Proximal Femoral Arthroplasty Research Articles

Outcomes After Abductor Reattachment to Proximal Femur Endoprosthesis After Tumor Resection

Resection of the proximal femur raises several challenges including restoration of the abductor mechanism. Few evaluated the outcomes of different techniques of abductor fixation to the proximal femur endoprosthesis. A retrospective review of patients who underwent proximal femoral arthroplasty with a minimum follow-up of 12 months was conducted. Patients were divided into two groups: (1) those with preserved greater trochanter (GT) reattached to the implant and (2) those with direct abductor muscle reattachment. Both groups were compared for surgical and functional outcomes. Group 1 patients were subdivided into those who received GT reinsertion using grip and cables and those reattached using sutures. Fifty-three patients were included with a mean follow-up of 49 months. There were 22 patients with reinserted GT and 31 patients with soft-tissue repair. The endoprosthesis revision rate was comparable between groups (P = 0.27); however, the incidence of dislocations was higher in group 2 (0/22 versus 6/31; P = 0.035). Trendelenburg gait (77% versus 74%), use of walking aids (68% versus 81%), and abductor muscle strength were comparable between both groups (P > 0.05). In group 1, 15 patients had GT reinsertion with grip and cables. Of those, five patients (33%) had cable rupture within 13 months of follow-up. GT displacement reached 12 mm at 12 months of follow-up in patients with grip and cables compared with 26 mm in patients with GT suture reinsertion (P < 0.05). Although GT preservation did not improve functional outcomes, it was associated with a lower dislocation rate despite frequent cable failure. Less displacement was observed when GT reattachment used grip and cables.

Proximal femoral replacement in non-neoplastic revision hip arthroplasty : five-year results.

AimsWith increasing burden of revision hip arthroplasty (THA), one of the major challenges is the management of proximal femoral bone loss associated with previous multiple surgeries. Proximal femoral arthroplasty (PFA) has already been popularized for tumour surgeries. Our aim was to describe the outcome of using PFA in these demanding non-neoplastic cases.MethodsA retrospective review of 25 patients who underwent PFA for non-neoplastic indications between January 2009 and December 2015 was undertaken. Their clinical and radiological outcome, complication rates, and survival were recorded. All patients had the Stanmore Implant – Modular Endo-prosthetic Tumour System (METS).ResultsAt mean follow-up of 5.9 years, there were no periprosthetic fractures. Clearance of infection was achieved in 63.6% of cases. One hip was re-revised to pseudo arthroplasty for deep infection. Instability was noted in eight of the hips (32%), of which seven needed further surgery. Out of these eight hips with instability, five had preoperative infection. Deep infection was noted in five of the hips (20%), of which four were primarily revised for infection. One patient had aseptic loosening of the femoral component and awaits revision surgery. The Kaplan-Meier survivorship free of revision of any component for any reason was 72% (95% confidence interval (CI) 51.3% to 92.7%), and for revisions of only femoral component for any reason was 96% (95% CI 86.3% to 105.7%) at five years.ConclusionDislocation and infection remain the major cause for failure, particularly in patients with pre-existing infection. The use of dual mobility cups, silver-coated implants, and less aggressive postoperative rehabilitation regimens would possibly aid in the reduction of complications. PFA performed in patients with periprosthetic fracture seem to fair better. This study supports the judicious use of PFA in non-oncological revision hip arthroplasties, and that they be performed by experienced revision arthroplasty surgeons.Cite this article: Bone Jt Open 2022;3(3):229–235.

Novel Cemented Technique for Trochanteric Fixation and Reconstruction of the Abductor Mechanism in Proximal and Total Femoral Arthroplasty: An Observational Study.

BackgroundLittle evidence exists regarding the clinical outcomes of cemented trochanteric fixation for abductor mechanism reconstruction in proximal or total femoral replacements. Clinical outcomes were assessed for a novel cemented technique for trochanteric fixation in femoral megaprostheses.MethodsA descriptive series of 13 patients who underwent proximal or total femoral arthroplasty from 2016 to 2019 were reviewed. Radiographic trochanteric displacement >1 cm defined construct failure. A Kaplan-Meier survival analysis was performed to determine survival rates for these cemented constructs. Demographic information was obtained to better characterize the patient population in whom this technique was used.ResultsEleven patients were included (age = 63.6 years; 45.4% females; body mass index = 31.7). Mean time to final radiographic follow-up was 73.8 weeks. Three of 11 (27.2%) patients had construct failure. Overall, survival at 1 year was 81.8%. At 2 years, survival of cemented constructs was 65.5%. More construct failures occurred in patients who sustained a postoperative dislocation than in those who did not (P = .05).ConclusionsThis novel cemented trochanteric fixation technique for reconstruction of the abductor mechanism in femoral megaprostheses had 81.8% survival at 1 year postoperatively. While longitudinal comparative studies with larger samples are needed, the cemented technique may provide a viable alternative to traditional cementless methods of trochanteric fixation. Increased construct failure rates after postoperative dislocation highlight the importance of robust abductor reconstruction in these implants.

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

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

Total Hip Arthroplasty for Periacetabular Metastatic Disease. An Original Technique of Reconstruction According to the Harrington Classification

BackgroundPeriacetabular metastatic disease requires complex acetabular reconstruction. The complication rate for these frail patients is high. Various cement-rebar reinforced techniques allowing cemented total hip arthroplasty (THA) have been described. The optimal procedure has not yet been identified. MethodsA continuous series of 131 THAs performed in 126 patients with periacetabular metastatic disease was prospectively included in this study. After bone metastasis curettage and cementation, an original technique of acetabular reconstruction was performed using a dual mobility cup cemented into an acetabular reinforcement device (ie, Kerboull cross-plate or Burch-Schneider antiprotrusio cage) according to the Harrington classification. Functional outcome for independent ambulation in the community, pain relief, and occurrence of dislocation or mechanical failure of the acetabular reconstruction were assessed. ResultsAt a mean follow-up of 33 ± 17 months, the improvement in the preoperative to postoperative functional outcome and pain relief was significant (P < .001). The dislocation rate was 2%. Two of the 3 cases of dislocation occurred in acetabular reconstructions associated with a proximal femoral arthroplasty. No mechanical failure or aseptic loosening of the acetabular reconstruction was observed. ConclusionThis study emphasized that our original technique combining bone metastasis curettage and cementation, acetabular reinforcement device and cemented dual mobility cup was effective to restore a painless functional independence and ensure a durable acetabular reconstruction able to face to adjuvant radiation therapy and mechanical solicitations for long survivors. In addition, dual mobility cup limited the risk of dislocation in patients undergoing THA for periacetabular metastatic disease.

The stability of the hip after the use of a proximal femoral endoprosthesis for oncological indications: analysis of variables relating to the patient and the surgical technique.

Instability of the hip is the most common mode of failure after reconstruction with a proximal femoral arthroplasty (PFA) using an endoprosthesis after excision of a tumour. Small studies report improved stability with capsular repair of the hip and other techniques, but these have not been investigated in a large series of patients. The aim of this study was to evaluate variables associated with the patient and the operation that affect post-operative stability. We hypothesised an association between capsular repair and stability. In a retrospective cohort study, we identified 527 adult patients who were treated with a PFA for tumours. Our data included demographics, the pathological diagnosis, the amount of resection of the abductor muscles, the techniques of reconstruction and the characteristics of the implant. We used regression analysis to compare patients with and without post-operative instability. A total of 20 patients out of 527 (4%) had instability which presented at a mean of 35 days (3 to 131) post-operatively. Capsular repair was not associated with a reduced rate of instability. Bivariate analysis showed that a posterolateral surgical approach (odds ratio (OR) 0.11, 95% confidence interval (CI) 0.02 to 0.86) and the type of implant (p = 0.046) had a significant association with reduced instability; age > 60 years predicted instability (OR 3.17, 95% CI 1.00 to 9.98). Multivariate analysis showed age > 60 years (OR 5.09, 95% CI 1.23 to 21.07), female gender (OR 1.73, 95% CI 1.04 to 2.89), a malignant primary bone tumour (OR 2.04, 95% CI 1.06 to 3.95), and benign condition (OR 5.56, 95% CI 1.35 to 22.90), but not metastatic disease or soft-tissue tumours, predicted instability, while a posterolateral approach (OR 0.09, 95% CI 0.01 to 0.53) was protective against instability. No instability occurred when a synthetic graft was used in 70 patients. Stability of the hip after PFA is influenced by variables associated with the patient, the pathology, the surgical technique and the implant. We did not find an association between capsular repair and improved stability. Extension of the tumour often dictates surgical technique; however, our results indicate that PFA using a posterolateral approach with a hemiarthroplasty and synthetic augment for soft-tissue repair confers the lowest risk of instability. Patients who are elderly, female, or with a primary benign or malignant bone tumour should be counselled about an increased risk of instability. Cite this article: Bone Joint J 2017;99-B:531-7.

OUTCOMES OF PALLIATIVE ORTHOPEDIC SURGERY FOR HIP DISLOCATION IN PATIENTS WITH CEREBRAL PALSY

Introduction. Hip dislocation is the key problem in patients with severe cerebral palsy (GMFCS IV, V) older than 10 years that affects life quality and limits functional capabilities. In the present study the authors evaluated the efficiency of the proximal femoral resection arthroplasty (pfra) and valgus proximal osteotomy of the femur (VPOF) associated with femoral head resection for pain control, improvement of postural management, hygiene and verticalization with total weight-bearing and correction of accompanying orthopaedic deformities. Material and мethods. A retrospective study compared two groups of patients where PFRA (7 cases, 13 hips) or VPOF (14 patients, 23 hips) were performed. Level V of GMFCS was reported in 10 patients, and level IV of GMFCS – in 11 patients. The mean age at time of surgery was 15.3±3.9 y.o. PFRA was performed in 7 cases (13 joints) and VPOF – in 14 patients (23 joints). Results. The authors did not observe any difference between the methods in respect of pain control, postural management, comfortable sitting position and hygiene. The verticalization with total weight-bearing and life quality improvement was achieved only after PVOF with femoral head resection associated with simultaneous knee and foot deformity correction performed according to the principles of Single-Event Multilevel Orthopedic Surgery. Conclusion. Both palliative methods allow to control pain syndrome, to achieve satisfactory postural management, comfortable sitting position and hygiene. But only VPOF with simultaneous knee and foot deformity correction provides possibility to verticalize the patient with weight-bearing using different orthopedic devices.

Осложнения при паллиативных вмешательствах при вывихе бедра у пациентов с ДЦП

Introduction Hip dislocation is one of the most severe orthopedic complications among the problems in patients above 10 years of age with severe forms of cerebral palsy (CP), when reconstructive intervention is impossible. The purposes of palliative surgical orthopedic treatment in patients of this category consist in elimination or reduction of the pain syndrome, as well as elimination of the hip faulty position, possibility of limb free mobilization, improving the patient’s care conditions. Proximal femoral resection arthroplasty and valgus support osteotomy of the proximal femur combined with head resection are the main methods of palliative surgical treatment. Purpose To evaluate the encountered errors and complications, as well as to compare the authors’ own observations with the literature data. Materials and Methods The authors analyzed the complications encountered in the process of palliative surgical treatment (37 surgeries) of the hip dislocation in 22 patients which represented severe forms of motor disorders for spastic CP forms. Level V by GMFCS was observed in nine (9) cases, Level IV – in 13 cases. Proximal arthroplastic resection was performed in 11 cases (Group 1), proximal valgus support osteotomy – in 26 cases. Results The authors observed five (5) complications in Group 1 after 11 interventions (45.5%). Correction of the developed complications led to the full achievement of the desired result of treatment in five of six patients from this group (83.3%): disappearance or significant reduction of the pain syndrome, ease of hygiene, a comfortable sitting position. In Group 2 where the purpose of treatment aside from the pain syndrome elimination, the increase in the range of passive hip mobilization and achieving the proper postural management consisted in creating the conditions for passive verticalization with the lower limb support, seven (7) complications occurred after 26 interventions (26.9 %). The proper result of treatment was achieved in 24 of 26 hips after surgical correction of the complications (92,3%). Conclusion In most cases, surgical intervention is required in order to eliminate the complications after the palliative intervention, that allows, in general, achieving the desired result of treatment. When the severe pain syndrome develops due to mechanical conflict between the hip and pelvic bones through heterotopic ossifications and marked periosteal stratifications, the femoral arthroplastic resection after palliative interventions allows controlling the pain syndrome, restoring the hip passive mobility, providing postural management, but not to impart weight-bearing to the limb. It’s necessary to use only the plates with angular stability and without placing the screws in the direction of the acetabulum.

Proximal Femoral Arthroplasty in Patients Undergoing Revision Hip Arthroplasty

Bone loss represents one of the greatest challenges in revision joint surgery. A retrospective review was conducted of both radiographic and clinical outcomes of eleven patients who underwent revision arthroplasty using a long extensively porous coated cylindrical femoral component. All patients' femurs presented with severe proximal femoral bone loss (Paprosky class IIIB and IV). With a mean follow-up of 8years (2 to 14) we report no femoral revisions and one acetabular revision to a constrained cup secondary to instability. All patients were clinically and radiographically stable. We did not observe any issue with proximal stress shielding or component loosening. The article reports that in patients with severe proximal femoral bone loss, extensively porous-coated non-modular stems are a viable option offering stable and predictable outcomes.

Systematic Review of Proximal Femoral Arthroplasty for Non-Neoplastic Conditions

Proximal femoral arthroplasty (PFA) is an established treatment modality following oncological resection. Increasingly, these prostheses are being used for non-neoplastic conditions such as fractures and bone loss associated with septic or aseptic loosening. We performed a systematic review of the literature to determine the failure rates, mortality rates and hip outcome scores when PFAs were used in non-neoplastic conditions. There were 14 studies with an average follow-up of 3.8years (range 0–14years) describing 356 PFAs. Re-operation for any reason occurred in 23.8% (85/356) of cases. The most common complications were dislocation (15.7%) and infection (7.6%). The mortality rate ranged from 0% to 40%. PFA provides an acceptable surgical solution when confronted with massive bone loss, but it has a high re-operation rate for dislocation and infection.

A Novel Technique for Femoral Canal Occlusion During Cement Pressurization in Proximal Femoral Arthroplasty

We describe a novel technique for occluding the femoral canal distal to the isthmus during proximal femoral arthroplasty. Synthetic bone models were reamed and sectioned to simulate loss of the proximal femur. Two experimental conditions were used. The first used no restrictor to act as a control. The second used calcium sulphate pellets impacted in distal femoral canal. A 100 × 12 mm Limb Preservation System stem (DePuy, Leeds, UK) was used in all experiments. We recorded cement pressure, leakage of cement, and penetration of cement into the femoral condyles. The calcium sulphate pellets prevented cement leakage, enabled higher cementing pressures, and prevented penetration of the cement into the femoral condyles. We would recommend this technique in cases where loss of proximal femoral bone loss requires the use of a cemented proximal femoral replacement.

Impaction Bone Grafting With Proximal and Distal Femoral Arthroplasty

Capacious diaphyses and poor bone stock in revision arthroplasty can lead to fracture and poor component fixation. Impaction bone grafting can be performed in salvage reconstructions in cases with extensive circumferential bone loss. We present a consecutive series of patients who underwent proximal or distal femoral reconstructions in combination with impaction bone grafting. The average age was 62 years, and the mean follow-up was 36 months (range, 24-84). No revisions were performed for mechanical failure, and radiographs revealed no evidence of implant loosening. No patient complained of end-of-stem thigh pain. There were 3 failures: 1 for periprosthetic fracture, 1 for instability, and 1 for infection. Impaction bone grafting can be used in combination with proximal and distal femoral arthroplasty to successfully manage cases with extensive bone loss after failed hip and knee arthroplasty. The procedure reconstitutes necessary bone stock, improves stress shielding, and provides immediate fixation in capacious canals.

Enhancing Soft Tissue Ingrowth in Proximal Femoral Arthroplasty With Aortograft Sleeve: A Novel Technique and Early Results

Hip abductor function is critical to joint stability after proximal femoral arthroplasty. Normal soft tissue relationships are often violated during this procedure for complete tumor resection. Abductor insufficiency leads to abnormal gait mechanics and poor function. To improve soft tissue stability about a metallic proximal femoral endoprosthesis, we devised a novel use of vascular graft material. Two patients received a proximal femoral arthroplasty using this technique. These patients were followed for an average of 26.5 months. They demonstrated mean active hip abduction of 48°, hip flexion of 90°, mean Musculoskeletal Tumor Society score of 24 (80%), and Toronto Extremity Salvage Score of 80. We believe that this technique may be useful in achieving soft tissue stability about a metal endoprosthesis and may facilitate better function in patients undergoing this surgery.

Purse-String Capsule Repair to Reduce Proximal Femoral Arthroplasty Dislocation for Tumor—A Novel Technique With Results

Hip joint dislocation is the most common complication after proximal femoral arthroplasty with a large endoprosthesis. Average dislocation rates are around 15%. In an attempt to decrease dislocations after proximal femoral arthroplasty for tumor resections, we devised a novel closure of the hip capsule. This technique uses a 3-mm cottony Dacron suture placed about the hip capsule in a circumferential, purse-string manner. Thirty-nine patients received hip hemiarthroplasty with purse-string capsular closure. Seven patients were lost to follow-up, leaving 36 patients available for analysis. One patient dislocated (2.8%). We believe this technique is useful in preventing dislocation in patients undergoing proximal femoral arthroplasty for oncologic disease.

Five-Year Results of Bipolar Arthroplasty With Bone Grafts and Reamed Acetabula for Osteoarthritis in Young Adults

Bateman universal proximal femoral arthroplasty combined with acetabular reaming was performed in 35 cases of osteoarthritis of the hip joint. The patients were from 21 to 59 years of age (average, 41 years of age) at the time of operation. The postoperative outcome for a middle term ranging from two to eight years, with an average of five years and nine months, was studied along with postoperative migration of the outer head. The clinical outcome, assessed by the evaluation criteria for hip function proposed by the Japanese Orthopaedic Association, was favorable. A stable average score of greater than 80 occurred for eight years postoperatively; the average preoperative score was 45. Of the 35 cases, seven cases (20%) had an upward migration of the outer head, and one case (2.9%) had an inward migration of 5 mm or more, but the migration did not affect the clinical outcome in any case. There was no certain relationship between the degree of rotation of the outer head and the extent of its migration. Migration of the outer head was prevented by postoperative exercise, in which total loading was initiated after the completion of the radiolucent zone around the outer head and its circumferential zone of osteosclerosis.

Global mechanical consequences of reduced cement/bone coupling rigidity in proximal femoral arthroplasty: A three-dimensional finite element analysis

Component loosening in total hip arthroplasty is often accompanied by substantial bony remodelling, associated initially with reduced stiffness of the cancellous bone bordering the cement, and eventually with the formation and proliferation of a compliant fibrous membrane at the bone/cement interface. An anatomically based three-dimensional finite element model has been developed to explore the salient stress changes occurring with progressive degradation of the stiffness of the cancellous bone in a thin zone bordering the cement. This border zone, modelled as a distinct linearly elastic and isotropic material layer, assumed a geometry and a range of mechanical properties inferred from eventual membrane thickness apparent in recent animal studies of component loosening. The major variables considered were: stiffness (elastic modulus) and compressibility (Poisson ratio) of the border zone, stiffness changes in the outlying cancellous bone, resultant hip contact force, and trochanteric muscle loadings. The results for the limiting case of a non-degraded border zone compared reasonably with previous studies of femoral reconstructions having rigid bone-to-cement attachment. Progressive decay of border zone stiffness produced complex changes in load transmission. Foremost among these were a generalized increase in stress levels (especially of transverse-plane tension) in the proximo-lateral cancellous bone, and a corresponding generalized decrease in stress levels in the proximomedial cancellous bone. There were also large bending moment increases in the prosthesis and its cement mantle, especially at mid-stem. At almost all sites, the critical stress levels were those developed for peak stance-phase loading, rather than for the lower loads (and different resultant contact force directions) occurring elsewhere in the gait cycle. The elevated proximo-lateral cancellous bone stresses occurring with eventual membrane development, consistent with localized bony hypertrophy seen in recent animal studies, may be a response to hoop stresses occurring during pistoning of the tapered cement mantle.

Mechanical consequences of fibrous membrane formation at the bone/cement interface in proximal femoral arthroplasty

Mechanical consequences of fibrous membrane formation at the bone/cement interface in proximal femoral arthroplasty