimeters of bone marrow graft (range 27 to 35 cubic RESULTS: There were a total of eight discrepancies between frozen
centimeters). The average total number of CFU-F injected in each and permanent sections out of 237 samples. For the tissue samples,
hip was therefore 147 x 103 cells (range 119 x 103 to 195 x 103 cells). concordance with permanent sections occurred 229 times (97%).
RESULTS: Clinical results were determined by the change in Analysis by procedure found that four of these had one frozen
Harris hip scores from preoperative evaluation to the last follow- section read as indeterminate, with positive permanent sections;
up visit, by the change in the radiographic progression and by the in all of these cases a prosthetic reimplantation arthroplasty
need of subsequent total hip arthroplasty. Bone marrow grafting was not performed untill a later date. In two cases, permanent
afforded better reduction in pain, effected a reduction with time sections were positive after negative frozen sections, however
in the number of hips that progressed to collapse, and delayed the these patients did not have re-implantation because other frozen
need for total hip replacement. Ten hips had collapsed and needed sections during the case were positive. In one case, the frozen
arthroplasty at the most recent follow-up after bone marrow section was positive, but the permanent section was negative
grafting, compared to 45 after core decompression. For hips with (had positive intra-operative culture); this patient underwent a
collapse, the mean survival time before collapse was 71.2 months successful staged revision. In one case, there was a false negative
(43.35- 60.96; 95% CI) for the bone marrow graft group and 38.5 (negative frozen, positive permanent), and the patient was
months for the control group (13.2-39.74; 95% CI). With the subsequently reimplanted. Upon notification of permanent
number available, there was a positive correlation (Spearman’s test) section diagnosis, they underwent 42 days of intravenous
between the duration of clinical survival before collapse and the antibiotics, but eventually became re-infected. Therefore, only
number or concentration of CFU-F in the graft group. These results one out of 162 procedures appeared to have been adversely
are explained by the fact that bone marrow injection improved affected by frozen/permanent section disgnosis discrepancies.
the repair process on MRI. Overall, 10 hips with bone marrow DISCUSSION AND CONCLUSION: A false negative diagnosis can
injection showed a total regression of the signal, 59 hips showed be a source of significant morbidity for re-implantation procedures.
a partial reduction (42 with BM and 17 with CD) and 55 hips did Therefore, it is critical that these be minimized. The results of
not show a significant reduction (10 with BM and 45 with CD). this study indicate that even with an experienced pathologist,
DISCUSSION AND CONCLUSION: Bone marrow grafting discrepancies can occur between frozen and permanent section
afforded better reduction in pain, reduction in the number of samples. Fortunately, in only one instance out of 162 procedures
collapses, delayed the need for total hip replacement, and improved did this appear to untowardly influence final outcome. To minimize
the repair process on MRI. the risk of a false negative interpretation, the senior authors
emphasize the necessity of attaining multiple tissue sections intra-
POSTER NO. P048 operatively if there is a high suspicion of infection.
How Do Frozen and Permanent Histopathological
POSTER NO. P049
Diagnoses Compare for Periprosthetic Hip Infections?
The Nine to 14-Year Follow-Up and Metal Ion Trend in
Alex A. Stroh, BS, Baltimore, MD Patients with Metal-on-Metal Hip Arthroplasty
Aaron J. Johnson, MD, Baltimore, MD Mitchell Bernstein, MD, Montreal, QC, Canada
INTRODUCTION: Periprosthetic joint infections can be challenging Nicholas Desy, MD, St-Lazare, QC, Canada
to accurately diagnose and treat. One diagnostic method has been Olga Huk, MD, Westmount, QC, Canada
intra-operative pathology using freshly frozen tissue samples. A Alain Petit, PhD, Montreal, QC, Canada
major concern is the intra- and inter-observer variability among David Zukor, MD, Montreal, QC, Canada
pathologists, and the impact this has on the accurate diagnosis of John Antoniou, MD, Montreal, QC, Canada
continued infection. Some patients may present with continued INTRODUCTION: Metal-on-metal (MoM) bearing use in total
infection following what should have been a definitive re- hip arthroplasty (THA) has undergone significant manufacturing
implantation procedure. The purpose of this study was to determine improvements, however, ongoing concerns exist with regards to
the discrepancy between diagnoses made from frozen sections biological compatibility in certain patients. The short-term reports
compared to the final permanent frozen section diagnosis and how of MoM THA have demonstrated systemic elevation of cobalt and
this may have affected surgical treatment and patient outcomes. chromium ions. Previous long-term studies have not uniformly
METHODS: Between 2005 and 2008, there were 162 individual

reported on clinical outcome measures, digital radiographic POSTER NO. P050
evaluations, and whole blood metal ions. The purpose of
the current study was to report the nine to 14-year clinical,
High Failure Rates with a Large Diameter Hybrid Total
radiographic, and metal ion trends in patients following MoM THA. Hip Replacement
METHODS: We prospectively followed 105 patients (115 hips) Ben Bolland, FRCS (Ortho), MBBS, MD, Hampshire, United
after second-generation metal-on-metal total hip arthroplasty Kingdom
between July 1997 and November 2001. Functional outcome was David Culliford, MSc, Southampton, United Kingdom
measured using the Harris Hip Score (HHS) and the University David Langton, Gateshead, United Kingdom
of CA Los Angeles (UCLA) Activity Score. Radiographic analysis
Jeremy Latham, FRCS, Southampton, United Kingdom
was performed using Einzel-Bild-Roentgen-Analyse (EBRA) by
two of the authors blinded to the study. Cobalt and chromium INTRODUCTION: This study reports the mid-term results of
metal ions were measured annually from whole blood and a large bearing hybrid metal on metal total hip replacement
analyzed using inductively coupled plasma-mass spectrometry. (MOMHTHR) using the cemented collarless polished tapered
RESULTS: Twenty hips were lost to follow up, two died for causes (CPT) stem in combination with a specific manufacturer’s modular
unrelated to their surgery, and 11 failed between 0.4 and 2.8 years head and cup. Further aims were to identify potential sites of failure
(mean, 1.1 years) due to manufacturer’s recall. Of our cohort, 105 from retrieval wear analysis and factors predictive of revision.
patients (115 hips) had complete radiographic, clinical and metal METHODS: Between 2002 and 2007, 199 MOMTHRs (185
ion data to be included in the final analysis. The mean age at surgery patients, 110 females and 75 males) were implanted with a mean
was 50.8 years (17 to 66). There were 41 females and 64 males. The age at surgery of 58.1 years (median 60yrs; range 29-77yrs) and
mean follow up was 11.2 years (range, 9 to 14 years). Six hips (5%) a mean follow up of 62 months (median 63; range 32-83mths).
were revised: two for infection at 0.2 and seven years; one for a Thirteen patients were lost to follow up. Clinical outcome was
loose stem at 1.3 years; and one for a loose cup at nine years. Two measured using the Oxford Hip Score (OHS). Patients were
patients were revised for aseptic loosening at nine and 11.4 years. also questioned for new onset symptoms, particularly lateral
One patient received wound debridement for a superficial infection based pain, clunking or fatigue. Those describing new onset
and did not have any components revised. There were no cases of symptoms were categorized as “painful hips.” Radiographs were
adverse local soft tissue reactions, including pseudotumours. The assessed for component migration, progressive radiolucenies
mean HHS and UCLA scores at the last follow up were 91 and 6.8, and peri-implant osteolysis. EBRA software was used to
respectively, from pre-operative values of 38 and 4.2. During the measure cup inclination and version. Metal ion levels were
follow up, the mean HHS varied from 90 to 94 while the mean measured at latest review. In revision cases explants were
UCLA score varied from 6.7 to 6.9. The mean acetabular inclination analyzed for wear at the articular and trunnion/head interfaces.
and anteversion was 40 degrees (range, 24 to 57), and 19 degrees RESULTS: Seventeen patients (8.6%) had undergone revision, and
(range, 3 to 39), respectively. Median cobalt levels peaked at a a further fourteen are awaiting surgery. The cumulative survival
value of 2.87 µg/L at 4 years (p<0.0001 vs. pre-operative) and rate, with revision for any reason was 92.4% (95%CI: 87.4-95.4) at
subsequently decreased to 2.0 µg/L after nine years (p=0.002 vs. five years. Including those awaiting surgery, the revision rate would
four years). Median chromium levels maximally increased up to be 15.1% with a cumulative survival at five years of 89.6% (95%
0.75 µg/L after five years (p<0.0001 vs. pre-operative) and tended CI: 83.9-93.4). Clinical: all revision cases and nine of the 14 (64%)
to decrease thereafter to values of 0.56 µg/L after seven years. The awaiting revision presented with symptoms. In those not revised
Kaplan-Meier survivorship was 87.7% for revision for all causes, or awaiting revision, 17 patients (9%) had painful hips. The mean
and 95.5% when excluding the hips revised for a manufacture’s OHS for all patients was 21 (3-39) pre-operatively and 45 (11-48)
defect at a mean of 11.2 years (range, 9 to 14 years) (Figure 1). post-operatively compared to 17 (6-31) pre-revision in the revision
DISCUSSION AND CONCLUSION: The Kaplan-Meier / awaiting revision cohort. Radiological: progressive radiological
survivorship in our study is comparable to other studies with changes were observed in 10 of the 14 patients diagnosed with
similar follow ups. Metal-on-metal implants are durable. Metal adverse reaction to metal debris (ARMD) and in all those awaiting
ions peaked at four years and decreased thereafter. Clinical scores revision. There was no significant difference in cup size (p=0.77),
have demonstrated that patients maintain their excellent outcomes. inclination (p=0.38) or cup version (p=0.12) when comparing
the revision / awaiting revision to the non revision cohorts. Metal
ion analysis: there was a significant increase in Co levels in the
revision / awaiting revision group (p=0.001) compared to the non
revision cohort, but this was not observed for Cr or Mo metal ions
(p= 0.14; p=0.22 respectively). Retrieval analysis: the stem had
obvious pitting and evidence of corrosion along the surface. The
mean bearing surface wear between head and cup was 1.86mm/
yr +/-1.55mm (+/-2SD). These values along with geometric
information gathered from redlux images did not demonstrate
abnormal wear volume, depth or position for the length of time
the implants had been implanted. The mean maximum out of
roundness of the taper was 34.5 microns +/-13.3 (+/-2SD; normal
range 8-10 microns). A characteristic pattern was observed with
two discrete regions of wear at polar opposites to each other on
the trunnion circumference margin. Multifactorial analysis: the
presence of an isolated raised Co level in the absence of either
symptoms or XR changes was not predictive of failure (p=0.675).
However both the presence of pain (p<0.001) and XR changes
(p<0.001) in isolation were both significant predictors of failure.

DISCUSSION AND CONCLUSION: This MOMHTHR series gives the surgeon learning DAA an algorithm for appropriate
has demonstrated unacceptable high failure rates and a high patient selection. Selecting the appropriate patient can reduce the
occurrence of ARMD. Retrieval analysis has highlighted concerns risks to the patient and minimize the cost to society of integrating
over excess wear at the trunnion along with evidence of corrosion new surgical techniques.
to the stem. Pain is a positive predictor of failure and new subtle
symptoms should not be overlooked. Metal ion levels remain a
useful aspect of the investigation work up but in isolation are not
specific or predictive of failure.
POSTER NO. P051

Predicting Difficulty of Femoral Preparation in the
Direct Anterior Approach for Total Hip Arthroplasty
Azim Karim, MD, Houston, TX
Kevin J. Leffers, MD, Galveston, TX
Stefan Kreuzer, MD, Houston, TX
INTRODUCTION: The advantages of the direct anterior approach
(DAA) for total hip arthroplasty (THA) include the preservation
of external rotators and hip abductors thus leading to quicker
recovery times. To our knowledge, there is no objective method in
the literature to predict the level of difficulty for femoral exposure
through the DAA. It would be beneficial to the surgeon learning
the DAA to assess difficulty pre-operatively to avoid prolonged
operative times. The purpose of this study was to develop a POSTER NO. P052
predictive model of femoral exposure difficulty in the DAA using a Corticosteroid Dosage and Risk of Avascular Necrosis
combination of demographic data and radiographic measurements. of the Femoral Head: A Meta-Analysis
METHODS: A total of 305 post-operative radiographs of consecutive
THAs in patients (184 female, 120 male) with primary or secondary
osteoarthritis, mean age 64.6 (range 26-91, SD=11.43) performed Aaron J. Johnson, MD, Baltimore, MD
through the DAA by one of the co-investigators from 12/2005 to Alex A. Stroh, BS, Baltimore, MD
12/2009 were retrospectively reviewed by two separate observers. Lynne C. Jones, PhD, Baltimore, MD
The observers were blinded to the difficulty level of femoral INTRODUCTION: Various studies have implicated corticosteroids
exposure. Standard post-operative AP pelvis films were assessed as a cause or associated risk factor for avascular necrosis of the
for with CAD software to make radiographic measurements as femoral head. The exact dosage and degree of exposure risk has
shown in Figure 1. Each radiograph was calibrated using the size not been clarified. In contradistinction, some studies have not
of the femoral head implant. Exclusion criteria included films that found any relationship between corticosteroids and avascular
had inadequate coverage of the entire pelvis, mal-rotation, or poor necrosis in certain patient sub-populations. The purpose
exposure. Statistical analysis was performed. A two-sided Kruskal- of this study was to assess the risk of developing avascular
Wallis test was utilized for non-parametric data. Chi-squared necrosis after varying corticosteroid dosages by conducting
tests and Fisher’s Exact Test were used to compare proportions. a meta-analysis of published reports. A secondary goal was
Statistically significant associations were then added to a to identify the patient populations who have the highest and
multivariate model predicting an outcome of difficult exposure. lowest risk of avascular necrosis with corticosteroid use.
RESULTS: The difficult exposures were equally distributed METHODS: The authors systematically reviewed the literature
throughout the study period. The side of the THA was not found on Medline that was related to hip osteonecrosis, and focused
associated with a difficult exposure (χ2=0.5516, p<.01) whereas on corticosteroid exposure. Bibliographies of review articles were
66% of difficult cases were male (χ2=38.5323, p<.01 ). Height, then analyzed for any additional relevant studies. We excluded
weight, BMI, and age were all independent predictors of a difficult reports that examined fewer than 50 patients or did not provide
exposure, with taller (>175cm) more difficult than shorter (p<.01), sufficient data to analyze risk of developing avascular necrosis
heavier (>100kg) more difficult than lighter (p<.01), higher BMI after corticosteroid exposure. We also stratified reports by levels of
(>32) being more difficult than lower BMI (p<.01), and younger evidence. The analysis was stratified by patient follow up, various
age (<60) being more difficult than older age (p<.01). Increased associated risk factors (i.e. smoking, alcohol, corticosteroids), disease
cup size (p<.01) and femoral head size (p<.01) were utilized in populations (i.e. renal transplant, systemic lupus erythematosus),
cases having difficult exposure. Radiographic criteria that were as well as type and administration route of corticosteroids (oral,
predictive of difficult femoral preparation were decreased distance intravenous, pulsed). Outcome parameters were the number and
(<110mm) between teardrop signs (p<.01), increased distance percentage of patients who developed avascular necrosis over
(>211mm) between the superior lateral acetabalum (p<.01), the study period. A chi-square analysis was used to compare the
and increased distance (>306mm) between the lateral edge of differences in disease rates for various subpopulations evaluated.
the greater trochanter’s (p=<.01). From this, we determined a RESULTS: There were 41 studies ranging in size from 50 to 4,388
pre-operative scoring tool to predict difficult exposure consiting patients for whom the corticosteroid dose/avascular necrosis
of sex, BMI, cup size, head size, and radiographic parameters. relationship could be ascertained. A total of 1,901 patients
DISCUSSION AND CONCLUSION: The DAA approach has proven developed avascular necrosis of the femoral head out of 28,361
difficult to learn for many surgeons. Careful patient selection can patients from all the studies (6.7%). Risk from individual studies
facilitate the learning curve and improve patient outcomes. We ranged from 0.3% to 44%. Patients who had inflammatory bowel
describe a simple to implement preoperative rating scale, which disease or were administered corticosteroids after neurosurgical

procedures had the lowest risk, and patients who had systemic lupus increased concentrations of vancomycin eluted from bone cement
erythematosus or severe acute respiratory syndrome had the highest when compared to vacuum-mixing. The UCS of bone cement is
risk. In 30 studies (73%), corticosteroid exposure and increasing significantly decreased after elution of vancomycin.
dosage were associated with increased risk, which included four
out of six level I or II studies. In 11 studies, no definite relationship POSTER NO. P054
could be established. The risk of avascular necrosis appeared to be The Course of the Femoral Artery in Congenital High
positively correlated with corticosteroid exposure and/or dosage
in patients who had bone marrow transplants, systemic lupus Hip Dislocation
erythematosus, cardiac transplant, or severe acute respiratory Jin Yamaguchi, MD, Nagoya, Japan
syndrome. Patients who had asthma, inflammatory arthritis (not INTRODUCTION: In the adult hip, the femoral artery or profunda
including systemic lupus erythematosus), or liver transplants, femoris artery usually runs apart from the acetabular anterior
on the other hand, appear to show little direct relationship roof. In a few cases the profunda femoris artery is injured at
between corticosteroid exposure and risk of avascular necrosis. the time of total hip arthroplasty (THA). We have experienced
DISCUSSION AND CONCLUSION: In some patient populations, injury to the profunda femoris artery during operation of the
there appears to be a weak link between corticosteroids and the primay acetabulum in cases of congenital high hip dislocation.
development of avascular necrosis. Many of the groups that had Retrospectively investigated, the femoral artery of the affected
weak links included patients who had inflammatory arthritis side ran more closely to the acetabular anterior roof than that of
(excluding systemic lupus erythematosus), who many authors the unaffected side. We analyzed anatomically the course of the
do not consider as having true hip avascular necrosis. However, femoral artery. We focused on (1) whether the femoral artery
in most studies, an association was found between increasing on the affected side would run more closely to the acetabular
corticosteroid exposure and risk. In addition, an incremental effect anterior roof than that on the unaffected side, (2) whether the
was observed, where increasing dosages led to a higher incidence iliopsoas muscle could not be seen between the femoral artery
of this disease. and acetabular anterior roof and (3) whether the profunda femoris
artery on the affected side would branch off the femoral artery, at
POSTER NO. P053 a more proximal level than on the artery on the unaffected side.
uMixing Technique Impacts Antibiotic Elution from METHODS: We retrospectively reviewed 48 patients / 56 hips of
congenital high hip dislocation. We excluded 15 patients / 17 hips
Bone Cement and Its Elution Compromises Cement without CT scan and one patient / one hip with a neuromuscular
Strength disorder. This left 33 patients / 39 hips (four males / 29 females).
Ryan P. Dunlay, MD, Kansas City, KS The overall mean age was 64.9 ± 8.1 years. There were 14 Crowe
Patrick G. Moodie, Overland Park, KS Type III hips / 25 Type IV hips.There were no Crowe Type I or II
Hao Zhu, PhD, Kansas City, KS hips. In the unilateral patients, the hip on the unaffected side
Kelly J. Hendricks, MD, Kansas City, KS was defined as the normal hip and the hip on the affected side
was defined as high hip dislocation. In this way, we evaluated
Terence McIff, PhD, Kansas City, KS
39 high hip dislocations and 27 normal hips. Radiographical
INTRODUCTION: Infection in total joint replacement has been a examination was performed using plain CT. We classified the
major complication since its inception. Many arthroplasty surgeons course of the femoral artery as the far group if the distance
routinely mix powdered vancomycin with bone cement in an between the femoral artery and acetabular anterior roof exceeded
attempt to decrease infection rates. Despite this common practice, 1cm and as the near group if it was less than 1cm. We evaluated
the impact of preparation technique on antibiotic elution and the the presence of iliopsoas muscle between the femoral artery and
role antibiotic elution has on cement strength have been neglected. acetabular anterior roof on the same image. We examined the
The goal of this study was to investigate the role mixing technique location of the femoral artery branching to the profunda femoris.
has on antibiotic elution rates and the properties of the cement. RESULTS: The distance between the femoral artery and acetabular
METHODS: Five cement samples in four groups (plain cement anterior roof was 6.69±3.26 mm in the high hip dislocation and
hand-mixed, plain cement vacuum-mixed, plain cement + 5g 11.76±3.11 mm in the normal hip group (p<0.0001). Near groups
vancomycin hand-mixed, and plain cement + 5g vancomycin were 29 hips of the 39 hips of high hip dislocation (74.4%) and six
vacuum-mixed) were prepared. Each sample underwent a CT scan hips of the 27 normal hips (22.2%) (p<0.0001). Only five iliopsoas
before and after elution of vancomycin. Each sample was incubated muscles could be seen in the 39 cases of high hip dislocation (12.8%)
in a solution of sterile phosphate-buffered saline (PBS) for a total of and all iliopsoas muscles could be seen in the 27 normal hips
six weeks and aspirates obtained every 24 hours for one week and (100%) between the femoral artery and acetabular anterior roof
at three and six weeks. High Performance Liquid Chromatography (p<0.0001). Seventeen femoral arteries branched to the profunda
(HPLC) was used to quantify antibiotic concentration. Each artery at the level of the primary acetabulum in the 39 cases of high
aspirate was inoculated with a human strain of Staphylococcus aureus hip dislocation (43.6%). Six femoral arteries branched at the level
to demonstrate clinical efficacy. All samples underwent Ultimate of the primary acetabulum in the 27 normal hips (22.2%) (p<0.05).
Compression Strength (UCS) testing before and after elution. DISCUSSION AND CONCLUSION: In this study, the femoral
RESULTS: Hand-mixing vancomycin with plain bone cement artery in high hip dislocation ran more closely to the acetabular
resulted in greater elution of vancomycin (p<0.05). Over the anterior roof than that of normal hip joint. The iliopsoas muscles,
first day the hand-mixed cement eluted 38% more vancomycin which protect a femoral artery and profunda femoris artery by
than the vacuum-mixed cement. Over the course of six interposing between these arteries and acetabular anterior roof,
weeks the hand-mixed cement eluted 52% more vancomycin could not be seen in most of the cases of congenital high hip
than the vacuum-mixed cement. Elution of vancomycin dislocation. The femoral artery of the high hip dislocation group
from hand-mixed and vacuum-mixed cement decreased its branched more proximally than that of the normal hip group
compression strength by 22% and 12% after six weeks (p<0.05). significantly. A profunda femoris artery usually runs behind a
DISCUSSION AND CONCLUSION: Hand-mixing technique femoral artery. When a femoral artery branches proximally, a

profunda femoris artery runs closely to the acetabulum. It is POSTER NO. P056
unlikely that the artery came close to the acetabular roof during
surgery. Preoperative evaluation of the artery is important to
Long Term Follow-Up of Cementless THR for
avoid injury. Attention should be paid to the course of arteries Osteonecrosis: Have We Improved on Cemented THR?
surrounding the hip. Nicholas Bedard, BS, Iowa City, IA
John J. Callaghan, MD, Iowa City, IA
POSTER NO. P055 Steve S. Liu, MD, Iowa City, IA
Have Large Femoral Heads Solved the Problem of Richard C. Johnston, MD, Iowa City, IA
Dislocation After Revision Total Hip Arthroplasty? INTRODUCTION: The results of cemented total hip replacement
Kace A. Ezzet, MD, La Jolla, CA (THR) for osteonecrosis of the hip are reported to be inferior to
Eric Levicoff, MD, Bryn Mawr, PA the results for other diagnoses. The authors evaluated the results
of cementless THR performed for osteonecrosis (consecutive non-
Kace A. Ezzet, MD, La Jolla, CA
selected series) at minimum 10-year follow up and compared them
INTRODUCTION: Dislocation after revision total hip arthroplasty to the author’s previously performed cemented consecutive non-
(THA) is a devastating complication that has been reported to selected series for the same diagnosis reported at comparable follow up.
occur in roughly 7-15% of cases. Newer bearings with larger METHODS: Eighty consecutive cementless THRs were performed
femoral head diameters are now being utilized in the hope of in 66 patients with osteonecrosis of the hip and were followed for a
decreasing the rate of dislocation. We wished to determine what minimum of 10 years. The average age at the time of surgery was 54
effect these modem implants have on dislocation rates following years. The cohort was compared to a consecutive series cohort of 48
revision THA, and hypothesized that larger heads would lead to cemented THRs performed in 38 patients for the same diagnosis and
lower dislocation rates. We compared revision THAs with femoral that had been followed by the same authors at a similar minimum
head sizes 32 mm and less to revision THAs with femoral head 10-year interval follow up. In addition to obtaining Harris
sizes 36mm and greater to determine if larger femoral heads Hip scores, hips were evaluated for revision of the components
have reduced the incidence of dislocation after revision THA. related to loosening and wear, and for radiographic loosening.
METHODS: Data were reviewed for 100 consecutive revision RESULTS: At minimum 10-year follow up, the comparative
THAs performed via the posterior approach by six joint surgeons prevalence for the cementless versus the cemented series for
at one hospital. All revisions occurring at our hospital during femoral revision for loosening, acetabular revision for loosening,
the time of the study, regardless of etiology, were included in the overall femoral loosening and overall acetabular loosening
analysis. All cases had at least one year of follow up. Information (radiographic) were 1.2% vs. 6.5% (p = 0.01), 0% vs. 13% (p =
was collected through mailed inquiries about dislocation status 0.0001), 1.2% vs. 13% (p = 0.0001) and 0% vs. 15.2% (p = 0.0001).
and telephone contact for those patients not responding via mail. In the cementless group, 7.5% of hips required a liner exchange
RESULTS: Of the 100 revision THA, 50 had femoral head sizes for wear (most hips had non-contemporary polyethylene).
32mm or less, and 50 had head sizes 36mm or greater. Sixteen DISCUSSION AND CONCLUSION: This study demonstrates a
patients were lost to follow up. Of the remaining 84, there were marked improvement in cementless THR fixation compared to
nine dislocations; five dislocations occurred in the group with head cemented fixation in patients with osteonecrosis of the femoral
sizes of 32mm or less, and four dislocations occurred in the group head. Bearing surface wear was the major cause of failure.
with head sizes of 36mm heads or larger. The dislocation rate for the Addressing this problem should provide even more durable results
cohort as a whole was 10.7%. The two groups had nearly identical in this active population.
dislocation rates, thus failing to show that larger head sizes have
significantly reduced the risk of dislocation after revision THA. POSTER NO. P057
DISCUSSION AND CONCLUSION: Dislocation continues to be
a significant problem following revision THA, despite availability Ceramic-Ceramic Bearing Decreases the Cumulative
of heads with diameters of 36mm and greater. Larger head sizes Long-term Risk of Dislocation: A 20-Year Study versus
did not solve the problem of dislocation in this cohort of patients. Ceramic-PE
This study highlights the persistently increased risk of dislocation
Philippe Hernigou, PhD, Creteil France, France
following revision THA, as well as the need to continue the
search for solutions to this clinical problem. Because head sizes
Alexandre Poignard, MD, Creteil, France
of greater than 40mm were rarely used in this cohort, we cannot Charles Henri Flouzat-Lachaniette, MD, Creteil, France
determine whether so-called jumbo heads will fare better than the INTRODUCTION: After total hip arthroplasty (THA) a widely
36 and 40mm heads that we utilized. Further studies are needed to variable prevalence of dislocation has been reported, partly
determine if larger head sizes are beneficial in certain subgroups of because of varying durations of follow up for this specific end-
patients as well as to identify pre-operatively (or intra-operatively) point. The purpose of the present study was to determine was to
which patients may need a more constrained bearing. determine the risk of first-time dislocation as a function of time
as well as the cumulative long-term risk of dislocation following
total hip arthroplasty in patients with two different bearing
surfaces, ceramic on ceramic and ceramic on polyethylene (PE).
METHODS: We reviewed 126 patients (252 hips) with bilateral
THA (one ceramic-ceramic, AL/AL and the contralateral ceramic-
polyethylene, AL/PE) who had THA performed between from
1978 to 1985, and who had survived at least 20 years after surgery.
Surgery was performed in both sides within a two years delay with
a posterolateral approach under general anesthesia in patients who
were average 50 years (range 31-61) old at the time of surgery. All
patients received the same implants except for the cup. The stem

was made of anodized titanium alloy (TiAl6V4) and was smooth 20% and leucocyte positive 24.7%. Female to male incidence ratio
and always cemented. The alumina head was 32 mm in diameter was 1:9. There was 23% incidence of bacteriuria under 65 years of
on each side and anchored through a Morse taper. The acetabular age. Diabetes was the most common (9.2%) co-morbidity, followed
component was a polyethylene cup or an alumina cup and was by renal disease (4.5%). Surgery was postponed in three patients
always cemented. The patients were followed at routine intervals (0.07%) with 3+ bacteriuria and large leucocytes until urine
and were specifically queried about dislocation. The cumulative risk culture result was negative following oral antibiotic treatment.
of dislocation was calculated with use of the Kaplan-Meier method. Of three periprosthetic infections, two underwent debridement
RESULTS: For hips with PE liners, the cumulative risk of a first-time and polyethylene exchange and one had two staged revision knee
dislocation was 1% (95% confidence interval, 0.9% to 1.1%) at one arthroplasty. Two of the infections had negative urine microscopy,
month and 2% (95% confidence interval, 1.7% to 2.3%) at one year but positive for diabetes and HIV. The other one periprosthetic
and rose with an increasing rate of 1.2% for the first two five year infection had positive urine microscopy, but negative urine culture.
periods to 4.5% at 10 years, rose with an increasing rate of 1.8% for DISCUSSION AND CONCLUSION: Asymptomatic bacteriuria
the next two five year periods to reach 8% at 20 years, and then rose is common even in younger patients and especially female.
with an increasing rate of 2.5% for the last two five years periods to Postponement of surgery should be considered only if significant
elevate to 13% (95% confidence interval, 9% to 17%) at 30 years other co-morbidities and other signs of cystitis/pyelonephritis are
for patients who were alive and had not had a revision by that time. present.
Multivariate analysis revealed that the relative cumulative risk of
dislocation (with PE liners) for female patients (as compared with POSTER NO. P059
male patients) was 1.8 and that the relative risk for patients who Multicenter RSA Evaluation of In Vivo Wear of Vitamin E
were 80 years old or more (as compared with those who were less
than 80 years old) was 1.5. Two underlying diagnoses, cognitively Stabilized Highly Cross-linked Polyethylene
impaired patients or neurologic desease, were also associated with Meridith E. Greene, Boston, MA
a significantly greater risk of dislocation. For hips with alumina Charles R. Bragdon, PhD, Boston, MA
liners, the cumulative risk of a first-time dislocation was 1% at Young-Min Kwon, MD, PhD, Boston, MA
one month, 2% at one year (95% confidence interval, 1.8% to Harry E. Rubash, MD, Boston, MA
2.1%) and then did not change at 20 years and at 30 years for Annie Gam-Pedersen, RN, Odense, Denmark
patients who were alive and had not had a revision by that time. Henrik Malchau, MD, Boston, MA
DISCUSSION AND CONCLUSION: The cumulative long-term
Soeren Overgaard, Odense, Denmark
risk of dislocation was greater for patients with PE cup than for
patients with ceramic cups. The reasons are probably the absence INTRODUCTION: Vitamin E doping of highly cross-linked
of wear with alumina cups, the difference between the histology of polyethylene is a method for enhancing long-term oxidative
the capsule of the hips with the two bearing surfaces (fibrous with stability of highly cross-linked ultra-high molecular weight
ceramic on ceramic; less fibrous and more elastic with PE cups), polyethylene for use in total joint arthroplasty. In vitro research and
and a better adhesion between the two components in ceramic development studies have shown that this material has improved
on ceramic hips. The different histological aspects observed on wear performance, better retention of mechanical properties, and
revisions are probably the most important factors to explain the high resistance to oxidation due to the anti-oxidative properties
absence of dislocation at the most recent follow up in the ceramic of vitamin E. The purpose of this study was to evaluate in vivo
group, even in women older than 80 years, in cognitively impaired properties of vitamin-E doped highly cross-linked polyethylene
patients, or in patients with occurrence of a neurologic desease. (VEPE), evaluate the stability of two acetabular cup surface coatings
and femoral stem stability using radiostereometric analysis (RSA).
POSTER NO. P058 METHODS: One-hundred-and-three hips in 99 patients were
recruited into an IRB approved, prospective five year RSA study
Significance of Asymptomatic Bacteriuria in Knee and at two centers. Tantalum beads placed in the VEPE liner, the
Hip Arthroplasty pelvic bone and the femur at the time of surgery, allow the
Arup K. Bhadra, MD, Mahwah, NJ measurement of femoral head displacement into the polyethylene
Jared Armstrong, MD, Prospect, KY as well as acetabular and femoral component stability. Fifty-one
Cameron A. Ghazi, BS, Prospect, KY hips received porous-titanium coated cups while 52 hips received
Arthur L. Malkani, MD, Louisville, KY plasma-sprayed cups. Either 32 or 36mm femoral heads were used.
RSA radiographs were scheduled immediately post-operatively, at
Madhusudhan R. Yakkanti, MD, Louisville, KY
three or six months, one, two, three and five years post-operatively.
INTRODUCTION: Infection is one of the most devastating RESULTS: Ninety-one hips were followed for three or six months,
and dreaded complications of total joint arthroplasty. The 64 for one year, 21 for two years, and four for three years. Data for
incidence and significance of asymptomatic bacteriuria in patients with the plasma-sprayed cup were available only at one
patients for hip and knee arthroplasty is unknown. The purpose year follow up. No significant difference was found in femoral head
of the study was to report the incidence of bacteriuria and penetration into the VEPE liner between the head sizes. The median
results of arthroplasty in respect to periprosthetic infection. head penetration was 0.03±0.01mm at one year, 0.04±0.01mm at
METHODS: This was a retrospective review of 400 consecutive two years, and 0.03±0.02mm at three years. The median proximal
patients (155 male, 245 female) with mean age of 65.6 years migration of plasma-sprayed cups was 0.22±0.05mm at one year
(43-89) undergoing knee and hip arthroplasty. Patients were while the median proximal migration of porous-titanium coated
evaluated for immediate preoperative urine microscopy results cups was 0.09±0.03mm at one year, 0.11±0.04mm at two years,
for bacteria, nitrite and leucocytes, comorbidities, perioperatve and 0.17±0.13mm at three years. Both cup types were stable by
treatment for urinary tract infection, postponement of surgery and one year, and the total penetration was not significantly different
periprosthetic infection. The mean follow up was 17 months (6-24). between the different coating types. The median femoral stem
All patients had perioperative urinary catheterization for 24 hours. subsidence was 0.13±0.23mm at six months, 0.16±0.27mm at one
RESULTS: The incidence of bacteriuria was 43% with nitrite positive

year, 0.06±0.14mm at two years, and 0.02±2.39mm at three years. RESULTS: Time 1, from 2004 through 2008, had 1,952 qualifying
DISCUSSION AND CONCLUSION: This study provides the first in hips with 1,845 having both version and abduction, and Time
vivo wear measurement of VEPE liners using RSA. The amount of 2, from 2009 through June 2010, had 385 qualifying hips, all
penetration into the liner observed during the early period (creep) of which had both version and abduction angles. For Time 1,
is low (0.04mm). Creep in other highly cross-linked polyethylene 1,192 (62%) acetabular cups were within the abduction range,
liners without vitamin E was reported as 0.1mm. There was no 1,422 (79%) were within the version range, and 908 (49%) were
significant change in femoral head penetration in vivo over time, within the range for both. For Time 2, 276 (72%) acetabular cups
indicating that little true wear occurred at the articulation. While were within the abduction range, 250 (65%) were within the
not statistically significant, the plasma-sprayed cups tended to version range, and 217 (56%) were within the ranges for both.
migrate more than the porous-titanium coated cups in the early Accuracy of abduction angle improved (p<0.01) while accuracy
months of follow up. Cups with both types of surface coatings were of version angle decreased (p<0.01). Accuracy of acetabular
stable by one year. Prior work has demonstrated that movement cup positioning being within range for both abduction angle
of the acetablular cup greater than 1.2mm in the first two years and version angle improved significantly (p=0.01), by 7%.
has a greater than 50% probability of revision. The relatively low DISCUSSION AND CONCLUSION: Malpositioning of the
amount of early movement seen in both groups is encouraging, acetabular cup has been correlated with numerous adverse clinical
indicating that the components were stable at one year follow up. outcomes including increased rate of dislocation, liner fracture,
While most stems were stable throughout, the high standard error and increased wear. The increased dislocation risk has been well
at three years results from one stem that migrated substantially by established, and implant wear has been shown to be significantly
six months (9.4mm). At one year, the stem was stable and at three greater for malpositioned cups. Specifically, it has been shown
years remains stable. The 9.4mm of distal migration was visible that surgical technique factors such as abduction angle of the
in plain radiographs. The patient is doing clinically well with no cup were the most predictive of polyethylene wear. This study
symptoms. The early results of this multicenter RSA study indicate demonstrates that increased awareness and feedback on the
that the VEPE has excellent wear performance; that the plasma- resulting abduction and version measurements from THA surgery
sprayed and porous-titanium coated components both stabilize over time improves the positioning of the acetabular component. A
during the first year in vivo; and that the femoral components were system where objective measurements are presented to the surgeon
stable. can significantly improve cup placement which could improve the
clinical outcome of THR patients.
POSTER NO. P060
ALTERNATE PAPER: ADULT RECONSTRUCTION HIP IV POSTER NO. P061
Cup Positioning in Total Hip Arthroplasty Improves with Three-dimensional Computed Tomography (3DCT)
Clinical Feedback Evaluation of Acetabulum After Periacetabular
Young-Min Kwon, MD, PhD, Boston, MA Osteotomy
Charles R. Bragdon, PhD, Boston, MA Yoshitsugu Tanaka, MD, Fukuoka, Japan
Michael Doerner, BA Masatoshi Naito, MD, Fukuoka, Japan
Mark C. Callanan, MA, Grand Rapids, MI Yoshinari Nakamura, MD, Fukuoka, Japan
David Zurakowski, PhD, Boston, MA Nobuhiro Kashima, MD, Fukuoka, Japan
Harry E. Rubash, MD, Boston, MA Takahiro Ida, MD, Fukuoka, Japan
Henrik Malchau, MD, Boston, MA Daisuke Kuroda, MD, Fukuoka City, Japan
INTRODUCTION: Acetabular cup positioning has been linked Tomohiro Nomura, MD
to dislocation and increased bearing surface wear. While studies Tomohiro Kobayashi, MD, Fukuoka, Japan
have shown various optimal orientation ranges, a common Masatoshi Naito, MD, Fukuoka, Japan
range of acceptable angles is the Lewinnek safe zone (5-25°
INTRODUCTION: This three-dimensional computed tomography
of anteversion and 30-50° of abduction). Cup angles that are
(3DCT) analysis shows that anterior rotation of the acetabular
outside the optimal ranges are linked to a variety of unsuccessful
fragment contributes to medialization of the femoral head in 30
outcomes, including dislocation of the hip. Another previous
patients following periacetabular osteotomy for hip dysplasia.
study found correlations between patient and surgical factors
Curved periacetabular osteotomy (CPO) is a modified Ganz
and acetabular component position. The purpose of this study
procedure that we have performed in our facility since 1995 to treat
was to determine if the accuracy of acetabular cup positioning
acetabular dysplasia from the prearthrosis stage to the advanced
improves when surgeons receive feedback on their performance.
stage in young patients. During the surgery, we use an image
METHODS: Post-op anteroposterior (AP) pelvis and cross-table
intensifier while performing rotation of the acetabulum, with
lateral radiographs were previously obtained for 2,061 patients
the main indices being femoral head coverage, acetabular roof
who received a total hip arthroplasty (THA) or hip resurfacing from
obliquity and medialization of the femoral head. However, the key
2004 -2008. The surgeries were performed by seven surgeons. AP
parameter for medialization of the femoral head remains unclear.
radiographs were measured using Hip Analysis Suite to calculate the
The purpose of this study was to investigate effective procedures
cup inclination and version angles. Acceptable ranges were defined
for medialization of the femoral head during CPO using 3DCT.
for abduction (30-45°) and version (5-25°). The same surgeons
METHODS: Thirty hips in 30 patients with hip dysplasia
performed a THA or hip resurfacing on 385 patients from January
underwent 3DCT scans with a slice thickness of 0.5 mm
2009 through June 2010. Cup inclination and version angles for
before and after surgery. A full search method that varied and
this set of surgeries were compared to surgeries from 2004-2008
superimposed a total of six directional and angular variables
to determine if cup inclination and version angles improved as
in three dimensions was used to investigate the relationships
a result of knowledge of the previous acetabular cup positioning
between 3D movements of the acetabulum and medialization
study. Improvement in accuracy was assessed by the chi-square test.
of the center of the femoral head. Multiple regression analysis

was used to clarify the relationships in the resulting data. * Significantly worse than other methods (Levene’s test)
RESULTS: Medialization of the femoral head was observed DISCUSSION AND CONCLUSION: Measuring from the
in 24 of the 30 patients. Among these 24 patients, 20 showed inferior aspect of the ischial tuberosities and to the midpoint
anterior rotation of the acetabular fragment in both the sagittal of the lesser trochanters is the most reproducible method
and axial planes. The remaining six cases with lateralization of for measuring LLD from a pelvic radiograph. This method
the femoral head had acetabular retroversion preoperatively. is also the least affected by pelvic positioning. The errors in
Among the different variables, anterior rotation of the measurements from pelvic radiographs can be high especially
acetabular fragment and presence of acetabular retroversion when there is patient mal-positioning. This information should
contributed significantly to medialization of the femoral head. be considered when using this method as the “gold standard”
DISCUSSION AND CONCLUSION: This retrospective study using with which to compare intra-operative measurement techniques.
3DCT showed that increased coverage of the femoral head and
absence of acetabular retroversion contribute to medialization of
the femoral head.
POSTER NO. P062

Measuring Leg Length Using Pelvic Radiographs
Catriona Heaver, MRCS, Loggerheads/Shropshire, United
Kingdom
Jean-Pierre St Mart, Essex, United Kingdom
Peter Nightingale, Birmingham, United Kingdom
Aabha Sinha, West Midlands, United Kingdom
Edward T. Davis, FRCS, Hagley, United Kingdom
INTRODUCTION: Leg length discrepancy (LLD) following total
hip arthroplasty (THA) remains common and can be a source
of patient dissatisfaction and distress. In an effort to reduce this
POSTER NO. P063
occurrence, surgeons undertake pre-operative templating and
use various forms of intra-operative measurements, including Swanson Implant Arthroplasty for Hallux Valgus in
computer navigation. With the advent of better technologies to Elder Patients
measure intra operative leg length the “gold standard” with which Koh Shimizu, MD, Chiba, Japan
to compare them is vital. This study aims to delineate how best to
Sara Shimizu, MD, Chiba, Japan
measure LLD form a pelvic radiograph and quantifies the errors.
METHODS: Three observers took a total of 9,600 measurements INTRODUCTION: Various surgical methods have been reported
from 100 pelvic radiographs. Four lines were constructed on for hallux valgus with sufficient results; however, several weeks
each of the radiographs, bisecting the acetabular teardrops are necessary for patients to walk by full weight bearing after any
(Line A- Methods 1/2), ischial spines (Line B- Method 3/4), osteotomy due to the risk of fracture and dislocation. Contrarily,
inferior sacroiliac joint (Line C- Method 5/6) and inferior it is possible for the patients to walk immediately after Swanson
obturator foramen (Line D-Method 7/8). Measurements were implant arthroplasty, although there are a few reports which
taken from these lines to the midpoint on the lesser trochanter describe its results in detail. The purpose of this study is to investigate
and to the tip of the greater trochanter. The effect of pelvic the results of Swanson implant arthroplasty for hallux valgus
positioning was also assessed using radiographs of a synthetic in elder patients, by analyzing the clinical symptoms and X-ray
pelvis and femur using the same eight methods by a single findings including hallux valgus angle and intermetatarsal angle.
observer. Intra-observer variability was analysed using within METHODS: Analysis of 118 cases of Swanson implant arthroplasty
subject standard deviation. Inter-observer variability was in 75 patients was performed. There were eight male and 67
analysed using the coefficient of inter-observer variability (CIV). female, and all the patients were older than 60 years and average
RESULTS: age was 73 years old. Swanson implant arthroplasty were
performed by one surgeon (K.S.) with additional soft tissue release
REPRODUCIBILITY OF LLD EFFECT OF PELVIC and tightening of medial capsule. All the patients were followed
MEASUREMENTS POSITIONING
clinically more than five years postoperatively with mean follow
Interobserver up period of 103 months. Radiographycally, hallux valgus angle
Intraobserver Intraobserver
METHOD Variability and metatarsal valus angle were measured, and bone absorption
Variability (SD) Variability (SD)
(CIV)
and position of the implant were checked in detail at 0, 1, 3, 6, 12,
1 Teardrop-LT 4 -0.037 8.67 36, 60 months postoperatively and at most recent examination.
2 Teardrop-GT 4.8 * -0.028 17.6 RESULTS: 1. Pain decreased significantly after surgery and good
condition continued until the most recent examination in all
3 Ischial Tuberosity-LT 3.5 0.006 6.76
the cases but one. 2. Average hallux valgus angle, which was 52°
Ischial Tuberosity- preoperatively, changed to 3° immediately after operation, 9° at
4 3.8 0.071 12.4
GT three months postoperatively, and 12° at most recent examination.
5 SIJ-LT 3.4 0.121 10.1 3. Average intermetatarsal angle, which was 29° preoperatively,
changed to 6° immediately after operation, 8° at 3=three months
6 SIJ-GT 4.6 * 0.078 19.7
postoperatively, and 9° at most recent examination. 4. There were no
7 Obturator-LT 3 0.063 7.4 cases with infection, skin necrosis, or sensory disturbance, although
8 Obturator-GT 3.3 0.001 17.7 bone absorption around the implant was revealed in one case.
DISCUSSION AND CONCLUSION: These results indicate that

Swanson implant arthroplasty was very effective to reduce pain were worrisome both for monoblock and modular acetabular
and correct deformity in most patients with hallux valgus. The best components from this system. Results were suboptimal in both
indication of this surgery is believed to be relatively elder patients men and women, although women seemed to fare more poorly
who hope for a quick return to normal daily activity, although their than men. Failures did not appear to be due to vertical component
activity is not as high as younger ones, considering permanence of positioning. We cannot endorse this bearing and have stopped
the implant. using it. The authors believe that all MoM bearings need to be
individually evaluated by independent research teams to document
POSTER NO. P064 safety and efficacy.
Poor Short-Term Outcomes with a Contemporary Metal
POSTER NO. P065
on Metal Total Hip Arthroplasty System
Kace A. Ezzet, MD, La Jolla, CA
The Utility of Erythrocyte Sedimentation Rate and
Yadin D. Levy, MD, San Diego, CA C-Reactive Protein in Determining Periprosthetic Hip
INTRODUCTION: Metal on metal (MoM) bearings have been Infections
adopted for total hip arthroplasty (THA) in an effort to reduce Christopher R. Costa, MD, Baltimore, MD
wear, improve longevity, and reduce dislocation rates compared Aaron J. Johnson, MD, Baltimore, MD
to polyethylene bearings. Concerns have been raised regarding Qais Naziri, MD, Baltimore, MD
high metal ion levels, adverse soft tissue reactions, and high Ronald E. Delanois, MD, Baltimore, MD
rates of clinical failure with some of these bearings. At least Michael A. Mont, MD, Baltimore, MD
two such bearings have now been withdrawn from the U.S.
marketplace. It is unknown whether these problems are design INTRODUCTION: The diagnosis of periprosthetic hip infections
specific or whether they apply to MoM bearing technology in is often challenging. Erythrocyte sedimentation rate (ESR) and
general. We report our unfavorable results with a modern MoM C-reactive protein (CRP) blood laboratory tests have commonly
THA system that is still commercially available in the U.S.A., been used to aid in the diagnosis. Controversy exists regarding the
but for which there is little published outcome data to date. efficacy and accuracy of serologic markers alone for diagnosing
METHODS: Utilizing prospectively acquired data from our periprosthetic infection of the hip. The senior author noted a
clinic’s joint registry, we identified 72 consecutive THAs in 62 high number of false-negative ESR and CRP values in patients
patients utilizing a MoM bearing from a single manufacturer. undergoing revision that were later confirmed for infection. The
Sixty-nine THAs utilized a Cobalt-Chrome (CoCr) monoblock purpose of this study was to determine the efficacy of ESR and
resurfacing acetabular component, and three had a modular CRP in the diagnosis of known periprosthetic hip infections.
titanium acetabular component with an internal CoCr liner. All We examined the sensitivity and specificity of these tests for
femoral components were non-cemented titanium prostheses predicting infection. Additionally, we examined the false-negative
with a modular titanium neck and modular cobalt-chrome head. rates of each test and compared these to other variables including
Follow-up ranged from three to 48 months. Mean age was 62 years. gender, body mass index, infection type, and immune status.
Mean acetabular component size was 51mm and mean femoral METHODS: Seventy-seven patients were identified with
head size was 45 mm. There were 31 THAs in males and 41 in periprosthetic hip infections and ESR and CRP data. A preset cutoff
females. In addition to revision as an endpoint, we also evaluated of greater than 30 mm/hr for ESR was used to determine the test
clinical failure, defined as aseptic hip pain in conjunction with at to be positive for infection or negative if it was less. CRP values
least one of the following: radiographic loosening, a demonstrable were also found to be either positive for infection if the value
peri-articular fluid collection or high metal ion levels in the blood. was greater than 10 mg/L or negative for lesser values. Sensitivity
Clinical failure was also designated when clinically significant hip and specificity was calculated for ESR and CRP alone, then for a
pain was reported and no source of referred pain could be identified. positive result in ESR and CRP in both tests, and lastly for a positive
RESULTS: Seven hips (9.7%) have been revised for acetabular result in either ESR or CRP. Chi-square analysis was performed to
loosening and/or painful ALVAL reaction (Aseptic Lymphocytic determine significance of false negatives compared to gender, body
Vascular Associated Lesion). One additional (non-revised) hip has mass index, primary diagnosis, type of infection, and immunity
failed with revision recommended due to severe pain with probable status. The validity of the cut-offs for ESR and CRP were evaluated
acetabular loosening and blood cobalt level over 100 micrograms with use of receiver operating characteristic (ROC) curves.
per liter (mcg/l). Average time from THA to revision was 21 months. RESULTS: ESR had a sensitivity of 89% and specificity of 69%.
Six clinically failed hips are under investigation for significant pain CRP had a sensitivity of 93% and a specificity of 40%. The
with high suspicion of ALVAL reaction. Three hips were moderately false-negative rate was 10.8% for ESR and 7% for CRP. For ESR
painful but these patients declined further work up. Total clinical and CRP combined (with either result positive), the false-
failure rate (including revisions) was 24% (17/72). Six failed hips negative rate was 3%. All false-negatives in the combined group
underwent metal ion testing with mean serum Chromium level were immunocompromised. Chi-square analysis did not find
8.8mcg/l and mean blood Cobalt level 27 mcg/l. Revision rate was a significant correlation between false-negatives and any other
6% in men and 12% in women. Clinical failure rate was 19% in variables. Receiver operating characteristic curves showed similar
men (6/31) and 27% in women (11/41). Femoral head size was not cutoff values to those previously reported in the literature. An
an independent risk factor for revision or clinical failure. Histologic ESR value of 32.5 mm/hr and a CRP value of 9.79 mg/L was
analysis of all revisions demonstrated strong ALVAL reaction, determined to maximize the sensitivity and specificity of the tests.
extensive tissue necrosis, or both. Mean acetabular inclination DISCUSSION AND CONCLUSION: In summary, when ESR and
angle of THAs revised or recommended for revision was 46 degrees CRP serologic tests are used in combination, they are excellent
(range 39 to 51). Clinical failure rate of monoblock cups was 20% adjunct tests to diagnose periprosthetic hip infection. We found
(14/69). All three modular cups had clinical failure or revision. similar sensitivity of ESR and CRP of 89 and 93%, respectively.
DISCUSSION AND CONCLUSION: Survivorship for this metal Although the specificity in this study was lower than what has been
on metal bearing was poor at short term follow up. Results reported elsewhere for ESR and CRP of 60 and 40%, respectively.

Physicians should be suspicious of patients who present with longer, with either survivorship or revision rate as outcomes
hip pain and have normal serologic tests and an underlying were included. This study consisted of 64 articles (14,505
immunocompromising disorder. The surgeon should have a higher arthroplasties) evaluating long-term outcome of cementless
degree of suspicion for infection intraoperatively in these patients. acetabular components, 43 papers (16,634 arthroplasties)
reporting the outcome of cemented acetabular component, and
POSTER NO. P066 seven studies (2,312 arthroplasties) comparing cemented and
Blood Management Affects Functional Outcome After cementless acetabular components. Meta-analysis and logistic
regression on pooled data were performed to compare these
Hip and Knee Arthroplasty studies. Because of the heterogeneity of these studies, the meta-
Robert Sproul, MD, San Francisco, CA analysis used a random effects model, while the logistic regression
Kevin J. Bozic, MD, MBA, San Francisco, CA included an overdispersion parameter to model high variance.
Thomas P. Vail, MD, San Francisco, CA RESULTS: Meta-analysis did not find any significant difference
Michael D. Ries, MD, San Francisco, CA between survivorship and revision rate of cemented and
cementless acetabular component. Logistic regression detected
INTRODUCTION: The risks and costs associated with blood
significant differences (p <0.02) for both: estimated odds ratio
transfusion has led to a reticence to prescribe blood products after
(OR) of surviving a cemented implant versus a cementless
hip and knee arthroplasty. The medical evidence against transfusion
one was 1.54 (95% confidence interval: 1.08-1.95), while that
is based in part upon non-orthopaedic conditions treated in the ICU
of revising a cemented cup versus revising a cementless one
setting. The specific aim of this study is to evaluate the relationship
was found to be 0.54 (95% confidence interval: 0.33-0.89).
between hemoglobin (Hb) levels and short term functional
The difference between the two analyses may be that meta-
outcomes following primary total hip and knee arthroplasty.
analysis was confined to a smaller set of studies (7 versus 107).
METHODS: We retrospectively reviewed the records of 542
DISCUSSION AND CONCLUSION: Regarding our results,
consecutive primary total hip and knee arthroplasty patients
cemented acetabular components seem to have a better survival
performed at a single institution over a two year period. The primary
and lower rate of revision compared to cementless cups. The use
outcome was postoperative walking tolerance of 10, 50, and 100 feet
of cementless acetabular components for better survivorship is not
with physical therapy (PT). Hb levels were recorded for each patient
supported by evidence. Perhaps the ease of insertion of cementless
preoperatively and on each postoperative day. Logistic and Poisson
components, the ability to utilize alternative bearing surfaces and
regression analysis were used to assess the association between
aggressive marketing are the main reasons for the popularity of
Hb levels and our primary and secondary outcome measures.
cementless THA in North America.
RESULTS: Pre and postoperative Hb levels were significantly
associated with the ability to walk 10, 50, and 100 feet postoperatively.
POSTER NO. P068
Hb levels were also significantly associated with ability to stand
with PT postop day 1, weakness or fatigue limiting participation Metal on Metal Local Tissue Reaction is Associated
with PT, need for a transfusion, length of hospital stay, and with Corrosion of Head Taper Junction
disposition to home versus skilled nursing or acute rehab facility. C. A. Engh, Jr, MD, Alexandria, VA
DISCUSSION AND CONCLUSION: Our findings have important
Henry Ho, MSc, Alexandria, VA
clinical implications for rapid mobilization protocols after surgery,
hospital length of stay, and disposition to home rather than post- Kevin B. Fricka, MD, Alexandria, VA
acute care. Further prospective studies are needed to confirm William J. Peace, MD, Denver, CO
these conclusions and to help define a possible patient specific INTRODUCTION: Corrosion at the head/neck taper interface
transfusion trigger intended to maximize functional recovery after has been associated with elevated ion levels and revision total
THA and TKA. Pre and postoperative Hb levels are significantly hip arthroplasty (THA). Elevated ion levels, tissue masses, and
correlated with short term functional outcomes following primary osteolysis have been reported in failed metal-on-metal (MOM)
hip and knee arthroplasty. hips. These failures are not completely understood at this time. It
is possible that taper junction corrosion could be a contributor to
POSTER NO. P067 MOM THA failure. We evaluated the extent of taper corrosion in
Acetabular Component in Total Hip Arthroplasty: Is large diameter MOM femoral heads retrieved for various reasons.
Our hypothesis was that corrosion would be associated with
There Evidence that Uncemented is Better? the occurrence of MOM adverse local tissue reaction (ALTR).
Bahar Adeli, BA, Philadelphia, PA METHODS: Twenty-nine retrieved MOM bearing CoCr heads from
Nader Toossi, MD, Philadelphia, PA a single manufacturer were analyzed. There were 19 (65%) 36mm
John J. Timperley, MD, Exeter, United Kingdom and 10 (35%) 40mm diameter heads in this study. All retrieved
Fares S. Haddad, FRCS, London, United Kingdom heads had a 12/14 taper and were mated with a CoCr stem. Mean
Javad Parvizi, MD, Philadelphia, PA age at revision was 56.7 years (range 36-79). Mean implantation
time was 2.5 years (range 0.04 to 8.03). Eleven of the heads came
INTRODUCTION: At this writing, almost all total hip arthroplasties
from patients who were diagnosed with ALTR. Taper corrosion
(THA) being performed in North America use cementless
was visually graded with a 5 point scale by three reviewers who
acetabular components. The impetus behind this trend is not well
were blinded to the revision diagnosis. The grading scale is a
understood. The objective of this systematic review and meta-
modification of a previously published scale. In addition corrosion
analysis was to compare the survivorships and revision rates of
products seen outside of the taper zone were recorded. Grading
cemented and cementless acetabular components utilized in THA.
score of taper corrosion: 1 (NONE) - No visual corrosion observed;
METHODS: Primary literature search in PubMed identified 3,488
2 (MILD) <30% of engaged taper surface discolored/dull; 3
articles of which 3,374 were excluded because of not meeting the
(MODERATE)- >30% of engaged taper surface discolored/dull OR
inclusion criteria or meeting the exclusion criteria. Only English
<10% of engaged taper surface has black/dull gray debris, pits or
articles on primary THA, with average follow up of 10 years or
etch mAK; 4 (SEVERE) - >10% but <50% of engaged taper surface

has black/dull gray debris, pits or etch mAK; 5 (EXTREME)- >50% free navigation system. All THAs were performed using a
of engaged taper surface has black/dull gray debris, pits or etch mAK. cementless cup (Plasma cup; B/BRAUN-Aesculap) with screw
RESULTS: Of the 29 retrieved heads, 14% had no visible fixation. After the surgery, CT evaluation was performed, and
corrosion, 41% had mild, 3% moderate, 21% severe and 21% three-dimensional cup alignmnet was calculated. Regarding
had an extreme degree of corrosion. The length of implantation the potential factors affecting the accuracy of the navigation
time was correlated with corrosion score (p=0.012 spearman’s assessment, we examined the effects of learning experience
rho correlation test). Nine heads had corrosion that extended of the surgeon, initial gap between the acetabular host bone
beyond the taper junction. Eight of those nine had a MOM and cup, thickness of soft tissue (STT) underlying the pubic
adverse tissue reaction. Corrosion extending beyond the taper symphysis and Crowe classification in developmental displasia
junction area correlated with ALTR (p<0.01 spearman’s rho of the hip (145 cases) on the assessment error. Statistical
correlation test). The mean corrosion score was 4.36 for cases assessment was undertaken using univariate and multivariate
with ALTR and 2.06 for other cases (p<0.01, Kruskal wallis test ). analyses. Discrepancy of more than 5° between the intra- and
DISCUSSION AND CONCLUSION: A total of 42% of our retrieved postoperative results was defined as indicating an assessment error.
MOM heads had severe to extreme taper corrosion. Patients that RESULTS: The mean difference between the intra- and postoperative
had an adverse local tissue reaction to a MOM bearing had more values was 3.5° ± 2.9° and 5.1° ± 3.3° in inclination and anteversion
corrosion and were more likely to have corrosion products outside angles respectively. The incidences of discrepancy of more than 5°
of the taper junction. Since we found that corrosion worsens with were 21.8% (42 cases) and 39.0% (75 cases) respectively. Crowe
time we are concerned that MOM ALTR failures will also increase classification did not influence the intraoperative assessment error.
with longer follow up. In the logistic regression for anteversion, we found that immature
surgical experience (during the first and 64th case) (odds ratio,
OR=3.4; p=0.006), existence of the initial gap of more than 2
mm between the acetabular host bone and the cup (OR=2.3;
p=0.04), obesity (STT of more than 65mm) (OR=47; p=0.0002)
were deemed as factors affecting the accuracy of the intraoperative
estimation by the navigation system. By contrast, assessment of
the inclination value was not influenced by any of these factors.
DISCUSSION AND CONCLUSION: In this study, we evaluated the
Image 1: Example of taper corrosion effects of the potential factors on the accuracy of the intraoperative
score 1 assessment of cup orientation in navigated THA. Among the factors
analyzed, surgical experience, the gap between the acetabular
host bone and cup, obesity were identified as factors affecting
the intraoperative assessment accuracy regarding the anteversion.
Among those, obesity as assessed by the soft tisue thickness was
shown to be highly correlated with the assessment error.
POSTER NO. P070

Image 2: Example of taper
Primary Total Hip Arthroplasty using a Direct Anterior
corrosion score 5 with corrosion vs. Posterolateral Approach: A Comparative Study
extended outside of taper Arup K. Bhadra, MD, Mahwah, NJ
Madhusudhan R. Yakkanti, MD, Louisville, KY
Arthur L. Malkani, MD, Louisville, KY
POSTER NO. P069 INTRODUCTION: Direct anterior approach was described
Risk Factors Affecting the Accuracy of the Image-free as muscle preserving procedure to improve results and
THA Navigation in Determination of Acetabular Cup reduce dislocation rate following total hip arthroplasty
(THA). Purpose of this study was to compare results of direct
Orientation anterior versus postero-lateral approach following THA.
Tomokazu Fukui, MD, Nishinomiya City, Hyogo, Japan METHODS: This was a retrospective review of 90 consecutive
Shigeo Fukunishi, MD, Nishinomiya, Japan patients undergoing THA by a single surgeon divided into
Shoji Nishio, Nishinomiya, Japan postero-lateral (PL) 50 (29 F, 21M) and direct anterior
Fujihara Yuki, Nishinomiya, Japan (DA) 40 (21 F, 19 M) groups. Respective mean age 60.7±
Shohei Okahisa, MD, Hyogo, Japan 11.8 and 60.2± 11.7 years were comparable. The minimum
Shinichi Yoshiya, MD, Nishinomiya, Hyogo, Japan follow up was two years (2-3.2 years). Early function along
with clinical and radiographic analysis was performed.
INTRODUCTION: Although the use of the image-free total hip RESULTS: The difference in mean value in PL and DA groups
arthroplasty (THA) navigation system is thought to improve the with respect to blood loss, operative time, hospital stay, BMI,
consistency of the prosthetic alignment, there are some cases with preoperative and postoperative Harris hip scores were not
discrepancy in the results between the intraoperative navigation significant. Average cup inclination and anteversion angle
and the postoperative radiological assessment. We have used in PL and DA was 46.4± 6.7 vs. 41.4± 5.8 degrees and, 27± 5.4
the OrthoPilot navigation system (B/BRAUN-Aesculap). In this vs. 24± 4.6 degrees. DA group had better postoperative day 2
study, we reviewed our clinical experience and attempted to walking distance 294.8 vs. 194.5 feet (p=0.002) and better VAS
identify factors affecting the assessment accuracy of this system. pain 1.9 vs. 3.5 (p=0.003). No dislocation, no revision surgery
METHODS: A retrospective analysis was performed for 192 in either group. DA group had complications in 11 patients
hips (185 patients) undergoing THA with the use of the image- (27.5%) - thigh lateral femoral cutaneous nerve pain seven

(17.5%), trochanteric bursitis three (7.5%) and hematoma one incorporated more aggressive treatment of the hyaline cartilage
(2.5%). PL group had trochanteric bursitis in four patients (8%). injury and preservation of the labrum (labral refixation). This study
DISCUSSION AND CONCLUSION: Direct anterior approach examines the independent effects of labral refixation and hyaline
is more effective than posterolateral approach for very early cartilage treatment on clinical outcomes in patients with FAI.
functional recovery and pain control but at a higher complication METHODS: A total of 192 hips (107 males and 85 females; mean
rate. age: 29 years) underwent open treatment for FAI with either surgical
dislocation or a limited anterior approach at two institutions.
POSTER NO. P071 Patients were prospectively evaluated with a modified Harris
The Outcome of Metal on Metal Bearing Surfaces in Hip Hip Score (HHS) and standardized radiographs. The 192 hips
were divided into groups by operative diagnosis (Group 1: intact
Arthroplasty labrum/no labrum; Group 2: labral tear only; Group 3: Outerbridge
Stephen Graves, MD, Adelaide, Australia (OB) grade 1 to 2 acetabular damage; Group 4: OB grade 3-4.
Richard de Steiger, MD, Richmond, Australia Additionally, the 131 hips with chondral lesions of acetabulum were
David Davidson, MD, University Of Adelaide, Australia assigned groups based upon treatment (Group A: no treatment; B:
Kara Cashman, BSc (HONS), Adelaide, Australia microfracture; C: resection and labral advancement). The clinical
Yen Liu, Adelaide, Australia results in these groups were analyzed at mean 28.8-month follow up.
Philip Ryan, FAFPHM, Adelaide, Australia RESULTS: The modified preoperative and postoperative HHS for
the groups were as follows: Group 1 (intact labrum) 68 to 94.6 (p
INTRODUCTION: The use of metal on metal (MoM) bearing < 0.01); Group 2 (labral damage/refixation) 71 to 95.3 (p < 0.01);
surfaces for primary conventional total hip replacement Group 3 (OB1-2) 68 to 95 (p < 0.01); Group 4 (OB3-4) 69 to 94 (p
has become more frequent in recent years. There has been < 0.01). Group A (no treatment of cartilage lesions) 64 (55-67, STD
increasing concern however regarding the use of this bearing 5) to 85 (53-99, STD 21) (p=0.13); Group B (microfracture) 67
surface. This study compared the outcome of over 18,000 (53-85, STD 13) to 80 (68-89, STD 9) (p<0.04); Group C (resection
MoM to over 93,000 metal on polyethylene (MoP) procedures. and labral advancement) 66 (43-87, STD 9) to 90 (48-100, STD 10)
METHODS: The data was obtained from a comprehensive national (p<0.001). In a subset of 27 hips with no labrum present either due
database that prospectively recorded these procedures over a 10- to previous surgery or calcification, the preoperative HHS improved
year period. Analyses were undertaken to examine the impact of less dramatically from 69 to 91 postoperatively (p < 0.01). There
age, gender, femoral head size and prostheses as well as determining was no significant difference in postoperative HHS between groups
the reasons for revisions. The principal outcome measure was time A and B and A and C, though group C (resection and advancement)
to first revision using Kaplan-Meier estimates of survivorship. was significantly better than B (microfracture) (p<0.02).
RESULTS: MoM has a significantly higher rate of revision DISCUSSION AND CONCLUSION: Previous work has
compared to MoP. At 10 years, the cumulative percent revision documented inferior clinical outcomes with labral resection and
for all MoM articulations was 8.8% (7.7, 10.1). This compared acetabular hyaline cartilage damage. In our study, more aggressive
to 5.6% (5.3, 6.0) for all MoP (HR>1 up to 6.5 years, p<0.001). management of FAI with labral takedown and resection of
When MoM articulations are used, females had a significantly damaged acetabular hyaline cartilage was associated with similar
higher rate of revision. There was no age related difference in clinical improvement to hips with an intact labrum and less severe
revision rate with older patients having the same rate of revision as hyaline cartilage damage (OB 0-2) supporting the idea that these
younger patients. There was an important relationship with head techniques are safe, clinically effective and preferable to labral
size. For head sizes <=32mm there was no difference between resection and neglect of the hyaline cartilage injury.
MoM and MoP. The difference in the revision rate between these
two bearing surfaces was only evident for head sizes >32mm. The POSTER NO. P073
outcome of different MoM prostheses varies, but when the head
size is >32mm most have a high rate of revision. When comparing Detection of Intraoperative Purulence is not Reliable
the same prostheses with different bearing surfaces MoM has for Diagnosis of Periprosthetic Joint Infection
a higher rate of revision. This higher rate of revision for MoM Bahar Adeli, BA, Philadelphia, PA
is due to an increased rate of loosening and metal sensitivity. Joseph Said, BS, Philadelphia, PA
DISCUSSION AND CONCLUSION: The use of MoM increases the James J. Purtill, MD, Philadelphia, PA
rate of revision in conventional total hip arthroplasty when head
Matthew Austin, MD, Philadelphia, PA
sizes >32mm are used.
POSTER NO. P072 INTRODUCTION: Diagnosis of periprosthetic joint infection
(PJI) presents a major challenge to orthopedic surgeons.
Influence of Labral Refixation and Acetabular Cartilage Currently a variety of diagnostic tests are available with varying
Treatment on Clinical Outcomes in FAI degrees of sensitivity and specificity. Intraoperative purulence
Christopher L. Peters, MD, Salt Lake City, UT has long been considered a definite sign of PJI. This study aims
Lucas Anderson, MD, Salt Lake City, UT to evaluate whether its presence is reliable in the diagnosis of PJI.
Breton A. Yates, BS, Salt Lake City, UT METHODS: Our prospective institutional database was used
Jill Erickson, PA, Salt Lake City, UT to identify PJI patients treated at our institution between
Javad Parvizi, MD, Philadelphia, PA January 2000 and March 2010. All patients were diagnosed
using our institutional criteria which involve results from
INTRODUCTION: Early results of treatment of femoroacetabular serology tests, microbiological cultures, or presence of purulence
impingement (FAI) with femoral and/or acetabular intraoperatively. Diagnostic value of purulence was determined
osteochondroplasty have been encouraging. Poor results have by calculating sensitivity, specificity, positive predictive value
been associated with labral resection and severe acetabular hyaline (PPV), and negative predictive value (NPV) against positive or
cartilage damage. In response, recent treatment trends have negative culture results as well as availability of sufficient serologic

markers and synovial cell count/differential for diagnosis of PJI. POSTER NO. P075
RESULTS: Of 978 patients with PJI, 470 had evidence of
intraoperative purulence while 508 patients did not. Presence of
The Transverse Acetabular Ligament as a Guide for
purulence was shown to have a sensitivity of 60% and specificity of Acetabular Component: A Clinical Study of 300 Crowe
90% for diagnosis of PJI when positive culture was used to indicate 1-4 Cases
PJI. The PPV was found to be 94% and the NPV was 49% in these Masahiro Inoue, MD, Eniwa, Japan
cases. When using positive serology from our diagnostic criteria to
Tokifumi Majima, MD, PhD, Sapporo, Japan
indicate PJI, presence of purulence was shown to have a sensitivity
of 51% and a specificity of 57%. The PPV for intraoperative
takayuki nakamura, Saitama, Japan
purulence was found to be 61% and the NPV was 47%. Satomi ABE, MD, Eniwa, Japan
DISCUSSION AND CONCLUSION: According to the low taiki kanno, MD, Hokkaido, Japan
sensitivity and NPV, presence of purulence cannot be used as takeshi Masuda, MD, Sapporo, Japan
an absolute sign of PJI and should not be a single diagnostic Akio Minami, MD, Sapporo, Japan
criterion, as it is absent in 52% of PJI cases. In patients with florid INTRODUCTION: Recent studies have supported usefulness
purulence, Staphylococcal species were most commonly isolated of the transverse acetabular ligament (TAL) as a guide for
in monomicrobial and polymicrobial cultures. the anatomical acetabular cup implantation in idiopathic
osteoarthritis with excellent clinical results. However, no
POSTER NO. P074 clinical study has been reported efficacy of the TAL in secondary
ALTERNATE PAPER: ADULT RECONSTRUCTION HIP VI osteoarthritis (OA) cases such as dysplastic hips or hips with
Assessing Safety and Clinical Efficacy of Revision Total congenital dislocation. Some reports difficulties of intra-op
visualization of the TAL in these secondary OA hips. The purpose
Hip Arthroplasty in Geriatric Patients of this study was to investigate effectiveness of the TAL as a
Zachary Zhang, BS, Dallas, TX guide of acetavelar cup anteversion in secondary osteoarthritis.
William Z. Morris, BA, Dallas, TX METHODS: A total of 305 secondary osteoarthritis cases (309 hips)
Reed Garza, BS, Dallas, TX were included in this study; 248 hips with dysplasia (Crowe 1-3),
Michael H. Huo, MD, Dallas, TX 10 hips with congenital dislocation (Crowe 4) and 51 others. We
INTRODUCTION: The number of revision total hip arthroplasties performed intraoperative visual assessment of the TAL according
(THAs) is growing, particularly for older patients. Revisions to the reported grading system (Grade 1: Normal-quality TAL
are associated with higher complications. The purpose of this visible on exposure of the acetabulum,Grade 2: TAL covered by soft
study was to determine if there were greater complications tissue, which needed to be cleared to expose the ligemnt , Grade 3:
and poorer short-term outcome in the geriatric (>75 years) TAL covered by osteophytes, which have to be remover to expose
patients than in younger patients following revision THAs. the ligament, Grade 4: No ligament identified). We also assessed
METHODS: All patients undergoing revision or conversion THA intra-operative cup placement according to reported classification
under a single surgeon were entered prospectively into a database (component aligned to TAL, averted, retroverted, too high, and
from 2004 to 2010 (total 439 cases). There were 40 patients too deep). All hips were followed up for short term clinical results.
older than 75 yrs (mean 80 yrs). These patients were matched to RESULTS: All 309 hips were classified as TAL Grade 1 (35 hips),
a cohort of 40 younger patients (mean age 58 yrs) based upon: Grade 2 (124 hips), Grade 3 (136 hips) and Grade 4 (14 hips). In 295
type of surgery, year of surgery, and peri-operative anesthesia and hips (95.5%), intra-operative TAL identification was possible with
rehab protocols. Outcome was assessed using the Harris hip score, or without removal of peri-acetabular soft tissue or osteophytes
peri-operative data, length of hospital stay, and complications. (TAL 1-3). We were able to align acetabular cup correctly to the
RESULTS: There were two mortalities in the geriatric group and TAL in 234 hips. At final follow up, four hips (1.4%) had posterior
one in the younger group during the 12-month follow-up period. dislocations (two hips in Crowe 1-3 and two hips in Crowe 4).
There was no significant difference with numbers available in the DISCUSSION AND CONCLUSION: Intra-operative identification
operative time (171 min. vs. 201 min., p=0.07), blood loss (900 of the TAL in 295 hips (95.5%) was possible. The cases included
ml vs. 1512 ml, p=0.63), nor length of hospital stay (7.4 days severe dysplastic hips that we experienced difficulty in identifying
vs. 5.6 days, p=0.08). There was no difference in the Harris hip bony landmAK. Dislocation rate was low with the TAL implantation
score either pre-operatively (52 vs. 56, p=0.33) or at the one- technique. The TAL can provide reliable intra-operative guide for
year follow up (89 vs. 93, p=0.33). There were six complications acetabular cup placement in secondar osteoarthritis hips.
in the geriatric group requiring two reoperations and three
repeat revisions. There were eight complications in the younger
group requiring one re-operation and two repeat revisions.
DISCUSSION AND CONCLUSION: Our data did not demonstrate
any significant differences between the two groups. Instead, our
data showed that revision THAs were equally safe and clinically
efficacious in the geriatric population as in the younger patients.

POSTER NO. P076 DISCUSSION AND CONCLUSION: This is a biomechanical
study that utilized fresh allograft bones to simulate the reaming
uHow to Increase the Strength of the Bone-PMMA of a normal cortical canal prior to cementation. The ‘rifling’ of the
Interface: Biomechanical Analysis of Smooth vs. cortical tube compared to a ‘smooth’ cortical tube (to simulate
Grooved Canals normal reaming techniques) dramatically increased the bone-
Martin M. Malawer, MD, Mclean, VA PMMA interface strength as determined by push-out and torsional
testing; ( increase > 275%). This study suggests by ‘rifling’ a smooth
INTRODUCTION: The technique of injection and polymethylmeth canal as the final step in the usual reaming process when using
acrylate (PMMA) composition has undergone ‘three generational PMMA will significantly increase the overall bone-PMMA strength
changes’ with the aim of increasing the overall strength of the and possibly decrease the eventual risk of aseptic loosening. Based
bone-PMMA-stem composite. Little emphasis,change or research upon this study a ‘new’ type of reamer has been developed for
of the bone-PMMA interface has occurred. Clinically, most aseptic clinical use (not FDA-approved).
loosening of a prosthesis occurs between the bone-cement interface
and not between the stem-PMMA interface. This is a biomechanical POSTER NO. P077
study to determine if the strength (push out and torsional) of
the bone-PMMA interface can be increased by changing the Stripe Wear in Metal-Metal THA Bearing Retrieval
internal architecture of the cortical wall by ‘rifling’ i.e., creating Analysis of Large Diameter Articulations
circumferential undercuts into the cortical bone in contrast to a Christopher L. Peters, MD, Salt Lake City, UT
‘smooth’ cortical wall which normally results after ‘routine’ reaming. Ian C. Clarke, PhD, Colton, CA
METHODS: We utilized 12 fresh frozen human allografts; all
Edward J. McPherson, MD, Los Angeles, CA
diaphyseal femoral cortical segments. All segments were precision
machined to 18mm diameter; Gp.1 controls (8); smooth cortical
Thomas K. Donaldson, MD, Colton, CA
canals to simulate standard reaming techniques and Gp2 were Edward J. McPherson, MD, Los Angeles, CA
eight grooved (undercuts) with 2, 3mm grooves at equal intervals. INTRODUCTION: Adverse wear in large diameter metal-metal
Fluted intramedullary stems 80 mm in length (diameter= 18mm) total hip arthroplasty (THA) bearings has garnered critical
were machined with four flutes with a sand blasted finish. All were attention in the last five years. Excess metal debris formation
16 mm in diameter thus leaving a 1 mm cement mantle. The test combined with a patient sensitivity toward metallic ions can
specimens consisted of the intramedullary stems cemented into the created a physiologic inflammatory response that can rival or
cortical segments under pressurization. All specimens were ‘potted’ exceed the effects of PE induced osteolysis. The pentultimate
in square aluminum tubing using resin for specimen fixation. These response is pseudotumor formation. This study examines the
tubes were held in place in the MTS® by specially designed fixtures. surface topography of 16 retrieved metal-metal large diameter
A standard MTS® machine was utilized for push-out and torsional THA bearings. We set out to determine specific wear patterns
testing measured in Kilo Newtons (KN) to failure. Failure was with this bearing construct and compare wear surface data
defined as a drop off of the Force curve as well as visual inspection with ceramic-ceramic bearing data obtained from our center.
of the bone-PMMA-stem construct. Analysis: a paired analysis of METHODS: Sixteen large diameter metal-metal hip bearings were
Gp 1 (controls) vs. Gp2 (grooved) was performed looking at force retrieved by two surgeons. At the time of retrieval, careful attention
to failure; push-out and torsional force and mode of failure defined was paid to extract the bearing construct without incurring surface
as the point of initiation of the crack in the cement mantle. Failures bearing damage. At the time of retrieval, the heads where etched
at the stem-PMMA or Bone-PMMA interface were recorded. with an osteotome to identify in-vivo bearing orientation. The cup
RESULTS: All of the grooved specimens (Gp2) had a significantly and head were each stored in a separate container to prevent ex-
higher force to failure in both push-out and in torsional testing vivo scratching. Clinically histories and pathology specimens were
than the non- grooved (Gp1.) specimens. The average increase in obtained by the surgeons for review. Surface analysis of the metal-
strength (force required to fail) of Gp2 (grooved) to non-grooved metal bearings included white light interferometry, a coordinate
(Gp 1) was 6.2 KN vs 2.6 KN i.e., 278% increase in (push-out) and measuring machine and SEM. Regional wear patterns where
283% (torsional) strength. None of the non-grooved specimens identified relative to polar and equatorial regions of the cup and head.
(Gp1) approached the lower limits of failure of the grooved RESULTS: Surface topographic analysis revealed common wear
specimens (Gp2). All specimens failed at the bone-PMMA interface patterns in all retrieval cases. All bearings showed aruciate stripe
and NOT at the stem-PMMA interface. wear on the femoral head with corresponding stripe wear linear
within the cup. Most stripe lines were located toward the midpolar
and polar regions of the head, and periphery of the cup. We visualized
stripe lines that crossed each other, indicating several directions of
excess wear. Those hip bearings with multiple stripe lines, and/
or deeply etched stripe lines, correlated with histologic reports of
lymphocytic inflammatory response surrounding the hip joint.
DISCUSSION AND CONCLUSION: Stripe wear is an aruciate
area of increased regional wear on the femoral head. A reciprocal
area is seen on the cup. Stripe wear was first identified with
ceramic-ceramic bearings. This study, with advanced topographic
measuring instruments, identifies stripe wear in metal-metal hip
articulations. Our findings show multiple stripe wear regions being
generated. We postulate that stripe wear regions are areas where the
large diameter femoral head is subluxating in a repetitive manner.
In our clinical review of these patients, all were asymptomatic
On inspection, the point of failure appeared to initiate at the grooves. for hip subluxation. Thus we name the term repetitive subclinical
subluxation (RSS). We infer that most stripe lines are occurring

from excessive subclinical wear. From this review, we believe large number of patients are required.
that surgeon technique is critical in providing optimum wear in
large diameter metal-metal bearings. To reduce RSS, hip bearings POSTER NO. P079
(built of any material design) should be carefully positioned. Do Pulmonary Emboli Arise from Lower Extremity Deep
Furthermore, appropriate femoral offset should be utilized to
reduced pelvic abutment which can also cause RSS. Venous Thrombosis?
Raviinder Parmar, MD, Naples, FL
POSTER NO. P078 Ronald Huang, Philadelphia, PA
Acute Kidney Injury Following Lower Limb Arthroplasty Ibrahim Raphael, MD, Philadelphia, PA
Daniela Racu-Amoasii, MD, Manchester, United Kingdom Javad Parvizi, MD, Philadelphia, PA
Krishnaiah Katam, MBBS, Birmingham, United Kingdom Richard H. Rothman, MD, Philadelphia, PA
Trevor Lawrence, West Midlands, United Kingdom INTRODUCTION: Venous thromboembolism (VTE) is an important
complication that may occur following total joint arthroplasty
INTRODUCTION: Acute kidney injury (AKI) formerly known as
(TJA). It is a commonly held belief that pulmonary emboli (PE)
“acute renal failure” results in rapid reduction in kidney function
arise from propagation of a deep venous thrombosis (DVT) and
associated with a failure to maintain fluid, electrolyte and acid-
that prevention of DVT will lead to a reduction in PE. Our study
base homeostasis. The UK NCEPOD published a report in 2010
was designed to examine the association between symptomatic
on AKI that revealed many deficiencies in the care of patients
DVT and PE in a consecutive group of patients undergoing TJA.
with AKI. The UK Renal Association has published the final
METHODS: This prospective study was initiated in April of 2010.
draft of Clinical Practice Guidelines for Acute Kidney Injury on
A total of 1,710 TJA were performed at our institution between
the 08/01/2011. In our study we determined retrospectively
April of 2010 and December of 2010. Patients who had signs/
the occurrence of this problem in a District General Hospital
symptoms of VTE postoperatively, were evaluated for both DVT
and its impact on the recovery after lower limb arthroplasty.
and PE. A total of 129 patients were evaluated for DVT and/or PE
METHODS: Data was collected retrospective study over three
by lower extremity ultrasound (US), chest CT, or V/Q scan within
months between October to December 2010 from theater
90 days of arthroplasty. Of the 129 patients who were evaluated
registers and the hospital database system. A total of 359 patients
for VTE, 78 had symptoms of DVT and 51 had symptoms of PE.
were identified. Preoperative (baseline) and postoperative
A test of association was performed in order to determine if the
blood investigations included Creatinine, Urea, K+, Na+, GFR,
odds of developing positive symptomatic PE was significantly
Haemoglobin were analyzed. Data collection also included type
increased following positive symptomatic DVT and vice versa.
of anesthesia, timing of operation, duration of procedure and
RESULTS: Of the 79 patients with symptoms of DVT, 14 had
estimated blood loss. From the hospital database system and
evidence of DVT of the lower extremities. Of 52 patients with
clinical letters we collected length of stay and time required
suspected PE, 16 had PE based on imaging. Of 37 scanned for
for blood results to come back to baseline. A diagnosis of AKI
both DVT and PE, only seven patients (19% of those scanned
was based on the International Kidney Disease Improving
for DVT and PE, 5.4% of the total cohort) had both DVT and PE.
Global Outcomes (KDIGO) staging classification as recently
DISCUSSION AND CONCLUSION: It appears that the commonly
recommended by UK Renal Association. Stage I Creatinine
held notion that PE arise from symptomatic or asymptomatic
increased by ≥ 26 µmol/L from baseline, Stage II Creatinine
DVT requires re-examination. PE and DVT may be part of a
increased by 200-300% and Stage III Creatinine increased ≥ 300%.
hypercoagulable state that can arise independently of each other.
RESULTS: In our study, 11.97% (43/359) of patients developed
Thus, guidelines that use DVT as a proxy for PE may result in over
acute kidney injury following lower limb arthroplasty. Eighteen
anticogulation of patients with all its associated risks. This study
patients (42%) developed Stage I (Cre increase ≥ 26 µmol/L),
was designed to examine the association between symptomatic
17 (39%) developed Stage II (Cre increase 200-300%) and
DVT and PE in a consecutive group of patients undergoing TJA. No
eight patients (19%) developed Stage III (Cre increase ≥ 300%)
significant association between developing PE and DVT was found
acute kidney injury. Most of these patients were operated
within 90 days of undergoing TJA.
during the afternoon session. Patients with acute kidney
injury stayed longer in hospital (12.58 days) compared to
POSTER NO. P080
similar age group of patients (5.95 days) admitted during the
same period. Some 25% of patients took more than a month Fracture of Modular Revision Femoral Stems at the
for renal parameters to come down to preoperative baseline. Mid-Stem Junction
DISCUSSION AND CONCLUSION: AKI is a new definition and Dror Lakstein, MD, Givataim, Israel
the incidence in our hospital is higher than the 1% expected
Eliaz Noam, MBA, BS, PhD, Tel Aviv, Israel
nationally. Patients with AKI are often complex to treat and timely
referral and transfer to renal services if appropriate should be Ofer Levi, MSc, Rehovot, Israel
considered. The aetiology of acute renal injury is very complex Yona Kosashvili, MD, Rishon Le Zion, Israel
and includes gentamicin antibiotic prophylactic, rapid blood loss David Backstein, MD, Toronto, ON, Canada
in elderly frail patients, nonsteroidal pain killers and preexisting Oleg Safir, MD, Toronto, ON, Canada
cardiac and renal pathology. The need for careful postoperative Allan E. Gross, MD, Toronto, ON, Canada
observation cannot be overemphasized together with judicious INTRODUCTION: Mechanical failure of femoral stems at
blood replacement as required. Acute kidney injury following the modular junction of revision hip arthroplasty systems
lower limb arthroplasty is a sensitive marker of postoperative care. has been reported only infrequently. In the current study,
A successful surgical outcome may not mean a successful renal the causes of six stem fractures, which occurred in vivo,
outcome. Patients with AKI are often complex to treat, and the new were analyzed with use of clinical data and failure analysis.
AKI definition and staging system allows an earlier detection and METHODS: Six patients with a fracture at the mid-stem junction
management of this condition. Further prospective studies with of a modular revision hip implant were identified in our database

of patients who had undergone revision arthroplasty. The POSTER NO. P081
characteristics of the patients with a fractured stem were compared
with those of 165 patients from the same prospective database who
Is Second Generation Metal-on-Metal Primary Total Hip
had a modular stem implanted, had at least two years of follow up, and Arthroplasty with 28mm Head a Worthy Option?
had not had a fracture of the stem. Failure analysis of three implants Young-Ho Kim, MD, Guri, Republic of Korea
(six fracture surfaces) was carried out, with use of microscopic, Kyu-Tae Hwang, PhD, Seoul, Republic of Korea
chemical, and microhardness characterization techniques. Yee-Suk Kim, MD, Seoul, Republic of Korea
RESULTS: Patients with a fractured stem had significantly Il-Yong Choi, MD, Seoul, Republic of Korea
higher body mass indices than patients without a stem fracture.
Radiographs demonstrated that these femoral implants lacked INTRODUCTION: Recently many authors have reported early
adequate osseous support of the junction area of the stem. osteolysis, pseudotumor and cancer probably due to adverse
All stems failed approximately 1 to 2 mm proximal to the reactions of metal ion, even in second generation metal-on-metal
body-stem junction, thus indicating the presence of a bending total hip arthroplasty (MoM THA). To identify whether second
moment. The chemical composition and microhardness generation MoM THA with 28mm head is still worthy enough
matched those of Ti-6Al-4V. Evidence of wear and fatigue to continue using, we investigated long-term survivorship and
were found on the fracture surface. A wear strip was also influencing factors associated with failure in these implants.
observed along the circumference of the stem near the junction. METHODS: We retrospectively reviewed 149 consecutive patients
DISCUSSION AND CONCLUSION: We concluded that the stem (195 hips) who underwent second generation MoM THA with
failure was initiated by a fretting fatigue mechanism and was 28mm head. Among them, 180 hips in 141 patients with a mean
propagated by a pure bending fatigue mechanism. Risk factors for age of 43 (19-55) years were available for clinical and radiographic
fractures of the modular junction include excessive body weight review at a mean of 13.4 (11-17) years postoperatively. Survivorship
and inadequate proximal osseous support because of trochanteric analysis with the end points of acetabular cup revision or
osteotomy, reduced reoperative bone stock, osteolysis, loosening periacetabular osteolysis as a failure was performed, and factors
and/or implant undersizing. Surgeons should consider the use of associated with failure and adverse reactions were also investigated.
implants with strengthened junctions when using modular stems RESULTS: Survival rate with acetabular cup revision for any cause
in such patients. and that with the development of periacetabular osteolysis were
97.8%, and 96.7% respectively at 17 years. Four hips were revised
due to cup loosening. Periacetabular osteolysis appeared in six
hips. But pseudotumor and cancer were not found. Mean Harris
hip score improved to 91.9 points at final follow up. No significant
factors associated with failure were evident according to cup
orientation, stem alignment, and patient-related factors.
DISCUSSION AND CONCLUSION: These encouraging long-term
results indicate that second generation MoM THA with 28mm head
may be worth using.
POSTER NO. P082

Low Prevalence of Unexpected Pathological Diagnoses
After Primary Total Hip Replacement
Scott A. Foster, MD, Mansfield, OH
Christopher J. Barr, BS, Boston, MA
Marc A. Bragdon, Boston, MA
Young-Min Kwon, MD, PhD, Boston, MA
INTRODUCTION: The cost and effectiveness of routine
pathologic review after total hip arthroplasty (THA) have been
previously reported on in a relative small cohort of patients. As
the costs associated with this process are not inconsequential,
the purpose of this study was to establish a prevalence of
unexpected pathological diagnoses after THA at one institution.
METHODS: A retrospective review of an institutional joint
replacement registry was done searching for all patients having
had THA. A total of 2,833 patients were identified. Femoral head
pathology reports from each case were obtained from the hospital
systems Research Patient Data Registry. The reports were scanned for
a list of pertinent abnormal diagnoses provided by the institutions
pathology service which included amyloid, enchondroma, gout,
leukemia, lymphoma, metastatic, osteomyelitis, Paget’s, avascular,
calcium pyrophosphate, necrotic bone and osteonecrosis.
RESULTS: Of the entire cohort there were 419 positive findings
(14.13%). Osteonecrosis was the most frequent diagnosis
with 220 cases, followed by avascular necrosis with 99 cases.
Calcium pyrophoshate was seen in 57 cases and there were 12

cases of necrotic bone. There were 25 cases of the remaining 3.2 1.03
diagnosis of which, fourteen were pre-existing. Of these 11 new Durom 333 (0.2- 144 96 (94-98) 1 - - (0.60- 0.9
diagnoses seven were enchondromas, one was gout, two were 5.1) 1.74)
5.6 1.11
lymphoma, and one was Paget’s. There were no unexpected Corin 96 (92-
91 (0.2- 87 52 92 (86-99) - (0.50- 0.8
cases of amyloid, leukemia, metastatic disease, or osteomyelitis. (Cormet) 100)
7.6) 2.48)
DISCUSSION AND CONCLUSION: The current study is the 3.5 0.93
single largest review of unexpected pathology identified during All HRAs 4,401 (0.0- 2,177 96 (96-97) 777 94 (93-95) 94 (93-95) (0.78- 0.4
routine femoral head examination after THA. This confirms 9.0) 1.10)
3.9
the low prevalence of unexpected diagnoses indicating limited
All THAs 48,409 (0.0- 25,482 96 (96-97) 14,607 95 (95-96) 94 (94-95) 1.0 -
yield associated with this process. In light of the current crisis in 9.0)
healthcare economy, and the projected increase in the number of
THAs over the next decade, further studies are required to examine POSTER NO. P084
the utility of routine pathological examination during THA in
Radiographic Evidence of Cam Type Femoroacetabular
providing cost-efficient quality medical care.
Impingement in Young Patients with Hip Osteoarthritis
POSTER NO. P083 Paul R. Kuzyk, MD, FRCSC, MSc, Toronto, ON, Canada
Hip Resurfacing Arthroplasty - Short Term Survivorship Michael Sellan, Caledon, ON, Canada
Zachary Morison, MSc
of 4,401 Hips from the Finnish Arthroplasty Register
Emil H. Schemitsch, MD, Toronto, ON, Canada
Matti Seppanen, MD, Turku, Finland
James P. Waddell, MD, Toronto, ON, Canada
Keijo Makela, MD, Turku, Finland
INTRODUCTION: Femoroacetabular impingement (FAI) may
Pekka Pulkkinen, PhD, Helsinki, Finland
contribute to the development of early onset hip osteoarthritis
Petri Virolainen, MD, Littoinen, Finland (OA). A cam lesion (or pistol grip deformity) of the proximal
Ville M. Remes, MD, Helsinki, Finland femur reduces head-neck offset resulting in cam type FAI. The
Antti Eskelinen, MD, PhD, Tampere, Finland alpha angle is a radiographic measurement recommended for
INTRODUCTION: Population-based register data from the diagnosis of cam type FAI. The purpose of this study was to
Nordic Arthroplasty Register Association (NARA) and from determine if patients that develop end stage hip OA prior to
the National Joint Register of England and Wales have revealed 55 years of age have radiographic evidence of cam type FAI.
that the outcome after hip resurfacing arthroplasty (HRA) is METHODS: The anteroposterior (AP) pelvis and lateral hip
inferior to that of conventional total hip arthroplasty (THA). radiographs of 244 patients (261 hips) who presented to our
METHODS: Based on data extracted from the Finnish institution for hip arthroplasty or hip fracture fixation between
Arthroplasty Register, the risk of revision of 4,401 HRAs 2006 and 2008 were retrospectively reviewed. Three cohorts
performed during 2001-2009 was analyzed using Cox regression were compared: 1) patients with end stage hip OA < 55 years old
model. The revision risk of the HRAs was compared to that (N=76); 2) patients with end stage hip OA ≥ 55 years old (N=84);
for 48,409 THAs performed during the same time period. 3) hip fracture patients ≥ 65 years old without radiographic
RESULTS: In the Cox regression analysis, there was no evidence of hip arthritis were used as controls (N=101). Patients
difference in revision risk between HRAs and THAs (RR 0.93, with inflammatory arthritis, avascular necrosis and post-traumatic
CI 0.78-1.10; p=0.4). Female patients had two times increased hip OA were excluded. Alpha angles were measured on the AP
revision risk compared to male patients (RR 1.98, CI 1.44- pelvis and lateral radiographs by three coauthors using ImageJ
2.71, p < 0.001). Hospitals that had performed 100 or more 1.43 software (National Institutes of Health, USA). For patients
HRA procedures had a reduced revision risk compared to those with end stage hip OA, AP alpha angles were measured on both
with less than 100 HRAs (RR 0.61, CI 0.41-0.88, p = 0.009). the hip with OA and the contralateral hip. Lateral alpha angles
DISCUSSION AND CONCLUSION: We found that HRA had were measured only on the hip with OA. For patients with hip
comparable short-term survivorship with THA at a nationwide fracture, AP alpha angles were measured on the non-fractured
level. Implant design had an influence on revision rates, as did hip and lateral alpha angles were measured on the fractured hip.
hospital procedure volume. Female patients had two times A one-way ANOVA with post hoc Tukey’s HSD test was used to
increased revision risk compared to male patients. compare the AP and lateral alpha angles for the three cohorts.
RESULTS: The intraclass correlation coefficient (ICC) for the three
Survival of HRA and THA, the reference group. End-point is defined as
coauthors measuring AP and lateral alpha angles was 0.85 and 0.86
revision of any component
respectively, indicating excellent inter-rater agreement. Patients < 55
Adjusted years old with end stage hip OA had the largest AP and lateral alpha
4-yr 6-year 8-yr
AR 4 AR 6 RR for p-
N MF yr survival survival survival angles (82.7±11.6 degrees AP and 63.9±18.5 degrees lateral). These
yr yr revision value
(95% CI) (95% CI) (95% CI) angles were significantly larger (p<0.01 for both comparisons) than
(95% CI)
4.4 0.72 patients ≥ 55 years old with end stage hip OA (71.7±17.8 degrees AP
BHR 1,856 (0.0- 1,253 97 (96-98) 668 96 (95-97) 95 (94-97) (0.56- 0.02 and 55.5±18.0 degrees lateral) and hip fracture patients without
9.0) 0.94) hip OA (52.7±10.9 degrees AP and 44.4±11.4 degrees lateral).
3.1 1.28
Comparing AP alpha angles of the contralateral hips, the mean AP
ASR 995 (0.3- 440 95 (93-97) 39 92 (89-95) - (0.95- 0.1
5.8) 1.73)
alpha angle for patients < 55 years old with hip OA (70.8o±13.2o)
2.5 0.94 was significantly larger (p=0.04) than patients ≥ 55 years old
ReCap 657 (0.4- 190 96 (94-98) 18 - - (0.59- 0.8 with hip OA (64.5±16.2 degrees) which in turn was significantly
5.7) 1.48) larger (p<0.01) than the hip fracture patients (52.7±10.9 degrees).
2.1 1.05 DISCUSSION AND CONCLUSION: Patients < 55 years old
Conserve
469 (0.4- 97 (95-98) - - - (0.61- 0.9
Plus
4.7)
65
1.83)
with hip OA had the largest mean AP and lateral alpha angles,

significantly larger than patients ≥ 55 years old with hip OA and DISCUSSION AND CONCLUSION: The amount of pain
hip fracture patients without hip OA. Thus many young patients improvement after impingement surgery is positively associated
with end stage hip OA do have radiographic evidence of cam type with the severity of pre-operative level of pain. The pre-op
FAI. Furthermore, this case-controlled study suggests that cam dGEMRIC index, the amount of femoral bone resection, the pre-
type FAI may contribute to the development of early onset hip op JSW, and the pre-op Tönnis grade were not associated with
OA. Survival of HRA and THA, the reference group. End-point one-year pain improvement (ΔWOMACp) in our study. All of our
is defined as revision of any component Survival of HRA and patients had minimal to no radiographic evidence of osteoarthritis
THA, the reference group. End-point is defined as revision of any and femoral resection was sufficient. Therefore, careful selection of
component. symptomatic patients with FAI for surgical treatment can lead to
predictable improvement in symptoms.
POSTER NO. P085
Which Factors Predict the Clinical Outcome after POSTER NO. P086
Femoroacetabular Impingement Surgery? Sterile Pseudotumour can Explain a High C-reactive
David Stelzeneder, MD, Boston, MA Protein
Kerri Murray, MPH, Boston, MA Tahir Mahmud, FRCS, London, ON, Canada
Eduardo N. Novais, MD, Aurora, CO Keshthra Satchithananda, FRCR, London, United Kingdom
Tallal C. Mamisch, MD, Bern, Switzerland Angus Lewis, FRCS, London, United Kingdom
Michael B. Millis, MD, Boston, MA Alexander D. Liddle, MBBS, London, United Kingdom
Young Jo Kim, MD, Boston, MA Shiraz Sabah, MD, London, United Kingdom
INTRODUCTION: The aim of this study was to compare Johann Henckel, BM, London, United Kingdom
pre-operative and intra-operative factors such as delayed John Skinner, FRCS, London, United Kingdom
gadolinium enhanced MRI of cartilage (dGEMRIC) index, Adam Mitchell, MD, London, United Kingdom
minimal joint space width (JSW), radiographic grade of Alister Hart, FRCS, London, United Kingdom
osteoarthritis, the patient reported pain level and the INTRODUCTION: Surgeons use blood C-reactive protein
amount of surgical bone resection to the one-year clinical (CRP) to help diagnose infection in a painful hip arthroplasty
outcome after femoroacetabular impingement (FAI) surgery. and decide between one or two stage revision. However,
METHODS: Thirty patients (13/17 m/f, age 27.8±8.2 years) with there are some case examples of a high CRP resulting from
cam or mixed FAI were included in this retrospective study. a sterile inflammatory pseudotumour seen around metal
Inclusion criteria were an age between 14 and 60 years, FAI surgery, on metal (MOM) hips. Our aim was to determine the
a preoperative dGEMRIC scan, and a pre-op WOMAC pain score relationship between CRP and infection / non-infection in
greater than 4. DGEMRIC was performed at 1.5T in 27 patients patients with a pseudotumour adjacent to a painful MOM hip.
and at 3T in three patients using a fast 3D isotropic T1 mapping METHODS: Ninety-seven patients were seen in our painful MOM
sequence. The dGEMRIC index at 3 Tesla was corrected for the higher hip replacement (MOMHR) clinic. Forty-six patients (11 males and
T1 values seen at higher field strength. On sagittal 3mm-reformats, 35 females) with 47 MOM hips fulfilled our inclusion criteria: 1) a
a region of interest (ROI) evaluation was performed on the most painful MOM hip sufficient to require revision, or with an Oxford hip
central sagittal slice. One ROI was selected for the acetabular score less than 30 out of 48; 2) a known serum CRP; 3) a metal artefact
cartilage from the anterior acetabular rim to the superior-most reduction sequence (MARS) MRI; 4) and a means of determining
point in the joint. Pre- and post-operative x-rays were evaluated infection from non-infection (hip aspiration or cultures from
for Tönnis osteoarthritis grade, JSW (both assessed on AP supine revision surgery). A CRP of > 10 mg/L was regarded as elevated. All
view), and alpha angles (on frog or Dunn view). Improvement in MRIs were evaluated by two senior musculoskeletal radiologists.
WOMAC pain and alpha angle was tested using Student’s t-test. The RESULTS: Twenty-nine out of 47 hips (62%) had a pseudotumour
clinical improvement in the WOMAC pain score was calculated as on MARS MRI, of which 12 (41%) had an elevated CRP. Nine
follows: ΔWOMACp = WOMAC pain pre-OP - WOMAC pain post- out of the 12 (75%) hips with a pseudotumour and an elevated
OP. A Pearson correlation comparing ΔWOMACp to the dGEMRIC CRP were not infected. The sensitivity and specificity for the
index, the amount of femoral bone resection (alpha angle pre-op - presence of a pseudotumour based on an elevated CRP was 0.47
alpha angle post-op), the pre-op JSW and the pre-op WOMAC pain and 0.61 respectively. The sensitivity and specificity of infection in
score was performed. An independent sample t-test was performed pseudotumour positive patients based on the CRP are 0.50 and 0.54
to compare ΔWOMACp between pre-op Tönnis grade 0 and I. respectively. This is lower than the accepted values for non-MOMHRs.
RESULTS: The mean pre-operative dGEMRIC value of our DISCUSSION AND CONCLUSION: Two-thirds of patients with a
cohort was 533.2±111.6 msec (standard deviation). The surgical painful MOMHR had a pseudotumour on MARS MRI. There was
resection improved the mean femoral neck alpha angle from poor correlation between an elevated CRP and a pseudotumour.
58.1±16.0 degrees pre-op to 42.5±8.1 post-op (p<0.001). The The sensitivity and specificity were low for diagnosing infection
WOMAC pain score decreased from 9.8±3.3 pre-op to 4.4±3.4 based on CRP in patients with pseudotumours on MRI.
post-op (p<0.001). The Tönnis grade was 0 (normal) in 14 and
I (mild osteoarthritis) in 16 patients pre-op and was 0 in 10 and
I in 20 patients post-op. ΔWOMACp was not different in patients
with pre-op Tönnis grade 0 and I (-6.1±1.8 vs. -5.1±5.2; p=0.48).
There was no correlation of dGEMRIC index with ΔWOMACp
(r=-0.05; p=0.82). ΔWOMACp also did not correlate with the
amount of femoral bone resection (r=-0.01; p=0.97) and the JSW
(r=0.32; p=0.09). The only factor associated with ΔWOMACp
was the pre-operative WOMAC pain score (r=0.56; p=0.001).

POSTER NO. P087 hip, we retrospectively evaluated the clinical and radiographic
results in 42 hips of 35 patients at a minimum 25-year follow up.
Do Health Related Quality of Life Scores Improve in METHODS: There were 33 women and two men. The mean age
Overweight Patients Following Total Hip Arthroplasty? of the patients at the time of the surgery was 28.7 years (range,
Scott A. Foster, MD, Mansfield, OH 14 - 48 years). The mean height was 152.2 cm (range, 130 - 175
Bryan M. Lawless, MD, Manchester, NH cm), and the mean weight was 54.8 kg (range, 38 - 73 kg). The
Meridith Greene, BA mean body mass index (BMI) was 23.6 (range, 17.3 - 30.6). The
Young-Min Kwon, MD, PhD, Boston, MA mean follow up was 27 years and two months (range, 25 - 32
years). Dome pelvic osteotomy was indicated to treat hips with
pain and dysfunction because of osteoarthritis secondary to
INTRODUCTION: Although the functional outcomes, survivorship, moderate or severe hip dysplasia and was not done for patients
and complications of total hip arthroplasty (THA) in overweight without disability because of hip pain. The stage of osteoarthritis
patients are well documented, health related quality of life before the surgery was graded as pre-arthritis (15 hips), early
improvement (HRQoL), as measured by a generalized instrument, osteoarthritis (19 hips), and advanced osteoarthritis (eight hips).
is not. The EuroQol5D (EQ5D) is a validated non-disease specific RESULTS: Pain score and total score of Harris Hip Score improved,
standardized instrument used to measure general health outcomes. whereas range of motion score reduced during the long-term
It is comparable across health conditions and can be used to follow up. Radiographically, the mean center-edge (CE) angle
compare cost-effectiveness of interventions. We sought to quantify and acetabular head index (AHI) improved from -3° (range,
HRQoL improvement in overweight patients following THA. -29 - 15°) and 50% (range, 22 - 77%) before the surgery to
METHODS: A retrospective review of an institution-wide 42.6° (range, 22 - 65°) and 95.9% (range, 75 - 100%) after the
registry was performed identifying all patients who underwent surgery, respectively. Thirteen hips (31%) had undergone THA at
THA and had EQ5D index scores, visual analog scale (EQ VAS, mean 21 years (range, 12.5 - 30.5 years). Kaplan-Meier survival
general health) scores, and UCLA Activity Scores. Among analysis with THA conversion as the end point showed a 61.6%
the 434 patients identified, three body mass index (BMI) probability (95% CI: 45 - 79) at mean 27 years. For pre-arthritis
subgroups were stratified (40). Preoperative and postoperative and early osteoarthritis hips before the surgery, the probability
scores were normally distributed: changes in mean scores were was 69.6% (95% CI: 51 - 88). Between the hips with excellent
analyzed by repeated-measures ANOVA with F-tests to assess and good results (22 hips, 52%) and the hips with fair and
differences in age, gender, BMI category, and the Charnley THA conversion hips (20 hips, 48%), there were no significant
case mix index as covariates in the multivariable models. differences in the preoperative characteristics except preoperative
RESULTS: All EQ5D index, EQ VAS, and UCLA scores showed radiological stage (pre/early/advanced: 12/7/3 vs. 3/12/5,
significant mean improvements postoperatively (p<0.001). p=0.028, chi-square test) and the preoperative limping (positive/
There were no significant differences in the scores between BMI negative: 4/18 vs 10/10, p=0.048, Fisher’s exact probability test).
groups or any of the other variables tested. Higher preoperative DISCUSSION AND CONCLUSION: Dome pelvic osteotomy
and postoperative EQ5D and UCLA scores were observed for is designed to provide a larger weight bearing surface and good
males and patients with BMI <30. Charnley case mix index congruity along the femoral head in sagittal plane, resulting in
was not correlated with any of the mean score improvements. reduced joint reaction forces. These results suggest that minimum
DISCUSSION AND CONCLUSION: All patients in our study 25-year results of dome pelvic osteotomy for the acetabular
reported improvement in HRQoL after THA regardless of BMI, dysplasia are encouraging for pre-arthritis and early osteoarthritis.
suggesting that obese and morbidly obese patients value their
quality of life improvement following THA as much as non-obese
patients.
POSTER NO. P088

Dome Pelvic Osteotomy for Developmental Dysplasia of
the Hip: Minimum 25-Year Follow Up
Takashi Sakai, MD, Suita, Japan
Takashi Nishii, MD, Osaka, Japan
Masaki Takao, MD, Suita, Japan
Satoru Tamura, MD, Osaka, Japan
Hirohito Abe, MD, Osaka, Japan
Kenji Ohzono, MD, Amagasaki, Japan
Hideki Yoshikawa, MD, Osaka, Japan
Nobuhiko Sugano, MD, Suita, Japan
INTRODUCTION: There were few reports concerning long-
term results of various pelvic osteotomy for developmental
dysplasia of the hip. Dome pelvic osteotomy (Figure) has been
introduced for acetabular dysplasia as a modification of Chiari
pelvic osteotomy. In this method, dome cutting of iliac bone on
the lateral aspect is done in order to acquire the accordance with
the sphericity of the femoral head and the wide contact area of
the iliac bone cutting. In order to elucidate long-term results
of dome pelvic osteotomy for developmental dysplasia of the

POSTER NO. P089 pincer, or combined. Acetabular labral tear type was determined
arthroscopically using a modification of the classification by
Comparison of Hemiarthroplasty versus THR Following Seldes et al: type 1 - tears at the chondro-labral junction; type
Intracapsular Fractured Neck of Femur 2 - intrasubstance tears, labral cysts, or labral ossification;
Simon Jameson, Middlesbrough, United Kingdom or type 3 - both chondro-labral and intrasubstance tearing.
Debbie Lees, MBBS, Tyne & Wear, United Kingdom RESULTSA total of 206 cases (46.4%) were type 1, 110 cases (24.7%)
Philip James, PhD, Alcester, Warwickshire, United Kingdom were type 2, and 128 cases (28.8%) were type 3. No difference was
Amar Rangan, FRCS, Middlesbrough, United Kingdom found between labral tear types with regard to FAI mechanism.
Furthermore, there were no differences in radiographic findings
James L. Mcvie, FRCS (Ortho), Middlesbrough, United
of crossover sign, ischial spine prominence, head-neck offset and
Kingdom alpha angle. Significant differences between the groups were found
Mike R. Reed, MBBS MD, Northumberland, United Kingdom regarding age (p=0.001), where hips with type 1 tears were youngest
INTRODUCTION: The treatment of choice for intracapsular and type 3 the oldest; acute onset of pain >0 in hips with type 3 tears.
fracture neck of femur fractures in active patients over 60 years DISCUSSION AND CONCLUSION: No correlation was found
remains unknown. In contrast with previous studies, a recent between labral tear type and FAI mechanism or morphology.
randomized controlled trial suggested hemiarthoplasty to However, associations were found with age, acuity of onset, and
be the best option - operation duration was shorter, blood Tonnis arthritic grade. The findings of this study do not support
loss less and early dislocation rates were lower. However, the theorized relationship between FAI mechanism and labral tear
numbers were small and follow up was short. We aimed to pattern. However, the significant correlations which were shown
compare the national data for complications following total suggest that labral tear pattern may be more reflective of the length
hip replacement (THR) or hemiarthroplasty in these patients. of the degenerative process in FAI.
METHODS: Hospital episode statistics (HES) data was analyzed
for patients over 60 years who underwent hemiarthroplasty POSTER NO. P091
or THR surgery for an intracapsular fractured neck of femur in
Mid-term Follow-up of Periacetabular Osteotomy (PAO)
the English NHS between January 2005 and December 2008.
Eighteen-month dislocation and revision rates were analyzed. in Patients with Hip Dysplasia
RESULTS: Following hip fracture, 13,565 patients Gorden D. (David) D. Potter, III, MD, Rochester, MN
underwent cemented hemiarthroplasty and 1,196 patients Eduardo N. Novais, MD, Aurora, CO
underwent cemented THR. Eighteen-month dislocation Robert T. Trousdale, MD, Rochester, MN
rate was significantly higher in the THR patients (2.08% Rafael J. Sierra, MD, Rochester, MN
versus 0.54%, OR=3.90, 95% CI 2.81-5.41). However, there
INTRODUCTION: There are very few published mid to long term
was no significant difference in 18-month revision rate.
studies reporting on the results of periacetabular osteotomy (PAO)
DISCUSSION AND CONCLUSION: In this national analysis there
for management of hip dysplasia in the young adult. The objective
was no significant differences in revision within 18 months of THR
of this study is to report the midterm follow up of PAO performed
compared with cemented hemiathroplasty. Dislocation rates were
in this group of patients with special attention to progression
higher following THR. Data on the apparent functional benefits of
of hip arthritis and conversion to total hip arthroplasty (THA).
THR were unavailable for this study.
METHODS: A total of 266 abductor sparing PAO performed on 235
patients were performed at one institution between 1996 and 2006.
POSTER NO. P090
Those with less than two-year clinical follow up were excluded
Acetabular Labral Tear Type in Relation to Mechanism leaving 135 hips in 118 patients for review. There were 21 males and 97
of Hip Impingement females with an average age at the time of surgery of 32 years. Clinical
Itamar Botser, Chicago, IL notes were reviewed for pain relief and radiographs were reviewed
for progression of hip arthritis according to criteria by Tönnis.
Dorea E. Martin, BS, Westmont, IL
RESULTS: The average clinical follow up was 82.1 mo (range 2
Benjamin Domb, MD, Westmont, IL to 14 years). 31 of 135 hips had progression in severity of Tönnis
INTRODUCTION: It has been postulated that bony morphology Grade. 103 hips were Tönnis 0, 19 T-I, 3 T-II and 10 radiographs
of femoro-acetabular impingement (FAI) may cause labral tears. were not available for review. Postop grade was 0 in 87, I in 26,
Furthermore, it has been suggested that labral tear patterns may II in 17 and III in four and radiographs were not available in
reflect the mechanism of impingement: cam-type impingement one hip. Thirteen hips (9.6%), required a THA at an average of
may preferentially damage the chondro-labral junction, while 82.9 months after the PAO (range 30.6 months to 165 months).
pincer-type impingement may cause intrasubstance tearing. The DISCUSSION AND CONCLUSION: Conversion to THA after PAO
hypothesis of the current study was that a relationship exists occurred in 10% of hips at an average of seven years. An additional
between bony morphology of cam and pincer FAI and type of labral 13% of the hips showed progression in hip arthritis on radiographs
pathology (chondro-labral detachment, intrasubstance damage or but have not required a THA at last follow up. Patients with
both). The purpose of the study was to examine the relationship symptomatic hip dysplasia and minimal radiographic arthritis
between impingement mechanism and labral tear type. should be considered candidates for a PAO but patient selection
METHODS: During the study period, data were collected and surgical technique are critical.
prospectively for all patients who underwent arthroscopy for
FAI. A total of 444 hips (421 patients) were included in the
study, after excluding hips with previous surgery, history of
fracture, previous hip disease, or Tonnis arthritic grade >1. All
patients had at least one of the following radiographic findings:
alpha angle >50° on modified Dunn view, or positive crossover
sign on AP-pelvis. FAI mechanism was characterized as cam,

POSTER NO. P092 joint space 2mm or less, the joint incongruence, concomitant
ITVO and post-operative lateralization of the femoral head.
Cementless THA with LDH MoM Heads - Short DISCUSSION AND CONCLUSION: The clinical and radiographic
Term Survivorship of 8,059 Hips from the Finnish results of a mean 18-year follow up of ERAO were excellent.
Arthroplasty Register
Jari Mokka, MD, Turku, Finland POSTER NO. P094
Keijo Makela, MD, Turku, Finland Prospective Long-term Evaluation of Treatment of
Petri Virolainen, MD, Littoinen, Finland Infected Orthopedic Devices with Implant Retention
Ville M. Remes, MD, Helsinki, Finland Rihard Trebse, MD PhD, Ankaran, Slovenia
Pekka Pulkkinen, PhD, Helsinki, Finland Andrej Trampuz, MD, Lausanne, Switzerland
Antti Eskelinen, MD, PhD, Tampere, Finland INTRODUCTION: Standard therapy for orthopedic
INTRODUCTION: Population-based register data from the device infections includes a two-stage exchange and
National Joint Register of Australia and England and Wales have prolonged antimicrobial therapy. In a subgroup of patients,
revealed that the mid-term outcome of cementless large diameter retention of the device seems to be an effective alternative.
head metal-on-metal total hip arthroplasty is inferior to that of METHODS: In a mid-term prospective study we evaluated treatment
conventional cemented metal on polyethylene total hip arthroplasty. efficacy of orthopedic device infections with implant retention.
METHODS: Based on data extracted from the Finnish Arthroplasty The inclusion criteria were: early manifestation, stable implant,
Register, the risk of revision of 8,059 cementless large diameter head known pathogen, susceptibility of staphylococci to rifampin, gram-
metal-on-metal total hip arthroplasties performed over 2002-2009 negatives to kinolones, and good condition of soft tissue (absece of
was analyzed using Cox regression model. The revision risk of these a fistula). From January 1999 through June 2009, 40 patients were
hips was compared to that for 16,978 cemented metal on polyethylene included and followed for at least two years. The mean age of the
total hip arthroplasties performed over the same time period. included patients was 68 years, 71% were females. There were 60%
RESULTS: In the Cox regression analysis, there was no difference total hip, 20% total knee replacements, and 20% of other devices.
in revision risks between cementless large diameter head metal-on- Among the pathogens the staphylococci predominated, especially
metal total hip arthroplasty and cemented metal on polyethylene Staphylococcus aureus. The average duration of symptoms before
total hip arthroplasty (RR 0.90, CI 0.74-1.10; p=0.3). However, in inclusions was 35 days. After initial two to four week intravenous
female patients aged 55 years or more, cementless large diameter therapy with β-lactam antibiotics, intravenously staphylococcal
head metal-on-metal total hip replcements showed a significantly infections were treated with oral ciprofloxacin 750 mg bid +
increased risk of revision as compared to cemented total hip rifampin 450 mg bid, streptococcal and enterococcal infections
replacements (RR 1.33, CI 1.04-1.70). Compared to the reference with oral amoxicillin 750 mg tid. For the methicilin-resistent germs,
implant in the present study (cementless Synergy stem combined we used vankomycin instead of β-lactams. For gram negatives we
with BHR cup) the cementless CLS stem combined with Durom used kinolones, and for anaerobes klindamycin or penicillin.
cup had a 2.9-fold (95% CI 1.17-6.90) increased risk of revision. Oral treatment lasted for 10 weeks (knee prostheses six months).
DISCUSSION AND CONCLUSION: We found that cementless RESULTS: There were four recurrent infections, two reinfections
large diameter head metal-on-metal total hip arthroplasty had with a different pathogen, and one aseptic loosening. The
comparable short-term survivorship with cemented total hip remaining 33 patients are completely free of problems related to
arthroplasty at a nationwide level. However, in female patients the implant involved. Implant survival probability with recurrence
aged 55 years or more, cementless large diameter head metal- as the end point was 97% after one year, 94% after two years and
on-metal total hip arthroplasty showed inferior results. Further, 82% after nine years according to Kaplan and Meier method.
implant design had an influence on revision rates. DISCUSSION AND CONCLUSION: In carefully selected patients,
device retention with antimicrobial treatment for three to six
POSTER NO. P093 months is an effective approach that gives lasting results.The
Mean 18-year Follow Up of Eccentric Rotational strengths of the study are: a careful patient selection, precise
diagnostic and therapeutic procedures, and long 100% patient
Acetabular Osteotomy follow up.
Yukiharu Hasegawa, MD, Nagoya City, Japan
INTRODUCTION: The goal of the eccentric rotational acetabular POSTER NO. P095
osteotomy (ERAO) is to correct the deficient acetabular coverage in Is Hydroxyapatite Coating Necessary to Improve
dysplastic hip to prevent secondary osteoarthritis. We investigated
the 18-year survivorship of symptomatic patients treated with ERAO. Survivorship of Porous-Coated Titanium Femoral
METHODS: We retrospectively evaluated the first consecutive Stem?
124 patients (130 hips). The mean age was 37.4 years, and the Young-Hoo Kim, MD, Seoul, Republic of Korea
average follow up was 18.2 years (15-22 years). Male patients Jun-Shik S. Kim, MD, Seoul, Republic of Korea
were seven and female were 117. Twenty-three hips were also Hyoung-Jin Kim, MD, Seoul, Republic of Korea
treated with intertrochanteric valgus osteotomy (ITVO).
Jin-Woo Choe, Seoul, Republic of Korea
RESULTS: The mean lateral CE angle was improved from 0 to 37
degrees. The mean HHS of 70 points was improved to a mean score INTRODUCTION: Although the results of the use of hydroxyapatite-
of 88 points at the time of final follow up. Conversion to a total coating (HA) stems in total hip arthroplasty (THA) have been
hip arthroplasty (THA) was performed in 12 hips. A Kaplan-Meier reported in several large series, a few studies have compared HA-
survivorship analysis is evaluated with the conversion to a THA as the coated and non-HA-coated stems in the same patient. The purpose
end point. A cumulative survivorship at 15 years and at 20 years follow of this prospective, randomized study was to evaluate the clinical
up was 95% and 86%, respectively. We identified four significant and radiographic results associated with proximally porous-coated
risk factors by multivariate analysis: a pre-operative minimum titanium stems that were identical in geometry but difference with

regard to proximal surface treatment (with or without HA-coating). and cord blood in the study group reveal that the placenta exerts a
METHODS: Bilateral simultaneous sequential THA was regulatory influence on metal ion transfer.
performed for 55 patients (110 hips). Thirty-nine men and 16
women (mean age, 46.3 years) received a HA-coated porous- POSTER NO. P097
coated titanium stem in one hip and a non-HA-coated porous- uA New Registration Method for Imageless Computer
caoted titanium stem in the contralateral hip. The mean duration
of follow up was 15.6 years (range, 15 to 16 years). At each Navigation in Total Hip Arthroplasty: A Cadaveric Study
follow up, the Harris hip score, the Western ON and McMaster Edward T. Davis, FRCS, Hagley, United Kingdom
Universities Osteoarthritis (WOMAC) score, University of CA, Los David J. Mayman, MD, New York, NY
Angeles (UCLA) activity scores and radiographs were evaluated. Holger Bathis, MD, Cologne, Germany
RESULTS: The mean postoperative Harris hip scores (93 vs. 91 mario Schubert, Feldkirchen, Germany
points), WOMAC scores (13.1±5.8 vs. 13.8±7.5 points), and Sabine Gneiting, Feldkirchen, Germany
UCLA activity score (7.8 point) were similar in both groups. Melanie Wegner, Feldkirchen, Germany
No patient had preference for one type over the other or thigh
pain at the final follow up. The mean polyethylene wear rate INTRODUCTION: The recent issues surrounding the problems of
per year (0.21 ± 0.023 mm vs 0.24 ± 0.025 mm) and incidence metal on metal bearing in hip arthroplasty have reinforced how
of acetabular osteolysis (16% vs. 15%) were similar in both crucial implant positioning is. One of the main barriers to the
groups. Femoral osteolysis was confined to calcar femorale in adoption of computer navigation is acquiring the anterior pelvic
both groups. No femoral component in either group was revised. plane (APP). Current registration methods require a repositioning
Kaplan-Meier survivorship analysis revealed that the rate of the of the patient to access the contra-lateral registration points.
survival of the femoral components was 100% (95% CI, 0.95 METHODS: We utilized a new lateral registration method on 18
to 1.0) in both groups at 16 years. The rate of the survival of the cadaveric hips from nine patients. The complete registration was
cup was 89% (95% CI, 0.85 to 0.95) in both groups at 16 years. performed in a lateral decubitus position. Registration points
DISCUSSION AND CONCLUSION: After long-term follow up, were taken from the ipsi-lateral anterior superior iliac spine (ASIS)
HA-coating on the porous surfaces of the titanium stem did not and a mid-sagittal point at the lumbar spine (taken through
improve or diminish the longevity of the stem. the drapes). All other points were taken from the acetabular
cavity and rim. Neither the contra-lateral ASIS nor points at the
POSTER NO. P096 pubis symphysis had to be acquired. For evaluation purposes,
the APP was directly acquired on the bone as a gold standard.
Intra-Uterine Metal Ion Exposure Assessment through RESULTS: In comparison to this gold standard, the average
a Controlled Study of Maternal and Cord Blood error for the new registration method was -0.9° (SD 3.2) for
Hena Ziaee, Birmingham, United Kingdom inclination and -1.3° (SD 3.8) for anteversion. The results
Chandra Pradhan, FRCS, Brinmginham, United Kingdom show that statistically within more than 95% of the cases
Joseph Daniel, FRCS, Birmingham, United Kingdom the acetabular component would have been orientated
within the “safe zone” as described by Lewinnek et al.
Derek J. McMinn, FRCS, Birmingham, United Kingdom
DISCUSSION AND CONCLUSION: This study demonstrates it
INTRODUCTION: Metal-metal surface replacement (MoMSRA) is possible to construct the APP from registration points taken in
continues to be used in young women. Systemic metal ion the lateral position, with a fully draped patient. This advancement
release and its effects cause concern. Do metal ions crossing the may reduce one of the barriers preventing patients from benefiting
placenta in pregnant women have potential mutagenic effects? from the use of computer navigation, in providing more accurate
The hypothesis is that metal ions pass freely through the placenta acetabular component placement.
and there is no difference in maternal and cord metal levels.
METHODS: This is a controlled cross-sectional study of women POSTER NO. P098
with MoMSRA. (n = 25, 3 bilateral, mean age 32 years, time
from implantation to delivery 60 months). The control group
Clinical and Radiographic Outcomes of Cementless
consisted of 24 subjects, mean age 31 years, with no metallic Total Hip Arthroplasty in Patients Under 30 Years of
implant and not receiving cobalt/chromium supplements. No Age
patient was known to have renal failure. Whole blood specimens Jeremy Gililland, MD, Salt Lake City, UT
were obtained before delivery and before any infusion or
Lucas Anderson, MD, Salt Lake City, UT
transfusion, and cord blood specimens immediately after delivery.
RESULTS: Cobalt and chromium were detectable in all specimens David Rothberg, MD, Salt Lake City, UT
in both cohorts. In the control group, the difference between Jill Erickson, PA, Salt Lake City, UT
maternal and cord levels was only 5 to 7% indicating free passage. Christopher Pelt, MD, Salt Lake City, UT
Study group cord cobalt (0.88 µg/L) and chromium levels (0.34 Christopher L. Peters, MD, Salt Lake City, UT
µg/L) were significantly lower than maternal cobalt (1.57 µg/L, INTRODUCTION: Total hip arthroplasty (THA) in young patients
p < 0.05) and chromium Levels (1.43 µg/L, p 0.05). However has historically been associated with increased complications and
there is a significant difference between the cord cobalt levels in poor survivorship. However, older techniques, small numbers, a
the study (0.88 µg/L) and control (0.41 µg/L, p < 0.05) groups. predominance of inflammatory arthritis, and little documentation
DISCUSSION AND CONCLUSION: The limitation of this study of functional improvement are common limitations of these
is that none of the patients in the study had the excessive metal studies. We hypothesized that modern cementless THA performed
ion levels recorded in recent times in some of the withdrawn primarily for non-inflammatory in a group of young patients
resurfacing arthroplasties. The differences between maternal and would lead to similar clinical and radiographic outcomes and
cord metal ions in the controls indicate that normally the placenta revision rates when compared to a cohort of older patients.
allows an almost free passage of metal ions. Within the range of METHODS: We performed a retrospective review of 97 consecutive
levels studied, the relative levels of metal ions in the maternal

cementless THAs performed by a single surgeon from 1996-2008 0.8% for all patients, 0% for men and 2.6% for women. In contrast
in 79 patients under the age of 30 with mean 65-month follow up the Oxford group, reported 26 (1.8%) revisions for adverse wear in
(24-151). The clinical and radiographic outcomes were compared 1,419 cases and an additional 41 (2.9%) revisions for other causes for
to a randomly selected control group of 100 cementless THAs a total failure rate of 3.7% with a similar mean follow up. Revisions
performed during the same time period with similar followup in for adverse wear represented 38% of all failures. The Oxford
98 patients over the age of 50. Primary outcome measurements cumulative Kaplan-Meier revision rate for adverse wear at eight
included the Harris hip score, clinical complications, and years was 4% for all patients, 0.5% for men and 9.4% for women.
radiographic analysis focusing on loosening and radiolucency. DISCUSSION AND CONCLUSION: Our low failure rate due
RESULTS: There was no difference in gender or BMI between the to adverse wear of 0.1% in 2,361 patients over 12 years is in
groups. There was a difference in the pre-operative diagnoses of agreement with the results reported from the Newcastle group
pediatric diseases (55% young vs. 8% old; p<0.001), avascular (0.15% in 670 cases), Schmalzried (0.51% in 588 cases) and
necrosis (20% young vs. 2% old, p=0.021), and idiopathic the Canadian Hip Resurfacing Group (0.1% in 3,432 cases). It
osteoarthritis (0% young vs. 86% old, p<0.001), with no appears that the majority of large reports on adverse wear now
difference in septic, post-traumatic, or inflammatory arthritis. do not confirm the surprisingly high rate widely reported by the
The overall rate of perioperative complications was similar Oxford Group. Also, in contrast to the Oxford report, all three of
between groups, though more transfusions were administered in our failures occurred in women with acetabular inclination angles
the young group (15% vs. 5%, p<0.01). There was no difference of ≥ 60° in the standing X-rays. All three women exhibited an
in the rate of femoral or acetabular radiolucencies nor in the unusual amount of pelvic forward flexion when comparing supine
rate of radiographic loosening between the two groups. There to standing X-rays, resulting in an acetabular measurement that
was no difference in the HHS at final follow up. The revision increased by an average of 8 degrees when a standing pelvis X-ray
rate was higher in the young group (9% vs. 2%, p<0.01). was measured. One reason that acetabular inclination angle may
DISCUSSION AND CONCLUSION: Contemporary cementless be difficult to correlate to adverse wear in some studies may be the
THA in patients under the age of 30 is associated with similar failure to routinely obtain standing pelvis X-rays. Our low failure
functional improvement and perioperative complications rate does not justify a policy of discriminating on the basis of age,
compared to older patients. The high prevalence of prior pediatric gender, implant size or diagnosis when offering hip resurfacing.
hip surgery in the young THA group may predispose to increased To avoid the rare wear failures in women, it may be advisable to
technical difficulty resulting in higher revision rates. Although develop operative techniques to avoid high inclination angles on
our revision rate was higher in the young patients, it is favorable postoperative standing pelvis X-ray, particularly in women.
compared to older techniques and consistent with the limited data
available with modern cementless techniques in patients of similar
age.
POSTER NO. P099

uIncidence of Adverse Wear Reactions in Hip
Resurfacing Arthroplasty: A Comparison with the
Oxford Study
Fei Liu, PhD, Columbia, SC POSTER NO. P100
Thomas P. Gross, MD, Columbia, SC Trends in Total Hip Arthroplasty Bearing Surface
INTRODUCTION: This study is to evaluate the risk of revision for Utilization in Medicare Patients
adverse wear reaction after metal-on-metal hip resurfacing in our Kevin J. Bozic, MD, MBA, San Francisco, CA
12-year experience with over 2,361 cases and to compare this to the Edmund Lau, MS, Menlo Park, CA
Oxford Report on “pseudotumors.” METHODS: Between July 1999
Kevin Ong, PhD, PE, Philadelphia, PA
and Feb 2011, the same surgeon performed 2,361 metal-on-metal
hip resurfacing arthroplasties in 1,956 patients (1,415 male vs. 541 Steven M. Kurtz, PhD, Philadelphia, PA
female; 72% vs. 28%) in the United States. The mean age was 51±8 Thomas P. Vail, MD, San Francisco, CA
years old. The primary diagnosis was osteoarthritis in 1,817 cases Harry E. Rubash, MD, Boston, MA
(77%); dysplasia in 251 cases (11%); osteonecrosis in 147 cases Daniel J. Berry, MD, Rochester, MN
(6%). The mean length of follow up was 4±3 years (range: 0.02 to INTRODUCTION: Total hip arthroplasty (THA) bearing
12 years) compared to four years (range: 0.05 to 9.45) in the Oxford surface utilization various widely throughout the U.S. The
study. The mean femoral component size was 50±4 mm. We used purpose of this study was to evaluate trends in THA bearing
the same criteria for failure, which was “symptoms severe enough surface utilization by age and gender in Medicare patients.
to cause revision.” We could not adequately analyze risk factors METHODS: The 100% Medicare database was used to stratify
because we had only three failures in 2,361 cases, (failure rate 0.1%). THA bearing usage by age and gender from 2005-2009.
RESULTS: In this study, the wear related failure rate was 0.1% Instrumental variable analysis (propensity scores) was used to
(3/2361). Failures due to all other causes occurred in 56 (2.4%) reduce unobserved bias.
cases. Revisions for adverse wear represented 5% of all failures. The RESULTS: For men age 65-74, ceramic-on-polyethylene (CoP)
three wear related failures (pseudotumors) occurred in two women usage increased; metal-on-metal (MoM) increased to 2007,
at a mean of six years (4,7,7), all with acetabular inclination angles but decreased from 2007-2009; metal-on-polyethylene (MoP)
greater than 60 degrees (measured on standing pelvis X-ray). In decreased to 2007, but then increased from 2007-2009; and
the revisions for other causes, there was a significant amount of ceramic-on-ceramic (CoC) decreased. For men age 75-84, similar
metalosis found in only one case; this was due to titanium shedding trends were observed, but CoP increased to 2007 then reMEd
from a loose acetabular component. At eight years post-operatively, constant from 2007-2009. For men age 85+, CoC decreased, CoP
our Kaplan-Meier cumulative revision rate for adverse wear was

and MoM increased to 2008 but decreased in 2009, while MoP
decreased to 2008 but increased in 2009. For women age 65-74
and 75-84, the temporal trends in bearing use were similar to men
in the same age group. For women 85+, CoC decreased; CoP and
MoM increased to 2007 then decreased from 2007-2009, while
MoP decreased to 2007 but increased from 2007-2009. In 2009,
for males, 53% had MoP, 33% MoM, 11% CoP, and 2% CoC.
For women, 57% had MoP, 30% MoM, 11% CoP, and 2% CoC.
DISCUSSION AND CONCLUSION: Substantial changes in THA
bearing usage have been observed between 2005 and 2009. A large
percentage of Medicare THA patients still receive hard-on-hard
bearings. Further study is needed to understand what factors are
driving these trends.
POSTER NO. P101

uPatterns of Failure in Metal-on-Metal Hip
Arthroplasty and Implications for Revision
Keshthra Satchithananda, FRCR, London, United Kingdom
Karuniyan V. Vipulendran, Haverfordwest, United Kingdom
Angus Lewis, FRCS, London, United Kingdom
INTRODUCTION: Previous studies have shown poor results
after revision of metal-on-metal hip replacement (MOM-
HR) for adverse reactions to metal debris, with high rates of
dislocation, loosening and reoperation. The revision burden POSTER NO. P102
in MOM-HR is increasing and optimal management remains Sterile Pseudotumour can Explain a High C-reactive
unclear. We present our revision series, demonstrating the role Protein
of pre-operative investigations in classifying such cases, allowing
Tahir Mahmud, FRCS, London, ON, Canada
accurate preoperative planning and avoidance of complications.
METHODS: Data were collected prosepectively on revisions of Keshthra Satchithananda, FRCR, London, United Kingdom
MOM-HR at our institution. Patients underwent preoperative Angus Lewis, FRCS, London, United Kingdom
radiographs, MRI, CT, and functional scoring. Intraoperative Shiraz Sabah, MD, London, United Kingdom
findings were recorded. Scores and complications were recorded at Alexander D. Liddle, MBBS, London, United Kingdom
follow up. Patients were classified into five groups by CT, MRI and Johann Henckel, BM, London, United Kingdom
intraoperative appearance, depending on the degree of muscle or bone John Skinner, FRCS, London, United Kingdom
loss and presence of pseudotumour or conventional cause of failure. Adam Mitchell, MD, London, United Kingdom
RESULTS: Thirty-nine hips (36 patients) were revised. Median age Alister Hart, FRCS, London, United Kingdom
was 61 (25-76), M:F ratio was 7:33. Eight patients were found to have
‘conventional’ causes of failure such as infection or impingement. INTRODUCTION: Surgeons use blood C-reactive protein
Seven had predominant osteolysis with no pseudotumour, seven (CRP) to help diagnose infection in a painful hip arthroplasty
had a destructive pseudotumour with muscle loss, two had a well- and decide between one or two stage revision. However,
demarcated large pseudotumour without local destruction. The there are some case examples of a high CRP resulting from
majority (15) had no findings of significant pseudotumour, muscle a sterile inflammatory pseudotumour seen around metal
or bone loss. Early results at a mean follow up of 20 postoperative on metal (MOM) hips. Our aim was to determine the
months (range 2-44 months) are favorable with one re-operation relationship between CRP and infection / non-infection in
for recurrent pseudotumour, no dislocations or re-revisions. patients with a pseudotumour adjacent to a painful MOM hip.
DISCUSSION AND CONCLUSION: Metal-on-metal hips fail METHODS: Ninety-seven patients were seen in our painful
in predictable patterns, determinable on preoperative imaging. MOMHR clinic. Forty-nine patients (11 males and 38 females)
Classifying such cases using imaging findings allows accurate with 50 MOM hips fulfilled our inclusion criteria: 1) a painful
preoperative planning and may lead to better outcomes after revision. MOM hip sufficient to require revision, or with an Oxford hip score
less than 30 out of 48; 2) a known serum CRP; 3) a metal artefact
reduction sequence (MARS) MRI; 4) and a means of determining
infection from non-infection (hip aspiration or cultures from
revision surgery). A CRP of > 10 mg/L was regarded as elevated. All
MRIs were evaluated by two senior musculoskeletal radiologists.
RESULTS: Thirty-two out of 50 hips (64%) had a pseudotumour
on MARS MRI, of which 15 (47%) had an elevated CRP. Twelve

out of the 15 (80%) hips with a pseudotumour and an elevated POSTER NO. P104
CRP were not infected. The sensitivity and specificity for the
presence of a pseudotumour based on an elevated CRP was 0.47
Tantalum versus Titanium Acetabular Shells in Young
and 0.61 respectively. The sensitivity and specificity of infection in Active THR Patients: A Radiostereometric Analysis
pseudotumour positive patients based on the CRP are 0.50 and 0.54 (RSA) Study
respectively. This is lower than the accepted values for non-MOMHRs. Marie E. Walcott, MD, Worcester, MA
DISCUSSION AND CONCLUSION: Two-thirds of patients with a
David C. Ayers, MD, Worcester, MA
painful MOMHR had a pseudotumour on MARS MRI. There was
poor correlation between an elevated CRP and a pseudotumour.
Michelle Aubin, MD, Worcester, MA
The sensitivity and specificity were low for diagnosing infection Jacob M. Drew, MD, Shrewsbury, MA
based on CRP in patients with pseudotumours on MRI. Peyton Hays, MD, Worcester, MA
Mark Eskander, MD, Pittsburgh, PA
POSTER NO. P103 Henrik Malchau, MD, Boston, MA
The Validity of Using Administratively Coded Charles R. Bragdon, PhD, Boston, MA
Complication and Comorbidity Data in TJA Outcomes INTRODUCTION: In the active total hip replacement (THR)
population, maintaining acetabular component stability and
Reporting limiting polyethylene wear are crucial components to preventing
Kevin J. Bozic, MD, MBA, San Francisco, CA premature implant failure. Titanium with fiber metal coating
Ravi Bashyal, MD, Oak Park, IL is among the most common materials used in cementless THR.
Shawn G. Anthony, MD, MBA, Boston, MA Trabecular metal, composed of porous tantalum, has a metallic
Brandon Shulman strut design resembling trabecular bone, designed to improve tissue
Vanessa Chiu, MPH, San Francisco, CA infiltration and limit migration. It is unknown if tantalum offers an
Harry E. Rubash, MD, Boston, MA advantage over titanium in the biologic fixation of porous-coated
acetabular shells. Radiostereometric analysis (RSA) provides
INTRODUCTION: Administrative claims data have increasingly highly precise measurements of micromotion that are otherwise
been used in public reporting of total joint arthroplasty (TJA) not detectable by routine radiographs. Currently, RSA offers
outcomes and ’value-based’ physician and hospital payment measurement accuracy at least an order of magnitude greater than
strategies. However, the accuracy and validity of administrative that of conventional computer aided radiographic techniques as well
claims data, particularly with respect to revision TJA procedures, is as being able to measure motion defined in all three dimensions.
unknown. The purpose of this study was to evaluate the concordance METHODS: In this IRB approved, prospective, randomized,
between administrative claims and the clinical record for 13 blinded study, 46 patients received a primary THR by a single
commonly reported comorbidities and complications in TJA patients. surgeon. Each patient was randomized to receive a titanium (n=23)
METHODS: Administratively coded diagnosis and procedure or tantalum (n=23) uncemented hemispheric cup. At the time of
codes obtained from hospital billing records from 1,350 surgery, tantalum RSA markers were implanted around the liner
consecutive primary and revision TJA procedures performed at periphery and 12 markers were implanted into the patient’s femur
three high volume institutions during 2009 were compared with and periacetabular bone. The patients all received a 28mm femoral
corresponding clinical documentation, including operative notes head and either a highly cross-linked (n=25) or a conventional
and discharge summaries. Administratively coded comorbidities polyethylene liner (n=21). RSA examinations, Harris Hip, UCLA,
and complications derived from hospital billing records were WOMAC, and SF-12 scores were obtained at two weeks, six months,
compared with clinical documentation. Concordance between and annually with the furthest patients evaluated through five years.
the administrative and clinical records was determined for each RESULTS: The randomized groups had comparable mean age
revision TJA-related ICD-9 comorbidity and complication code. (58 +/- 7 years), preoperative UCLA activity score (5 +/- 2), and
RESULTS: Concordance was excellent for diabetes and post- BMI (30 +/- 4). In evaluating cup stability, the tantalum shells
op MI (K>0.80), very good for chronic lung disease, coronary demonstrated less median translation than the titanium shells at
artery disease, and post-operative DVT/PE (K=0.60-0.79), and each time-point, but there was no statistical difference between
moderate for congestive heart failure, obesity, prior MI, peripheral the two shells. At six months, the median translation of tantalum
arterial disease, bleeding complications, history of DVT/PE, and titanium was -0.01mm and 0.04mm, and reMEd stable with
prosthetic-related complications, and post-op renal failure median vertical translation of -0.02mm and 0.04mm at four
(K=0.40-0.59). All comorbidities and complications had a high years, respectively. Mean UCLA, WOMAC, Harris Hip, and SF-12
degree of specificity (>92%), but lower sensitivity (29-100%), PCS and MCS scores improved similarly in both groups through
indicating that comorbidities and complications coded in the four years, with no significant difference between the groups.
administrative record were highly accurate, but often incomplete. DISCUSSION AND CONCLUSION: Following THR, both
DISCUSSION AND CONCLUSION: Administratively coded cohorts of patients demonstrated excellent clinical outcomes with
comorbidities and complications have moderate to excellent statistically significant improvements in function and pain relief
correlation with the clinical record. However, the specificity of with no significant difference between the two groups. Although
administrative claims is much higher than the sensitivity. These tantalum porous-coated acetabular shells demonstrated less
findings underscore the need for improved, unambiguous clinical vertical translation at all time points, there was no statistically
documentation related to TJA procedures. significant difference in shell migration, and both shells
demonstrated excellent stability with minimal micromotion at
four years.

POSTER NO. P105 condition and demographic factor with the risk of PJI. The median
time when PJI was diagnosed was 6.6 months after primary THA.
Second Generation Highly Crosslinked Polyethylene: RESULTS: Comorbid conditions and demographic factors
Five Year Linear Wear associated with an increased adjusted risk of PJI (in decreasing
James A. D’Antonio, MD, Sewickley, PA order of significance) were depression (HR=1.96, 95% CI: 1.10-
William N. Capello, MD, Indianapolis, IN 3.49; p=0.022), obesity (HR=2.12, 95% CI: 1.08-4.16; p=0.0292),
Rama Ramakrishnan, Mahwah, NJ cardiac arrhythmia (HR=2.40, 95% CI: 1.08-5.33; p=0.0318),
and female gender (HR=0.55, 95% CI: 0.30-0.991; p=0.0466).
INTRODUCTION: In 1998 first generation highly crosslinked
DISCUSSION AND CONCLUSION: Depression, obesity, cardiac
polyethylenes (HXLPE) were introduced and are reported
arrhythmia, and female gender are independently associated
to have low wear. However, concerns exist regarding their
with an increased risk of PJI in THA patients. This information
mechanical strength and or retained free radicals. Second
is important when counseling patients regarding the risk of PJI
generation HXLPE were developed to lower wear, maintain
following THA, and for risk-adjusting publicly reported THA
mechanical strength, and have oxidative resistance.
outcomes.
METHODS: Crosslinking for the second generation material was
achieved using a sequential irradiating and annealing process (3
POSTER NO. P107
cycles of 3 Mrad followed by heating at 130º Centigrade for eight
hours). After machining the specimens were sterilized using gas Patient-specific Prediction of the Three-dimensional
plasma. In a multicenter prospective study, 155 patients (167 Structure of the Human Pelvis Based on Plain
cases) have three year, 124 patients (132cases) four years, and 46
patients (51cases) five years clinical and radiographic follow up.
Radiographs
RESULTS: The head penetration (wear rate) per year after the William Murphy, Winchester, MA
first year of bedding-in is 0.024 mm/yr at three years, 0.020 Jens Kowal, PhD, Boston, MA
mm/yr at four years, and 0.015 mm/yr over five years. The KM Stephen Murphy, MD, Boston, MA
survivorship revision for any reason is 97.8%, and no revision has INTRODUCTION: Acetabular component malpositioning
occurred for a bearing surface failure. No osteolysis has been seen. during total hip arthroplasty (THA) and hip resurfacing can
DISCUSSION AND CONCLUSION: We previously reported linear lead to impingement, instability, accelerated wear, wear-induced
head penetration rates for the first generation annealed HXLPE osteolysis, irritation of the psoas tendon, pseudotumor in metal-
and found that the estimated wear rate was 0.034 mm/yr at five on-metal bearings, and revision surgery for any of these problems.
years, 0.031mm/yr at 10 years, and was 72% lower than the control The majority of acetabular components that are placed using
conventional polyethylene (0.141mm/yr). The linear wear rate at traditional methods are malpositioned with studies showing
five years for the annealed second generation highly crosslinked malpositioning rates outside of the Lewinnek ‘‘safe zone’’ between
polyethylene is 0.015 mm/yr. and represents a wear reduction of 59% and 78%. Mechanical navigation instruments, docked
89% compared to the control and a 56% reduction compared to to the ipsilateral hemipelvis on a patient-specific basis, have
the first generation annealed at five years. been shown to reliably achieve cup positioning when adjusted
using CT imaging to within +/- 10 degrees of abduction and
POSTER NO. P106 anteversion in 70 of 70 patients. The current study assesses the
Risk Factors for Periprosthetic Joint Infection feasibility of achieving similar accuracy when predicting patient-
specific three dimensional structure based on plain radiographs.
Following Primary Total Hip Arthroplasty METHODS: Statistical models of the pelvis were developed using
Kevin J. Bozic, MD, MBA, San Francisco, CA CT studies of 402 hips (101 left female, 96 left male, 94 right
Edmund Lau, MS, Menlo Park, CA female, 111 right male). The material was derived from patients
Vanessa Chiu, MPH, San Francisco, CA undergoing total hip arthroplasty who had both a preoperative
Derek Ward, MD, San Francisco, CA CT study and plain radiographs. Inclusion criteria for model
Nathan Wetters, BS, Chicago, IL development were the absence of prior surgery or gross pelvic
Qais Naziri, MD, Baltimore, MD asymmetry. Surgery using the mechanical navigation device was
Michael A. Mont, MD, Baltimore, MD then planned for 57 hips treated by THR using CT imaging as
previously described. These 57 hips were not used to develop the
Terence J. Gioe, MD, Apple Valley, MN
statistical model. Exclusion criteria for this group was a history of
Craig J. Della Valle, MD, Chicago, IL prior surgery to the pelvis or cancer or radiation treatment to the
INTRODUCTION: Periprosthetic joint infection (PJI) is a rare pelvis. Only one of the 57 hips met the exclusion criteria leaving 56
but devastating complication of total hip arthroplasty (THA). for analysis. The CT plan was considered the ground truth. Surgery
The purpose of this study was to identify the specific patient using the mechanical navigation device was also planned using the
comorbidities and demographic factors that are independently statistical models together with AP and lateral pelvic radiographic
associated with an increased risk of PJI in THA patients. images. The plain radiographs had simple, specific criteria for
METHODS: A case-control study design was used to compare 499 acceptance that can easily be met by radiology technologists.
unilateral primary THA patients from one of six clinical sites who No magnification markers are required. The cup abduction and
did not develop PJI with 88 unilateral primary THA patients from the operative anteversion errors that would result from planning the
same clinical sites who developed a PJI. The impact of 29 co-morbid surgery using radiographs instead of CT were calculated for a cup
conditions and other demographic factors on PJI was examined that was aimed for 40 degrees of abduction and 25 degrees of flexion.
using multivariate Cox regression, controlling for age, sex, race, RESULTS: The errors resulting from planning the three-dimensional
and all other baseline comorbidities. Both the crude and adjusted docking of the mechanical navigation device using statistical
hazard ratios for each comorbid condition and demographic factor models and plain radiographs instead of planning on a 3D model
were calculated and the p-value associated with the hazard ratio was from CT imaging are as follows: Operative Anteversion: mean
used to rank the significance of the association of each comorbid

error 2.20 degrees; Standard Deviation: 1.40 degrees; Range: 0.08 POSTER NO. P109
to 5.45 degrees; Operative Inclination: mean error 1.95 degrees;
Standard Deviation: 1.50 degrees; Range: 0.05 to 5.05 degrees.
Prevalence and Treatment of Intra-articular Pathology
DISCUSSION AND CONCLUSION: Cup malposition following Recognized at Periacetabular Osteotomy for Dysplasia
total hip replacement and hip resurfacing is a critical surgical Christopher L. Peters, MD, Salt Lake City, UT
technique factor that affects outcome. The mechanical navigation Jill Erickson, PA, Salt Lake City, UT
device is a simple mechanical navigation device that can be Christopher Pelt, MD, Salt Lake City, UT
uniquely adjusted for each patient according to the surgeon’s cup
INTRODUCTION: Although periacetabular osteotomy (PAO) is
orientation goal with results that are equivalent to traditional
recognized as an effective treatment for symptomatic hip dysplasia
navigation, when based on CT imaging. While CT imaging may
in young adults, identification and treatment of associated intra-
be prudent for hips with prior surgery, trauma, or gross pelvic
articular pathology such as chondrolabral injury and abnormal
asymmetry, planning the surgery based on plain radiographs is
femoral head-neck offset is poorly defined. Routine anterior hip
simpler and more practical. The current study demonstrates that
arthrotomy and characterization of intra-articular pathology was
simple plain radiographs may be used for pre-operative planning
performed in a consecutive series of PAOs performed from 2002-
in routine circumstances with small additional errors when
2009. Treatment of the identified intra-articular injury is described.
compared to CT. These findings suggest that better cup positioning
METHODS: A total of 149 consecutive PAOs had routine
can be routinely achieved using simple plain radiographs, without
anterior hip arthrotomy and characterization of intra-articular
the need for complex intraoperative navigation systems, and with
pathology. Prior to these cases, 42 additional PAOs had either
minimal additional OR time.
no arthrotomy or selective arthrotomy. The average age was
25.8 (range15-47) and there were 133 females and 58 males.
POSTER NO. P108
The average BMI was 25.5 (range 11-41). The average EBL was
One Intraoperative Dose of Tranexamic Acid is Safe and 561 cc (range 100-2000 cc). The PAO was performed according
Effective in Revision Total Hip Arthroplasty to the technique described by Ganz et al., via a modified Smith-
Kevin Smit, MD, London, ON, Canada Petersen approach. Damage to the acetabular cartilage and
labrum, abnormal femoral head-neck offset, and other intra-
Doug Naudie, MD, London, ON, Canada
articular pathology was recorded in a prospective database for each
Donna Berta, BScN, London, ON, Canada case. Failure was defined as conversion to total hip arthroplasty.
Fiona E. Ralley, MD, London, ON, Canada RESULTS: Intraoperative findings included decreased femoral head
James Howard, MD, London, ON, Canada neck offset in 127 hips, a labral tear or degeneration in 23 hips, and
INTRODUCTION: Revision total hip arthroplasty (THA) has various other pathology such as ganglion cyts or loose bodies in
been associated with an increased risk of perioperative blood loss seven hips. Femoral head neck offset improvement was performed
requiring transfusions. Tranexamic acid (TEA) has been proven to in 127/149 hips (85%). Labral debridement or repair was performed
be safe and effective in preventing blood loss in primary THA. Our in 23/149, 15.4%. The mean HHS improved from 60 (range 20-88)
purpose was to study the effect of TEA on blood loss in revision THA. to 87 (range 49-100) at last follow up. There were five failures (3.3%)
METHODS: We performed a retrospective comparative study in the routine arthrotomy group compared to six failures in the non-
on 343 patients who had undergone revision THA between arthrotomy groups (14%). Only one case had secondary FAI due to
January 2006 and March 2010. A total of 108 patients did not excessive anterior over-coverage requiring anterior debridement.
receive TEA while 235 patients received one intraoperative dose DISCUSSION AND CONCLUSIONS: Symptomatic acetabular
of 20 mg/kg of TEA given immediately before skin incision. dysplasia is commonly associated with abnormal femoral
We then compared changes in hemoglobin, transfusion morphology and/or chondrolabral injury. Treatment, such as
rates, hospital length of stay, and complications between the labral repair and correction of abnormal femoral head-neck
two groups. No other routine patient care practices or blood offset, is associated with improved clinical outcome with PAO
conservation program strategies were altered during this time. and may minimize the complication of secondary FAI. Routine
RESULTS: There was a significant reduction in hemoglogin (Hb) loss anterior arthrotomy at the time of PAO can effectively identify
in the TEA group compared to the No TEA group for revision THA associated intra-articular pathology. Additional future operative
(48±18 g/L and 43±18 g/L, respectively, p=0.01) and a significant modifications, such as the use of hip arthroscopy for simultaneous
reduction in transfusion rates (45.4% and 33.6%, respectively, or staged treatment, may also be beneficial.
p=0.03) and average amount transfused (1.3±1.9 units and 0.9±1.6
units, respectively, p=0.03). The effect of TEA on Hb loss was most POSTER NO. P110
significant in procedures that involved revision of both the femoral ALTERNATE PAPER: ADULT RECONSTRUCTION HIP III
and acetabular components (58±18g/L and 49±15g/L, respectively, Clinical and Metal Ion Comparison of 36mm, 40mm
p=0.01). There was not a significant difference in recorded major
adverse events with the administration of TEA (9 and 9 respectively). and 44mm Metal-on-Metal Total Hip Arthroplasty
DISCUSSION AND CONCLUSION: One 20 mg/kg intraoperative Nayla G. Papadopoulos, Montreal, Canada
dose of TEA significantly reduced red blood cells loss and Sarantis Abatzoglou, MD, Montreal, QC, Canada
transfusion rates in patients undergoing revision THA compared to Laura M. Epure, Montreal, QC, Canada
a patient cohort who did not receive the TEA protocol. This single Alain Petit, PhD, Montreal, QC, Canada
dose protocol was not associated in an increased complication rate. Maricar Alminiana, Montreal, QC, Canada
John Antoniou, MD, Montreal, QC, Canada
INTRODUCTION: Cobalt-Chromium alloy for metal-on-metal
(MM) hip prostheses have superior wear resistance compared
to the conventional polyethylene-on-metal prostheses, making
it a more suitable alternative for younger patients. The potential

carcinogenic effect of metal ions, mainly Cobalt (Co) and Methods: We searched major medical and publishers databases
Chromium (Cr), found in the blood of patients with MM hip making no restrictions for study type, yet restricted results to
prostheses is a serious cause of concern. Tissue damage correlates English language sources. Both authors independently rated
with levels of oxidative stress markers (OSM) such as total anti- the methodological features and the data were aggregated.
oxidant status (TAS), total peroxides (TP), and nitrotyrosine Results: 738 articles were found, nine of these contained direct
(NT) which are all thought to be affected by Cr and Co levels. comparisons of navigated (NAV) and nonnavigated (N-NAV)
As larger head bearings encourage fluid film lubrication and THA. These nine studies were of varying methodological
consequently decrease wear, we hypothesize that metal ion levels quality involving 1479 THA with a mean age of 59.10 years
as well as oxidative stress markers may correlate with greater were included, 80.00% had primary osteoarthritis and 42.13%
wear rates, smaller head bearings and increased physical activity. were female. There was no statistically significant difference in
METHODS: In this prospective study, we followed 90 patients mean abduction and anteversion acetabular component angles
undergoing total hip arthroplasty (THA) with different head sizes between the NAV and N-NAV groups. There was a statistically
of Cobalt-Chromium-Molybdenum prostheses (34 patients for significant difference in the incidence of acetabular component
36mm group, 42 patients for the 40mm group and 14 patients placement in the safe zone, with NAV having significantly more
for the 44mm group). Patient follow up and data collection safe placements than NNAV: safe zone abduction (NAV 90.82%,
occurred at year 0.16, 0.33, 1 and 2. Patients with bilateral hip N-NAV 86.57%, p < 0.0001) and safe zone anteversion (NAV
involvement, concurrent metal hardware, multiple co-morbidities, 85.36%%, NNAV 74.82%, p < 0.0001). Dislocation rates were
inflammatory joint disease or infection were excluded from this also statistically significant, with NAV having significantly fewer
study. Whole blood samples collected at each follow-up visit were dislocations than N-NAV (NAV 1.03%, N-NAV 2.49%, p = 0.0317).
analyzed by inductively coupled plasma-mass spectrometry (ICP- Discussion and Conclusion: Although this meta-analysis did
MS) to determine the levels of Co, Cr and Mo. Serum nitrotyrosine not find a statistically significant difference in navigated and non-
levels were quantified using Nitrotyrosine-EIA essay whereas navigated acetabular component placement, it is clear that final
total peroxide concentration were measured with Biomedica acetabular component angles are more often placed within the safe
OxyStat assay and TAS with the Oxford Biomedical total anti- zone with navigation. Dislocation rate was significantly improved
oxidant power kit. During each visit, patients’ clinical outcomes with navigation. These outcomes demonstrate the possible patient
were recorded with calculation of both Harris Hip Scores (HHS) benefit from navigation and the resulting tighter control of
and University of CA Los Angeles Activity Scores (UCLA). Mann- component position.
Whitney U test was used to compare head bearing sizes with
metal ions concentration. Non parametric studies were used to SCIENTIFIC EXHIBIT NO. SE02
correlate HHS and UCLA scores with metal ions concentration uFailure of Modular Necks in Primary Total Hip
as well as metal ion concentration with oxidative stress markers.
RESULTS: Using Mann-Whitney U test, preliminary results Replacement: Can We Prevent It?
failed to show statistical difference in metal ions concentration Francesco Traina, MD, Bologna, Italy
between each of our study group at any given follow-up time. Massimiliano Baleani, MSc, Bologna, Italy
Nonparametric studies were used for the correlation of the Paolo Erani, BS, Bologna, Italy
HHS and UCLA scores with each type of ions. For the HHS Barbara Bordini, MD, Bologna, Italy
correlation, we found a Spearman’s Rho of 0.2008 (P=0.0009) Marcello De Fine, MD, Bologna, Italy
for Co, 0.1899 (P=0.0018) for Cr and - 0.07923 (P=0.2293) Susanna Stea, BS, Bologna, Italy
for Mo. For the UCLA correlation, a Spearman’s Rho of 0.2742
Aldo Toni, MD, Bologna, Italy
(P=0.0001) was found for Co, 0.2253 (P=<0.001) for Cr and
-0.0628 (P=0.3637) for Mo. Plasma markers for oxidative stress Introduction: Modular neck hip prostheses have some
also show no statistical correlation with metal ion concentration. advantages respect to monoblock stems. Modular neck stem
DISCUSSION AND CONCLUSION: Our results show no allow adjusting the CCD-angle, offset, neck version and length
correlation between prosthetic head size and concentration of independently of stem size. The introduction of the neck-stem
metal ions released in the blood as well as between oxidative stress coupling increases the risk of mechanical failure. In fact, in the
markers and metal ion levels. No strong correlation was shown to last years several reports described cases of coupling failure.
be present between the metal ions concentration and either the Therefore, more severe minimum requirements for fatigue
Harris Hip Scores or UCLA Activity Scores. strength must be defined. The aim of this study was answering
two open questions: How could the preclinical validation be
improved? What can surgeons do to reduce the risk of failure?
Clinical outcomes of two modular neck prostheses
SCIENTIFIC EXHIBITS From July 1995 to October 2009, two different modular neck hip
prostheses were implanted in our department. The first prosthesis
was implanted in 2,558 patients, the second one in 1,932 patients.
SCIENTIFIC EXHIBIT NO. SE01 The two patient groups did not differ in age, sex, body weight (mean
Acetabular Component Positioning in Total Hip 73 kg) and preoperative diagnosis. All patients were regularly
Arthroplasty: An Evidence-Based Analysis followed up. The hip prostheses were similar in stem design, both
being anatomically shaped. The neck-stem couplings were also
Joseph T. Moskal, MD, Roanoke, VA
similar in dimensions. However, the two coupling were different
Susan G. Capps, PhD, Warsaw, IN in cross section shape: the former had a rectangular-shaped oval
Introduction: Advocates for navigated hip arthroplasty cross section, the latter a nut shaped one. Additionally, the second
emphasize the potential for improved component placement. We one had an inventory allowing wider corrections. No failures
conducted a meta-analysis of published literature to investigate were observed for the first modular neck prosthesis at a mean
the claim of increased acetabular component precision. follow up of 9.2 years (range 5-15). Conversely, 24 mechanical

failures (1.24%) were observed with the second modular body debris, ellipsoidal articulation zones defined by
neck prosthesis at a mean follow up of 4.1 years (range 1-6). scratching, arrays of parallel scratches changing direction
Post marketing assessment of fatigue performance in echelon, and gouging with plastic deformation.
The two modular prostheses complied with the essential Discussion and Conclusion: These results show that maintenance
requirements, having received the CE mark approval (the first of a lubrication layer between MoM surfaces is not achieved. The
design was also FDA-approved). The standard reference for fatigue ubiquity of scratches on bearing surfaces indicates hard debris
testing was defined on the basis of the in vivo mechanical failure particles are widespread. Alignment of scratches indicates that dry
of the Charnley cemented stem. Therefore, it does not consider the contact is occurring during low-velocity articulation and reversal.
worst condition that a neck-stem junction may undergo in vivo. Evidence of rim contact is consistent with re-engagement of the head
A new experimental procedure for fatigue testing of the neck-stem and the liner following subluxation. These phenomena occur on all
coupling was defined. The test aims to simulate the activity causing designs, and therefore represent a framework for documenting in
the major stress at the coupling, i.e. stair climbing of a heavy vivo wear and damage. This has important implications in regard
patient. The stem was oriented at 27° of flexion (instead of 9° to the performance of all contemporary MoM hips on the market.
according to standard requirements), it was loaded 4 times a body
weight of 110 kg (4.4kN) and simulated a 10-year patient activity. SCIENTIFIC EXHIBIT NO. SE04
Both modular neck prostheses failed during the fatigue test. However, Primary and Revision Anterior Supine Total Hip
a difference was found between the selected prostheses. The first
modular prosthesis showed fatigue strength of 14% below the Arthroplasty: An Analysis of Complications and
proposed minimum requirement. The second modular prosthesis, Reoperations
with a similar neck configuration, was about 28% below the proposed Keith R. Berend, MD, New Albany, OH
limit. However, considering the worst configuration available in Michael J. Morris, MD, New Albany, OH
the inventory, the second modular prosthesis fell down to 40%. Adolph V. Lombardi, Jr, MD, New Albany, OH
A further reduction was observed when coupling contamination
was simulated or when the neck was not forced by impaction. Introduction: Anterior total hip arthroplasty (ASI-THA) has
Discussion: A more severe requirement should be introduced for emerged as a muscle sparring, less-invasive procedure. Reports
preclinical validation of modular neck stems, to predict the failure have focused on a high intra-operative and postoperative
observed in vivo. In 2010 a new version, fulfilling the proposed complication rate, increased transfusion risk, and questionable
minimum requirements, was introduced to the clinical practice. clinical benefit. The purpose of this study is to report the early
Hence, the final confirmation will be achieved in the following complications and reoperations following primary and revision
years. Up to date no mechanical failures have been recorded. ASI-THA. Methods: A retrospective review of our electronic
Anyway, the preclinical validation can not consider errors in the database identified 1000 consecutive ASI-THA performed by a
clinical practice. The fatigue strength of the coupling is strongly single surgeon between January 2007 and December 2010. There
affected by prosthesis design but also by surgical procedure. were 956 primary and 44 revision THA. The surgical technique
Possible mishandling procedures that affect neck strength are has been previously described but involves a supine, anterior
contamination of the junction with third body debris, accidental approach using a modified Smith-Petersen interval and a standard
damaging of the coupling, inadequate impaction of the neck. operative table without traction. Average age, height, and weight
were 63 years (SD 12), 68 inches (SD 4), and 198 pounds (SD 50).
SCIENTIFIC EXHIBIT NO. SE03 Results: The transfusion rate was 5%. Intraoperatively there were
3 calcar cracks and 1 canal perforation treated with cerclage cables.
Imaging of MoM Hip Retrievals Offers a New Lexicon of There were 4 wound complications requiring debridement. Four
Hip Wear Phenomena Common to This Class of Devices hips had significant lateral femoral cutaneous nerve parathesias
John H. Currier, MS, Hanover, NH not resolved at 12 months. One femoral nerve palsy occurred. At
Douglas Van Citters, PhD, Hanover, NH up to 40 months follow-up there have been 16 revisions (1.6%):
Ivan M. Tomek, MD, Lebanon, NH 6 periprosthetic femur fractures, 1 stem subsidence, 2 acetabular
failures, 3 dislocations (2 primary, 1 revision), and 3 infections
Stephen R. Kantor, MD, Lebanon, NH
(2 perioperative-revision, 1 acute hematogenous). Discussion and
Karl Koenig, MD, Hanover, NH Conclusion: This 4 year experience with primary and revision ASI-
Evan M. Carlson, Hanover, NH THA demonstrates an acceptable perioperative rate of transfusion,
Barbara H. Currier, MChE, Hanover, NH complication, and reoperation. Femoral-sided complications
John P. Collier, DE, Hanover, NH appear to be the majority, likely a result of more difficult femoral
Background: Clinical results for current generation MoM devices exposure. The complication rate is higher in revision procedures.
are mixed, with adverse tissue reaction commonly reported.
The recall of a widely used MoM system has heightened interest SCIENTIFIC EXHIBIT NO. SE05
and scrutiny of all devices. This study uses imaging techniques Smoking Is a Harbinger of Early Failure With
tailored to convex and concave surfaces to document the wear
phenomena occurring on a variety of contemporary MoM devices.
Ultraporous Metal Acetabular Reconstruction
Methods: Retrievals from 9 MoM systems were studied (6 THA Adolph V. Lombardi, Jr, MD, New Albany, OH
designs and 3 resurfacings). Head diameters 36 - 54 mm; in Keith R. Berend, MD, New Albany, OH
vivo duration 13.8 -56.7 mos.; all cups had cementless ingrowth Michael J. Morris, MD, New Albany, OH
surfaces. Bearing surfaces were imaged using stereo microscopy, Joanne B. Adams, BFA, CMI, New Albany, OH
3-dimensional digital imaging at resolution to 1000x, and Michael A. Sneller, BS, New Albany, OH
white light interferometry with resolution better than 5 nm. Tawnya Tucker, MT, New Albany, OH
Wear features and damage were documented and analyzed.
Introduction: Acetabular reconstruction with newer
Results: All retrievals show scratching due to 3rd
ultraporous metal in both complex primary and revision

total hip arthroplasty (THA) has increased survivorship with same but with components that have a suboptimal record, or even
stable fixation and few failures. Smoking is considered a recalled components; 3) asymptomatic patient with suboptimal
risk factor for surgical complications including transfusion, component position; 4) symptomatic patient with well-positioned
infection, and cardiac. We hypothesized that the early results components; 5) symptomatic patient with suboptimal component
of ultraporous metal acetabular reconstruction would be position; 6) asymptomatic patient with mildly, moderately or
unaffected by smoking in complex primary and revision THA. highly elevated cobalt or chromium levels, with or without
Methods: Between 1999 and 2009, ultraporous acetabular abnormal imaging (ultrasound or MRI); 7) mildly symptomatic
components were used in 535 hips (500 patients) for 160 patient with normal ion levels or marginally elevated ions with
complex primary and 375 revision cases. Of these patients 17% or without abnormal imaging. Case examples for each clinical
were smokers, 29.5% previous smokers, 49.0% non-smokers, scenario will be presented along with an algorithmic approach to
and 4.5% unknown. Early failures possibly related to negative management of the patient. The general approach to all patients
effects of smoking were considered any infection, failure of returning for follow-up with a MoM arthroplasty begins with a
in-growth, or periacetabular fracture. Failures not considered detailed history. Patients should be queried regarding any episodes
related to smoking included dislocation and implant breakage. of pain, discomfort or compromise of function. Symptomatic
Results: There were 33 failures at an average of 18 months post- patients should be closely evaluated for all intra-articular and
operative for a failure rate of 6.2%: 15 infections, 13 failure extra-articular causes of hip pain. In large head MoM arthroplasty,
of ingrowth, 3 dislocations, and 1 each liner fracture and aseptic loosening of the acetabular component maybe the source
periacetabular fracture. The failure rate in smokers was 11%, in of pain and is frequently difficult to diagnose. Ruling out sepsis as
non-smokers 3.8%, and in previous smokers 5.3% (Pearson’s a possible cause of pain is clearly indicated. Plain x-ray evaluation
6.5; p=0.01). With only smoking related failures included, the should be carefully performed to rule out loosening and to assess
rate was 9% in smokers and 3.6% in non-smokers (4.6; p=0.03). component position. Laboratory evaluation commences with ESR
With previous smokers included as smokers failure is 9.2% and CRP, which may be elevated. Serum metal ions at an approved
(6.2; p=0.01) and included as non-smokers 5.8% (3.7; p=0.05). laboratory facility should be obtained. An aspiration is performed.
Discussion and Conclusion: Even with ultraporous metal A cloudy to creamy fluid with a predominance of monocytes is often
technology, smoking is a significant risk factor for early failure in indicative of MoM failure; however, cell count should be obtained
complex primary and revision THA. Quitting smoking reduces as well as culture and sensitivity. Finally, imaging studies should
the inherent risk. Smoking cessation should be considered during include ultrasound or metal artifact reduction sequence (MARS)
preoperative education. MRI of the hip joint, specifically evaluating for fluid collections
about the hip. If an adverse reaction to metal debris is suspected
SCIENTIFIC EXHIBIT NO. SE06 then revision to metal or ceramic-on-polyethylene is indicated
Hip Society: Algorithmic Approach to Diagnosis and and can be successful. A delay in revision maybe associated
with extensive soft tissue damage (ie: necrosis) and hence poor
Management of Metal-on-Metal Arthroplasty clinical outcome for the revision. Discussion and Conclusion: In
Adolph V. Lombardi, Jr, MD, New Albany, OH summary, a systematic approach to the evaluation of patients with
Robert L. Barrack, MD, Saint Louis, MO MoM arthroplasty should be adopted.
Keith R. Berend, MD, New Albany, OH
John M. Cuckler, MD, Naples, FL SCIENTIFIC EXHIBIT NO. SE07
Joshua J. Jacobs, MD, Chicago, IL Impact of Patient Characteristics on Direct Medical
Michael A. Mont, MD, Baltimore, MD Costs in Total Hip and Knee Arthroplasty
Thomas P. Schmalzried, MD, Los Angeles, CA Hilal Maradit-Kremers, MD, MSc, Rochester, MN
Introduction: The evolution of hip arthroplasty has been plagued Sue L. Visscher, PhD, Rochester, MN
by challenges including polyethylene wear with subsequent James Moriarty, MSc, Rochester, MN
osteolysis and dislocation. Metal-on-metal (MoM) arthroplasty James Naessens, MPH, Rochester, MN
was reintroduced specifically to address these issues. It has been
David G. Lewallen, MD, Rochester, MN
estimated that since 1996 more than 1,000,000 MoM articular
couples have been implanted worldwide. With increasing clinical Introduction: Total hip arthroplasty (THA) and total knee
experience a number of adverse reactions to metal debris have arthroplasty (TKA) are two highly cost-effective procedures.
been identified. This metal debris may be generated from the It is unclear how the costs of these procedures are affected
bearing couple or from tapered junctions. Well- functioning by demographics, indications, comorbidities and short-term
MoM arthroplasties have demonstrated a 3-5X increase in cobalt complications. The purpose of this study was to determine the
and chromium levels, which appears to be independent of head impact of patient characteristics and short-term complications
diameter and reaches a steady state after approximately two years. on direct medical costs in THA and TKA during the index
However, significant ion release may lead to type IV hypersensitivity hospitalization and 90-day window following surgery
- an immune response that results in an undesirable outcome Methods: The study population included more than 19,000
such as pain, loosening and osteolysis. These excessive ions may primary or revision THA and TKA procedures between 1/1/2000
cause direct cytotoxicity. A typical histological appearance has - 09/31/2008 at a large tertiary care center in the Upper Midwest.
been termed aseptic lymphocytic vasculitis associated lesion Clinical data were obtained from the institutional Total Joint
(ALVAL). A small number of patients will develop so-called Registry and included demographics, dates and types of
pseudotumors, which are fluid-filled masses, histologically procedures, indication for surgery and arthroplasty complications
containing giant cells, metal debris and necrotic tissue. Methods: (infections, cardiovascular, fracture, thromboembolytic).
Patients with MoM arthroplasty generally fall into one of the Residency, payor status and Comorbidities were derived from
following clinical scenarios: 1) an asymptomatic patient with well administrative data (Elixhauser method). Total direct medical
positioned components that have a good clinical track record; 2) costs during index hospitalization and the 90-day window
following each procedure were obtained from the Olmsted County

Healthcare Expenditure and Utilization Database (OCHEUD). Methods: This study included the initial 100 consecutive primary
Cost data included all medical costs (related or unrelated to THA performed by a single surgeon using CAN (GrpNAV, N=100,
orthopedics) and were adjusted to nationally representative unit 2009-10), with a mix of metal- and ceramic-on-polyethylene
costs in 2010 inflation-adjusted dollars. The value for each unit [MOP, COP] bearing surfaces, which were compared to three
of service was adjusted to national cost norms using bottom- multi-surgeon series from the same institution previously studied
up valuation techniques. Part A billed charges were adjusted by regarding DL and FH size. Prior series included a consecutive
using Medicare department level cost-to-charge ratios and wage ceramic-on-ceramic [COC] series (GrpCOC, N=320, 1997-
indexes. Part B physician services were valued using Medicare 2005) and that series’ concurrent matched cohort metal-on-
reimbursement rates. Regression models were used to estimate polyethylene series (GrpMOP, N=268, 1997-2005), performed
the effect of age, sex, comorbidities and short-term complications prior to common use of large FHs, and a consecutive mixed
on direct medical costs, after adjusting for age and sex. bearing series, including MOM, MOP, and COP (GrpLRG, N=300,
Results: Room and board (25-27%), operating room/surgery (30- 2008), performed at the height of use of large MOM FHs. All 984
33%) and implant (13-16%) costs comprise the largest proportion THA in the 4 series were performed via a posterolateral approach
of costs in both THA and TKA. Total costs for revision THA and by joint replacement fellowship faculty. Minimum follow up
TKA were 25% and 45%, respectively higher than primary was six months in GrpNAV and one year in the other cohorts.
procedures and this difference was mainly driven by implant costs. Results: In GrpNAV, mean AC abduction was 41° with 100% 30-
Implant costs were 43% higher in revision THA than in primary 50° and mean ANT 20° with 78% 10-30°. There were no DLs.
THA, and 180% higher in revision TKA than in primary TKA. DL rates varied from 5% (GrpMOP) to 0% (GrpNAV), with
Surgical encounter hospital costs were highest for younger (<25 significant differences between GrpMOP and each of the other
years) patients (e.g., primary THA: $23,822 for the youngest vs. cohorts, but not among GrpNAV, GrpLRG, and GrpCOC (all <1.5%).
$21,993 for the oldest). However, the 90-day period professional Mean FH head size was graduated, GrpMOP (28mm)
costs were highest for patients >85 years and lowest for patients < GrpCOC (33mm) < GrpNAV (36mm) < GrpLRG
<25 years (primary THA: $4,126 vs.$3,242). Revision THA (38mm), with significant differences between GrpMOP vs
and TKA for infections were associated with higher costs than GrpCOC, GrpCOC vs GrpNAV, and GrpNAV vs Grp LRG.
revisions for instability. An increase in the number of a patient’s FH size appeared to be protective regarding DL, to a limit. For
preoperative comorbidities was associated with higher costs. all groups, dislocation rate was 2%, with significant differences
Average hospital costs for both the surgical encounter and the regarding <28mm(5%) vs >32mm(1%) and <32mm(3%) vs
follow-up period for patients with at least 4 comorbidities were >36mm(1%), but not regarding <36mm(2%) vs >38mm(1.4%).
at least 35% higher than those of patients with no comorbidities. DL rate was not significantly different regarding GrpLRG (1%) vs
Among the various comorbidities examined, coagulopathy, GrpNAV (0%). However, no dislocations occurred in GrpNAV while
lymphoma and metastatic cancers were associated with the highest employing significantly smaller FH size (>40mm 18% of GrpNAV
costs. Presence of any postoperative complication was associated vs 42% of GrpLRG; >44mm 1% of GrpNAV vs 22% of GrpLRG).
with 20-25% higher costs and the most costly complications were Conclusion: Reviewing single institution series totaling 984 THA
vascular (myocardial infarction, bleeding) and infections events. dating from 1997 to 2010 and representing eras of predominantly
Conclusions: In both THA and TKA, the costs of initial 28mm MOP, 32mm COC, 36-44mm MOP/MOM, and navigated
hospitalization and follow-up care are significantly affected 36mm MOP/COP bearing surfaces, a FH size >36mm appeared
by patient characteristics and implant costs. An increase in the to be dislocation protective. However, advantage with FH size
number of comorbidities and selected specific comorbidities >36mm could not be demonstrated. The use of CAN in THA offered
also drive the costs higher. The proportion of different kinds of a promising tool for minimizing instability (DL 0%). A navigated
hospital and professional costs during the surgical encounter THA series with predominantly 36mm FH size demonstrated a DL
and 90-day window following surgery vary with patient age and rate equivalent to a non-navigated series with significantly larger
comorbidities. For revision surgery, the much higher implant costs FH size, offering an alternative to reliance on MOM THR with 40-
observed represent a controllable factor likely most amenable 44+ mm head sizes for the purpose of minimizing DL.
to cost containment efforts for those procedures. The continued
failure to account for the increased overall costs associated with SCIENTIFIC EXHIBIT NO. SE09
select patient comorbidities, diagnoses and demographic factors Groin Pain After Total Hip Arthroplasty
when health policy and payment decisions are made, risks further
Ronald Huang, Philadelphia, PA
reducing access to care for those patients in greatest need.
Camilo Restrepo, MD, Philadelphia, PA
SCIENTIFIC EXHIBIT NO. SE08 Nitin Goyal, MD, Arlington, VA
Effect of Computer-Assisted Navigation on Dislocation
Introduction: Persistent groin pain after total hip arthroplasty
After Primary Total Hip Arthroplasty (THA) is an under-reported and under-treated complication. As
Victor Hakim, MD, Frisco, TX complications with alternative bearing surfaces (most significantly
Richard H. Walker, MD, La Jolla, CA metal-on-metal) have come to light, authors have recently
Introduction: Dislocation [DL] after primary total hip recognized an increased incidence of groin pain in metal-on-metal
arthroplasty [THA] is a common complication with reported rates THA, hip resurfacing, and conventional metal-on-polyethylene
between 1 and 5%. Optimal acetabular component [AC] position THA. The overall incidence of groin pain after hip arthroplasty
and increased femoral head [FH] size have been associated with has been reported in the literature to be as high as 18%. There
reduced dislocation rates. Computer-assisted navigation [CAN] are multiple possible causes and the treating surgeon must
has introduced a new method to optimize THA AC position. We follow a methodological approach to diagnosis and treatment.
reviewed our initial series of primary THA performed with CAN, Methods: At out institution we have developed an algorithmic
hypothesizing that primary THA using CAN would have a low approach to management of groin pain after THA. The evaluation
prevalence of DL and could offset the advantage of larger FH sizes. of groin pain should begin in all cases by ruling out infection.

Screening tests should include the erythrocyte sedimentation multiple electronic medical databases focusing on specific
rate, and C-reactive protein level, and subsequent fluoroscopically conditions falling under major categories including: cardiology,
guided joint aspiration if serology values are abnormal or strong pulmonology, hematology, rheumatology, nephrology,
suspicion for infection remains. Another cause of groin pain hepatology, peripheral vascular disease, immunosuppression,
is component loosening, subluxation, and impingement. We transplant medicine , neuromuscular disease, endocrinology,
have developed a protocol for radiographic, cross sectional, and metal hypersensitivity, drug/alcohol/tobacco abuse, infectious
ultrasound examination of the prosthetic hip for evidence of the disease, dentistry, obesity, age, and malnutrition. For each topic,
latter causes for groin pain. Finally, extrinsic causes of pain should emphasis was placed on studies that examined total hip or knee
be investigated - including radiculopathic/ intra-abdominal/ arthroplasty, were published within the past ten years, represented
vascular pathologic causes. Groin pain in patients with MOM THA higher levels of evidence, and dealt specifically with preoperative
follows along the same path as above but also includes evlautaion risk factors or the effect of treatment of risk factors prior to
of the hip with metal subtraction MRI and also serum ion levels. surgery. When studies specific to TJA were unavailable, general
Results: In this scientific exhibit we will present the step by step orthopaedic, general surgical and medical literature was used.
algorithmic approach to management of groin pain following Results: Based on available literature, a screening protocol and
THA. We will present the outcome of surgical intervention for a 50-point checklist encompassing a wide variety of potential
select group of patients in whom percutanous and/or open release patient conditions was formulated. Specific recommendations
of iliopsoas was perfomed. The technique and outcome of revision were provided for the associated risk for each condition as were
THA for patients with “malposiioned” acetabular component in recommended measures to allay that risk. For multiple topics, high
whom iliopsoas bursitis and/or impingement existed will also be level of evidence TJA studies specifically addressing the effectiveness
discussed. We will present the outcome of cross sectional studies of preoperative risk stratification and treatment of relevant co-
in a group of patients in whom subtle component loosening was morbidities were lacking. Inferences from case series and from general
detected. The outcome of management of extrinsic pathology surgical and medical literature were necessary in some situations.
that had masqueraded as groin pain will be presented. Finally Discussion and Conclusion: Orthopaedic surgeons are frequently
the outcome of revision THA for patients with MOM failure referred patients from physicians who are unaware of the risks of
(groin pain with/without pseudotumor) will be discussed. TJA in the presence of multiple co-morbidities. At the same time,
Discussion and Conclusion: The management of groin pain “medical clearance” and “preoperative optimization” are typically
following THA can be a source of frustration for both the patient left to the discretion of the medical consultant or primary care
and the surgeon. Based on extensive experience managing patients physician and do not always address appropriate risk factors for
with this problem, we have developed an algorithmic approach to complications during or after TJA. Every surgeon or institution
this problem that enables us to reach a diagnosis in these patients should have a rational, uniform approach and a set of evidence-
in a timely fashion. The joint registry database at our instution based criteria in assessing and preparing patients for TJA. These
will be the source of data on patients with groin pain who were measures will help minimize postoperative complications
treated at our institution and will provide rationale behind each and adverse events associated with known risk factors.
intervention. We believe this scientific exhibit is likely to be of This algorithmic approach was implemented at the authors’
agreat benefit to general orthopedic surgeons or those specializing institution in October 2010 and its validity as a means of reducing
in hip arthroplasty who not infrequently encounter this problem peri-operative morbidity associated with TJA is currently being
in their patients. prospectively evaluated.
SCIENTIFIC EXHIBIT NO. SE10 SCIENTIFIC EXHIBIT NO. SE11

Preoperative Risk Stratification and Risk Reduction for Development and Early Results of the ANCHOR Hip
Elective Total Hip and Knee Reconstruction Preservation Surgery Study Group
Vincent Ng, MD, Gahanna, OH John C. Clohisy, MD, Saint Louis, MO
David Lustenberger, Cincinnati, OH Paul E. Beaule, MD, Ottawa, ON, Canada
Kimberly B. Hoang, BS, Columbus, OH Christopher Larson, MD, Edina, MN
Ryan J. Urchek, Columbus, OH Daniel J. Sucato, MD, Dallas, TX
Matthew Beal, MD, Columbus, OH David A. Podeszwa, MD, Dallas, TX
Jason H. Calhoun, MD, Columbus, OH Perry L. Schoenecker, MD, Saint Louis, MO
Andrew H. Glassman, MD, Columbus, OH Rafael J. Sierra, MD, Rochester, MN
Introduction: Modern surgical technique and perioperative care Robert T. Trousdale, MD, Rochester, MN
have reduced the incidence of systemic and local complications after Michael B. Millis, MD, Boston, MA
total joint arthroplasty (TJA). Nevertheless, the elective nature of Introduction: Hip preservation surgery has become more
TJA, the rising prevalence of co-morbidities in TJA candidates, and commonplace over the past decade. Contemporary literature
the recent modifications in government reimbursement policies primarily includes single-surgeon retrospective case series. There
have provided additional impetus to fully evaluate and address risk is a need for more sophisticated clinical outcome studies with
factors prior to surgery. The existing orthopaedic and primary care large patient cohorts. The academic network of conservational
literature lacks a consistent and detailed methodology to achieve Hip Outcomes Research (ANCHOR) is a multi-center study
so-called “medical clearance” and preoperative optimization for group developed to investigate the diagnosis and treatment of hip
TJA. Many articles that address this topic are limited to generalities preservation procedures. The purpose of this exhibit is to present
and recommendations of specialist referral. The objective of this the rationale, developmental design, data collection process and
study was to develop a specific, comprehensive, evidence-based early enrollment results of the ANCHOR Hip Preservation study
algorithmic approach to risk-stratify and triage TJA candidates. group. Methods:The initial A NCHOR study group includes 9
Methods: A systematic literature search was performed of institutions with 13 surgeons. Initial efforts were directed at

consensus regarding clinical outcome measures, preoperative metal ion levels were correlated with pathologic findings of
and post-operative radiographic measures, clinical nomenclature, necrosis. Our findings would suggest that high serum metal ion
surgical procedure data collection and standardized clinical levels may be associated with advanced tissue damage, and we
outcome endpoints. Multi-center data collection, data transfer, would recommend that ion levels should be routinely monitored
quality assurance, and data input were then developed. Results: in MOM THA patients and consideration given for early revision in
Prospective, multi-center data collection began in 2008 and patients with markedly elevated levels.
continues. To date, 1303 consecutive joint preservation cases have
been enrolled. 65% of patients are female, the average patient age SCIENTIFIC EXHIBIT NO. SE13
is 26 years. These cases include comprehensive clinical, exam, Managing the Infected Total Hip: New Solutions to an
radiographic and patient questionnaire data. 458 PAO and 845
FAI cases are being studied. Periacetabular osteotomy was most Old Problem
commonly performed for classic acetabular dysplasia followed by Khaled J. Saleh, MD, MSc, FRCSC, FACS, Springfield, IL
Perthes disease and acetabular-based impingement. FAI procedures Javad Parvizi, MD, Philadelphia, PA
were most commonly performed for combined cam and pincer Keith R. Berend, MD, New Albany, OH
deformities. The most commonly utilized FAI procedures include Steven J. MacDonald, MD, London, ON, Canada
hip arthroscopy 60%, surgical dislocation 28%, and periacetabular Michael J. Morris, MD, New Albany, OH
osteotomy 3%. Discussion and Conclusion: Development of Kevin J. Mulhall, MD, Dublin, Ireland
prospective multi-center longitudinal data collection for hip
preservation procedures is feasible and has been accomplished Introduction: Infection after total hip arthroplasty (THA) is
by the ANCHOR study group. These data provide clinical a devastating complication. The annual rates of primary THA
epidemiology information on pre-arthritic hip disorders and will increased 50%, from 47/100,000 in 1990 to 69/100,000 in 2002.
serve a basis for multiple future longitudinal cohort studies. The incidence of infection after primary THA is between 1-2 %
and is higher in populations with metabolic, immunological,
SCIENTIFIC EXHIBIT NO. SE12 dermatological, and nutritional risk factors. With the current
infection rates and the emergence of resistant strains, infection in
Pathologic, Serologic, and Tribologic Findings in Failed THA is becoming a major problem that surgeons in the US have
Metal on Metal Total Hip Arthroplasty to face. With the use of certain measures, such as preoperative
Christopher Pelt, MD, Salt Lake City, UT preparation, patient nutrition, clean surgical techniques, and
Jill Erickson, PA, Salt Lake City, UT antibiotic cement, there has been a decreased incidence of
Ian C. Clarke, PhD, Colton, CA infection. However, once infection develops, the strategies change
focus towards eradication or suppression of infection while
Thomas K. Donaldson, MD, Colton, CA
preserving the patient function and minimizing patient morbidity.
Edward J. McPherson, MD, Los Angeles, CA Methods: A comprehensive search of the literature was
Christopher L. Peters, MD, Salt Lake City, UT performed, using Medline, to find peer-reviewed articles on
Introduction: Revision of failed metal on metal (MOM) total infection after THA. Microbiology, risk factors, timing of
hip arthroplasty (THA) is increasingly prevalent. Various biologic presentation, and diagnostic and management algorithm
responses to MOM implants, including pseudotumors, aseptic and outcome data on infection control were reviewed.
lymphocytic vasculitis-associated lesions (ALVAL), and now Results: Microbiology, risk factors, timing of presentation,
more generically, adverse local tissue response (ALTR) have been and diagnostic and management algorithm and
described. In a series of revised MOM implants we investigated outcome data on infection control were reviewed.
serum cobalt and chromium levels, the pathologic tissue Discussion and Conclusion: The purpose of this exhibit is to
examinations and a tribologic analysis of the retrieved implants. highlight current methods to diagnose infection after THA and
We hypothesized that the host biologic response (pathology) strategies to manage established deep infection after THA. The
could be correlated with the serologic and tribologic findings. exhibit will present a systematic approach to diagnosis of infected
Methods: Sixteen patients underwent revision of failed or THA at different postoperative periods and strategies to manage
symptomatic MOM THA at an academic medical center. Serum an infected THA. The emphasis will be on surgical techniques of
cobalt and chromium levels were measured per a standard component removal, advances in spacer options in a two stage
protocol. Retrieved tissue and implants from sixteen subjects re-implantation, selection of antibiotics in cement and currently
were sent for a detailed pathologic exam as well as a tribologic utilized strategies to determine timing of re-implantation.
analysis of the implants, performed at a dedicated tribology Information will be provided in the value of preoperative
lab. Pathologic findings were classified in two main categories: serological markers, hip aspiration and synovial fluid analysis
Group 1 (10/16 patients) was macrophage/necrosis dominant as well as role of pre and intra-operative biopsy in deciding time
while Group 2 (6/16) patients was fibrous/lymphocyte dominant. of re-implantation. Moreover, the exhibit will discuss current
Results: Group 1 had a mean Cobalt level of 128.7 (range 60.8- salvage techniques to manage reinfection after revision THA.
198.9) and mean Chromium level of 41.2 (range 15.6-62.1) and Finally, a multi-disciplinary protocol to minimize infection will
Group 2 had significantly lower mean serum Cobalt and Chromium be highlighted.A systematic approach to diagnose and manage
levels (Co 5.1 vs Cr 2.2, p<0.01). Metallosis was documented as a infected total hip arthroplasty, incorporating modern techniques,
common intraoperative finding in Group 1 but not Group 2. On has been proven to yield improved results.
tribologic examination the dominant finding on all retrievals
was polar stripe wear corresponding to edge loading at the rim of
the cup, and did not differ between the two pathologic groups.
Conclusion: Variability in the biologic response to MOM THA
implants can be seen despite similar tribologic wear patterns.
However, intraoperative findings of metallosis and high serum

SCIENTIFIC EXHIBIT NO. SE14 Discussion: Using the protocol described in this scientific exhibit,
excellent clinical and radiographic outcomes were found for
Outcomes of Total Joint Arthroplasty in Jehovah Jehovah’s Witness patients who had undergone TJA. Patients had an
Witnesses overall survivorship of 97% at mean approximately 5 year follow-
Aaron Johnson, MD, Baltimore, MD up with excellent clinical and radiographic results. We believe that
Qais Naziri, MD, Baltimore, MD the use of this special blood management protocol involving a
Michael Mont, MD, Baltimore, MD team approach to preoperative evaluation, appropriate anesthesia,
Steven Harwin, MD, New York, NY and surgical and post-operative management was responsible for
minimizing complications.
Introduction: Total joint arthroplasty (TJA) can be quite
challenging in Jehovah’s Witness patients because of the potential SCIENTIFIC EXHIBIT NO. SE15
for marked blood loss. Because patients can not accept allogeneic or
autologous blood transfusions, multiple strategies to prevent blood A Multi Disciplinary Approach to the Understanding of
loss can be used in these patients, which include special methods Femoroacetabular Impingement
of preoperative screening and treatment, anesthesia protocols, Paul E. Beaule, MD, Ottawa, ON, Canada
special surgical techniques, and various types of devices and in Mario Lamontagne, Ottawa, ON, Canada
most cases, blood recovery re-infusion systems. In this two-center
Kawan Rakhra, MD, Ottawa, ON, Canada
study we report on our experiences with the use of a special blood
management protocol for these patients. The purpose of this scientific
Hanspeter Frei, PhD, Ottawa, ON, Canada
exhibit was to present the details of this protocol, and to review Andrew Speirs, MSc, Ottawa, ON, Canada
the complications as well as clinical and radiographic outcomes Arturo Cardenas-Blanco, PhD
of Jehovah’s Witness patients who underwent a primary TJA. Mark Schweitzer, Ottawa, ON, Canada
Methods: All patients underwent a specific blood management Introduction: Although the clinical presentation and radiographic
strategy, which included preoperative, perioperative, and evaluation of femoroacetabular impingement (FAI) have
postoperative measures. A coordinated team including internists, greatly progressed, defining the exact pathomechanism of how
hematologists, intensivists, and anesthesiologists evaluated the and when patients develop hip pain and subsequent arthritis
patient preoperatively to optimize the patient’s condition, and is still lacking. This exhibit will present a multidisciplinary
if necessary, to administer hemoglobin enhancing drugs such as approach of hip kinematics/kinetics, advanced MR imaging
epoetin, folate, and iron according to an established algorithm. as well as biomechanical analysis to better understand FAI.
Expected blood loss for each type of procedure was estimated. Methods: Three groups of patients are being prospectively
Intraoperative measures included hypotensive anesthesia, evaluated: Asymptomatic individuals with cam deformity;
meticulous hemostasis using mechanical devices and topical symptomatic patients undergoing unilateral hip surgery with
agents, rapid surgery, cell saver, and avoidance of drains if possible. bilateral deformities; and a control group. All patients underwent
Antifibrinolytic agents were administered as needed. Postoperative 3D motion analysis as well as advanced MR imaging with T1Rho
measures included microvenipunctures, iron supplements, cartilage mapping and quantitative computer tomography to assess
and epoetin. Pharmacological DVT prophylaxis was avoided subchondral bone density. In addition, surgical specimens were
if possible. Additionally, databases from two institutions were taken intraoperatively of the cam lesion for biomechanical testing.
reviewed to identify 186 patients (206 joints) who were Jehovah’s Results: Motion analysis has shown that the FAI group had
Witnesses. Evaluated patients included only those operated on by attenuated hip abduction, frontal range of motion (ROM)
one of two high-volume surgeons between 1998 and 2009, with and sagittal ROM during gait which may be caused by muscle
a minimum follow-up of two years. There were 110 women and weakness and soft tissue restriction. The decreased frontal
76 men who had a mean age of 62 years (range, 26 to 85 years), pelvic ROM could result from limited mobility at the sacro-
a mean body mass index of 32.5 kg/m2 (range, 15 to 53 kg/m2), lumbar joint. During squatting, the FAI group showed a limited
and a mean follow-up of 62 months (range, 24 to 120 months). sagittal pelvic ROM, which contributed to their decreased
The diagnoses were 146 patients who had osteoarthritis, 19 squatting depth. Postoperatively, squat performance improved,
who had rheumatoid arthritis, and 31 who had osteonecrosis. likely because of the combined effects of increased knee and
Subsequent procedures and complications were reviewed. ankle angles as well as an increased posterior pelvic pitch.
Results: For the total hip arthroplasties, the mean Harris Hip score Some studies in the literature have shown an inverse relationship
(HHS) improved from 52 points (range, 22 to 78 points) to 93 between a Magnetic Resonance parameter, T1rho, and the
points (range, 58 to 100 points) with an overall 96% survivorship proteoglycan content in articular cartilage. Taking advantage of
at last follow-up. The mean Knee Society knee and function scores the non-invasive character of MR, we are using this quantitative
improved from 59 points (range, 20 to 75 points) and 48 points imaging technique, T1rho, to assess the integrity of articular
(range, 5 to 70 points) points, respectively, to 90 points (range, 61 to cartilage in the three different subject groups. Our group has
100 points) and 83 points (range, 45 to 100 points) points with an found statistically significant differences between FAI and
overall 98% survivorship at last follow-up. There were three hip re- healthy asymptomatic patients. T1rho values in FAI patients
operations: two because of loose acetabular cups and one because were higher than in controls, indicating a lower PG content,
of a loose stem (All revision patients were doing well clinically as expected. Typical bone sclerosis was seen in quantitative
(HSS > 80 points) at last follow-up. Other complications included CT imaging. Comparison to MR findings can help explain the
one superficial wound infection treated with antibiotics, one case role of subchondral bone density changes in degeneration.
of skin necrosis that responded to local wound care and antibiotics, Cartilage from the cam deformity showed lower stiffness and
and one greater trochanter fracture (treated non-operatively). higher permeability compared to cadaveric controls, as expected
For the knees, Three patients underwent a re-operation; one for in arthritic cartilage. Further fitting with a fibril-reinforced finite
flexion instability at two years, one for tibial loosening at 7 years, element model demonstrated lower fibril stiffness, indicative of
and one for late instability at 8 years. All revision patients were compromised collagen fibrils. Correlation of cartilage mechanical

properties with MR findings will allow non-invasive assessment of SCIENTIFIC EXHIBIT NO. SE17
tissue mechanical function. Histological analysis showed complete
loss of proteoglycan in the top 40% of tissue thickness which
Analyzing Failure of Total Joint Arthroplasty to Enable
explains the altered biomechanical properties. Some tidemark Future Success: The Role of a Multicenter Retrieval
duplication was also seen in specimens from the cam deformity. Program
Discussion and Conclusion: Because of the complexity of hip Steven M. Kurtz, PhD, Philadelphia, PA
biomechanics as well as the three-dimensional nature of the
impingement deformity, a multidisciplinary approach provides a
better assessment of this dynamic pathology.
SCIENTIFIC EXHIBIT NO. SE16 Amanda D. Marshall, MD, San Antonio, TX
Improving the Accuracy of Acetabular Component Michael A. Mont, MD, Baltimore, MD
Orientation: Avoiding Malposition Bernard N. Stulberg, MD, Cleveland, OH
Joseph T. Moskal, MD, Roanoke, VA Clare M. Rimnac, PhD, Cleveland, OH
Susan G. Capps, PhD, Warsaw, IN
Introduction: Total Joint Arthroplasty (TJA) is a successful surgical
Introduction: There are numerous causes of poor acetabular procedure being offered to nearly 1 million in the United States
component orientation such as poor visualization, increased each year. However, TJA failures represent an immense burden
patient BMI, mechanical guide inaccuracies, and changes in patient on orthopedic healthcare. Over 12 years ago we established a
position during implantation. Negative outcomes may include multicenter retrieval program that examines the etiology of failure
dislocation, impingement, wear, leg length, and revision. The of joint prostheses by performing integrated analyses of the clinical,
combination of newly developed techniques incorporating patient- patient, and implant factors contributing to the need for revision
specific morphology and quantitative technology may improve surgery. The program has been funded by the National Institutes of
acetabular component orientation and thus patient outcomes. Health over the past decade. This scientific exhibit will discuss the
Methods: Existing literature was used to review conventional structure, the role, and recent findings of this retrieval program.
techniques for acetabular component orientation including benefits Methods: There are currently 10 clinical revision centers and two
and disadvantages of using these techniques. Next, more recently regional, university-based retrieval analysis centers in biomedical
developed techniques, including anatomic landmAK and patient- engineering departments that collaborate in the retrieval program.
specific morphology, along with quantitative technologies such as The clinical centers are based in the Northeast, South, Midwest,
computer-aided navigation, were explored; again placing particular and Southwestern regions of the United States and are intended
attention on the benefits and the disadvantages of these methods. to represent a nationwide collection of hip and knee devices from
Results: Acetabular component position using conventional a variety of manufacturers. The revision centers include not only
techniques is particularly influenced by variables such as urban academic centers, but also urban non-teaching and rural
patient size, deformity and/or position regardless of surgeon community hospitals. Each revision center has a dedicated clinical
experience and practice volume. Anatomic landmAK and coordinator who is responsible for obtaining informed consent and
patient-specific morphology, when used alone or in conjunction clinical data collection. As a consecutive series of revisions at each
with quantitative technology, demonstrate a reduction in center, the retrieval collection represents an unbiased sampling of
intra-and inter-surgeon acetabular component variability. both short and long term revisions. The prostheses and the retrieved
Discussion and Conclusion: Acetabular component placement tissue (selected cases) are packaged and transported to retrieval
has long aimed for standardized safe-zones rather than a centers for analyses. The multidisciplinary personnel at the retrieval
patient-individualized target-zone. As the population needing analysis centers include biomedical engineers, biologists, and
THA increases, the prevalence of complications and problems students who perform surface analysis, histological examination,
will increase even if the incidence decreases. Therefore, reliable wear particle analysis and chemical characterization of the explants.
methods for improving acetabular component alignment should Results: To date, 1,454 hip and 985 knee prostheses have been
be welcome. Incorporating anatomic landmAK, including patient- retrieved between 2000 and 2011. Many of the findings of the
specific morphology, has the potential to provide more accurate Retrieval Program have been published previously (26 peer-
and individualized target zones particularly when coupled with reviewed journal articles and 45 conference abstracts). In this
quantitative technology such as computer-aided navigation, thus scientific exhibit we will present recent findings of the analyses
improving the precision of acetabular component placement. which includes information on metal-on-metal failures, squeaking
in ceramic bearings, and in vivo oxidation of highly cross linked
polyethylene. Particular attention is given to the difference in
performance of different HXLPE formulations, the penetration rate
of various femoral heads (aluminum ceramic, zirconium ceramic,
ZTA, metal, and oxinium) on different types of HXLPE, and the
influence of femoral head size on penetration rate with HXLPE.
Discussion and Conclusion: Our academic mission is to
expand the multicenter research collaboration into a nationally
representative network of revision surgeons, biomedical engineers,
and biologists to better understand the complex conditions
contributing to hip and knee revision surgery in the United
States. However, the success of retrieval analysis hinges upon the
participation of all stakeholders, including not only researchers,
but also patients, hospitals, manufacturers, and, through public
NIH funding, society. One of the most important, and perhaps

the most cost effective, strategies to reduce the national revision demonstrates that the initial results for advanced porous coatings
burden is to better understand the etiology of failure of TJA so that are promising. However, there is still a gap in clinical knowledge
revisions can be avoided in the future. This scientific exhibit will regarding the ultimate extent of ingrowth that will be achieved in
allow us to demonstrate how such a program can be designed, humans and whether the use of these advanced coatings will result
operationalized, and deliver value to patients and orthopedic in a reduction in revision rates for aseptic loosening. Our academic
health care. We invite orthopedic surgeons who routinely perform mission is to expand the multicenter research collaboration into a
revision surgery and have an interest in retrieval analysis to join nationally representative network of revision surgeons, biomedical
our unique research collaboration. engineers, and biologists to better understand the complex conditions
contributing to hip and knee revision surgery in the United States.
SCIENTIFIC EXHIBIT NO. SE18 One of the most important, and perhaps the most cost effective,
Porous Coatings strategies to reduce the national revision burden is to better
understand the etiology of failure of TJA so that revisions can be
Judd Day, PhD, Philadelphia, PA
avoided in the future. We invite orthopedic surgeons who routinely
Josa Hanzlik, MS, Philadelphia, PA perform revision surgery and have an interest in retrieval analysis
Gregg R. Klein, MD, Paramus, NJ to join our unique research collaboration.
Harlan B. Levine, MD, Tenafly, NJ
Mark A. Hartzband, MD, Franklin Lakes, NJ SCIENTIFIC EXHIBIT NO. SE19
Javad Parvizi, MD, Philadelphia, PA Understanding and Accurately Tracking the Reasons
for 90-Day Readmission Following Total Joint
Steven M. Kurtz, PhD, Philadelphia, PA Arthroplasty
James M. Saucedo, MD, Chicago, IL
Introduction: Total Joint Arthroplasty (TJA) is a successful
surgical procedure being offered to nearly 1 million in the Geoffrey Marecek, MD, Chicago, IL
United States each year. However, achieving reliable and durable Lois M. Huminiak, RN, MS, Chicago, IL
fixation between the implant and host bone has historically S. D. Stulberg, MD, Chicago, IL
presented a challenge and aseptic loosening remains a leading Lalit Puri, MD, Glenview, IL
reason for revision surgery. Although the use of bone cement Introduction: Readmission after Total Joint Arthroplasty (TJA)
provides reliable fixation, concerns about the durability of the places a great burden on the health care system. As reimbursement
cement mantle led to the development of porous coatings to systems place increased emphasis on quality measures such
promote direct integration between the implant surface and host as readmission rates, understanding and accurately tracking
bone. In this exhibit, the rationale for and clinical performance the causes for readmission becomes increasingly important.
of these coatings will be reviewed and supplemented with Methods: We queried an electronic database for all patients
analysis of implants retrieved in a multicenter retrieval program. who underwent Total Hip Arthroplasty (THA) or Total Knee
Methods: Arthroplasty device manufacturers’ websites were Arthroplasty (TKA) at our institution from 2006 through 2010.
surveyed to identify the current generation of porous coatings that We identified those who had been readmitted within 90 days
are being actively marketed. A survey of the available literature of the original procedure. We then collected demographic and
was performed to identify the design characteristics of the current clinical data as well as readmission diagnoses by ICD-9 code. We
generation of porous coatings and to compare the current generation compared rates of readmission using a chi-squared test. In addition,
to historical coatings. Particular care was taken to include clinical two senior-level orthopaedic residents performed a blinded
survival and any analysis of bony ingrowth in retrieved devices. analysis of de-identified medical records of 87 random patients
Further, 2439 devices retrieved in a multicenter retrieval study and assigned a diagnosis and ICD-9 code for that readmission
were screened to identify devices from the newest generation of encounter. The resident-derived diagnoses were then compared
porous coatings. The retrieved devices were examined for evidence with the coder-derived diagnoses and analyzed for agreement
of bone ongrowth, and a subset was examined to quantify using binomial proportion with 95% exact confidence limits.
bone ingrowth using scatter scanning electron microscopy. Results: 6436 patients underwent THA or TKA during the study
Results: The newest generation of porous coatings demonstrates period. This cohort of patients represented a diverse payer mix,
open celled structures with increased porosity, and a higher including Medicare 43.4%, PPO 36.5%, HMO 10.2%, and Self-
coefficient of friction than previous generations. Clinical studies Pay/Other 9.9%. Readmission rates were as follows: unilateral
have demonstrated that bone loss due to stress shielding can be THA, 190 of 2546 (7.46%); bilateral THA, 0 of 13 (0%); unilateral
reduced because of the decreased stiffness at least one of the advanced TKA, 288 of 3553 (8.11%); bilateral TKA, 32 of 337 (9.50%) for
porous coatings. It has also been demonstrated using RSA that a combined rate of 7.92%. There was no significant difference in
component migration can be reduced by using advanced coatings. the rate of readmission among unilateral THA, unilateral TKA,
With the exception of case studies, study of bone ingrowth into and bilateral TKA (p=0.36). While there was a wide variety of
the newest generation of coatings was generally limited to animal readmission diagnoses, the top three were cellulitis (ICD-9 Group
studies. Our collection of retrieved advanced coatings included a 682, 4.97%), procedure-related complications (ICD-9 Group 996,
sufficient number of porous tantalum coated devices to examine 15.51%), and wound complications (ICD-9 Group 998, 18.49%).
bone ingrowth in multiple anatomical locations. The extent and In comparing the readmission diagnoses, we found that 22 of
degree of ingrowth into acetabular shells, femoral stems, patellas 87 patients were incorrectly coded for a rate of 25.3% (95% CI =
and tibial trays from short-term retrievals was in the range of that 16.6%, 35.8%). The most common incorrect coding was related
observed in retrieval studies of sintered bead or titanium mesh to post-operative stiffness and need for manipulation after TKA.
coatings. Complete bridging of bone from the surface through the There were several mis-categorizations regarding postoperative
porous coating was observed regionally in multiple components. infection (cellulitis vs. wound dehiscence vs. deep infection).
Discussion and Conclusion: Our investigation of the literature Conclusions: Readmission within 90 days after THA or TKA

occurs with substantial frequency. Postoperative stiffness
requiring manipulation (within ICD-9 Group 996) and wound
complications (within ICD-9 Group 998) are the most common
reasons for readmission. Procedure-related complications and
wound complications accounted for more readmissions than any
single medical complication. We also found that readmission
diagnoses are frequently coded incorrectly. The rate of mis-coding
suggests the need for regular audits and highlights the need for clear
documentation in the medical record. A clearer understanding of
the factors related to complications should make a reduction in
their occurrence possible; however, use of readmission diagnoses
without specific attempts to assure their accuracy may not be an
appropriate quality measure given the frequency with which errors
occur.

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What is the study investigating regarding inferior vena cava (IVC) filter placement?

What is the study investigating regarding inferior vena cava (IVC) filter placement?

What are the top three reasons for readmission within 90 days of total joint arthroplasty according to the study?

What are the top three reasons for readmission within 90 days of total joint arthroplasty according to the study?

ADULT RECONSTRUCTION HIP

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uRisk Factors for Pseudotumor in Metal-on-Metal Hip Maximum of either cobalt or

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INTRODUCTION: Pseudotumors are sterile, inflammatory Inclination

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