Metaphyseal Bone Stock Research Articles

Cementless Primary Stems in Revision Hip Arthroplasty: A Narrative Review.

Cementless primary stems in revision hip arthroplasties may be conservative options to preserve bone stock and provide adequate reconstruction of the hip biomechanics. However, there is still little evidence about indications, limitations, and outcomes. This narrative review showed that conventional standard stems were adopted in different revision settings, up to Paprosky IIIA grade bone defects. In cases of acceptable metaphyseal bone stock, when a scratch fit of at least 4 cm can be achieved, a conventional cementless stem may be an adequate solution. Mid-term clinical and radiographic outcomes and survival rates were similar to long revision stems, whereas complications, surgical time, and costs were lower among conventional stems. However, unsuitable contexts for conventional stems included canal diameters larger than 18 mm and failed revision stems with cortical weakening. Even short stems can be considered in revisions, in order to preserve bone stock and stay proximal to femoral remodeling zones and bone/cement plugs. Short stems were successfully adopted up to Paprosky IIIA bone defects, achieving mid-term survival rates not inferior to long revision stems. Ageing, osteoporosis, and intraoperative femoral fractures were the main negative prognostic factors. In very select cases, a downsizing technique (from longer to shorter stems) may be adopted to simplify the procedure and reduce complications.

Simultaneous Tunnel Grafting and Anterior Cruciate Ligament Reconstructions Revision Using Double Suspensory Fixation: A Single-Stage Solution

The anterior cruciate ligament (ACL) is often vulnerable to sports-related injuries, leading to numerous ACL reconstructions (ACLRs) annually in the United States. Although largely successful, these procedures face the risk of recurrent instability due to graft failure. ACLR failures are typically attributed to technical errors and patient-related factors, with improper positioning of the tibial and femoral tunnels as the most common technical mistake. Current 2-stage revision techniques involve primary bone grafting followed by secondary tendon graft placement, resulting in increased costs and extended rehabilitation times. This article proposes a single-stage revision strategy involving simultaneous tunnel grafting and ACLR revision. The method employs double suspensory fixation by adjustable loop buttons, thereby eliminating the dependence on metaphyseal bone stock for stable graft fixation. This new procedure may offer a more efficient and cost-effective approach, reducing the need for a second surgery and potentially allowing patients to return to normal activities more quickly.

Clinical and radiographic outcomes after total hip arthroplasty with the NANOS neck preserving hip stem: a 10 to 16-year follow-up study

BackgroundShort-stem Hip Arthroplasty (SHA) are increasingly implanted in recent years thanks to their potential advantage in preserving metaphyseal bone-stock. Among them, the NANOS® short-stem implant demonstrated satisfactory results to short and mid-term. The purpose of this retrospective study was to evaluate the clinical and radiographic outcome of the Nanos® short stem at a minimum follow-up of 10 years.MethodsSixty-seven patients aged 53 ± 20 years were enlisted in the study, for a total of 72 hips. Primary outcomes were survivorship of the implant and clinical outcome measured using the Hip disability and Osteoarthritis Outcome scores (HOOS) and the Short Form Survey (SF12) questionnaire. The secondary outcome was a radiological evaluation calculating the inclination and the anteversion angle of the acetabular cup for each implant and investigating osteolysis, heterotopic ossifications and stem position.ResultsWe observed a 95.5% stem survivorship. The complication rate was 7.6% and three implants underwent revision because of an aseptic loosening, an infection and a periprosthetic fracture due to trauma.Among 58 patients (63 hips) evaluated in an outpatient visit 10–16 years after surgery, improvement in clinically relevant scores comparing with baseline was observed: HOOS score increased after surgery in all its subcategories (from 32.25 ± 14.07% up to 91.91 ± 9.13%) as well as SF12 which increased by more than 18 percentage points.On clinical assessment, the range of motion (ROM) was restored at follow-up, 1 patient (1.7%) showed a squeaking hip and 2 (3.4%) reported leg-length discrepancy. Neutral stem positioning was achieved in 58 hips and heterotopic ossifications occurred in 10 hips (16%).ConclusionsThe current study reports good clinical and radiological outcomes following NANOS® short-stem hip implant at minimum 10 years-follow-up. Since the high rate of stem survivorship, the low complication rate demonstrated and the overall patient satisfaction, our results suggest NANOS® neck-preserving prostheses should be considered as a valid alternative to standard implants.

Short neck-preserving femoral stem for total hip arthroplasty: medium-term results of a 68-case series.

Short stems seem to be a good alternative for young patients as they offer promising results, rapid recovery and preservation of metaphyseal bone stock. This is one of the few studies in the literature to report medium-term clinical-radiological results for short hip stems. This prospective study evaluated 68 short femoral stems in 63 patients treated with total hip replacement. Clinical, functional and quality-of-life outcomes were measured at 6 and 12months, and annually thereafter until the end of follow-up. The radiological analysis included measurements of potential leg length discrepancies, stem alignment and signs compatible with stress shielding. Fifty-four males (59 hips) and nine females (9 hips) of an average age of 44.3years (range, 25-68) were studied. The most common diagnosis was osteoarthritis (51.5%). Mean overall follow-up was 7.8years (range, 5.8-9.8). The overall survival rate was 97.1% (95% CI 88.7-99.7%). Surgery resulted in an increase of 42.3 ± 1.1 points in the modified Harris Hip Score and 21.9 ± 0.6 points in the Oxford Hip Score (p < 0.001, respectively). Moreover, the pain score as measured on a numerical rating scale (NRS) improved from 95.8 to 36.3. As regards function, an improvement was observed from 3.2 ± 0.8 points to 6.8 ± 1.14 points on the University of California at Los Angeles activity score (p < 0.001, respectively). The radiological analysis showed an absence of radiolucencies or stress-shielding throughout the series. The complications rate at the end of follow-up was 5.7%. The use of ultra-short cylindrical stems with complete anchorage in the femoral neck was shown to offer promising medium-term results. Such stems appear to be a good option for young patients, who are likely to require several revisions over their lifetime.

Mid-term subsidence and periprosthetic radiolucency of the AMIStem: a 5-year EBRA-FCA analysis

BackgroundThere has been an evolution in cementless total hip arthroplasty (THA) with newer short stem designs aimed to preserve metaphyseal bone stock and facilitate implantation through minimally invasive approaches. While early subsidence has been correlated to aseptic loosening in conventional stems, there is a paucity of data regarding short stems. The current study aims to report on stem subsidence and mid-term clinical outcomes of a cementless, metaphyseal-anchored short femoral stem, specifically designed for the direct anterior approach (DAA).MethodsNinety-four consecutive patients (100 hips) with a minimum follow-up of 5 years following cementless THA were included in this single-center retrospective study. Subsidence was evaluated using the “Ein-Bild-Roentgen-Analyse” (EBRA). Periprosthetic radiolucency allocated to the zones of Charnley and Gruen was assessed. Additionally, demographic and implant-related factors potentially associated with increased subsidence and clinical outcomes were evaluated.ResultsAt the last follow-up, the average stem subsidence was 1.98 ± 1.20 mm, with 48% of the implants demonstrating subsidence of > 2 mm. Periprosthetic radiolucency of > 2 mm was found in 26% of the implants in zone 1 and in 9% in zone 7, respectively. Neither the amount of subsidence nor proximal periprosthetic radiolucency was associated with aseptic loosening or worse clinical outcomes.ConclusionsComparable to other proximally fixed short stem designs, the highest subsidence was observed within the first 3 months following implantation. No demographic or implant-related factors were found to have a statistically significant influence on stem subsidence. Periprosthetic radiolucency and subsidence of the AMISstem is not correlated with worse clinical outcomes at 5-year follow-up.

Facing metaphyseal bone stock defects: Mid- and longterm results of cones

Facing metaphyseal bone stock defects: Mid- and longterm results of cones

Surgical and Protocolized Management of Distal Radius Nonunion

Abstract Introduction Nonunion of the distal radius is an extremely rare and serious complication with unpredictable outcomes. The aim of the present study is to analyze the radiological and functional results after a protocolized surgical treatment. Material and Methods A retrospective review of case series of patients with diagnosis of nonunion of the distal radius surgically treated from 2010 to 2016. The diagnosis of nonunion was made at 6 months without signs of consolidation. According to computed tomography (CT) scan images, we propose a classification of this complication as type I: no deformity or mild deformity, with subchondral metaphyseal bone stock beneath lunate facet greater than 10 mm, with no degenerative changes at the distal radioulnar joint (DRUJ); type II: moderate deformity or degenerative changes in the DRUJ, distinguishing between IIA and IIB based on the subchondral metaphyseal bone stock; and type III: degenerative changes at the midcarpal joint. In all cases, a reconstructive technique consisting of volar locking plate osteosynthesis with autologous tailored iliac crest graft was performed, hence none of the cases were classified as type III. Results In total, six cases were included. Mean follow-up: 58 months (range: 30–108 months). Consolidation was achieved in a mean period of 5 months (range: 3–9 months). Average active range of motion: flexion: 54° (range: 10°–80°); extension: 40° (range: 10°–85°); supination: 82.5° (range: 75°–85°); pronation 80° (range: 55–85°); radial deviation: 15° (range: 5°–20°); and ulnar deviation 15° (range: 5–20°). Mean strength: 24.15 Kg (6.9–35 Kg). The average score on the Visual Analog Scale (VAS) at rest was of 0.6 (0–2), and with movement, it was of 1.8 (0–4). The mean postoperative score on the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was of 18.48 (range: 0–50.8). Average radial height: 9.65 mm (range: 7–12 mm); average radial angulation: 17° (10°–20°); volar tilt: 8.36° (range: 0.2°–21°); average ulnar variance: 1.52 mm (range: 0–3.5 mm). Complications: persistent nonunion, superficial wound infection, acquired residual ulnar club hand deformity, radiocarpal arthritis, and midcarpal arthritis. Nevertheless, no salvage techniques were needed or requested during the follow-up, with all patients in an active work situation or living an active life in complete normality. Conclusions The protocolized surgical treatment of pseudoarthrosis of the the distal radius, based on our proposed classification, offers good functional outcomes in the long-term follow-up.

Five-year outcome after conversion of a hemiarthroplasty when used for the treatment of a proximal humeral fracture to a reverse total shoulder arthroplasty.

The reasons for failure of a hemirthroplasty (HA) when used to treat a proximal humeral fracture include displaced or necrotic tuberosities, insufficient metaphyseal bone-stock, and rotator cuff tears. Reverse total shoulder arthroplasty (rTSA) is often the only remaining form of treatment in these patients. The aim of this study was to evaluate the clinical outcome after conversions from a failed HA to rTSA. A total of 35 patients, in whom a HA, as treatment for a fracture of the proximal humerus, had failed, underwent conversion to a rTSA. A total of 28 were available for follow-up at a mean of 61 months (37 to 91), having been initially reviewed at a mean of 20 months (12 to 36) postoperatively. Having a convertible design, the humeral stem could be preserved in nine patients. The stem was removed in the other 19 patients and a conventional rTSA was implanted. At final follow-up, patients were assessed using the American Shoulder and Elbow Surgeons (ASES) score, the Constant Score, and plain radiographs. At final follow-up, the mean ASES was 59 (25 to 97) and the mean adjusted Constant Score was 63% (23% to 109%). Both improved significantly (p < 0.001). The mean forward flexion was 104° (50° to 155°) and mean abduction was 98° (60° to 140°). Nine patients (32%) had a complication; two had an infection and instability, respectively; three had a scapular fracture; and one patient each had delayed wound healing and symptomatic loosening. If implants could be converted to a rTSA without removal of the stem, the operating time was shorter (82 minutes versus 102 minutes; p = 0.018). After failure of a HA in the treatment of a proximal humeral fracture, conversion to a rTSA may achieve pain relief and improved shoulder function. The complication rate is considerable. Cite this article: Bone Joint J 2018;100-B:761-6.

Short stem total hip arthroplasty for osteonecrosis of the femoral head in patients 60\xa0years or younger: a 3- to 10-year follow-up study

BackgroundIn young patients with osteonecrosis of the femoral head (ONFH), short-stem total hip arthroplasty (THA) could allow a potential advantage in preserving metaphyseal bone-stock, when revision surgery might become necessary. However, only a few studies have evaluated the outcome of short-stem THAs in ONFH. We reviewed the prospectively collected data of a cementless partial neck-retaining short-stem with ceramic-on-ceramic bearings in ONFH patients.MethodsThirty patients (37 hips) younger than 60 years (mean age at surgery, 51.5 years) underwent THA with the NANOS® stem (Smith and Nephew, Marl, Germany) from January 2006 to December 2012. All patients received a 32-mm or 36 mm ceramic femoral head. Harris hip score, WOMAC and UCLA activity score were recorded. Postoperative radiographs were evaluated for bone-implant fixation and osteolysis. Further analysis correlated clinical findings with implants characteristics and patient demographics at mean 5.6 years’ follow-up (range, 3–10 years).ResultsThe clinical and functional results improved significantly (p < 0.001). At latest follow-up, mean HHS, WOMAC, and UCLA activity scores were 90 (range, 71–100), 94 (range, 76–100), and 6.3 (range, 4–10) points, respectively. The diameter of the femoral head did not influence the clinical outcome (p = 0.661). All hips showed bone ingrowth fixation of the acetabular and femoral components. No patients showed osteolysis. No revision for any reason was performed during the study period.ConclusionsThe excellent clinical results and fixation pattern at mean 5.6 years’ follow-up reveal this implant as a reliable option in advanced stage of ONFH either. Further investigations are crucial to determine the long-term durability and to assess whether the association of ceramic-on-ceramic bearings, can be useful to achieve longer survivorship and lower complications rates.Trial registrationRegistry number: ISRCTN 91336248; date of registration: 04/07/2017.

Custom intramedullary intercalating device for treatment of supracondylar fracture between constrained total knee arthroplasty and well-fixed total hip arthroplasty

Management of periprosthetic fractures between ipsilateral total knee arthroplasty (TKA) and total hip arthroplasty (THA) is difficult, and is further complicated in the setting of poor femoral bone stock. We present a case of supracondylar fracture between THA and long-stemmed TKA femoral components in a patient with rheumatoid arthritis, deficient metaphyseal bone stock, and recurrent fractures. A long custom intramedullary intercalating component was devised to link the well-fixed existing THA stem to a revision distal femoral component. The resulting construct was stable and allowed for full weight-bearing ambulation, representing a useful treatment option in the management of periprosthetic fractures between revision TKA and well-fixed THA.

Fracture at the stem–condylar junction of a modular femoral prosthesis in a varus–valgus constrained total knee arthroplasty

We present a rare case of fracture of the modular femoral component in a varus-valgus constrained total knee arthroplasty (TKA) prosthesis which occurred 2 years after implantation. Both femoral and tibial components underwent a second revision using a constrained hinged TKA. Laboratory analysis revealed insufficient metaphyseal bone stock in association with inadequate cement mantle incorporation which made implant fixation solely reliant on the intramedullary stem construct. It was therefore hypothesized that high repetitive stresses over the junction of the modular component led to the fracture. Case report, Level IV.

Bone Integration of New “Stemless” Hip Implants (Proxima Vs. Nanos). A DXA Study: Preliminary Results

The development of short femoral prostheses has the advantage to preserve bone and soft tissues, restore hip geometry, permit mini-invasive techniques and allow quickly return to an active life, but very few studies described bone reaction to these new designed prostheses. The aim of the present study was to evaluate the osseointegration of two different partial neck retained stemless hip prosthesis at one year after surgery, measured by the changes of periprosthetic bone mineral density (BMD) in 5 regions of interest (ROIs) using a dual-energy X ray absorptiometry (DXA) device. The signs of stress-shielding were evaluated by standard radiographs. Thirty-two uncemented primary total hip arthroplasty (THA) patients allocated into 2 groups were evaluated. In the first group (n=19) a Proxima (De-Puy-J&J) hip stem was implanted. In the second group (n=12) a Nanos (Smith & Nephew) hip stem was used. We found that both the implants preserve metaphyseal bone stock and increase periprosthetic BMD. In Nanos prostheses a significant higher BMD values were observed in region of interest (ROI) 3 and 4 (p<0.05). No differences were found in ROIs 1, 2, and 5. Proxima stem seem to produce a physiological strain distribution in the femur. No signs of stress-shielding were present in both the implants. In conclusion, this preliminary DXA analysis showed a physiological integration of both the stems that reproduces the biomechanical stress of proximal femur. New designed short stem implants showed optimal osseointegration after one year, and therefore appears an excellent alternative to traditional long stem hip prostheses.

Periprosthetic DXA after total hip arthroplasty with short vs. ultra-short custom-made femoral stems

Background and purpose Dual-energy X-ray absorptiometry (DXA) analysis of the 7 periprosthetic Gruen zones is the most commonly used protocol to evaluate bone remodeling after the implantation of conventional femoral stems. We assessed the value of DXA after cementless primary total hip arthroplasty (THA) by comparing the effect of progressive shortening of the stem of two femoral implants on periprosthetic bone remodeling using a specifically developed protocol of analysis with 5 periprosthetic regions of interest (ROIs).Patients and methods Bone mineral density (BMD) was evaluated in 37 patients in the plateau stage, 3 years after THA. Two femoral implants featuring conceptually new designs and surgical technique were tested: types 1 and 2, characterized by extremely short stem and virtual absence of distal stem, respectively.Results We found that progressive shortening of the femoral stem produces more proximal loading, which effectively preserves metaphyseal bone stock and increases periprosthetic BMD in the medial ROIs over time. In the type 2 group, higher absolute BMD values were observed in medial ROIs 4 and 5. No differences were found in ROIs 1, 2, and 3.Interpretation This study shows the flexibility of DXA in adapting the protocol of periprosthetic analysis to the specific requirements of new implant designs, and it shows its high sensitivity in evaluation of the biological response of bone to changes in implant shape.

Uncemented femoral revision arthroplasty using the modular revision prosthesis MRP-TITAN revision stem

Restoration of a painless hip joint capable of bearing weight by uncemented implantation of a rotationally stable, modular revision stem anchored in the diaphysis. Prosthetic stem loosening with osteolytic bone defects (defect classification types I–III according to Paprosky), material failure with broken prosthesis, sub-and/or periprosthetic femoral fractures, and tumors. Extensive osteolysis preventing diaphyseal anchorage of the prosthetic stem. Transgluteal approach to the hip joint. Removal of the loose prosthetic stem and, if cemented, the bone cement as well. Excision of intramedullary granulation tissue. Reaming of the medullary cavity with flexible reaming shafts and formfit, uncemented implantation of the star-shaped modular revision stem with diaphyseal press-fit. If there is extensive loss of metaphyseal bone stock, augmentation with autogenous-allogenic bone should be performed. Mobilization on two underarm crutches from the 1st postoperative day. Removal of the Redon drains after 48 hours. Partial loading with 20 kg for 6 weeks postoperatively. If plain radiographs show unchanged seating of the prosthesis after 6 weeks, loading can be increased by 10 kg per week until full weight bearing is achieved; thrombosis prophylaxis is continued throughout. Radiologic checkups will be done after 3, 6, and 12 months. After that, the patient should be checked annually. Forty-five patients (N = 48 prostheses) with an average age of 67.2 years (min/max: 42.4–87.4 years) were investigated. The average implantation time of the Modular revision prosthesis MRP-TITAN revision stem was 4.7 years (min/max: 1.0–9.0 years). The Harris hip score for Paprosky bone defect types I–III had increased from 25.6 preoperatively to 71.4 postoperatively at the time of the final follow-up (p 3 0.05). Extensively defective bone was diagnosed preoperatively in 32 patients (1Paprosky IIB). Plain radiographs showed stable anchorage without migration in 44 patients. In one case, the stem (implantation time 2.36 years) was replaced due to increasing axial subsidence (15 mm). Good integration of bone graft with subsequent defect regeneration was seen in all patients with bone trans-plant (N = 30). Postoperative dislocation occurred in six patients and required closed reduction in four cases. Open reduction was performed in two patients, whereby the external rotation angle of the prosthetic neck was corrected without dismantling the distally anchored prosthetic stem components. The mechanical failure rate over the follow-up period of 9 years was 1 out of the 48 prospectively investigated prostheses. The rate of survival according to Kaplan-Meier was 97%.

Distraction Osteogenesis for Nonunion After High Tibial Osteotomy

The purpose of this study was to determine whether distraction osteogenesis can be used to treat hypertrophic nonunion associated with angular deformity and shortening after Coventry style high tibial osteotomy. Five consecutive patients were retrospectively reviewed. In all patients the alignment had collapsed into excessive varus or valgus and leg length discrepancy was present. The leg length discrepancy, malalignment, and nonunion were treated simultaneously with distraction. Union was achieved by the time of fixator removal, which averaged 4.4 months. The Hospital for Special Surgery knee score significantly improved from 42 to 89. The mechanical axis deviation significantly improved by 5 cm. The coronal plane deformity significantly improved by 13 degrees, and leg length discrepancy improved significantly from 2.3 to 0.5 cm. Metaphyseal bone stock increased by 43%, and the Insall-Salvati ratio increased from 1.1 to 1.2 and remained within normal limits. All patients were satisfied with the procedure, and none have had or need a total knee replacement at an average followup of 4 years. Distraction osteogenesis of nonunion after high tibial osteotomy is a minimally invasive and successful procedure. It leads to bony union with correction of deformity and leg length discrepancy and prevents the need for total knee replacement at intermediate-term followup. The increase in metaphyseal bone stock may make total knee replacement technically easier.