Revision of metal-on-metal hip replacements with dual-mobility bearings and acetabular component retention.

Aims: In metal-on-metal (MoM) hip arthroplasties and resurfacings, mechanically induced corrosion can lead to elevated serum metal ions, a local inflammatory response, and formation of pseudotumours, ultimately requiring revision. The size and diametral clearance of anatomical (ADM) and modular (MDM) dual-mobility polyethylene bearings match those of Birmingham hip MoM components. If the acetabular component is satisfactorily positioned, well integrated into the bone, and has no surface damage, this presents the opportunity for revision with exchange of the metal head for ADM/MDM polyethylene bearings without removal of the acetabular component. Methods: Between 2012 and 2020, across two centres, 94 patients underwent revision of Birmingham MoM hip arthroplasties or resurfacings. Mean age was 65.5 years (33 to 87). In 53 patients (56.4%), the acetabular component was retained and dual-mobility bearings were used (DM); in 41 (43.6%) the acetabulum was revised (AR). Patients underwent follow-up of minimum two-years (mean 4.6 (2.1 to 8.5) years). Results: In the DM group, two (3.8%) patients underwent further surgery: one (1.9%) for dislocation and one (1.9%) for infection. In the AR group, four (9.8%) underwent further procedures: two (4.9%) for loosening of the acetabular component and two (4.9%) following dislocations. There were no other dislocations in either group. In the DM group, operating time (68.4 vs 101.5 mins, p < 0.001), postoperative drop in haemoglobin (16.6 vs 27.8 g/L, p < 0.001), and length of stay (1.8 vs 2.4 days, p < 0.001) were significantly lower. There was a significant reduction in serum metal ions postoperatively in both groups (p < 0.001), although there was no difference between groups for this reduction (p = 0.674 (cobalt); p = 0.186 (chromium)). Conclusion: In selected patients with Birmingham MoM hips, where the acetabular component is well-fixed and in a satisfactory position with no surface damage, the metal head can be exchanged for polyethylene ADM/MDM bearings with retention of the acetabular prosthesis. This presents significant benefits, with a shorter procedure and a lower risk of complications.

Infrequent fractures and resilient bone mineral density: bone health in patients with Fanconi anemia.

Not available.

Multifocal Insulinoma as the Unique Presenting Feature of Multiple Endocrine Neoplasia Type 1 in an Adolescent.

INTRODUCTION: Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant inherited disorder defined by the presence of two of the following endocrinopathies: primary hyperparathyroidism, anterior pituitary tumors, and duodenopancreatic neuroendocrine tumors (NETs). NETs, which can secrete hormones including insulin, gastrin, and glucagon, among others, are common in patients with MEN1 and are a major cause of morbidity and premature death. NETs are more common later in life, with very few cases described in children. Here, we describe a unique case of an adolescent with multifocal pancreatic NETs as the single presenting feature of MEN1. CASE PRESENTATION: A 13-year-old healthy male presented with severe weakness, altered mental status, and syncope in the setting of a venous blood glucose (BG) of 36 mg/dL. Workup showed an elevated insulin level (14 µIU/mL) when BG was 39 mg/dL with positive response to glucagon, concerning for hyperinsulinism. Diazoxide and chlorothiazide were started but not well tolerated secondary to emesis. Three suspected NETs were identified by magnetic resonance imaging and 68-Ga DOTATATE PET-CT imaging, including the largest, a 2.1 cm mass in the pancreatic head. A fourth mass in the pancreatic tail was identified via intraoperative ultrasound. All lesions were successfully enucleated and excised, and glucose levels normalized off diazoxide by post-op day 2. While the primary lesion stained for insulin and somatostatin by immunofluorescence (IF), consistent with his clinical presentation, the additional tumors expressed glucagon, somatostatin, pancreatic polypeptide, and chromogranin A but were negative for insulin. Genetic testing confirmed a pathogenic heterozygous mutation in MEN1 (c.969C>A, p.Tyr323). He had no other signs of MEN-associated comorbidities on screening. DISCUSSION/CONCLUSION: This case demonstrates that young patients with MEN1 can present with multifocal NETs. These NETs may have polyhormonal expression patterns despite a clinical presentation consistent with one primary hormone. Our patient had clinical symptoms and laboratory evaluation consistent with an insulinoma but was found to have four NETs, each with different IF staining patterns. Advanced preoperative and intraoperative imaging is important to identify and treat all present NETs. Moreover, serum hormone levels pre- and posttreatment could help evaluate whether NETs are actively secreting hormones into the bloodstream or simply expressing them within the pancreas. Finally, this case highlights the importance of genetic testing for MEN1 in all young patients with insulinomas.

The Exeter-Trident THA with ceramic-on-ceramic-bearings: 10-year outcomes in 275 total hip arthroplasties.

AIMS: This study reports on the Exeter-Trident total hip arthroplasty (THA) using an alumina ceramic-on-ceramic bearing with 10-year clinical and radiographic follow-up. PATIENTS AND METHODS: Between January 2001 and January 2006, 275 THAs were performed. Mean age at surgery was 52.7 (17-86) years, with 84 patients (33.6%) aged <50 years. The primary outcome was all-cause construct survival at minimum 10 years. Secondary outcomes included functional and noise scores. Radiographs were compared between baseline and latest follow-up and assessed for component loosening, migration and lysis. RESULTS: No patient was lost to follow-up. Mean follow-up for surviving patients was 12.5 (9.5-15.6) years. Kaplan-Meier survival for all-cause revision was 94.0% (95% CI, 90.5-97.5) at 14.3 years. 2 patients had a femoral component fracture. All scores improved significantly at latest follow-up. HSS-NQ for 247 hips (90.2%) at mean 9.1 (7.0-14.4) years post implantation showed most hips (93.1%) reported no more than occasional noise. At minimum 5 years, radiolucency around the acetabular component was observed in 2 hips (0.8%), and lysis at the interface in 1 hip (0.4%). On the femoral side, endosteal lysis was observed in 7 hips. CONCLUSIONS: The Exeter-Trident THA with alumina ceramic-on-ceramic bearings performed well in this population. Patients are at low risk of revision in the first decade. However, there is a small risk of stem fracture as a late complication and some patients experience significant noise.

Mixed manufacturer dual mobility bearing and the Exeter V40 Stem: is it safe? Short-term results in primary and revision hip replacement.

The aim is to review clinical and radiological outcomes for all cases of primary and revision THA, combining a cemented stem (Exeter V40) with a dual mobility component from a different manufacturer (SERF Novae), to evaluate whether concerns regarding mixing components from different manufacturers are justified. We identified 72 hip replacements performed between May 2010 and December 2015 using the SERF Novae dual mobility cup with an Exeter V40 stem, the majority of which were cemented (90%) and revisions (58%). Patients were evaluated clinically and radiologically at a minimum of two years. There were five (6.9%) dislocations; three (4.2%) requiring revision - one of which was an intra-prosthetic disarticulation and two infections. No cases were lost to follow-up and 49 surviving cases were reviewed at a mean of 4.0 (range 1.8-8.1) years following surgery. Pain and functional outcome scores all improved. There were no radiological failures and no revisions for aseptic loosening of stem or cup. The combination of Exeter cemented stem with a dual mobility bearing from a different manufacturer results in acceptable short-term outcomes in terms of hip stability, revision rates and patient-reported measures.

Intraoperative cell salvage in revision hip arthroplasty.

Aims: The aim of this study was to perform a systematic review of the evidence for the use of intraoperative cell salvage in patients undergoing revision hip arthroplasty, and specifically to analyze the available data in order to quantify any associated reduction in the use of allogenic blood transfusion, and the volume which is used. Methods: An electronic search of MEDLINE (PubMed), Embase, Scopus, and the Cochrane Library was completed from the date of their inception to 24 February 2022, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were patients aged > 18 years who underwent revision hip arthroplasty when cell salvage was used. Studies in which pre-donated red blood cells were used were excluded. A meta-analysis was also performed using a random effects model with significance set at p = 0.05. Results: Of the 283 studies which were identified, 11 were included in the systematic review, and nine in the meta-analysis. There was a significant difference (p < 0.001) in the proportion of patients requiring allogenic transfusion between groups, with an odds ratio of 0.331 (95% confidence interval (CI) 0.165 to 0.663) associated with the use of cell salvage. For a total of 561 patients undergoing revision hip arthroplasty who were treated with cell salvage, 247 (44.0%) required allogenic transfusion compared with 418 of 643 patients (65.0%) who were treated without cell salvage. For those treated with cell salvage, the mean volume of allogenic blood which was required was 1.95 units (390 ml) per patient (0.7 to 4.5 units), compared with 3.25 units (650 ml) per patient (1.2 to 7.0 units) in those treated without cell salvage. The mean difference of -1.91 units (95% CI -4.0 to 0.2) in the meta-analysis was also significant (p = 0.003). Conclusion: We found a a significant reduction in the need for allogenic blood transfusion when cell salvage was used in patients undergoing revision hip arthroplasty, supporting its routine use in these patients. Further research is required to determine whether this effect is associated with types of revision arthroplasty of differing complexity.

Male pediatric, adolescent, and young adult reproductive survivorship.

As pediatric, adolescent, and young adult cancer survival rates increase, emphasis is placed on reducing late effects, including reproductive complications and potential impact to fertility. Male survivors are at risk of abnormalities in sperm, hormone deficiencies, and sexual dysfunction. This can impact one's progression into puberty and ability to have a biological child and impacts quality of life following treatment. Access to reproductive care is important and requires patient assessment and appropriate referral to reproductive specialists. This review addresses reproductive complications associated with therapy, standard-of-care testing, and therapeutic interventions. The psychologic impact on psychosexual functioning is also addressed.

Incidence of Symptomatic Venous Thromboembolism (VTE) in 8,885 Elective Total Hip Arthroplasty Patients Receiving Post-operative Aspirin VTE Prophylaxis.

BACKGROUND: Venous thromboembolism (VTE) is a potentially reducible cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeon's mind. The National Institute for Health and Care Excellence (NICE) published updated guidelines in 2018 which recommend the use of both mechanical and pharmacological methods in patients undergoing elective total hip arthroplasty (THA). OBJECTIVES: The aim of this study was to present the symptomatic VTE incidence in 8,885 patients who underwent THA between January 1998 and March 2018 with Aspirin as the primary agent for pharmacological thromboprophylaxis. Intermittent calf compression stockings are routinely used from the time of surgery until mobilization (usually the following day) with prophylactic doses of low molecular weight heparin (LMWH) during inpatient stay (from 2005 onwards) and then Aspirin 150mg once daily for six weeks on hospital discharge (or Aspirin only prior to 2005), with use of other therapies occasionally as required. METHODS: Analysis of prospective data collection from consecutive patients at a single institution undergoing THA was performed with the incidence of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) occurring within six months of the index operation as the primary outcome measure. Ninety-day all-cause mortality of this cohort of patients was also analysed. RESULTS: 8,885 patients were reviewed. This included 7230 primary, 224 complex primary and 1431 revision cases. The overall incidence of symptomatic VTE after elective THA was 1.11% (99/8885) - with the incidence of symptomatic DVT of 0.59% (52/8885) and the incidence of symptomatic PE of 0.53% (47/8885). There was no significant difference (χ2 test, p=0.239) in the symptomatic VTE incidence between primary (1.20% - 89/7230), complex primary (0.89% - 2/224) and revision cases (0.70% - 10/1431). The 90-day all-cause mortality was 0.88% (78/8885). Cardiovascular and respiratory disease were the main causes of death following surgery. Only 0.03% of deaths (n= 3) within 90 days of index surgery were due to PE. There was no significant difference (p=0.327) in length of stay (and hence amount of pharmacologic prophylaxis with LMWH received by patients before commencement of Aspirin) with the average length of stay for those patients who did not suffer a VTE of 6.8 days compared with 7.6 days for those who did suffer a VTE. CONCLUSION: Our results support the use of aspirin as an effective form of prophylaxis against symptomatic VTE following THA in contradiction to NICE and American Academy of Orthopaedic Surgery (AAOS) recommendations. It is not associated with an increased incidence in symptomatic DVT, PE or death compared to other published studies. The fact that it is inexpensive, readily available, requires no monitoring and does not pose an increased risk of bleeding are other advantages of using aspirin for VTE prophylaxis.

Cemented Femoral Stem Fixation: Back to the Future.

BACKGROUND: Periprosthetic fractures following elective and nonelective hip arthroplasty remain one of the most common modes of early failure. METHODS: This symposium will explore the current role of cemented fixation and periprosthetic fracture, focusing on history and rationale for cemented stem fixation, registry data, and other potential advantages of cemented stem fixation. A meticulous and methodical surgical technique of cemented stem fixation is paramount to the success and will be thoroughly discussed. RESULTS: The role of stem fixation, and its effect on periprosthetic fracture is well-documented in the literature. Yet despite this, the utilization of cemented stem fixation remains low in the United States. This paradox is multifactorial. CONCLUSION: In addition to a notable reduction in the risk of periprosthetic femur fractures, cemented stem fixation has numerous other advantages and is reproducible with a methodical surgical technique.

Gonadal function in pediatric Fanconi anemia patients treated with hematopoietic stem cell transplant.

Gonadal dysfunction and reduced fertility are clinical manifestations well described in patients with Fanconi anemia (FA) and following hematopoietic stem cell transplantation (HSCT). It is difficult to differentiate gonadal dysfunction from the primary disease itself or from HSCT procedures. Therefore, it is important to manage expectations about gonadal failure and infertility for all patients with FA, regardless of the HSCT status. We performed a retrospective analysis of 98 pediatric patients with FA who were transplanted between July 1990 and June 2020 to evaluate the incidence of gonadal dysfunction in female and male patients with FA. New-onset premature ovarian insufficiency (POI) was diagnosed in a total of 30 (52.6%) patients. Follicle-stimulating hormone and luteinizing hormone levels were increased in patients diagnosed with POI. Anti- Mullerian hormone levels declined in POI patients after HSCT (r2=0.21; P=0.001). Twenty (48.8%) male patients were diagnosed with testicular failure. Follicle-stimulating hormone levels increased after HSCT even in patients without testicular failure (r2=0.17; P=0.005). Inhibin B levels decreased over time after HSCT in patients with testicular failure (r2=0.14; P=0.001). These data indicate brisk decline in already impaired gonadal function in transplanted children with FA.

Reduced-Intensity Conditioning Mitigates Risk for Primary Ovarian Insufficiency but Does Not Decrease Risk for Infertility in Pediatric and Young Adult Survivors of Hematopoietic Stem Cell Transplantation.

Hematopoietic stem cell transplantation (HSCT) is a curative therapy for many pediatric malignant and nonmalignant conditions. Gonadal insufficiency or infertility is present in almost all HSCT survivors who received a myeloablative conditioning (MAC) regimen. Reduced-intensity conditioning (RIC) regimens are being increasingly used in medically fragile patients or in patients with nonmalignant diagnoses to limit the toxicities associated with HSCT; however, the short-term and long-term gonadal toxicity of RIC regimens in pediatric and young adult survivors remains unknown. In this study, we compared the prevalence of gonadal insufficiency and infertility among pubertal and postpubertal pediatric and young adult survivors of HSCT who received a RIC regimen versus those who received a MAC regimen. Twenty-three females (RIC, n = 8; MAC, n = 15) and 35 males (RIC, n = 19; MAC, n = 16) were included in this single-center, retrospective cross-sectional study. Eligible patients were those with available laboratory results who were ≥1 year post-HSCT, age <40 years, and pubertal or postpubertal as assessed by an endocrinologist. Follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and anti-Müllerian hormone (AMH) levels were measured in females, and FSH, LH, total testosterone, and inhibin B (InhB) levels were measured in males. Twenty-one males (RIC, n = 11; MAC, n = 10) underwent semen analysis through a separate consent. Parametric and nonparametric analyses were undertaken to compare the RIC and MAC groups. Female patients who received RIC were less likely than those who received MAC to develop primary ovarian insufficiency, as demonstrated by elevated FSH (P = .02) and low estradiol (P = .01) or elevated LH (P = .09). Most females in the RIC (75%) and MAC (93%) groups had low AMH levels, indicating low or absent ovarian reserve, with no significant difference between the groups (P = .53). In males, there were no significant differences between the 2 groups in the prevalence of abnormal FSH, LH, testosterone, or InhB levels. Ten of 11 RIC males (91%) and 10 of 10 MAC males (100%) had azoospermia or oligospermia, at a median time to semen analysis from HSCT of 3.7 years (range, 1.3 to 12.2 years). RIC may pose less risk than MAC for primary ovarian insufficiency among female survivors of HSCT; however, both female and male recipients of either RIC or MAC regimens are at high risk for infertility. In the largest reported series of semen analyses of pediatric and young adult male recipients of RIC, azoospermia or oligospermia was found in nearly all (91%) RIC survivors. All patients undergoing HSCT should receive counseling about the high risk of gonadal toxicity, and efforts should be made to preserve fertility in patients undergoing either RIC or MAC.

Development of the Revision Hip Complexity Classification using a modified Delphi technique.

AIMS: The aim of this modified Delphi process was to create a structured Revision Hip Complexity Classification (RHCC) which can be used as a tool to help direct multidisciplinary team (MDT) discussions of complex cases in local or regional revision networks. METHODS: The RHCC was developed with the help of a steering group and an invitation through the British Hip Society (BHS) to members to apply, forming an expert panel of 35. We ran a mixed-method modified Delphi process (three rounds of questionnaires and one virtual meeting). Round 1 consisted of identifying the factors that govern the decision-making and complexities, with weighting given to factors considered most important by experts. Participants were asked to identify classification systems where relevant. Rounds 2 and 3 focused on grouping each factor into H1, H2, or H3, creating a hierarchy of complexity. This was followed by a virtual meeting in an attempt to achieve consensus on the factors which had not achieved consensus in preceding rounds. RESULTS: The expert group achieved strong consensus in 32 out of 36 factors following the Delphi process. The RHCC used the existing Paprosky (acetabulum and femur), Unified Classification System, and American Society of Anesthesiologists (ASA) classification systems. Patients with ASA grade III/IV are recognized with a qualifier of an asterisk added to the final classification. The classification has good intraobserver and interobserver reliability with Kappa values of 0.88 to 0.92 and 0.77 to 0.85, respectively. CONCLUSION: The RHCC has been developed through a modified Delphi technique. RHCC will provide a framework to allow discussion of complex cases as part of a local or regional hip revision MDT. We believe that adoption of the RHCC will provide a comprehensive and reproducible method to describe each patient's case with regard to surgical complexity, in addition to medical comorbidities that may influence their management. Cite this article: Bone Jt Open 2022;3(5):423-431.

Is rationing of total hip arthroplasty justified? Working to optimize patient accessibility to surgery using long-term patient-reported outcome data.

AIMS: The aim of this study was to assess medium-term improvements following total hip arthroplasty (THA), and to evaluate what effect different preoperative Oxford Hip Score (OHS) thresholds for treatment may have on patients' access to THA and outcomes. METHODS: Patients undergoing primary THA at our institution with an OHS both preoperatively and at least four years postoperatively were included. Rationing thresholds were explored to identify possible deprivation of OHS improvement. RESULTS: Overall, 2,341 patients were included. Mean OHS was 19.7 (SD 8.2) preoperatively and 39.7 (SD 9.8) at latest follow-up. An improvement of at least eight-points, the minimally important change (MIC), was seen in 2,072 patients (88.5%). The mean improvement was 20.0 points (SD 10.5). If a rationing threshold of OHS of 20 points had been enforced, 90.8% of those treated would have achieved the MIC, but only 54.3% of our cohort would have had access to surgery; increasing this threshold to 32 would have enabled 89.5% of those treated to achieve the MIC while only depriving 6.5% of our cohort. The 'rationed' group of OHS > 20 had significantly better OHS at latest follow-up (42.6 vs 37.3; p < 0.001), while extending the rationing threshold above 32 showed postoperative scores were more significantly affected by the ceiling effect of the OHS. CONCLUSION: The OHS was not designed as a tool to ration healthcare, but if it had been used at our institution for this cohort, applying an OHS threshold of 20 to routine THA access would have excluded nearly half of patients from having a THA; a group in which over 85% had a significant improvement in OHS. Where its use for rationing is deemed necessary, use of a higher threshold may be more appropriate to ensure a better balance between patient access to treatment and chances of achieving good to excellent outcomes. Cite this article: Bone Jt Open 2022;3(3):196-204.

Bone Health Outcomes at 1 Year after Hematopoietic Stem Cell Transplantation in a Heterogeneous Pediatric Population.

Impaired bone mineral density (BMD) is a known complication of hematopoietic stem cell transplantation (HSCT) in adults and may lead to increased fracture risk. Less is known in children about the risks for impaired BMD and fragility (low trauma) fractures after HSCT. In this study, we evaluated the incidence of fragility fractures in a large diverse pediatric HSCT recipient population and identified risk factors for both fracture and impaired BMD. We reviewed the records of 237 patients age ≤21 years at the time of transplantation who underwent HSCT at our institution between January 2015 and March 2018. The primary endpoint was the incidence of fragility fractures, and the secondary endpoint was assessment of BMD on dual-energy X-ray absorptiometry (DXA). DXA studies were available for analysis in 79 of 206 patients who were alive at 1 year after HSCT, and the median height-for-age adjusted z-score for spine BMD was 0.15. Among the 237 patients in this study, 25 (10.5%) had evidence of at least 1 fragility fracture on imaging. In the patients with at least 1 fragility fracture, 18 (72%) sustained spine fractures. The median time to fracture was 5.9 months after HSCT. Mortality at 1 year was proportionally higher, although not statistically significantly so (P = .11) in patients who had at least 1 fragility fracture (24%; 6 of 25) compared with patients without a fragility fracture (12%; 25 of 212). Vitamin D status at 1 year post-HSCT was sufficient (>20 ng/mL) in 94% of the patients assessed (160 of 171). There was no difference in the incidence of fracture between vitamin D-sufficient patients and vitamin D-insufficient patients (P = 1.0). The incidence of fracture was significantly higher in patients with graft-versus-host disease (GVHD) compared with those without GVHD (15% vs 6%; P = .02). There was no significant difference in fracture occurrence between patients who received reduced-intensity conditioning and those who received myeloablative conditioning. The cumulative glucocorticoid dose was significantly associated with fracture in patients exposed to glucocorticoids for >3 months (P = .03). The incidence of fragility fractures, especially vertebral compression fractures, after pediatric HSCT is striking. Furthermore, there may have been additional, asymptomatic patients in our cohort with undetected, occult fractures. The high incidence of fragility fractures seen in this study advocates for establishing bone health screening protocols with attention to spinal imaging in pediatric patients undergoing HSCT.

Incidence of thyroid dysfunction in children after HSCT with reduced intensity conditioning (RIC) or myeloablative conditioning (MAC).

We have previously demonstrated a 11% incidence of post-transplant de novo thyroid disease, even with a radiation-free RIC regimen. Following the enactment of a universal late effects screening program at our institution, we compared the outcomes of 108 pediatric hematopoietic stem cell transplant recipients after a RIC regimen (n = 33) to those after a MAC regimen (n = 75) during the same time period. Overall, 10% of subjects developed thyroid dysfunction after HSCT, with a median follow-up of 669 days. Seven subjects had primary hypothyroidism prior to HSCT. Of the thirty-one subjects who received RIC, one (3.2%) developed a new thyroid disorder, compared to the nine of sixty-nine (13.0%) subjects who received MAC (p = .167). No significant associations were seen with donor type, graft-vs.-host disease, or total body irradiation. Nine of the 10 subjects who developed thyroid disease after transplant were asymptomatic. Continued follow-up of this contemporary cohort will further delineate risk factors for post-transplant-associated thyroid dysfunction and better inform discussions of transplant-associated sequelae.

B2 or not B2? That is the question: a review of periprosthetic fractures around cemented taper-slip femoral components.

AIMS: Periprosthetic fractures (PPFs) around cemented taper-slip femoral prostheses often result in a femoral component that is loose at the prosthesis-cement interface, but where the cement-bone interface remains well-fixed and bone stock is good. We aim to understand how best to classify and manage these fractures by using a modification of the Vancouver classification. METHODS: We reviewed 87 PPFs. Each was a first episode of fracture around a cemented femoral component, where surgical management consisted of revision surgery. Data regarding initial injury, intraoperative findings, and management were prospectively collected. Patient records and serial radiographs were reviewed to determine fracture classification, whether the bone cement was well fixed (B2W) or loose (B2L), and time to fracture union following treatment. RESULTS: In total, 47 B2W fractures (54.0%) and one B3 fracture (1.1%) had cement that remained well-fixed at the cement-bone interface. These cases were treated with cement-in-cement (CinC) revision arthroplasty. Overall, 43 fractures with follow-up united, and two patients sustained further fractures secondary to nonunion and required further revision surgery. A total of 19 B2L fractures (21.8%) and 19 B3 fractures (21.8%) had cement that was loose at the cement-bone interface. These cases were managed by revision arthroplasty with either cemented or uncemented femoral components, or proximal femoral arthroplasty. One case could not be classified. CONCLUSION: We endorse a modification of the original Vancouver system to include a subclassification of B2 fractures around cemented femoral prostheses to include B2W (where cement is well-fixed to bone) and B2L (where the cement is loose). Fractures around taper-slip design stems are more likely to fracture in a B2W pattern compared to fractures around composite beam design stems which are more likely to fracture in a B2L pattern. B2W fractures can reliably be managed with CinC revision. Cite this article: Bone Joint J 2021;103-B(1):71-78.

Long-Term Survival of the Cemented Exeter Universal Stem in Patients 50 Years and Younger: An Update on 130 Hips.

BACKGROUND: There is variable evidence regarding survivorship beyond 20 years of total hip arthroplasties in young patients. We report the long-term results of the Exeter cemented hip system in patients ≤50 years at minimum of 20 years. METHODS: Clinical and radiological outcomes of 130 consecutive total hip arthroplasties in 107 patients aged 50 years or younger at primary operation were reviewed; 77% had a diagnosis other than osteoarthritis. All patients were followed at 5-year intervals, no patients were lost to follow-up, and the status of every implant is known. RESULTS: Mean age at surgery was 41.8 (17-50) years. Mean follow-up was 22.0 (20.0-26.1) years. There were 79 hips surviving, 14 hips (11 patients) deceased, and 37 hips revised. Reasons for revision: 29 hips for aseptic cup loosening (26 stems revised using cement-in-cement, three left in-situ); three stems for femoral osteolysis, two related to acetabular polyethylene wear (14.1 and 17.0 years), one with Gaucher's disease (21.1 years); one broken stem (12.9 years); one cup for instability (4.3 years-stem revised using cement-in-cement); and two hips with infection (8.5 and 23.8 years). There were no cases of aseptic loosening of the Exeter stem. There were no radiologically loose stems although eight patients had radiological evidence of loosening of the cemented cup. Survivorship at 22 years was 74.9% for revision for all causes and 96.3% for revision of the stem for aseptic loosening or lysis. CONCLUSION: The Exeter cemented stem has excellent survivorship at minimum 20 years in young patients. Acetabular component survivorship was less favorable, but the advent of highly cross-linked polyethylene may improve this in the long term.

Pituitary disease in pediatric brain tumor survivors.

INTRODUCTION: Treatment of childhood brain tumors, including surgical resection and especially external beam radiation, often results in endocrine complications manifested by hypopituitarism, which can involve growth hormone deficiency, hypothyroidism, adrenal insufficiency, disorders of puberty, diabetes insipidus, and hypothalamic obesity. AREAS COVERED: A comprehensive literature search was conducted on Medline (publications from the 1990s to 01/2019) including systematic reviews, meta-analyses, longitudinal controlled studies, retrospective cohort studies, and case reports. Herein, we present an up-to-date review of the current literature regarding endocrine sequellae of childhood brain tumor survivors. EXPERT OPINION: Late endocrine sequellae can arise many years after the initial treatment of tumor, so at least annual surveillance of growth, puberty, weight, development, and endocrine status is recommended for at least 10 years after tumor therapy. This follow up should encompass childhood and adulthood among survivors. If found early, outcomes of endocrinopathies are favorable when treated appropriately. Newer tumor therapy modalities, such as proton beam radiation, offer the potential for fewer endocrine complications, but such benefit has yet to be demonstrated, and more research into short- and long-term outcomes is needed.

The Exeter Short Revision Stem for Cement-in-Cement Femoral Revision: A Five to Twelve Year Review.

BACKGROUND: Cement-in-cement femoral revision is a proven technique in revision total hip arthroplasty, with excellent results reported using standard-sized Exeter stems. The Exeter 44/00/125 short revision stem was introduced in 2004 to facilitate cement-in-cement revision. The stem is 25-mm shorter and has a slimmer body than standard stems to facilitate adjustment of depth of insertion and stem version. It is not known if this change in stem size affects its long-term performance. We therefore reviewed the outcome of all Exeter short revision stems used for cement-in-cement revision in our unit, with a minimum of 5 years of follow-up. METHOD: One hundred sixty-six cases were performed between 2004 and 2010. Mean follow-up of surviving patients was 8.1 years (range 5.0-11.7). The fate of all 166 hips were known and included in the survival analysis. RESULTS: Median clinical scores improved significantly. Sixteen hips required re-revision (infection 6, loose cup 3, periprosthetic fracture 3, instability 2, stem fracture with chronic infection 1, and pain 1). Kaplan-Meier survival analysis at 10 years revealed 100% survival for aseptic stem loosening, 96.8% survival for stem failure, and 88.9% survival for all causes. CONCLUSION: The Exeter short revision stem performed as well as standard length stems for cement-in-cement revision in this the largest and longest review of their use. Larger registry-based studies may provide additional information on the performance of this stem.