Non-cemented Implants Research Articles

A Comparative Study in the Treatment of Fracture Neck of Femur with Cemented and Non Cemented Bipolar Prosthetic Replacement in Rural Hospitals of Bangladesh

Background: The treatment of fracture neck of femur with bipolar prosthetic replacement is commonly performed using cemented and non-cemented implants. This study compares the clinical outcomes, complications, and patient satisfaction between these two methods in rural hospitals of Bangladesh. Methods: This comparative study was conducted in rural hospitals of the Kishorganj district, Bangladesh, from January 2023 to December 2023, to evaluate the outcomes of cemented versus non-cemented bipolar prosthetic replacement in patients with femoral neck fractures. Results: The age range of participants was 48 to 68 years. Regarding gender distribution, 44.4% of patients in the Cemented group were male, compared to 37.0% in the Non-Cemented group. The cemented group had a mean hospital stay of 8.3 ± 2.1 days, while the non-cemented group had a slightly longer stay of 9.0 ± 2.3 days. Postoperative infection rates were higher in the cemented group (11.1%) compared to the non-cemented group (3.7%), with diabetic patients showing a higher infection risk in both groups. Patient satisfaction was 78% in the cemented group and 74% in the non-cemented group, with no significant difference between the two groups (p > 0.05). Conclusion: Cemented bipolar prosthetic replacement offers the advantage of shorter hospital stays and slightly higher patient satisfaction, but at the cost of a higher infection rate, particularly among diabetic patients. Non-cemented prostheses provide comparable long-term outcomes with a lower infection risk, making them a viable option for patients with comorbid conditions

The Effect of Cemented Implants Placed During Initial TKA on Surgical Time and Expenses in Revision TKA.

Revision total knee arthroplasty (rTKA) is a complex procedure that often requires the removal of previous implants. There is little information evaluating the difference between removing cemented or noncemented knee prostheses in revision surgeries. The purpose of this study was to determine whether removing cemented or noncemented implants would affect surgical time and expenses incurred during revision procedures. This retrospective cohort study used a single-institution database to identify 300 patients who underwent femoral and tibial implant rTKA from 2016 to 2022 because of mechanical complications (infection cases excluded). Radiographs and surgical reports were used to confirm whether the fixation technique was cemented (N = 243) or noncemented (N = 57). The primary outcomes were surgical time and surgery costs. Secondary outcomes included readmission rates, revision implants used, stem usage, and insurance type. The average surgical time was 121 minutes for noncemented and 128 minutes for cemented procedures (P = 0.118). The 90-day readmission rates for each group were similar at 7.00% for the cemented cohort and 8.77% for the noncemented cohort (P = 0.643). For patients with Medicare Advantage, the respective surgery costs were $1,966 for noncemented and $1,968 for cemented TKA (P = 0.988). For patients with commercial insurance, the respective surgery costs were $4,854 for noncemented and $5,660 for cemented TKA (P = 0.330). Primary knee fixation type, cemented or noncemented, did not appear to influence the surgical duration or surgical costs of both-implant revision knee surgery indicated for mechanical complications.

Impact of Zweymüller Stem Modification on Clinical and Radiological Outcomes

Background. According to the analysis of large arthroplasty registers we have noted the increase in the use of non-cemented implants, because the latter shows the same results of implant survival as well as cemented implants. On the other hand, they can affect the quality of the bone around the implant in different ways. These components differ in shape, length, and surface properties. According to the analysis of the arthroplasty register of the Vreden National Medical Research Center of Traumatology and Orthopedics, a significant decrease of the Alloclassic femoral stem using can be noted. In parallel the use of its SL-PLUS MIA modification has increased significantly.
 Aims of the study: 1) to determine the influence of changes in the design of the Zweymller-type femoral stem on midterm and long-term outcomes and its survival; 2) to identify the characteristics of adaptive remodeling of periprosthetic bone tissue around these femoral stems; 3) to determine risk factors for aseptic loosening of these femoral stems.
 Methods. 492 cases of hip arthroplasty using the Alloclassic and SL-PLUS MIA femoral stems were observed, with an average follow-up 78.6 months. The patients were divided into 2 groups according to the type of femoral stem. The assessment the hip articulation condition was carried out using the HHS and OHS. The intensity of the pain syndrome was assessed by VAS, and the level of patients satisfaction. The dynamic analysis of X-rays was also performed visually.
 Results. A significant improvement in clinical and functional results was observed according to the HHS and OHS in both groups of patients, regardless of the type of femoral stem. Analysis of X-rays over time showed differences in the behavior of these two femoral component models. The radiolucent lines around the femoral stem are absent in SL-PLUS MIA group, in Alloclassic stem group radiolucent lines are present even at a minimal period (12 months). We also found that a tight fit of Zweymller femoral stems in the distal shaft is a risk factor for severe stress-shielding syndrome, especially in the funnel channels. But ceteris paribus, a distal tight fit of SL-PLUS MIA stems despite similar geometry of the distal part does not lead to such frequent manifestation of severe stress shielding.
 Conclusion. The change in Zweymller stem design from Alloclassic to SL-PLUS MIA improved the nature of adaptive remodeling in the periprosthetic area of the femur. It may improve the long-term results of primary hip arthroplasty, but these differences require closer observation.

Hip replacement in femoral neck fractures: the role of cementation and its technical difficulties.

Hip fractures in elderly patients are an arising problem due to aging of population and still represent a controversial challenge for orthopedic surgeon who should help achieve the best functional recovery in the shortest time. Cementation in hip replacement plays an important role, but it should be carefully planned considering the possible risks. According to the literature, there are still no certainties regarding the superiority of an uncemented implant compared to a cemented one. The purpose of this work is to conduct an overview of the scientific literature that can clarify the advantages and disadvantages of cemented and non-cemented implants from a biological and biomechanical point of view.

Prevention of Bacterial Infection after Knee Arthroplasty: a Randomized Control Trial

Aim: To assess the efficacy of an absorbable calcium-hydroxyapatite (HAC) coating applied to the articular surface of prosthetic implants, in combination with vancomycin, following non-cemented total knee replacement (TKA). Study Design: Randomized control trial Place and duration: This study was conducted at Muhammad Medical College and Hospital Mirpurkhas, Pakistan from June 2020 to June 2021 Methodology: The 126 patients were split into two groups and each received a total of 135 noncemented TKAs. Knees in Group 1 had non-cemented implants put in without any kind of anti-infection care. The local anti-infection treatment, a pasty combination of 2 g absorbable Hac and 1–2 g vancomycin, was applied to 62 knees in Group 2. On the articular surface of the implants, a thin coating of the paste was applied. Both groups of patients got systemic antibiotic treatment. Results: Although there was no case of loosening, three deep infections occurred in group 1 (which did not get a local anti-infection treatment), which was 4.1 percent, in the early or intermediate postoperative phase. Arthroscopic debridement and antibiotics were utilized to treat the infection. No infections or joint laxity were seen in group 2. Conclusion: In non-cemented TKA patients, our research found that a local anti-infection therapy may be a useful addition to systemic antibiotic therapy in preventing deep infections. Keywords: bacterial infection, prevention, knee replacement.

The insidious risk of periprosthetic fracture in clinically functional total hip arthroplasties: A biomechanical study of willed joints.

Femoral bone quality is a major risk factor of periprosthetic fracture after total hip arthroplasty (THA), which has mortality similar to native hip fractures but higher short-term morbidity. The goal of this study was to quantify cortical strains at the site of expected Vancouver Type-B periprosthetic fracture as a function of bone mineral density, femoral stem material, and fixation method using a series of 29 autopsy-retrieved, clinically asymptomatic hip joints with THA. Periprosthetic bone mineral content and density was assessed using dual-energy X-ray absorptiometry by Gruen Zone. Specimens then underwent combined cyclic axial and torsional loading, increasing incrementally from 100 N and ±1 Nm to peaks of 700 N and ±5 Nm. All specimens experienced significantly higher strains on the lateral surface than on the anterior surface, indicating that the bending loads in the frontal plane, rather than axial/torsional loads, had the predominant effect. Multiple significant relationships (p = 0.04, p = 0.02) were found between predicted periprosthetic strains calculated from radiographic measurements and observed principal strains. Though THA in the present study were in successful clinical service, the produced results indicated that some femurs with rigid cemented or noncemented implants were potentially at high risk for Vancouver Type-B fractures, which may be predicted radiographically.

Osseointegration in uncemented total hip arthroplasty: A study of 37 cases

Introduction: Osseointegration is the ability of implants to establish mechanical and functional bond with bone without forming any connective tissue. Osseointegration is useful for clinical follow-up in many implants e.g. dental implants, hearing aids, spinal fusion implants, prosthesis. Endoprosthesis functions pain free when their anchoring components are firmly fixed to the osseous tissue. Total hip arthroplasty is a common procedure in many conditions that reduces pain and improves functions. Non-cemented implants need precise preparation of implant bed and additional fixation device such as screws or projections that cut into the bone to achieve stability. The long term stability and function of joint replacement can be evaluated on the basis of outcomes. If improper osseointegration occurs then fibrinous tissue formed between bone and implant that cause weak and loose implant. Materials and Methods: This was an observational type of study where non-cemented total hip replacement done by different surgeons were included for follow-up. The follow-ups were done in US Bangla Medical College Hospital, Narayangonj and Kurmitola General Hospital, Dhaka between July 2017 to December 2019. A total of 37 patients of total hip replacement were included in this study strictly following inclusion and exclusion criteria. Results and Discussion: To see the functional outcome Harris Hip Score (HHS) was done. Mean HHS at their final follow-up was 88.32±10.32. There were 19 (51.44) patients in excellent category, 11 (29.7%) in good, 4 (10.8%) fair and 3 (8.1%) in poor category according to HHS. Engh’s score was used to see the radiological outcome and it is divided into two part Fixation and Stability. Mean fixation Engh’s score was 5.27±4.63 and stability score was 9.46±8.78. Mean of total Engh’s score was 14.73±12.67. Out of 37 patients 25 (67.6%) patients were bone ingrown, 7 (18.9%) in-growth suspected, 3 (8.1%) suboptimal but stable and 2 (5.4%) were unstable according to Engh’s score for radiological evaluation. Conclusion: To see the osseointegration accurately CT scan or other precise imaging technique should be used. However radiographic evaluation of uncemented total hip arthroplasty by x-ray is valuable method to see osseointegration. But it needs long term follow-up.

Evaluate the results of Noncemented Total Hip Replacement (THR)

Introduction: Total Hip Replacement is one of the most successful orthopaedic procedures performed now-a-days. A British orthopaedic surgeon named Charnley first introduced with this treatment. A noncemented joint prosthesis, sometimes called a press-fit prosthesis, is specially textured to allow the bone to grow onto it and adhere to it over time. Aim of the study: The study aims to determine the results and the complications associated with non-cemented total hip replacement (THR). Methods: This cross-sectional study was conducted in the Department of Orthopaedic Surgery, National Institute of Traumatology and Orthopedic Rehabilitation (NITOR), Dhaka, Bangladesh during the period from February 2016 to February 2018. Sample size was 35. Statistical analysis of the results was done by computer software devised in the statistical packages for social scientist (SPSS-25) and MS excel-16. Results: In total 35 patients in this cross-sectional study from the total of 35 patients we found most of the patients were male 29(82.86%) and female 6(17.14%). Most of the patients found in 31-40 age group 14(40.00%), then 41-50 and that was 11(31.43%) respectively 5(14.29%) found in 21-30, 11(31.43%) in 41-50 and 4(11.43%) in >61. So most of them found excellent on the score of 90-100, 20(57.14%), then 11(31.4%) was 80-89 score as good, 3(8.6%) found in 70-79 score fair and below <70 score found 1(2.9%) as poor. Conclusion: There is many reasons that may have caused surgeons in the past to move away from the use of cemented implants have been found to be unwarranted and the evidence does not support the increasing using of noncemented implants. In particular, the risk of mortality in cemented THA has not been found to be higher than noncemented THA.

Current Evidence-based Indications for Modern Noncemented Total Knee Arthroplasty.

Total knee arthroplasty (TKA) is one of the most common procedures performed in orthopaedic surgery. Traditionally, most TKAs have been performed by cementing the implant to the bone with polymethyl methacrylate to provide fixation. Noncemented implants that rely on boney ingrowth for fixation are increasingly appealing to surgeons, given success in total hip arthroplasty and the desire for long-term stability of implants in younger patients. Despite high failure rates with early designs, several series of recent designs have demonstrated improved survivorship, although this has not been confirmed in larger registry studies. Modern screwless designs with improved porous coating are thought to contribute to better ingrowth and have been designed to address previous implant pitfalls. Surgeons must be aware of the potential advantages and limitations of noncemented TKA.

The Use of Cement in Hip Arthroplasty: A Contemporary Perspective.

Notable advances in hip arthroplasty implants and techniques over the past 60 years have yielded excellent survivorship of fully cemented, hybrid, and reverse hybrid total hip replacements as demonstrated in joint registries worldwide. Major advances in noncemented implants have reduced the use of cement, particularly in North America. Noncemented implants predominate today based on procedural efficiency, concern related to thromboembolic risk, and a historic belief that cement was the primary cause of osteolysis and implant loosening. With the decline of cemented techniques, press-fit fixation has become common even in osteoporotic elderly patients. Unfortunately, there is a troubling rise in intraoperative, as well as early and late postoperative periprosthetic fractures associated with the use of noncemented implants. Despite the success of noncemented fixation, an understanding of modern cement techniques and cemented implant designs is useful to mitigate the risk of periprosthetic fractures. Cemented acetabular components can be considered in elderly patients with osteoporotic or pathologic bone. Cemented stems should be considered with abnormal proximal femoral morphology, conversion of failed hip fixation, inflammatory arthritis, patient age over 75 (especially women), osteoporotic bone (Dorr C), and in the treatment of femoral neck fractures.

Reemplazo de cadera en pacientes jóvenes: Experiencia con vástago corto preservador de cuello femoral

BackgroundThe growing trend in the use of non-cemented implants and the development of technologies that attempt to restore the anatomy and joint function with greater bone preservation has increased the use of short stems in the total hip replacement (THR). The objective of this study is to describe functional results, radiological restoration of the anatomy, complication and revision rate of patients undergoing THR using short femoral stems with metaphyseal cervical fixation with lateral cortical support. Materials and MethodsA prospective descriptive study was performed that included 45 hips of patients with hip osteoarthritis of any origin. The follow-up was 18 months. The outcome variables evaluated were: 1. Integration of the implant, 2. Complications dependent on the femoral implant, 3. Subsidence, and 4. Re-intervention. The functional result was additionally evaluated using the Western Ontario and McMaster Universities Arthritis Index (WOMAC). ResultsDuring the period from December 2011 to July 2017, an improvement was observed in functional status in 97% (n: 44) of patients, with no reoperations. DiscussionBone integration of the implant was observed in 100% of the cases, making the results comparable with the reports in the literature. It is believed that the use of short stems in total hip replacement is a safe procedure, with good outcomes. It also has the advantage of an adequate bone integration of the implant, and guaranteeing a better bone stock in the next surgery. Evidence LevelIV.

Prothèse totale de hanche Accolade/Trident par voie antérieure directe mini invasive sans table de traction: courbe d’apprentissage et résultats au recul minimum de 5 ans

BackgroundThe direct minimally invasive anterior approach (DMIAA) in total hip arthroplasty (THA) is widely accepted. In our department the DMIAA according to Rachbauer together with the Trident cup and Accolade stem was introduced in 2004. The purpose of the study was to demonstrate the five year results and to analyze the learning curve of a new introduced approach. Patients and MethodsBetween July 2004 and May 2006 a consecutive series of 151 THA in 147 patients was retrospectively analyzed. All patients were planned to received a THA with the Accolade/Trident implant system using the DMIAA without traction table. Clinical and radiographic data, complications and survivorship were documented with a follow-up of at least 5 years. ResultsRegarding cup implantation there were 11 (7.3 %) failed intentions to treat due to missing pressfit (8 cases) and acetabular floor perforation (3 cases). No failed intentions to treat occurred during stem implantation. Total implant survival after 5 years follow-up after exclusion of 11 cases with failed intention to treat (n=140) was 96.9 % (SD 1.4; CI: 94.3 %–99.6 %). After exclusion of the failed intentions to treat (n=140, n=4 in the first 20 cases) there was significant (p<0.001) difference between the first 16 implants with a 5 year-survival of 83.2 % (SD 8.6; CI: 66.4 %–100 %) and 95.7 % (SD 0.9; CI: 93.9 %–97.5 %) for the following 124 implants. Radiolucent lines were observed in Gruen zone 1 in 3.3 % and in Gruen zone 1 and 2 in 1.1 %. DiscussionTHA with Accolade/Trident using the DMIAA without traction table according to Rachbauer temporary exposed patients to a higher risk of implant revisions, which was normalized after the first 20 cases. Results of the learning curve are comparable to other techniques using an orthopaedic traction table. After the typical learning curve, the rate of 5 years implant failure is in accordance with the registry data for non-cemented implants. The Accolade stem showed minimal radiographic signs of radiolucency. Level of evidenceIV, retrospective, consecutive case series.

Total hip arthroplasty with accolade/trident through the direct minimally invasive anterior approach without traction table: Learning curve and results after a minimum of 5 years

BackgroundThe direct minimally invasive anterior approach (DMIAA) in total hip arthroplasty (THA) is widely accepted. In our department the DMIAA according to Rachbauer together with the Trident cup and Accolade stem was introduced in 2004. The purpose of the study was to demonstrate the five-year results and to analyze the learning curve of a new introduced approach. Patients and methodsBetween July 2004 and May 2006, a consecutive series of 151 THA in 147 patients was retrospectively analyzed. All patients were planned to received a THA with the Accolade/Trident implant system using the DMIAA without traction table. Clinical and radiographic data, complications and survivorship were documented with a follow-up of at least 5 years. ResultsRegarding cup implantation, there were 11 (7.3%) failed intentions to treat due to missing pressfit (8 cases) and acetabular floor perforation (3 cases). No failed intentions to treat occurred during stem implantation. Total implant survival after 5 years follow-up after exclusion of 11 cases with failed intention to treat (N=140) was 96.9% (SD 1.4; CI 94.3–99.6). After exclusion of the failed intentions to treat (N=140, N=4 in the first 20 cases), there was significant (p<0.001) difference between the first 16 implants with a 5 year-survival of 83.2% (SD 8.6; CI 66.4–100) and 95.7% (SD 0.9; CI 93.9–97.5) for the following 124 implants. Radiolucent lines were observed in Gruen zone 1 in 3.3% and in Gruen zone 1 and 2 in 1.1%. DiscussionTHA with Accolade/Trident using the DMIAA without traction table according to Rachbauer temporary exposed patients to a higher risk of implant revisions, which was normalized after the first 20 cases. Results of the learning curve are comparable to other techniques using an orthopaedic traction table. After the typical learning curve, the rate of 5 years implant failure is in accordance with the registry data for non-cemented implants. The Accolade stem showed minimal radiographic signs of radiolucency. Level of evidenceIV, retrospective, consecutive case series.

Direct comparison of additively manufactured porous titanium and tantalum implants towards in vivo osseointegration

Material properties of implants such as volume porosity and nanoscale surface modification have been shown to enhance cell-material interactions in vitro and osseointegration in vivo. Porous tantalum (Ta) and titanium (Ti) coatings are widely used for non-cemented implants, which are fabricated using different processing routes. In recent years, some of those implants are being manufactured using additive manufacturing. However, limited knowledge is available on direct comparison of additively manufactured porous Ta and Ti structures towards early stage osseointegration. In this study, we have fabricated porous Ta and Ti6Al4V (Ti64) implants using laser engineered net shaping (LENS™) with similar volume fraction porosity to compare the influence of surface characteristics and material chemistry on in vivo response using a rat distal femur model for 5 and 12 weeks. We have also assessed whether surface modification on Ti64 can elicit similar in vivo response as porous Ta in a rat distal femur model for 5 and 12 weeks. The harvested implants were histologically analyzed for osteoid surface per bone surface. Field emission scanning electron microscopy (FESEM) was done to assess the bone-implant interface. The results presented here indicate comparable performance of porous Ta and surface modified porous Ti64 implants towards early stage osseointegration at 5 weeks post implantation through seamless bone-material interlocking. However, a continued and extended efficacy of porous Ta is found in terms of higher osteoid formation at 12 weeks post-surgery.

Comparison of marginal bone loss between internal- and external-connection dental implants in posterior areas without periodontal or peri-implant disease.

PurposeThe purpose of this retrospective study with 4–12 years of follow-up was to compare the marginal bone loss (MBL) between external-connection (EC) and internal-connection (IC) dental implants in posterior areas without periodontal or peri-implant disease on the adjacent teeth or implants. Additional factors influencing MBL were also evaluated.MethodsThis retrospective study was performed using dental records and radiographic data obtained from patients who had undergone dental implant treatment in the posterior area from March 2006 to March 2007. All the implants that were included had follow-up periods of more than 4 years after loading and satisfied the implant success criteria, without any peri-implant or periodontal disease on the adjacent implants or teeth. They were divided into 2 groups: EC and IC. Subgroup comparisons were conducted according to splinting and the use of cement in the restorations. A statistical analysis was performed using the Mann-Whitney U test for comparisons between 2 groups and the Kruskal-Wallis test for comparisons among more than 2 groups.ResultsA total of 355 implants in 170 patients (206 EC and 149 IC) fulfilled the inclusion criteria and were analyzed in this study. The mean MBL was 0.47 mm and 0.15 mm in the EC and IC implants, respectively, which was a statistically significant difference (P<0.001). Comparisons according to splinting (MBL of single implants: 0.34 mm, MBL of splinted implants: 0.31 mm, P=0.676) and cement use (MBL of cemented implants: 0.27 mm, MBL of non-cemented implants: 0.35 mm, P=0.178) showed no statistically significant differences in MBL, regardless of the implant connection type.ConclusionsIC implants showed a more favorable bone response regarding MBL in posterior areas without peri-implantitis or periodontal disease.

Potential of allogeneic bone grafts as antibiotic carriers : Effect of different preparation processes on efficacy

The rising number of primary joint replacements worldwide is causing an increase of endoprosthetic revision surgery due bacterial infection. Revision surgery using non-cemented implants seems beneficial for the long-term outcome, and the use of antibiotic-impregnated bone grafts might control the infection and provide agood support for the implant. In this study, we evaluated the release of antibiotics from fresh-frozen and lyophilized allogeneic bone grafts. Heat-treated, lyophilized and fresh frozen cryopreserved bone chips were impregnated with gentamicin sulphate, gentamicin palmitate and vancomycin, and calcium carbonate/calcium sulphate treated with antibiotics. The efficacy of each preparation was measured by drug release tests and bacterial susceptibility using B.subtilis, S.aureus and methicillin-resistant Staphylococcus aureus. The release of gentamicin from lyophilized bone was similar to the release rate from fresh frozen bone during the entire experiment. This might be related to the similar porosity and microstructure of the bone chips. The release of gentamicin from lyophilized and fresh frozen bone was high on the first and second days, then decreased and stayed at alow rate until the end of the second week. Depending on the surgical strategy, either polymethylmethacrylate or allogeneic bone are able to deliver sufficient concentrations of gentamicin to achieve bacterial inhibition within 2 weeks after surgery. In the case of uncemented revision of joint replacements, allogeneic bone can deliver therapeutic doses of gentamicin and peak levels immediately and afortnight after implantation.

Anatomical and Functional Preliminary Results of Total Non-Cemented Hip Prostheses

The aim of this work was to assess the preliminary anatomical and functional results of patients to establish prospects. Materials and method: We report here the preliminary results of a retrospective mono-centric, homogeneous and continuous series, of 21 non-cemented total hip implants, implanted from January 2011 to December 2014. The mean follow-up time was 24 months. The patients were evaluated by Harris’s hip at the last follow-up. Results: The mean age of the intervention was 30 years. In our series, we observed a male predominance (60% of cases). Clinically, the Harris score varied significantly from 52.6 ± 11.4 pre-operatively to 85.1 ± 5.1 during the last follow-up visit. Among the items in the score, pain was the parameter that showed the greatest improvement. Thigh pain was observed in only one patient operated on the two sides. At the level of radiology, the femoral implant showed great stability. Bone resorption was suspected in 14 cases (66.66%), and confirmed in 4 cases (19.04%) with excellent bone remodeling, illustrated by the Engh and Massin scores. A loosening and a prosthetic dislocation was observed in a patient (4.76%). Any heterotopic ossification was observed. Conclusion: Our study confirmed good clinical and radiological results of the non-cemented hip prosthesis series in young patients. The rates of aseptic loosening, acetabular edges or osteolysis are low and stable over time.

Lyophilized allogeneic bone tissue as an antibiotic carrier.

The rising number of primary joint replacements worldwide causes an increase of revision surgery of endoprostheses due bacterial infection. Revision surgery using non-cemented implants seems beneficial for the long-term outcome and the use of antibiotic-impregnated bone grafts might control the infection and give a good support for the implant. In this study we evaluated the release of antibiotics from fresh-frozen and lyophilized allogeneic bone grafts. Lyophilized bone chips and fresh frozen bone chips were mixed with gentamicin sulphate, gentamicin palmitate, vancomycin, calcium carbonate/calcium sulphate impregnated with gentamicin sulphate, and calcium carbonate/calcium sulphate bone substitute material impregnated with vancomycin. The efficacy of each preparation was measured by drug release tests and bacterial susceptibility using B. subtilis, S. aureus and methicillin-resistant Staphylococcus aureus. The release of gentamicin from lyophilized bone was similar to the release rate from fresh frozen bone during all the experimental time. That fact might be related to the similar porosity and microstructure of the bone chips. The release of gentamicin from lyophilized and fresh frozen bone was high in the first and second day, decreasing and keeping a low rate until the end of the second week. Depending on the surgical strategy either polymethylmethacrylate or allogeneic bone are able to deliver sufficient concentrations of gentamicin to achieve bacterial inhibition within two weeks after surgery. In case of uncemented revision of joint replacements allogeneic bone is able to deliver therapeutic doses of gentamicin and peak levels immediately after implantation during a fortnight. The use of lyophilized and fresh frozen bone allografts as antibiotic carriers is recommended for prophylaxis of bone infection.

Outcome after treatment of Vancouver B2 peri-prosthetic femoral fractures: revision arthroplasty and compression cerclage system fixation

Background: Peri-prosthetic femoral fractures after total hip arthroplasty (THA) are increasing year by year. The aim of this study was to evaluate the treatment effect of Vancouver B2 peri-prosthetic femoral fractures using uncemented revision with compression cerclage system (CCS). Methods: Fourteen patients with a diagnosis of Vancouver type B2 fracture were enrolled between 2002 and 2013. All patients were managed by revision arthroplasty, using cementless femoral long stems with CCS were used to aid the reconstruction where indicated. Results: All the fractures had both clinical and radiological union. The outcome was optimal, subjectively as satisfactory by all patients and this is substantiated objectively, by a post operative mean Harris hip score of 83.0. For Vancouver B2 peri-prosthetic femoral fracture, long stemmed revision was suggested with good clinical outcome. The use of non-cemented implants at revision surgery seemed a natural progression. And CCS is a promising strategy with several advantages. Conclusions: Uncemented revision with CCS system appears to be an attractive option for peri-prosthetic fractures (PPF) with unstable femoral stems.

CORR Insights®: What is the Prognosis of Revision Total Hip Arthroplasty in Patients 55 Years and Younger?

Where Are We Now? Encouraged by the clinical success of THA in elderly patients, surgeons now implant THAs in younger patients with hip arthritis. Unfortunately, traditional hip implants do not last as long in this population, partly due to the higher activity levels of younger patients. These patients also often have structural deformities around the hip, mostly on the acetabular side, which contribute to their early osteoarthritis. Some research suggests [3] using implants with a long track record of clinical success to prevent even more disappointing outcomes. However, the clinical reality is completely different. Younger patients are in the midst of a total hip paradox. In an effort to overcome the disappointing outcomes of THA in younger patients, orthopaedic companies promoted and orthopaedic surgeons implanted, the most cutting-edge prostheses in this young patient group. However, these implant selections currently remain unsupported by clinical data [2]. I believe this will continue to result in an increasing number of failed hip arthroplasties in relatively young patients. Where Do We Need To Go? Revisions are inevitable when surgeons implant THAs in young patients. We should use only implants with a proven clinical track record, along with a reputation for being easily revised. We need revision techniques and implants that can restore the biomechanics of the hip. We currently have only a limited understanding of this issue. The valuable paper by Adelani et al. tries to fill this gap, reporting the outcome of modern revision techniques using noncemented implants in 103 hips. The authors use a case-control study design to evaluate intermediate-term survivorship, complications, and activities of revision procedures relative to primary implantations. As expected, the authors found more complications, and lower clinical outcome scores in the revision groups. However, the authors found a striking difference in the followup outcomes. After a mean followup of nearly 7 years, the survival rate of the revision THA was 69%, compared with 99% of the primary noncemented total hips. Although the few studies available on the topic may not be precisely comparable, the outcome of the newer noncemented implants in revisions for younger patients is not better than the results reported in these older outdated reports, championing cemented techniques. With the increasing number of expected revisions in relatively young patients, there is strong need for revisions techniques with better long-term outcomes. How Do We Get There? Surgeons must discuss the unsatisfying long-term outcomes of primary THA with their young patients. We need to develop techniques or implants for primary THA with better long-term outcomes. Most of the implant failures are seen on the acetabular side. Hopefully, the newer acetabular implants using trabecular metal and highly-crosslinked polyethylene will be helpful [4]. Maybe a more biological approach — restoring as much bone as possible during primary total hip of the often distorted acetabulum using bone grafts — can be another valuable treatment option for this young patient population [1]. Orthopaedic surgeons should follow their patients on a regular basis, in order to identify patients who are losing bone and to intervene before it becomes severe. There currently exist no revision techniques that offer acceptable durability for young patients. Newer techniques, like using trabecular metal augments, remain unproven. Perhaps newer polyethylenes can be part of the fresh strategy. Biological reconstruction techniques focusing on bone repair, such as impaction allografting of the acetabulum [1], may also be helpful.