Restoration Of Bone Stock Research Articles

Femoral impaction allografting for significant bone loss in revision hip arthroplasty.

Femoral impaction bone allografting in revision hip arthroplasty facilitates physiological reconstruction with restoration of bone stock, allowing implantation of a standard cemented femoral component. The purpose of this study was to report our experience in femoral component revision arthroplasty with impaction morsellised cancellous bone allograft using custom impactors and a cemented triple-taper polished stem. Retrospective analysis of all cases of femoral component revision hip arthroplasty with impaction bone grafting undertaken by a single surgeon from 2005 to 2011. Outcome measures included radiographic analysis of stem subsidence over time, graft remodelling and incorporation, and clinical progress. We reviewed 47 consecutive hips in 44 patients, mean age 62 years (37-88). Femoral impaction with allograft was performed as either single stage (41 cases) or 2-stage (6 cases) procedures. All patients received a cemented C-stem prosthesis. The mean follow-up period was 5.1 (1.3-9.4) years. The median preoperative bone defect score was 3 (interquartile range [IQR] 2-3) using the Endo-Klinik classification. Radiological evidence of graft incorporation was observed in 89% (281 of 315 zones) with additional remodelling observed in 33% (103 of 315 zones). The median stem subsidence at 1-year follow-up was 1.1 mm (standard deviation [SD] 1.24 mm, range 0-6 mm). The median Oxford Hip Score at the most recent follow-up was 36.5. To date no femoral component has undergone further revision. Encouraging results have been obtained with this technique for the treatment of significant bone loss in revision hip arthroplasty, allowing implantation of a standard prosthesis.

Reconstruction of non-contained acetabular defects with impaction grafting, a reinforcement mesh and a cemented polyethylene acetabular component

This review summarises the technique of impaction grafting with mesh augmentation for the treatment of uncontained acetabular defects in revision hip arthroplasty. The ideal acetabular revision should restore bone stock, use a small socket in the near-anatomic position, and provide durable fixation. Impaction bone grafting, which has been in use for over 40 years, offers the ability to achieve these goals in uncontained defects. The precepts of modern, revision impaction grafting are that the segmental or cavitary defects must be supported with a mesh; the contained cavity is filled with vigorously impacted morselised fresh-frozen allograft; and finally, acrylic cement is used to stabilise the graft and provide rigid, long-lasting fixation of the revised acetabular component. Favourable results have been published with this technique. While having its limitations, it is a viable option to address large acetabular defects in revision arthroplasty. Cite this article: Bone Joint J 2017;99-B(1 Supple A):25-30.

Use of Cortical Strut Allograft After Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty

BackgroundCortical strut allografts restore bone stock and improve postoperative clinical scores after revision total hip arthroplasty (THA). However, use of a cortical strut allograft is implicated in delayed healing of an extended trochanteric osteotomy (ETO). To date, there are no reports directly comparing ETO with or without cortical strut allografts. MethodsWe reviewed prospectively gathered data on 50 revision THAs performed from 2004-2014 using an ETO. We compared the demographic, radiological, and clinical outcome of patients with (16 hips) and without (34 hips) cortical strut allograft after an ETO. ResultsThere were no significant differences in Western Ontario McMaster Universities Osteoarthritis Index or Harris Hip Score between the ETOs with and without a cortical strut allograft. Fifteen of the ETOs (94%) with a cortical strut allograft and 31 of the ETOs (91%) without a cortical strut allograft were in situ at final follow-up (P = 1.000). A higher proportion hips with cortical strut allograft (100%, 16 patients) had preoperative Paprosky grade bone loss more than IIIA compared to those without allograft (29%, 10 patients) (P < .001). There were no differences in femoral stem subsidence (P = .207), alignment (P = .934), or migration of the osteotomized fragment (P = .171). Fourteen of the ETOs (88%) in patients with cortical strut allograft united compared to 34 ETOs (100%) in patients without allograft (P = .095). ConclusionOur study shows that the use of cortical strut allograft during revision THA with ETO does not reduce the rate of union, radiological or clinical outcomes.

Favorable Early Results of Impaction Bone Grafting With Reinforcement Mesh for the Treatment of Paprosky 3B Acetabular Defects

BackgroundWe present the early institutional experience with the use of impaction bone grafting, mesh augmentation, and cement fixation of an all-polyethylene cup for the treatment of Paprosky 3B acetabular defects during revision total hip arthroplasty. MethodsBetween 2005 and 2014, 21 patients (9 men, 12 women) with Paprosky 3B acetabular defects who underwent revision total hip arthroplasty using this technique were reviewed clinically and radiographically. Average age and body mass index were 72.4 (range, 48-91) years and 24.5 (range, 18.9-31) kg/m2, respectively. All patients underwent revision for aseptic loosening. Surgical technique included the use of a peripheral mesh to contain the defect, followed by impaction of morselized fresh-frozen bone graft and cement fixation of a polyethylene cup. ResultsComplications occurred in 6 patients (29%) including limp (2), sciatic nerve palsy that resolved (1), limb length discrepancy (1), and greater trochanteric fracture (1). After an average follow-up of 47 months (range, 13-128 months), the average Hospital for Special Surgery hip score was 35.5 (range, 20-40). Radiographic assessment revealed cephalad cup migration of 2.29 mm (range, 0-20 mm) and medial migration of 1.57 mm (range, 0-6 mm). One patient has radiographic loosening and no symptoms 120 months postoperatively. No patient returned to the operating room for a related reason or is scheduled to undergo acetabular re-revision surgery. ConclusionImpaction bone grafting is a reliable technique for the treatment of Paprosky 3B acetabular defects. It restores bone stock like no other available for addressing these defects. Longer follow-up is required to assess potential deterioration of fixation.

Nonmodular Tapered Fluted Titanium Stems Osseointegrate Reliably at Short Term in Revision THAs.

The ideal femoral component for revision THA is undecided. Cylindrical nonmodular stems have been associated with stress shielding, whereas junctional fractures have been reported with tapered fluted modular titanium stems. We have used a tapered fluted nonmodular titanium femoral component (Wagner Self-locking [SL] femoral stem) to mitigate this risk. This component has been used extensively in Europe by its designer surgeons, but to our knowledge, it has not been studied in North America. Added to this, the design of the component has changed since early reports. We asked: (1) Does the Wagner SL stem have low rates of rerevision and other complications at a minimum 2 years after surgery? (2) Is the Wagner SL stem associated with high levels of patient function and pain relief at a minimum 2 years after surgery? (3) Does the Wagner SL stem have low rates of subsidence at a minimum 2 years after surgery? (4) Is the Wagner SL stem associated with proximal femoral bone remodeling at a minimum 2 years after surgery? Between May 2011 and December 2012, we performed 198 femoral revisions, of which 104 (53%) were performed using the Wagner SL femoral stem; during that period, our institution gradually shifted toward increasing use of these stems for all but the most severe revisions, in which modular fluted stems and proximal femoral replacements still are used on an occasional basis. Median followup in this retrospective study was 32 months (range, 24-46 months), and one patient was lost to followup before the 2-year minimum. The femoral deformities in this series were Paprosky Type I (10 hips), Paprosky Type II (26), Paprosky Type IIIA (52), Paprosky Type IIIB (nine), and Paprosky Type IV (two). Functional assessment was performed using the Oxford Hip Score (OHS), WOMAC, SF-12, and the University of California Los Angeles (UCLA) activity score. All complications and cases of revision were documented. All patients had radiographs performed within 1 year of the latest followup. These were assessed by two surgeons for signs of proximal femoral bone remodeling and subsidence. Complete preoperative scores were available for 98 patients (98 of 104; 94%). The mean OHS preoperatively and at final followup were 39 (SD, 15) and 87 (SD, 19), respectively (p < 0.001; mean difference, 48; 95% CI, 43-53). Average WOMAC scores were 44 (SD, 15) and 87 (SD, 20), respectively (p < 0.001; mean difference, 43; 95% CI, 38-48). At final followup, signs of restoration of proximal femoral bone stock was noted in 45 of 103 hips (44%). Six (six of 104; 6%) patients had subsidence of 10 mm to 15 mm. In the remainder (98 of 104; 94%), the mean subsidence was 2 mm (range, 0-9 mm). One revision was performed for loosening associated with infection. The Wagner SL stem is a viable option for patients with Paprosky Types II and III defects undergoing revision THA. This component provides high levels of patient function with low revision rates and low rates of subsidence during the early postoperative phase. They provide a viable alternative to modular components for treatment of Types II and III defects without the risk of junctional fractures. They can be used for very selected Type IV defects, however this extent of bone loss is most easily addressed with other techniques such as a proximal femoral replacement. Level IV, therapeutic study.

CORR Insights®: No Difference between Trabecular Metal Cones and Femoral Head Allograft in Revision TKA: Minimum 5-year Followup.

Where Are We Now? A substantial increase in the volume of primary TKA in conjunction with increases in patient lifespan has resulted in an increased need for revision TKA. An analysis of revision TKA volume in Medicare beneficiaries showed revision volume increased 105.9% from 1991 to 2010 [2]. There is some degree of bone loss associated with each revision procedure because of initial bone resection at the time of primary TKA, osteolysis from wear debris or other causes, and bone loss associated with component removal. Minor bone defects (Anderson Orthopaedic Research Institute [AORI] Types 1 and 2 [4]) are usually managed simply with cancellous cavitary bone grafting, bone cement with or without screws, or peripheral metal augments. Larger defects (AORI Types 2B and 3 [2]) make it more difficult to achieve durable implant fixation because of the loss of bone support. Historically, structural allografts have been used to reconstruct these defects, with 91% demonstrating satisfactory function in a report of 46 subjects at a mean followup duration of 97 months [5], although problems with nonunion, late graft collapse, and the potential for disease transmission have been identified [1]. These problems have resulted in the development of metaphyseal sleeves and trabecular metal cones to enhance long-term fixation [3, 6, 7]. Short-term results with these devices have been favorable but have analyzed only a single method of defect management rather than comparative studies of multiple techniques. The current report is the first to compare different techniques (structural allograft versus trabecular metal cones). The authors observed no differences in pain relief, function, or repeat revision TKA rates between patients treated with the two approaches. Where Do We Need To Go? Numerous questions remain regarding management of large bone defects in revision TKA. Will the findings of this small study, which includes a combined total of only 45 patients (30 femoral had allografts versus 15 trabecular metal cones), be confirmed in larger and more diverse revision TKA populations? Will the clinical results remain similar with longer followup duration since some reports of use of structural allografts have demonstrated failure due to graft resorption at followup intervals longer than 10 years? Should a revision TKA utilizing either of these techniques fail, what are the results of a repeat revision procedure? Does one technique result in a simpler or more complex re-revision procedure? For example, will use of a structural allograft provide restored bone stock for future revisions? Should infection occur, does an incorporated structural allograft or trabecular metal cone require total removal? How difficult is removal of a well-fixed trabecular metal cone and what are the technical tips for safe removal? Does removal of a well-fixed trabecular metal cone result in a substantial amount of retained third-body metallic debris particulate that may accelerate polyethylene wear in repeat revision procedures? Allografts can be sterilized using multiple methods; to what degree are there clinically important tradeoffs among these approaches? Will irradiation of frozen grafts to reduce disease transmission result in unacceptable reductions in mechanical strength compared to fresh-frozen allografts? Lastly, is use of modular stem extensions necessary for all revision TKA operations utilizing one or both of the techniques studied in the current evaluation? If so, how long should the stems be? Are short cemented stem extensions adequate or will longer stem extensions engaging diaphyseal bone prove more durable? How Do We Get There? Randomized comparative analyses of the two techniques with followup duration of a minimum of 10 years are necessary. While difficult to accomplish, a multicenter effort would likely be required to create a case volume adequate to draw firm conclusions. In such a study, it would be beneficial to include a third technique of using porous coated metaphyseal sleeves [3] as these are commonly used for Types 2B and 3 [2] bone defects. All Type 2B and 3 bone defects [4] are not the same. Some have more loss of cortical rim support than others. The amount of bone loss using the AORI bone defect classification [4] is variable. A more-critical evaluation of defect size and shape is necessary to better discern whether structural bone allografts or trabecular metal cones are superior in the management of specific bone defect geometries. Of course, bone defects also occur on the femur; are results different when dealing with femoral versus tibial defects? For example, Type 3 femoral defects have the potential for loss of collateral ligament support; does this influence which approach might be better? These questions and others call for larger, longer-term, randomized and likely multicenter studies. To accomplish this, economic support from national organizations such as the Knee Society and the American Association of Hip and Knee Surgeons would be helpful as their memberships contain leaders in TKA with competent databases necessary to provide the required meaningful data.

Effect of anatomic site and irradiation on the rates of revision and infection of allograft-prosthesis composites after resection of a primary bone tumor: a meta-analysis.

Allograft-prosthesis composite reconstruction after resection of a primary bone tumor may have theoretical advantages, such as restoration of bone stock and soft tissue attachments. However, the reported results of APC of different anatomical sites differ widely. We conducted a meta-analysis to estimate the revision and infection rates associated with allograft-prosthesis composite (APC) reconstructions after resection of a primary bone tumor. We looked for variables, such as anatomic sites and irradiation of the allograft, associated with these outcomes. We searched Medline, EMBASE, and Cochrane Library. The primary outcome was the revision rate, and the secondary outcome was the infection rate. Random effects meta-analyses of single proportions were used to estimate pooled rates of events. Meta-regression models were built to assess the effect of moderators on relevant both outcomes. Thirty-one studies were included: 9 about acetabulum APC, 9 about proximal femur APC, 4 about proximal tibia APC, and 9 about proximal humerus APC. The revision rates ranged from 16% (95% CI 10-25%) for proximal humerus to 38% (95% CI 26-52%) for acetabulum, and were significantly different between anatomic sites (p=0.028). The infection rates ranged from 8% (95% CI 4-16%) for proximal humerus to 23% (95% CI 16-33%) for proximal tibia and 23% (95% CI 15-35%) acetabulum APCs, and were significantly different between anatomic sites (p=0.008). Finally, we found that irradiation of the allograft was significantly associated with revision rates (p=0.033) and infection rates (p<0.001). Results of an APC reconstruction after resection of a primary malignant bone tumor vary significantly between anatomic sites and after irradiation of the allograft.

Effect of thermodisinfection on mechanic parameters of cancellous bone.

Revision surgery of joint replacements is increasing and raises the demand for allograft bone since restoration of bone stock is crucial for longevity of implants. Proceedings of bone grafts influence the biological and mechanic properties differently. This study examines the effect of thermodisinfection on mechanic properties of cancellous bone. Bone cylinders from both femoral heads with length 45mm were taken from twenty-three 6-8months-old piglets, thermodisinfected at 82.5°C according to bone bank guidelines and control remained native. The specimens were stored at -20°C immediately and were put into 21°C Ringer's solution for 3h before testing. Shear and pressure modulus were tested since three point bending force was examined until destruction. Statistical analysis was done with non-parametric Wilcoxon, t test and SPSS since p<0.05 was significant. Shear modulus was significantly reduced by thermodisinfection to 1.02±0.31GPa from 1.28±0.68GPa for unprocessed cancellous bone (p=0.029) since thermodisinfection reduced pressure modulus not significantly from 6.30±4.72 GPa for native specimens to 4.97±2.23 GPa and maximum bending force was 270.03±116.68N for native and 228.80±70.49N for thermodisinfected cancellous bone. Shear and pressure modulus were reduced by thermodisinfection around 20% and maximum bending force was impaired by about 15% compared with native cancellous bone since only the reduction of shear modulus reached significance. The results suggest that thermodisinfection similarly affects different mechanic properties of cancellous bone and the reduction of mechanic properties should not relevantly impair clinical use of thermodisinfected cancellous bone.

Role of Cages in Revision Arthroplasty of the Acetabulum.

➤ The outcome of acetabular revision is heavily influenced by the degree of associated bone loss.➤ Uncemented hemispherical acetabular components can be used in the majority of acetabular revisions, although occasionally the degree of bone loss precludes the stability of the hemispherical component at the correct anatomic level or there is minimal bleeding host bone left for biologic fixation.➤ Massive acetabular bone loss resulting in the need for bone grafts or highly porous augments involving more than half of the acetabulum is one of the main indications for the use of cages.➤ The cup-cage reconstruction is based on bone-grafting the deficient acetabulum and securing a hemispherical, highly porous metal component with multiple screws to bridge the discontinuity and off-loading the hemispherical component with a titanium cage spanning from ischium to ilium.➤ In addition to managing pelvic discontinuities, the cup-cage construct can also be used in hips without discontinuity as the hemispherical, highly porous metal component is used to restore bone stock.➤ In situations in which there is not enough bleeding host bone to secure a hemispherical component, a highly porous metal augment can be used to address the osseous deficiency. The augment is also protected with a cage to assist bone ingrowth.

Diagnosis and Management of Periprosthetic Elbow Infection.

➤ Periprosthetic elbow infections rarely involve systemic symptoms such as fever or malaise.➤ Unlike tests for periprosthetic hip and knee infections, the diagnostic utility of blood testing and joint aspiration for periprosthetic elbow infection has not been demonstrated to date.➤ Intraoperative histological analysis has good specificity (93.1%) but very low sensitivity (51.3%) for periprosthetic elbow infection.➤ Emerging diagnostic options such as implant sonication, molecular analysis, and advanced synovial fluid cytokine and protein analysis may reduce diagnostic uncertainty in the future.➤ Recommended surgical treatment options for an infection at the site of an elbow arthroplasty include implant retention and debridement, two-stage revision with or without techniques for restoration of bone stock and triceps continuity, and resection arthroplasty.

The Use of Structural Distal Femoral Allograft for Acetabular Reconstruction of Paprosky Type IIIA Defects at a Mean 21 Years of Follow-Up

BackgroundRevision total hip arthroplasty in patients with a nonsupportive superior acetabulum often requires secondary augmentation beyond a hemispherical cup to achieve reliable fixation. Treatment options include using a higher hip center, jumbo cup, custom triflange implant, cages, or filling the superior defect with a bilobed implant, structural allograft, or metal augments. We previously reported a cohort of 31 patients treated with porous-coated hemispherical cups and distal femoral allograft for Paprosky type IIIA acetabular defects. MethodsThe original cohort of 31 hips was retrospectively reviewed. Fourteen patients died with <15 years of follow-up, and 2 were lost to follow-up. This left 15 patients for evaluation including 5 males and 10 females, with an average age of 61 years (range: 37-74 years) at the time of surgery. Acetabular revision was performed with the use of a porous-coated hemispherical cup along with structural distal femoral allograft, cut to resemble the number 7, and secured with 6.5-mm cancellous screws with washers. ResultsOverall, 7 hips failed, resulting in a Kaplan-Meier survivorship of 72% at 25 years of follow-up. In surviving patients, radiographs demonstrated components to be well fixed, and average Merle d'Aubigné score increased from 5 to 10 points. There were a subset of patients that failed early (median: 6.2 years), but the remaining patients demonstrated excellent clinical and radiographic results. ConclusionsThe use of distal femoral allograft can be considered in young patients with type IIIA acetabular defects that could benefit from restoration of bone stock.

Proximal humeral osteoarticular allografts: technique, pearls and pitfalls, outcomes.

Allograft transplantation is a biologic reconstruction option for massive bone defects after resection of bone sarcomas. This type of reconstruction not only restores bone stock but it also allows us to reconstruct the joint anatomically. These factors are a major concern, especially in a young and active population.We are describing indications, surgical techniques, pearls and pitfalls, and outcomes of proximal humeral osteoarticular allografts, done at present time in our institution.We found that allograft fractures and articular complications, as epiphyseal resorption and subchondral fracture, are the main complications observed in proximal humerus osteoarticular allograft reconstructions. Nevertheless, only fractures need a reconstruction revision. Joint complications may adversely affect the limb function, but for this reason, an allograft revision is rarely performed.

The jumbo cup: Easiest and safest solution

Jumbo cups can be used to address many acetabular revision cases with bone loss. The technique of implantation is relatively straight forward, and there is the potential to maximize bone-to-cup surface area, approximate the natural hip center, and to obtain a construct that allows immediate weight bearing. Experience from multiple sources has demonstrated survivorship up to 83% at 20 years, limited mostly by the wear of conventional polyethylene. A contraindication to this method is irradiated bone and a limitation is restoration of peripheral acetabular bone stock, which could compromise further revision surgery.

CORR Insights(®): What Are the Risk Factors and Management Options for Infection After Reconstruction With Massive Bone Allografts?

M assive allografts remain an important reconstructive alternative in the armamentarium of musculoskeletal oncologists, adult reconstruction, and other orthopaedic surgeons. Allografts replace osseous defects with like-tissue, restore bone stock for eventual revision reconstructions in younger patients, and offer anatomic tendon attachments and resulting muscle function (for example, in knee extensor, hip abductor, and shoulder rotator cuff grafts) not yet achievable by tendon-to-metal interfaces. When a flawless allograft or allograft-prosthesis composite reconstruction is performed, and the all-too-frequent complications (namely, infection, fracture, and nonunion) are avoided, the functional outcomes achievable frequently surpass those possible by other means, with these other means generally being limited to megaprosthesis reconstruction, resection arthroplasty variants, or some form of amputation. Unfortunately, infection following massive allograft reconstruction is common. The crude infection rate of 9% at 10 years of followup found in the study by Aponte-Tinao and colleagues [1] remains consistent with previously published estimates in patients treated with bulk allograft infection, which range from 8.5% to 13% [5, 6]. Infections frequently coexist with, or predispose to, the other dreaded allograft complications of This CORR Insights is a commentary on the article ‘‘What Are the Risk Factors and Management Options for Infection After Reconstruction With Massive Bone Allografts?’’ by Aponte-Tinao and colleagues available at: DOI: 10.1007/s11999-0154353-3. The author certifies that he, or anymember of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJEConflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors andboardmembers are onfile with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. This CORR Insights comment refers to the article available at DOI: 10.1007/s11999-0154353-3. The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Army, the Department of the Navy, Department of Defense, nor the U.S. Government. The author is a military service member. This work was prepared as part of his official duties. Title 17 U.S.C. 105 provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. 101 defines a U.S. Government work as a work prepared by a military service member or employee of the US Government as part of that person’s official duties.

Acetabuloplasty with bone grafting in uncemented hip replacement for protrusion.

This retrospective study investigated midterm outcomes of uncemented total hip replacement with acetabuloplasty using impacted bone grafts in acetabular protrusion or primary hip arthritis with an inadequate thickness of the medial acetabular wall. The medial acetabular wall was augmented by impaction bone grafting, and an uncemented cup was implanted in all cases. Hip centre of rotation, medial acetabular wall thickness and cup positioning were evaluated radiologically, with the Harris Hip Score determined at each follow-up. A total of 32 patients (39 hips) were followed for a mean of 4.5 years, with significant improvement of the Harris Hip Score at the last follow-up. Hip centre of rotation was restored close to the optimal position. Medial acetabular wall thickness and cup position obtained immediately postoperatively were maintained up to the last follow-up, without statistically significant differences. Bone graft integration was observed in all cases by one or two years postoperatively, with no signs of loosening or cup migration at the last follow-up. Heterotopic ossification was identified in 15.4% of cases, without clinical evidence of hip mobility impairment or pain. Impaction bone grafting for acetabuloplasty, associated with the implantation of an uncemented cup, yields good midterm results in patients with acetabular protrusion and with primary hip arthrosis with a thinned medial acetabular wall. The restored bone stock and medial acetabular wall thickness enable the placement of the hip centre of rotation close to the optimal location, which could offer further long-term benefits.

Satisfying outcomes scores and survivorship achieved with impaction grafting for revision THA in young patients.

BackgroundThe increasing number of total hip arthroplasties (THAs) performed in younger patients will inevitably generate larger numbers of revision procedures for this specific group of patients. Unfortunately, no satisfying revision method with acceptable survivorship 10 years after revision has been described for these patients so far.Questions/purposesThe purposes of this study were to (1) analyze the clinical outcome; (2) complication rate; (3) survivorship; and (4) radiographic outcome of cemented revision THA performed with impaction bone grafting (IBG) on both the acetabular and femoral sides in one surgery in patients younger than 55 years old.MethodsDuring the period 1991 to 2007, 86 complete THA revisions were performed at our institution in patients younger than 55 years. In 34 of these 86 revisions (40%), IBG was used on both the acetabular and femoral sides in 33 patients. Mean patient age at revision surgery was 46.4 years (SD 7.6). No patient was lost to followup, but three patients died during followup. None of the deaths were related to the revision surgery. The mean followup for the surviving hips was 11.7 years (SD 4.6). We also analyzed complication rate.ResultsThe mean Harris hip score improved from 55 (SD 18) preoperatively to 80 points (SD 16) at latest followup (p = 0.009). Six hips underwent a rerevision (18%): in four patients, both components were rerevised; and in two hips, only the cup was revised. Patient 10-year survival rate with the endpoint of rerevision for any component for any reason was 87% (95% confidence interval [CI], 67%–95%) and with the endpoint of rerevision for aseptic loosening, the survival rate was 97% (95% CI, 80%–100%). In total six cups were considered radiographically loose, of which four were rerevised. Three stems were radiographically loose, of which none was rerevised.ConclusionsIBG is a valuable biological revision technique that may restore bone stock in younger patients. Bone stock reconstruction is important, because these patients likely will outlive their revision implants. Bone reconstruction with impaction grafting may facilitate future revisions.Level of EvidenceLevel IV, therapeutic study.

Proximal Femoral Allograft in Two-Stage Revision for Failed Septic Hip Arthroplasty

Infection after hip prostheses is a potentially devastating complication, and a serious medical and surgical challenge, especially when associated with Paprosky type III femoral bone loosening. Treatment is difficult and options are limited. We report on a 2-stage revision of 15 patients undergoing femur reconstruction with massive allografts. Materials and methods: This was a prospective study which included 15 patients (10 men and 5 women) with infected hip prosthesis, associated with Paprosky type III femoral proximal massive bone loss. The median age of patients was 64 years with a preoperative functional status score of 6. The average number of procedures to the same hip after the first arthroplasty was 6. All patients benefited from a 2-step surgery with massive allografts and locking prosthesis. The average follow-up time was 36 months. Results: Infection was monomicrobial in 14 cases; and was polymicrobial in 4 cases. Methicillin-resistant Staphylococcus epidermidis was the main bacteria (n = 10). The average C-reactive protein level before the second procedure was 2.3 ± 3.4. It was normalized in 8 cases. We recorded 13 cases of primary consolidation without another surgery, 3 cases of relapse, 2 traumatic dislocations and 2 fractures of the allograft. Conclusion: Hip prosthesis infection is a potentially catastrophic complication with significant negative ramifications for both the patient and the healthcare system. Massive allografts use in Paprosky III femoral defect remains very attractive for bone stock restoration and hip function improvement.

Acetabular defect reconstruction in revision hip arthroplasty with a modular revision system and biological defect augmentation.

Revision of failed total hip arthroplasty with severe acetabular bone loss represents a rare but challenging problem. Anatomic reconstruction with biological defect augmentation as solid bone transplants or cancellous bone restores bone stock while providing good component stability. The objective of this study was to present short- to mid-term results of revision total hip arthroplasty with a modular ring system in a consecutive series of patients with severe acetabular bone loss. We retrospectively reviewed 39 consecutive patients (39 hips) with severe acetabular bone loss (Paprosky type 3 A and 3 B) reconstructed with revision total hip arthroplasty using the cementless modular ring system MRS-Titan®. The MRS-Titan® consists of independent ring systems that are adapted modularly to the defect situation. Combined with acetabular defect reconstruction by using cancellous bone in impaction grafting technique, the MRS-Titan® system offers a cement-free revision system that enables defect-adapted customization to individual anatomic matters, bridging of the acetabular bone defect and reconstruction of the centre of rotation. Initial stability of the implant was obtained by screw fixation. Harris hip score and sequential radiographs were used to evaluate clinical and radiographic results. At an average follow up of 31 months (range 12-69 months) 33 of 39 (84.6 %) of the implants were considered radiographically stable without signs of acetabular migration of more than 2 mm in the horizontal or vertical direction, implant rotation or screw breakage. Complications included six implant failures (15 %). We recorded one aseptic loosening of the MRS prosthesis after 20 months. Five patients (12.8 %) had to undergo revision surgery because of periprosthetic joint infection. Two patients had a dislocation postoperatively. The mean Harris hip score improved from 27 ± 14 points preoperatively to 76 ± 15 points at the time of last follow up. By achieving stable implant fixation and providing potential for biological fixation, treatment of severe acetabular bone loss in revision total hip arthroplasty with the modular ring system MRS-Titan provides a durable solution with good clinical and radiographic results and allows us to accomplish major goals of reconstruction.

The clinical and radiological evaluation of the use of an allograft-prosthesis composite in the treatment of proximal femoral giant cell tumours.

Giant cell tumour is the most common aggressive benign tumour of the musculoskeletal system and has a high rate of local recurrence. When it occurs in proximity to the hip, reconstruction of the joint is a challenge. Options for reconstruction after wide resection include the use of a megaprosthesis or an allograft-prosthesis composite. We performed a clinical and radiological study to evaluate the functional results of a proximal femoral allograft-prosthesis composite in the treatment of proximal femoral giant cell tumour after wide resection. This was an observational study, between 2006 and 2012, of 18 patients with a mean age of 32 years (28 to 42) and a mean follow-up of 54 months (18 to 79). We achieved excellent outcomes using Harris Hip Score in 13 patients and a good outcome in five. All allografts united. There were no complications such as infection, failure, fracture or resorption of the graft, or recurrent tumour. Resection and reconstruction of giant cell tumours with proximal femoral allograft-prosthesis composite is a better option than using a prosthesis considering preservation of bone stock and excellent restoration of function. A good result requires demanding bone banking techniques, effective measures to prevent infection and stability at the allograft-host junction.

Mid-to long-term results of revision total hip replacement in patients aged 50 years or younger.

Revision total hip replacement (THR) for young patients is challenging because of technical complexity and the potential need for subsequent further revisions. We have assessed the survivorship, functional outcome and complications of this procedure in patients aged < 50 years through a large longitudinal series with consistent treatment algorithms. Of 132 consecutive patients (181 hips) who underwent revision THR, 102 patients (151 hips) with a mean age of 43 years (22 to 50) were reviewed at a mean follow-up of 11 years (2 to 26) post-operatively. We attempted to restore bone stock with allograft where indicated. Using further revision for any reason as an end point, the survival of the acetabular component was 71% (sd 4) and 54% (sd 7) at ten- and 20 years. The survival of the femoral component was 80% (sd 4) and 62% (sd 6) at ten- and 20 years. Complications included 11 dislocations (6.1%), ten periprosthetic fractures (5.5%), two deep infections (1.1%), four sciatic nerve palsies (2.2%; three resolved without intervention, one improved after exploration and freeing from adhesions) and one vascular injury (0.6%). The mean modified Harris Hip Score was 41 (10 to 82) pre-operatively, 77 (39 to 93) one year post-operatively and 77 (38 to 93) at the latest review. This overall perspective on the mid- to long-term results is valuable when advising young patients on the prospects of revision surgery at the time of primary replacement.