Long-stem Revision Research Articles

Surgical outcomes of periprosthetic distal femur fractures after total knee arthroplasty classified by Su et al. system

BackgroundPeriprosthetic fractures of the distal femur remain a challenge to treat due to variations in both patient- and fracture-specific factors. This study was designed to analyze the outcomes of different subtypes of periprosthetic distal femur fractures based on the Su et al. classification system. MethodsThirty-six patients were classified with Su et al. system. All Type I and II fractures were managed with a locking plate. Most Type III fractures were managed with locking plate, while two were managed with long-stem revision arthroplasty due to evidence of implant loosening. Outcomes were measured and analyzed based on healing time, revision rate, and complication rate. ResultsOf the 36 patients, 30 (83.3%) achieved acceptable fracture union, while the remaining 6 (16.7%) experienced either delayed union or non-union. Type I fractures showed a significantly lower healing time than Type II and III fractures managed by locking plate. Delayed union was present in the Type II group, while non-union was recorded for two Type III fractures. Need for revision was more prevalent in fracture Types II and III. ConclusionThe Su et al. system of classification for periprosthetic fractures of the distal femur matches the clinical outcomes of this study and would seem to be useful in the approach to the treatment of these fractures. The majority of these fractures can be managed with locking plate with reasonable results. However, if the implant is loosened in Type III fractures, revision arthroplasty is suggested.

Cementless, Fluted, Long-Stem Hemiarthroplasty for Vancouver B2 and B3 Periprosthetic Fractures Around Hip Hemiarthroplasty

BackgroundThe purpose of this study was to assess the effectiveness of a cementless, modular, fluted, long-stem hemiarthroplasty for the treatment of Vancouver type B2 and B3 periprosthetic femoral fracture around hip hemiarthroplasty. MethodsThis was a retrospective case-control study comparing 46 patients revised to hemiarthroplasty (HA group) and 31 revised to total hip arthroplasty (THA group). Functional outcome was evaluated by the Merle d’Aubigné score, and the Katz scale based on activities of daily living. Comorbidity was assessed by the Charlson index, and cognitive function by a mini-mental test score. Radiological evaluation was also performed. ResultsMean postoperative follow-up was 3.3 (range, 2-4) years in the HA group and 3.9 (range, 2-5) in the THA group. The need for transfusion and hospital stay were significantly higher in the THA group. Postoperatively, both groups had a significant decrease in mean hip function (P = .001) although the mean Merle (P = .121) and Katz (P = .214) scores were similar at final follow-up. Likewise, there were no significant differences between groups in pain or loss of life independence. All fractures were united but one in the HA group. There were no dislocations in the HA group, and 3 in the THA group. ConclusionThe management of Vancouver B2 and B3 periprosthetic femoral fracture around hemiarthroplasties with a long-stem revision cementless bipolar hemiarthroplasty, supplemented with wire cerclages and cancellous allograft, was an effective option in terms of fracture healing and stability of the implant with a low rate of complications. Nevertheless, a significant functional impairment was also observed in either group.

Severe Pseudotumor Formation on an Asymptomatic Well Functioning Metal-On-Metal Total Hip Arthroplasty - A Case Report and Follow - Up

A 72-year-old patient who had metal-on-metal (MMO) total hip arthroplasty (THA) 7 years ago has developed a gluteal mass and pain. Plain radiographs showed a well-fixed THA on the left side with an increased acetabular inclination. Needle aspiration of the mass showed “milky stained” highly viscous liquid. After the approval of the patient, a revision total hip arthroplasty had been performed. There were severe necrosis and granulomatous type reactions all around the hip and the components. After extensive debridement, all the components were removed and a long-stemmed revision total hip arthroplasty with polyethylene insert was performed. We think that patients with MMO THA must be carefully reviewed after the surgery even if they are asymptomatic.

Management of Vancouver B2 peri-prosthetic femoral fractures: following the evidence

This study by Shi (1) is one in a series of studies that have demonstrated the effectiveness of long-stem revision arthroplasty supplemented with cerclage for the management of Vancouver B2 peri-prosthetic femur fractures after total hip arthroplasty (THA). No randomized trials exist addressing the optimal management of such fractures; instead, management guidelines have been developed based upon accumulation of level IV evidence. This study reported the outcomes of 14 patients after a mean of 5.2 years. All patients had clinical and radiological fracture union within 6.5 months and no adverse events were reported. A mean Harris hip score of 83 points is above what has been typically reported for revision THA (2).

Plate failure following plate osteosynthesis in periprosthetic femoral fractures.

Increasing numbers of total knee and hip arthroplasties result in a growing number of periprosthetic femoral fractures (PPFF). PPFF with a stable stem component are treated commonly with plate osteosynthesis. Therefore plate failure is seen as a major complication. The aim of this retrospective study was to investigate the patients' outcome after plate failure. The database of a Level 1 trauma center was searched for all patients treated for a PPFF with plate osteosynthesis. Patients with plate failure were investigated specifically. Standard demographic data, details on initial arthroplasty, trauma, and treatment were recorded for all patients. All fractures were classified and their outcome reviewed. Seven (8.8%) out of 80 patients treated with plate osteosynthesis following PPFF met our inclusion criterion being plate failure. All these patients were female, with an average age at primary surgery of 74 ± 13 years and a mean follow-up of 885 days (range, 264-2549). Four patients suffered a PPFF after total hip arthroplasty (THA) (2 Vancouver Type B1 and 2 Type C) and three after total knee arthroplasty (TKA) (Lewis-Rorabeck Type II). Following plate failure, four patients healed uneventfully and three patients experienced complications such as pseudarthrosis, screw loosening, and further plate failure. In patients with poor bone quality, bone graft, bone cement, and bone biologics have to be considered in revision surgery. Furthermore, long-stem revision and tumor prosthesis are an additional solution.

Primary cementless hip arthroplasty as a potential risk factor for non-union after long-stem revision arthroplasty in periprosthetic femoral fractures.

In case of stem loosening in periprosthetic femoral fractures (PPFF), revision arthroplasty should be performed. The first hypothesis of this study was that advanced patient age and female gender shows higher non-union rates. The second hypothesis was that primary cementless arthroplasty is associated with a higher non-union rate compared to cemented primary hip arthroplasty. All PPFF occurring between January 2000 and June 2010 treated by revision arthroplasty were included. Multiple regression analysis was performed to identify independent variables leading to fracture non-union. Eighty one patients (78 % female) met the inclusion criteria. In 20/81 patients (24.7 %) no adequate fracture healing could be determined on radiographs 12 months after revision surgery. Although age and female gender showed a positive correlation with bony non-union after PPFF as expected, the p-values were not statistically significant. Multiple regression analysis revealed primary cementless prosthesis (p = 0.001) to be the only independent variable associated with non-union. Non-cemented primary prosthesis might be a negative predicting factor for the development of non-union after long-stem revision arthroplasty in PPFF. We therefore recommend the thorough debridement of pannus tissue thus inducing bone healing before the implantation of revision prostheses.

Management of a Chronically Infected and Unstable Revision Hip Prosthesis with Total Femur Arthroplasty and Antibiotic Cement – Case Report and Review of the Literature

Background: Infection, instability, periprosthetic fracture, and severe bone loss are troublesome issues in revision hip arthroplasty. The occurrence of all four together represents a unique therapeutic challenge. Literature Review : Total femoral arthroplasty is described following tumor resection and in revision arthroplasty with severe bone loss. In these complex cases infection remains a significant concern with rates between 0 and 47% reported. For cases with infection, 2-stage revision procedures have been developed using antibiotic beads or custom total femur antibiotic spacers. However, these techniques involve long periods of non-weight-bearing that may be poorly tolerated in an older population. Case Presentation : A patient with a chronically infected and dislocating long-stemmed revision hip arthroplasty presented with a severely comminuted distal femur fracture. A 1-stage revision was successfully performed using a modular total femur prosthesis coated with antibiotic cement. Conclusion : This is the first reported instance of a successful 1-stage revision for infection and severe bone loss using total femur prosthesis. This technique may allow for early mobilization and the avoidance of multiple surgical procedures.

Interprosthetic Femoral Fractures

Interprosthetic femoral fractures, ones occurring between ipsilateral total hip and total knee arthroplasties, are an increasingly common and challenging problem for orthopaedic surgeons. The purpose of this study was to report specific fracture locations and treatment outcomes associated with a protocol of femoral plate fixation that spanned the interprosthetic zone applied with modern soft tissue preserving reduction techniques without adjuvant bone grafts. Retrospective cohort study. One Level I and one Level II trauma center. A consecutive cohort of 25 patients with 26 interprosthetic femur fractures surgically treated by one of four orthopaedic traumatologists were retrospectively reviewed. There were nine fractures of the femoral shaft (Orthopaedic Trauma Association [OTA] 32) about hip arthroplasty prostheses and 17 supracondylar fractures (OTA 33) about total knee prostheses. Five patients with six fractures were excluded as a result of lack of follow up (n = 4) or deviation from the treatment protocol (n = 2). The remaining 20 fractures were all low-energy closed injuries in elderly patients (average age 80 years; range, 56-98 years; 14 females and six males). A common surgical treatment protocol included plate fixation that spanned the entire interprosthetic zone (overlapping the stem proximally and knee component distally) and the use of biologic tissue-preserving plating techniques without use of supplemental bone grafts of any kind. Fracture healing, time to full weightbearing, malunion, nonunion, and the presence of any hardware failure. Supracondylar interprosthetic fracture patterns (OTA 33A) were two times more common than proximal diaphyseal fractures (OTA 32) (Vancouver B), 65% versus 35%. All 20 fractures healed after the index procedure. The average time to weightbearing as tolerated was 13 weeks (range, 6-22 weeks). There were three malunions (one 10° valgus, one 9° extension, and one 10° flexion), two cases of painful implants (one required removal), and one loose long-stem revision hip prosthesis (required total femur replacement). All other implants remained well-fixed. All complications occurred in patients with supracondylar fracture patterns. There were no additional associated peri-implant fractures. Interprosthetic femoral fractures tend to occur more frequently in the supracondylar region about total knee arthroplasty components than in the diaphysis about hip stems. Modern biologic plating techniques that span the entire interprosthetic zone to eliminate additional stress risers show reliable union rates without the use of adjuvant bone graft while maintaining limb alignment and implant survivorship.

A prospective study of hip revision surgery using the Exeter long-stem prosthesis: function, subsidence, and complications for 57 patients

BackgroundThe long-stem Exeter femoral component is commonly used in revision hip surgery. Subsidence of the femoral stem in primary hip arthroplasty has been studied extensively, but much less is known about its significance in revision surgery. This prospective study examined the relationship between radiological subsidence, Western Ontario and McMaster (WOMAC) osteoarthritis index pain score, patient satisfaction and complication rates for the long-stem Exeter hip prosthesis.Materials and methodsData was prospectively collected for a single-surgeon series of 96 patients undergoing revision surgery with a mean follow-up period of 36 months. Pre- and post-operative clinical evaluation was carried out using the validated WOMAC osteoarthritis index. Radiographic evaluation was carried out on magnification-adjusted digital radiographic images.ResultsData from 57 patients were analysed. The mean rate of subsidence recorded was 0.43 mm/year, with a mean total subsidence of 0.79 mm [95% confidence interval (CI) 0.57–1.01] at 36.3 months. There was no correlation between subsidence and post-operative WOMAC score, complication rate or patient satisfaction. There was a statistically significant reduction between pre-operative and post-operative WOMAC scores, with means of 33.5 and 10.7, respectively (P < 0.001), and high patient satisfaction.ConclusionOur subsidence rates for long-stem revision femoral components are lower than the published data but demonstrate the same plateau. Radiographic subsidence does not appear to relate to functional outcome or complication rates in our data.

Outcome of revision surgery for failed primary Souter-Strathclyde total elbow prosthesis

Total elbow arthroplasty is used for the treatment of the painful, destroyed elbow joint. With the increase in elbow replacement surgery in recent years, the number of revision surgeries will also increase. At our center, 236 primary Souter-Strathclyde total elbow prostheses have been placed. Twenty-four of these have been revised and were followed up for a mean of 74 months (range, 12-165 months). The postoperative clinical outcome after revision surgery can approximate the outcome after primary elbow replacement. Unfortunately, 8 elbows needed to be re-revised, 7 elbow prostheses loosened, and we had 1 early dislocation during follow-up. Three of the eight re-revised elbows had a third revision. Two other patients had a resection arthroplasty because of deep infection after the first revision. After 5 years, 73.8% of the revised elbow prostheses were still in situ. The lack of other satisfactory treatment options, combined with the satisfactory clinical results, justify revision surgery of elbow prostheses. The absence of intraoperative fracture during removal of the relatively small standard components and the availability of long-stemmed revision components, which facilitate fixation in the impaired bone, both support our preference for the Souter-Strathclyde prosthesis.

Distal Femoral Allograft Reconstruction for Massive Osteolytic Bone Loss in Revision Total Knee Arthroplasty

Massive osteolytic bone loss in revision total knee arthroplasty has been an uncommon challenge. From 2001 to 2002, 11 knees in 10 patients underwent revision of failed modular PFC (Johnson and Johnson Orthopaedics, Raynham, Mass) total knee arthroplasties with distal femoral allografts and long-stemmed revision implants for massive osteolytic induced femoral bone loss. The mean follow-up was 42 months (range, 36-48 months). Radiographic graft incorporation was demonstrated in all 11 knees with no cases of loosening. The Knee Society Pain Scores improved by an average of 25.4 points, and the function scores improved by an average of 23.3 points. The outcomes of distal femoral allografts in the reconstruction of massive osteolytic bone loss associated with failed modular PFC (Johnson and Johnson Orthopaedics) total knee arthroplasties are favorable.

Periprosthetic Femoral Fractures Associated With Contralateral Hip Disease

Femoral osteolysis associated with contralateral hip degenerative changes is a risk factor for ipsilateral periprosthetic femoral fracture. We report 5 comminuted proximal shaft fractures around loose femoral implants occurring in patients with both symptomatic femoral lysis and a painful hip on the other side. Our evolving strategy involves timely revision surgery once this pattern is recognized. Once fracture has occurred, emergent revision requires extensive medical evaluation, availability of long-stem revision implants, and appropriate instrumentation and allografts for fracture fixation.

Cemented long-stem revision total knee arthroplasty

From 1981 to 1989, 38 cemented, posterior, stabilized, revision, total knee arthroplasties (TKAs) were performed at the authors’ institution using the stemmed kinematic stabilizer prosthesis of a single design. The mean clinical follow-up after the index procedure was 10.1 years. The Knee Society pain score averaged 17 points before revision and improved to 51 points at last follow-up, and the function score averaged 48 points before revision and improved to 57 at last follow-up. Ten-year component survival free of revision or removal for any reason was 96.7%; 11-year component survival free of revision for aseptic loosening was 95.7%. Cemented stem fixation in revision TKA provides good clinical results with durable fixation at an average of 10 years’ follow-up.

Long-term results after cemented revision of the femoral component in total hip arthroplasty

The need for revision total hip arthroplasty has been increasing. The early results have been poor, and different revision techniques have been introduced. We report our results of 84 consecutive cemented first-time revisions of femoral components performed from 1981 through 1988 using a long-stem revision component. The average time to follow-up was 11.4 years (range, 7.9–15.0 years). Patients with 47 revisions had died; 2 of these had been rerevised. Two additional patients were lost to follow-up for other reasons. Of the living patients, 12 had been rerevised, leaving 23 patients (23 hips) for complete follow-up evaluation, including clinical and radiographic assessment. Of 23 patients, 15 reported no pain, 4 had only slight pain, and 4 had more severe pain. In 4 cases, there were definite radiographic signs of loosening of the femoral component. Kaplan-Meier survivorship analysis showed an overall 10-year survival of the femoral component of 77.9%. Using rerevision because of aseptic loosening or definite radiographic loosening as endpoint, the 10-year survival was 80.7%. Simple recementation is well indicated in elderly patients with only minor bone loss.

The use of bulk allografts in revision knee arthroplasty

During the revision of a failed total knee implant, when large osseous defects are encountered, the surgeon has the following three options for managing severe bone loss: revision with a custom implant, revision with a rotating-hinge component, or reconstruction with an allograft and a long-stemmed revision component. An allograft reconstruction replaces the damaged bone, albeit with dead bone; whereas the other two options require additional bone to be removed. By using a bone defect classification system preoperatively, the surgeon estimates the extent of bone damage and orders the proper revision system and allograft material. A durable revision arthroplasty is achieved by using long-stemmed implants that provide axial stability, cementless stems that permit compressive loads, and step cuts that achieve rotational stability.

Fractures of the ipsilateral femur after hip arthroplasty: A statistical analysis of outcome based on 487 patients

A complete review of the literature revealed 487 patients in 26 published reports with ipsilateral femur fractures occurring about the femoral prosthetic stem. This review included general surveys, multicenter studies, and case reports. Based on these studies, the authors divided the fractures into six types: type 1, intertrochanteric; type 2, proximal femur; type 3, spanning the prosthesis tip; type 4, distal to the prosthesis tip; type 5, comminuted blowout; and type 6, supracondylar. Type 1–5 fractures were stratified into the following treatment groups: traction, casting and partial weight bearing, cerclage wiring, screw/plate fixation, long-stem revision with plus/minus supplementation fixation or bone-graft, and other less frequently reported techniques. A statistical analysis of each type of fracture in terms of the various treatments used and the clinical outcome was performed. The best results based on the literature would be cerclage wiring or long-stem revision for types 2, 3, and 5 fractures ( P < .02). For type 4 fractures, traction and long-stem revisions were about equally successful (at 77 and 74%, respectively), and were both superior to screw/plate fixation or cerclage fixation ( P < .01). Other factors, such as cemented versus cementless prostheses, stable versus unstable prostheses, overall medical condition of the patient, and other parameters, should be analyzed and considered when choosing a treatment course. Based on the authors' results, suggestions for the treatment of each fracture type are offered.

Clinical and radiographic evaluation of long-stem femoral components following revision total hip arthroplasty

Fifty-four consecutive, long-stem revision hip arthroplasties were performed in 53 patients. In order to evaluate periprosthetic femoral changes, all cases utilizing cement, requiring bone-grafts for prosthetic stability, or with a follow-up period of less than 2 years were omitted. Thus, 32 long-stem revision hip arthroplasties in 32 patients were reviewed. Twenty-three Porous Coated Anatomic (Howmedica, Rutherford, NJ) and nine Bi-Metric (Biomet, Warsaw, IN) stems were implanted, with an average follow-up period of 3.6 years (range, 2–6 years). Prosthetic canal fill averaged 94% proximally and 80% distally. Intraoperative complications included three femoral shaft fractures. Harris hip scores averaged 47.8 points, before surgery and 87.6 points at the final follow-up evaluation, with 81% of patients the pain-free. Only three cases of subsidence and one case of osteolysis were noted. By 1 year, proximal osteopenia (off-load) ( P = .005), bony condensation about the porous surface (spot weld) ( P = .05), and pedestal formation ( P = .004) were observed. The presence of distal cortical hypertrophy, ( P = .02) spot weld ( P = .001), and pedestal formation ( P = .05) correlated significantly with offload. Pedestal formation and distal cortical hypertrophy were commonly found together ( P = .001). Despite significant periprosthetic remodeling, adequate fixation and satisfactory early clinical scores were achieved in this setting. Contrary to similar reviews using extensive bone-grafts, acceptable pain-free clinical results were obtained with these components.

Principles of cementless total hip revision and use of APR revision hip

To date, cementless revision surgery has been as much an art as a science. A classification is presented that types revisions according to bone quality. The anatomic porous replacement (APR) socket is used in all Type 1 and 2 revisions and most Type 3 revisions except when 100% of the cup is supported by bone graft. In this situation, a bipolar component is selected. The use of the classification allows preoperative planning of stem type and need for bone graft. A primary APR stem can be used for Types 1 and 2a. An APR long-stem revision is used for Type 2b and Types 3a, 3b, and 3c. The most critical factor required for a stable fit (preventing subsidence) and proximal fixation is a match of the proximal and distal fill. The proximal stem has rotational stability when anteroposterior fit is as good as medial-lateral fit.

Variations in the Density of Bone Cement After Centrifugation

Barium sulfate added to bone cement to provide radiopacity has a density about four times greater than that of polymerized radiolucent bone cement. Because centrifugation might make a clinically significant change in the distribution of barium sulfate, this process was studied. Radiolucent and radiopaque Simplex-P bone cement (Howmedica, Inc., Rutherford, New Jersey) were mixed with and without cooling and centrifuged for two or four minutes at 2,000 g or 1,000 g (gravity acceleration). The density of sections of the hardened bone cement was measured using the Archimedes principle. Erythromycin and colistin were added to cement batches to test whether or not centrifugation affected the distribution of antibiotics. Direct and radiographic observation and density measurements (cooled specimens, 2,000 g, p less than 0.01) verified that barium sulfate does accumulate at the bottom of the centrifugation tubes. Thin sections of the bone cement revealed that only larger particles (20-100 micron) of barium sulfate were deposited at the bottom. No evidence of redistribution of antibiotics after centrifugation was seen. It is recommended that Simplex-P bone cement be reformulated to eliminate concern about inhomogeneities that arise from centrifugation. Further, it is recommended that cooled, centrifuged antibiotic cement be used for long-stem revision hip surgery, where longer setting times are necessary, and room temperature cement for "fresh" hip surgery. A total centrifuge time of two minutes with a 2,000 g maximum force is recommended.