Stem Revision Research Articles

Case series of patients with pathological dyaphiseal fractures from metastatic bone disease.

Fractures on pathologic bone have major impact on life quality. The appropriate treatment is not standardized, but the current literature delineates that surgery must provide adequate stabilization for the life expectancy. We aimed to review the epidemiology, treatment outcomes and survival in our department. The electronic database from a major referral centre was searched for patients treated for tumours and fractures by the corresponding ICM-10 codes over fiveyears. Eighty-nine patients were identified. Eleven females and nine males, with an average age of 64years underwent 23 operations during the selected timeframe. Six fractures were subtrochanteric, five at the femoral neck and five at the femoral diaphysis. Seventeen cases were metastatic carcinomas, out of which five mammary, three pulmonary and seven carcinomas of undetermined origin without immunohistochemistry. Fourteen types of surgical intervention were osteosynthesis with intramedullary nails and six were partial hip replacements of which one had proximal femur resection and revision stem hemiarthroplasty. Four patients had single metastatic lesions which underwent resection and defect filling using PMMA cement (polymethylmethacrylate). The follow-up period ranged between two and sevenyears or until death. Only five patients (25%) were alive at the last follow-up. Local recurrence appeared in one patient. There was one immediate post-operative complication (dehiscent wound) and one implant failure after five years and was replaced with a larger diameter (exchange nailing). Both hip arthroplasty and femoral nailing are safe and routine procedures that are performed with relatively technical ease and low surgical stress and few peri-operative complications for the patient. They allow for immediate mobilization and weight-bearing with moderate and rapidly decreasing pain and discomfort.

Surgical treatments for Vancouver type B1 periprosthetic femoral fractures

Objective To investigate the outcomes of the treatments for the patients with Vancouver type B1 periprosthetic femur fractures. Methods Seventeen patients with periprosthetic femoral fractures (5 males and 12 females; average age, 70.4 years, range from 37 to 86 years) who underwent revision arthroplasty or open reduction and internal fixation between December 2006 and June 2016 were retrospectively reviewed. Periprosthetic femoral fractures occurred at the mean time of 65.1 months after arthroplasty. Twelve patients underwent open reduction and internal fixation and five cases underwent total hip or stem revision with Solution from Depuy, Wagner from Zimmer, Echelon from Smith & Nephew or Secur-Fit Max from Stryker due to primary bone loss, acetabular component wear or long-time prosthesis use respectively. Data were collected at 1, 3, 6 and 12 months and then each year postoperatively. All patients were followed up, and the results of X-ray, postoperative Harris hip score, stability of prosthesis and complications were also evaluated. Results A total of 5 patients underwent revision arthroplasty, and 12 patients underwent open reduction and internal fixation. The mean follow-up duration was 56 months (range from 7 to 120 months). Total blood loss in the open reduction and internal fixation group and in revision group was 385±129 ml and 531±113 ml respectively. The operation duration in the open reduction and internal fixation group was 72±36 min while it was 126±48 min in the revision group. The postoperative Harris hip score in the open reduction and internal fixation group was significantly increased compared with preoperative Harris hip score (68.8±18.4 vs. 46.2±9.6), as well as in the revision group (75.0±8.9 vs. 57.4±13.0). For the incidence of complications, in the open reduction and internal fixation group, one patient suffer with delayed fracture union, one patient complained about persistent pain and one suffered a secondary fracture, while in the revision group one suffered from blood loss and one with long-term pain. Conclusion Open reduction and internal fixation is an optimal intervention for Vancouver B1 fracture, and revision arthroplasty can be considered as a safe alternative in patients with primary bone loss, implant of short survival time, severe liner wear or long-term prosthesis use. Key words: Arthroplasty, replacement, hip; Periprosthetic fractures; Femoral fractures; Reoperation; Fracture fixation, internal

Long-term survivorship of the Corail™ standard stem

IntroductionThe Corail™ stem, which was first introduced in 1986, has since been modified twice: first to make the neck thinner and then to change the location of the laser markings. The survival and complications of the first-generation straight, titanium, hydroxyapatite-coated stem are known; however, there is little specific information about the latest-generation stem. This led us to conduct a retrospective study to determine the: (1) long-term survival; (2) clinical and radiographic outcomes; (3) complications; and (4) risk factors for revision of the newest Corail™ stem. HypothesisThe newest Corail™ AMT (Articul/EZE™ Mini Taper) standard stem has comparable survival to prior models. Patients and methodsThis single-center, retrospective study included 133 patients (140 hips), who underwent primary total hip arthroplasty (THA), between January and December 2004, in which a Corail™ Standard stem was implanted using a posterolateral approach. Patients who underwent revision THA, THA due to femoral neck fracture or who received lateralized (offset) stems were excluded. The mean age at the time of THA was 69±13 years [35–92] in 85 men (61%) and 55 women (39%) who had a mean BMI of 27kg/m2±11 [16–39]. At the latest follow-up, 32 patients (32 hips) had died and 8 patients (8 hips) had less than 3 years’ follow-up, thus were not included in the clinical evaluation. The Merle d’Aubigné (PMA) score was collected. The stem's survivorship was calculated using the Kaplan-Meier method with revision for aseptic loosening and revision or implant removal for any reason as the end-points. The Cox model was used to analyze risk factors for revision. The mean follow-up was 10±3 years [3–12]. ResultsThe PMA score was 12±2.6 [5–17] preoperatively and 16±2.7 [7–18] at the last follow-up (P<0.00001). Eighteen complications (12.8%) were recorded at the last follow-up. There were 15 early complications: 6 dislocations, 5 calcar fractures (4 treated by wire cerclage and 1 by stem change plus wire cerclage), 2 greater trochanter fractures (treated non-surgically) and 2 cases of sciatic nerve palsy. There were 3 late complications: 2 cases of iliopsoas irritation and 1 ceramic insert fracture. Stem survival for surgical revision due to aseptic loosening was 98% (95% CI: [0.96–1]). At 12 years, 95% of stems had not been revised or removed (95% CI: [0.92–0.99]). Being less than 58 years of age at the time of surgery was the only risk factor significantly associated with stem revision for any reason (P=0.04). ConclusionSurvival of the Corail™ Standard stem is similar to that of previous generation stems. The changes made in this stem solved the neck failure problem and did not induce new complications. Level of evidenceLevel IV (retrospective study).

Les pivots coniques avec traitement de surface sur le 1/3 proximal ont un taux de complication plus élevé que les pivots cylindriques avec traitement de surface sur les 2/3 proximaux en arthroplastie primaire pour luxation congénitale avec ostéotomie fémorale de raccourcissement

BackgroundThe results of cementless stems in total hip arthroplasty (THA) done because of congenital dislocation with step-cut osteotomy is not well known, particularly the influence of the design and the role of extent of porous coating. Therefore, we performed a retrospective study to evaluate the mid- to long-term results THA performed with a single type acetabular component and different geometry and fixation type stems with ceramic bearings in the setting of step-cut subtrochanteric osteotomy in high hip dislocated (HHD) patients. We asked if the stem type affect the outcomes in terms of (1) intra- and postoperative complication rates, (2) radiographic outcomes, (3) prosthesis survival in step-cut subtrochanteric shortening osteotomy. HypothesisThe type of the stem, whether cylindrical or tapered does not affect the outcome if the femoral canal fit and fill is obtained and the step-cut femoral shortening osteotomy is primarily fixed. Materials and methodsForty-five hips in 35 patients with a mean follow-up of 10 years (range, 7–14 years) were evaluated. The single type cementless cup was placed at the level of the true acetabulum, a step-cut shortening femoral osteotomy was performed and reconstruction was performed with two different types of tapered stem in twenty-two hips (Synergy™ and Image™ proximally coated, Smith and Nephew, Menphis, TN, USA) and one type of cylindrical stem (Echelon™ with 2/3 coated, Smith and Nephew, Menphis, TN, USA) in twenty-three hips. Harris hip scores (HHS) and a University of California Los Angeles (UCLA) activity scores were calculated for all patients and successive X-rays were evaluated regarding component loosening and osteolysis, along with complications related to bearing, step-cut osteotomy and stem types. ResultsForty-one hips (91%) had good and excellent clinical outcome according to HHS. The mean UCLA activity scores improved from 3.2±0.6 points (range, 2–4) preoperatively to 6.3 points±0.5 (range, 5–7) at the latest follow-up. The mean femoral shortening was 36±10mm (range, 20–65mm). Four (9%) dislocations were observed. There were five (11%) intraoperative femoral fractures and three (7%) cases of nonunion, which were observed in tapered stems. Cylindrical stems had superior neutral alignment primarily. With any stem revision as the end point, cylindrical stems had a higher survival rate (100%) than all tapered stems (82%; 95% confident interval [CI] 77%–97%) at ten years. With any revision as the end point, the 10-year survival rate for acetabular component (Reflection-Ceramic Interfit) and for femoral components were 98% (95% CI, 85%–99%) and 91% (95% CI, 78%–97%), respectively. ConclusionsThere were more implant related complications in HHD patients undergoing THA when tapered stems with 1/3 proximal coating were used to reconstruct a step-cut osteotomized femur, compared to cylindrical stems 2/3 coated. Level of evidenceIV, retrospective study.

The accuracy of Intramedullary Femoral alignment in Total Knee Replacement in the prescence of ipsilateral Hip Replacement

Objectives:During total knee replacement (TKR) surgery, the most commonly used method for aligning the distal femur appropriately is via an intramedullary (IM) distal femoral alignment rod. The alignment of the rod itself is reliant on the isthmus which is used to most accurately place the rod in the correct anatomical axis. In the instance of something preventing the rod from entering the isthmus correctly, such as a hip replacement, then the degree of accuracy could be assumed to be even less. Mechanical-anatomical malalignment has been shown to decrease the implant (TKR) survival and so methods of increasing accuracy of alignment relative to the mechanical axis have been developed. At present the most accurate method intraoperatively is computer navigation and several studies have demonstrated improved alignment. An increasing number of patients year on year are having both knee and hip replacements and as the population ages the likelihood of having both a knee and hip replacement will also increase. We propose that the presence of a hip replacement within the isthmus of the femur may further decrease the accuracy of the IM alignment of the femur leading to incorrect implant positioning.Methods:The study was conducted on 10 cadaveric specimens (20 femurs). Computational navigation instrumentation was attached in turn to each femur and the ideal alignment data recorded in a standard fashion by a single operator (principal investigator). A standard entry port was then be made in the femur for the introduction of the IM rod. An IM rod was then inserted with the distal femoral cutting block in the accepted position recorded blindly on the computer navigation (both in terms of varus/valgus alignment to the mechanical axis and the degree of flexion). The process was then repeated at 3 levels to represent primary and revision hip lengths from the greater trochanter (replicating the changes that would occur in the presence of a hip replacement) The process was recorded three times at each level.Results:The resection angles between the cutting surface and the mechanical axis were measured and collected by means of computer navigation system. The results show that the IM alignment had mean Valgus of 0 degrees +/- 0.8 but with a hip replacement in situ this increased to 0.46 degrees +/- 1.49 (range 2.5 varus to 4.5 valgus), with a revision stem 0.825 +/- 1.68 (range 2.5 varus to 4.5 valgus) and long stemmed revision 1.325 +/- 2.09 (range 5 varus to 6.5 valgus). In terms of Flexion IM alignment had a mean flexion of 0.92 +/- 1.7 (range 3 extension to 4 flexion) but with a hip replacement in situ this increased to 1.88 degrees +/- 2.03 (range 2.5 extension to 8.5 flexion), with a revision stem 2.35 +/- 2.2 (range 2.5 extension to 8 flexion) and long stemmed revision 2.75 +/- 2.16 (range 3.5 extension to 7 flexion).Conclusion:This Study concludes that the prescence of a hip replacement, in particular long stemmed prosthesis, further reduces the accuracy of IM alignment in the Femur for Total Knee Replacement. Consideration of an alternative method, such as navigation, should be considered in such situations.

The impact of subsidence on straight and curved modular cementless revision stems in hip revision surgery

Subsidence is one of the potential complications in femoral stem revision total hip arthroplasty surgery, and can affect stability and osseointegration.A retrospective study was conducted on the outcomes at one year and 5 years (specifically subsidence and clinical relevance) of 40 consecutive femoral total hip arthroplasty revisions, comparing two modular cementless revision stems, straight vs. curved, with 20 patients in each group. No mechanical failure was observed, and there was an improvement in functional outcomes. Mean radiological subsidence was 9.9±4.9mm (straight=10.75mm vs. curved=9.03mm), with no statistically significant difference between groups (p=0.076). Fourteen patients (35%) had ≥10mm of subsidence, up to a maximum of 22mm.The subsidence found in this study is similar to published series, with no short-term clinical manifestations, or an increased number of complications or stem loosening in either the straight or curved group. No differences in subsidence were observed at one year and 5 years after surgery between the 2 types of stems.

Total hip arthroplasty after failed osteosynthesis of proximal femoral fractures: Revision and mortality of 80 patients.

Total hip arthroplasty (THA) after failed osteosynthesis for proximal femoral fractures is associated with higher revision rates, particularly for dislocation. The purpose of this study was to report our results with THA after failed osteosynthesis within a treatment period of 10 years. A retrospective cohort study including 80 consecutive patients was conducted. After a minimum follow-up of 1 year, we evaluated revision for any cause including dislocation, outcome, and mortality. We performed 48 THAs with standard components only and 32 THAs with revision implants. Routinely, a 36-mm femoral head was used, and trochanteric fixation was performed in one-third of the cases. Total revision rate for any cause was 21%, which included six infections, six periprosthetic fractures, and five hematomas. One hip dislocation was also treated. Treatment with uncemented revision stem revealed significantly higher number of revisions-compared to standard cemented or uncemented stem. The mortality rate after 1 year was 9%, and the mean Parker score at follow-up was 6.6 (range: 0-9). THA was associated with an increased surgical revision rate, but hip dislocation was documented only once. In most cases, a standard implant with a large 36-mm femoral head size was sufficient. Uncemented revision stem revealed significantly higher number of revisions-compared to standard cemented or uncemented stem. One-year mortality was lower than expected.

Clinical results in early and mid term of using the S-ROM femoral stem in revision

To investigate and the clinical effect of S-ROM modular stem in femur reconstruction in hip revision arthroplasty. From January 2008 to January 2016, 21 patients received revision hip arthroplasties using S-ROM stems. There were 5 males and 16 females with an average of 48.33 years old(range, 29 to 73 years old). There were 13 cases caused by aseptic loosening, 4 cases by infection, 2 cases by nonunion of sub-tuberosity osteotomy, 1 case for repeated dislocation, 1 case for traumatic great trochanter fracture. Primary THA reasons:12 cases for DDH(9 cases for Crowe IV), 5 cases for femoral neck fracture, 2 cases for necrosis of femoral head, 2 cases for proximal femoral deformity caused by early infection. The femur bone defects included Paprosky II in 11 cases, IIIa in 9, and IIIb in 1. Harris hip score , pain score and hip flexion were recorded before and after operation. The subjective satisfaction was recorded at the last follow-up. The operation time and blood loss were 189 min(125 to 290 min) and 867 ml (200 to 2 000 ml). At the final followup, the pain score improved from (17.14±9.56) points preoperatively to (41.71±2.03) points (t=11.42, P=0.00). The function score improved from (24.01±11.02) points preoperatively to (49.95±5.38) points (t=9.73, P=0.00). Harris hip score improved from (41.15±14.81) points preoperatively to(91.67±5.83) points(t=15.33, P=0.00). The degree of hip flexion increased from (93.10±27.27) points preoperatively to (121.90±16.62) points at the last follow-up (t=4.59, P=0.00). The mean subjective satisfaction was 9.48(10 points system), 14 of which were completely satisfactory. The last follow-up hip X-ray showed 21 cases of bone ingrowth, and other femoral stem without loosening or sinking sign significantly. There were 5 cases with bone anchor syndrome around proximal femoral cuff. There were 5 cases of proximal femur fracture, 3 cases of lesser trochanter fracture, 2 cases of greater trochanter fracture intra-operatively. Due to femoral canal stenosis, there were 4 cases of pre-tied wire at lesser trochanter to prevent fractures. There was 1 case of traumatic femoral fracture around stems with a distal oblique fracture, open reduction and locking plate fixation was performed. Other patients had no nerve stretch injury, dislocation, infection and lower limb deep vein thrombosis and other complications at the final follow-up. S-ROM prosthesis has satisfactory results in hip revision arthroplasty with Paprosky II and III femoral defects. Especially for patients with Crowe IV DDH and other proximal femoral deformities, it is possible to adapt to the medullary cavity morphology. Excellent initial stability, less complications and long-term biological fixation can be achieved with S-ROM in femur revision.

Effect of femoral head size and surgical approach on risk of revision for dislocation after total hip arthroplasty

Background and purpose — Recurrent dislocation is the commonest cause of early revision of a total hip arthropasty (THA). We examined the effect of femoral head size and surgical approach on revision rate for dislocation, and for other reasons, after total hip arthroplasty (THA).Patients and methods — We analyzed data on 166,231 primary THAs and 3,754 subsequent revision THAs performed between 2007 and 2015, registered in the Dutch Arthroplasty Register (LROI). Revision rate for dislocation, and for all other causes, were calculated by competing-risk analysis at 6-year follow-up. Multivariable Cox proportional hazard regression ratios (HRs) were used for comparisons.Results — Posterolateral approach was associated with higher dislocation revision risk (HR =1) than straight lateral, anterolateral, and anterior approaches (HR =0.5–0.6). However, the risk of revision for all other reasons (especially stem loosening) was higher with anterior and anterolateral approaches (HR =1.2) and lowest with posterolateral approach (HR =1). For all approaches, 32-mm heads reduced the risk of revision for dislocation compared to 22- to 28-mm heads (HR =1 and 1.6, respectively), while the risk of revision for other causes remained unchanged. 36-mm heads increasingly reduced the risk of revision for dislocation but only with the posterolateral approach (HR =0.6), while the risk of revision for other reasons was unchanged. With the anterior approach, 36-mm heads increased the risk of revision for other reasons (HR =1.5).Interpretation — Compared to the posterolateral approach, direct anterior and anterolateral approaches reduce the risk of revision for dislocation, but at the cost of more stem revisions and other revisions. For all approaches, there is benefit in using 32-mm heads instead of 22- to 28-mm heads. For the posterolateral approach, 36-mm heads can safely further reduce the risk of revision for dislocation.

Impacto del hundimiento en vástagos de revisión rectos y curvos modulares en cirugía de revisión de cadera

Subsidence is one of the potential complications in femoral stem revision total hip arthroplasty surgery, and can affect stability and osseointegration.A retrospective study was conducted on the outcomes at one year and 5 years (specifically subsidence and clinical relevance) of 40 consecutive femoral total hip arthroplasty revisions, comparing two modular cementless revision stems, Straight vs. Curved, with 20 patients in each group. No mechanical failure was observed, and there was an improvement in functional outcomes. Mean radiological subsidence was 9.9±4.9mm (straight=10.75mm vs. curved=9.03mm), with no statistically significant difference between groups (p=0,076). Fourteen patients (35%) had ≥10mm of subsidence, up to a maximum of 22mm.The subsidence found in this study is similar to published series, with no short-term clinical manifestations, or an increased number of complications or stem loosening in either the Straight or Curved group. No differences in subsidence were observed at one year and 5 years after surgery between the 2 types of stems.

Management of Periprosthetic Fractures

Periprosthetic fractures may occur intraoperatively or postoperatively. The incidence of is approximately 0.6% in primary and 2.4% in revision total hip arthroplasty. Predisposing factors include stress risers, osteolysis, osteopoenia, singly or in combination. Focusing on postoperative fractures, this paper provides a management algorithm. If the fracture is stable, conservative treatment is appropriate. If the fracture is not stable, one needs to determine whether the prosthesis is loose or not. If the prosthesis is loose, further management will depend on the quality of the bone stock. Good bone stock will allow revision with a long stem or impaction grafting, while poor bone stock will require extensive allografting. Similarly, the adequacy of the bone stock determines the management regime if the pros-thesis is not loose. In the presence of good bone stock, it is usually possible to carry out open reduction and internal fixation. Poor bone stock requires bicortical onlay allografting. From 1994 to 1998 36 periprosthetic fractures, 14 with stable implants and 22 with unstable, were treated. The stable implants were treated with Dall Miles plates, fixed with cables and crimp-sleeves, bicortical screws distal to the fracture and unicortical screws proximally. The fracture united in 11 hips, two of which subsequently required prosthetic revision for femoral loosening. In one hip the fixation failed with fracture of the cables. Despite other adverse reports, this type of system is recommended for fixation of periprosthetic fractures where the prosthesis is stable. The 22 periprosthetic fractures with unstable implants were treated using the Bicontact long stem revision implant. Two distal interlocking screws provided early rotational and axial stability, and 14 patients had additional allografting. Radiological evidence of fracture healing was apparent in all cases. One prosthesis subsided by more than 5 mm with fracture of the interlocking screws. Cementless long stem revision is the treatment of choice for periprosthetic fractures associated with a loose implant. To ensure successful outcome it is necessary to determine the extent of the fracture, to assess fracture stability and to appreciate the available and appropriate treatment options. It is necessary to ‘be prepared’: these are challenging problems and the final decision often hinges on intraoperative findings.

Cortical Fenestration for Megaprosthesis Stem Revision.

Background:The most common modes of failure for megaprostheses are aseptic loosening followed by periprosthetic infection and stem fracture. Surgical technique for bone and implant exposure is controversial and may influence the success of revision and the need for additional future revisions. The purpose of this study was to evaluate the effectiveness of cortical fenestration for megaprosthesis revision, particularly for stem fracture.Methods:From 1985-2014, 196 adult and pediatric patients underwent limb salvage with a distal femoral or proximal tibial megaprosthesis (109 cemented, 87 pressfit). A retrospective chart review was performed to assess the rate of revision based on cemented or pressfit fixation and the use of a cortical window to extract the failed stem.Results:27% (29 of 109) of cemented and 18% (16 of 87) of pressfit implants were revised for stem failure. The reasons for revision in the cemented group were loosening (62%), infection (24%), and stem fracture (13%). In the pressfit group, the reasons were loosening (43%), infection (31%), stem fracture (6%), limb-length discrepancy (6%), malrotation (6%), and local recurrence (6%). A cortical window was used in 10 of 45 initial revisions (7 cemented, 3 pressfit) including all of the stem fractures, and in 2 of 15 subsequent re-revisions.Conclusion:Cortical fenestration is an effective, bone-preserving method of implant extraction, particularly for broken or cemented stems. It is associated with low rates of loosening and no increase in periprosthetic fractures.

Clinical outcomes of total hip arthroplasty using Wagner SL revision stem in femoral intertrochanteric fractures for patients with old fracture or painful arthritis before injury

To retrospectively study the clinical results of total hip arthroplasty(THA) using Wagner SL revision stem for patients with femoral intertrochanteric fracture. From 2006 January to 2009 December, 29 consecutive patients with femoral intertrochanteric fractures were performed THA using Wagner SL revision stem and intertrochanteric reconstruction, including 18 males and 11 females with an average age of 49 years old ranging from 43 to 58. Among them, 8 cases were oboslete femoral intertrochanteric fractures and 21 cases were the intertrochanteric fractures with painful arthritis before injuries. After the operation, the follow-up results were evaluated with clinical and radiographic criteria. The clinical follow-up results were evaluated by Harris score, limb length discrepancy, ROM of hips and the strength of the hip abductor. The X-ray imaging follow-up results were evaluated by periprosthetic osteolysis, prosthesis loosening and radiolucent. All the operations were successfully completed without serious complications associated with THA. Twenty-nine cases were followed up for a mean duration of 8.2 years (ranged, 6 to 10). There was no acceptable thigh pain. The first time walk after operation, 8 patients with oboslete intertrochanteric fracture complained the surgical sides were longer, with the passage of time, the complaint significantly reduced. At 3 months after operation, X-ray films of 21 cases showed intertrochanteric fractures healed well who had painful arthritis before injuries. An average of 6 months after operation (ranged, 3 to 8), X-ray films of 8 cases of oboslete intertrochanteric fracture showed that the bone graft and trochanter with obvious callus connection. There were no obvious prosthesis subsidence on X-ray film at the final follow-up. The recovery of hip movement range was satisfactory, no hip abduction strength was weak. More than 6 years after the operation, according to the Harris scoring evaluation of hip joint, the result was excellent in 18 cases, good in 9 cases, general in 2 cases. The clinical results of total hip arthroplasty using Wagner SL revision stem for patient with femoral intertrochanteric fracture is a reliable method, intertrochanteric reconstruction not only makes for prosthesis and joint stability, but also increases bone reserve.

Global fit concept in revision hip arthroplasty for cementless press-fit femoral stems

A revision stem may be required after a femoral extended trochanteric osteotomy (ETO) is made during revision hip arthroplasty. The two main complications of straight cementless femoral stems are subsidence due to inadequate osteointegration and stress-shielding. We will describe an original revision method with ETO that uses a straight cementless stem. The goal of this method was to achieve the most extensive press-fit possible during stem implantation to improve the transmission of stresses to the bone and to prevent reduction in bone density. The intramedullary preparation was done after closure and fixation of the ETO, which allows impaction of the revision stem with metaphyseal and diaphyseal press-fit. We report encouraging results with preservation of periprosthetic bone stock and good osteointegration of these revision stems at the final follow-up. Pronounced sagittal curvature or large bone defects are contraindications for this technique.

Tapered stems one-third proximally coated have higher complication rates than cylindrical two-third coated stems in patients with high hip dislocation undergoing total hip arthroplasty with step-cut shortening osteotomy

BackgroundThe results of cementless stems in total hip arthroplasty (THA) done because of congenital dislocation with step-cut osteotomy is not well known, particularly the influence of the design and the role of extent of porous coating. Therefore we performed a retrospective study to evaluate the mid to long-term results THA performed with a single type acetabular component and different geometry and fixation type stems with ceramic bearings in the setting of step-cut subtrochanteric osteotomy in high hip dislocated (HHD) patients. We asked if the stem type affect the outcomes in terms of (1) intra and postoperative complication rates (2) radiographic outcomes (3) prosthesis survival in step-cut subtrochanteric shortening osteotomy. HypothesisThe type of the stem, whether cylindrical or tapered does not affect the outcome if the femoral canal fit and fill is obtained and the step-cut femoral shortening osteotomy is primarily fixed. Materials and methodsForty-five hips in 35 patients with a mean follow up of 10 years (range, 7–14 years) were evaluated. The single type cementless cup was placed at the level of the true acetabulum, a step-cut shortening femoral osteotomy was performed and reconstruction was performed with two different types of tapered stem in twenty-two hips (Synergy™ and Image™ proximally coated, Smith and Nephew, Menphis, TN, USA) and one type of cylindrical stem (Echelon™ with 2/3 coated, Smith and Nephew, Menphis, TN, USA) in twenty-three hips. Harris hip scores (HHS) and a University of California Los Angeles (UCLA) activity scores were calculated for all patients and successive X-rays were evaluated regarding component loosening and osteolysis, along with complications related to bearing, step-cut osteotomy and stem types. ResultsForty-one hips (91%) had good and excellent clinical outcome according to HHS. The mean UCLA activity scores improved from 3.2±0.6 points (range, 2–4) preoperatively to 6.3 points±0.5 (range, 5–7) at the latest follow-up. The mean femoral shortening was 36±10mm (range, 20–65mm). Four (9%) dislocations were observed. There were five (11%) intra-operative femoral fractures and three (7%) cases of non-union, which were observed in tapered stems. Cylindrical stems had superior neutral alignment primarily. With any stem revision as the end point, cylindrical stems had a higher survival rate (100%) than all tapered stems (82%; 95% confident interval [CI] 77–97%) at ten years. With any revision as the end point, the 10-year survival rate for acetabular component (Reflection-Ceramic Interfit) and for femoral components were 98% (95% CI, 85–99%) and 91% (95% CI, 78–97%), respectively. ConclusionsThere were more implant related complications in HHD patients undergoing THA when tapered stems with 1/3 proximal coating were used to reconstruct a step cut osteotomized femur, compared to cylindrical stems 2/3 coated. Level of evidenceIV, retrospective study.

Modified Extended Trochanteric Osteotomy for the Treatment of Vancouver B2/B3 Periprosthetic Fractures of the Femur

BackgroundFemoral component revision is the treatment of choice for Vancouver type B2/B3 periprosthetic femur fractures (PFFs). The purpose of this study was to report the clinical outcome of revision total hip arthroplasty with the use of a modified extended trochanteric osteotomy (ETO) in PFF treatment. MethodsA total of 43 cases between 2000 and 2014 were analyzed. Clinical and radiographic evaluation was performed with a mean follow-up of 40 months. Patient survival after revision surgery, complications, radiographic outcomes, and quality of life and hip function were assessed. ResultsMerle d'Aubignè and Postel score averaged 15, and mean postoperative Harris hip score was 70. Radiographic evaluation revealed that the ETO and fractures healed in all but 1 patient within 9 months. Component stability and apparent osseointegration were not coincident with healing of the osteotomy and fracture sites proximal to the inserted stem. Six patients (15%) developed postoperative complications, which included the following: 1 nonunion with progressive subsidence, 2 hip dislocations, 2 deep infections, and 1 breakage of the modular junction of the revision stem. ConclusionThe modified ETO with a lateral approach to the hip for the treatment of PFF is compatible with fracture healing, a low dislocation rate, and good clinical results. However, component stability and apparent osseointegration are coincident with fracture healing only in the distal aspect of the inserted stem. Absence of proximal osseointegration might lead to poor osseous support resulting in inadequate fatigue strength at the junction of the dual modular revision stem.

Cement-in-cement femoral component revision in the multiply revised total hip arthroplasty: results with a minimum follow-up of five years.

We present the clinical and radiological results at a minimum follow-up of five years for patients who have undergone multiple cement-in-cement revisions of their femoral component at revision total hip arthroplasty (THA). We reviewed the outcome on a consecutive series of 24 patients (10 men, 14 women) (51procedures) who underwent more than one cement-in-cement revision of the same femoral component. The mean age of the patients was 67.5 years (36 to 92) at final follow-up. Function was assessed using the original Harris hip score (HHS), Oxford Hip Score (OHS) and the Merle D'Aubigné Postel score (MDP). The mean length of follow-up was 81.7 months (64 to 240). A total of 41 isolated acetabular revisions were performed in which stem removal facilitated access to the acetabulum, six revisions were conducted for loosening of both components and two were isolated stem revisions (each of these patients had undergone at least two revisions). There was significant improvement in the OHS (p = 0.041), HHS (p = 0.019) and MDP (p=0.042) scores at final follow-up There were no stem revisions for aseptic loosening. Survival of the femoral component was 91.9% (95% confidence intervals (CI) 71.5 to 97.9) at five years and 91.7% (95% CI 70 to 97) at ten years (number at risk 13), with stem revision for all causes as the endpoint. Cement-in-cement revision is a viable technique for performing multiple revisions of the well cemented femoral component during revision total hip arthroplasty at a minimum of five years follow-up. Cite this article: Bone Joint J 2017;99-B:199-203.

Partial exchange in total hip arthroplasty : What can we combine?

In case of hip revision arthroplasty, one component (cup/stem) is often well fixed and does not need to be exchanged. The newly implanted component needs to be compatible with the well-fixed implant. The combination of implants from different companies leads to "mix and match" or even mismatch between the implants. The objective of this work was to describe possible combinations including their specifications that need to be considered in partial exchange of hip prostheses. For this purpose the literature, surgical techniques of companies and judgements concerning this topic were analysed and our own results and experiences were included. Partial revision arthroplasty can be challenging and needs to be planned in detail. In case of isolated cup or inlay revision with exchange of amodular head the cone of the stem needs to be identified. Aceramic head may be used in revision with atitanium sleeve even from adifferent company as long as they are compatible. Patients however need to give their informed consent for this mix and match procedure. This procedure is done frequently and good study results support this, however from a juristic point of view a definite recommendation cannot be given. If the inlay of acup is replaced, the original inlay should be used. If this is not available anymore, it can be manufactured as aspecial product in many cases. If this is also not possible, an inlay can also be cemented into awell-fixed cup. Biomechanical and clinical studies support this off-label technique. In case of an isolated exchange of the stem with aceramic inlay that is retained in awell-fixed cup, the revision stem and ceramic head need to be from the same company as the cup. In case of ceramic fracture, aceramic head with atitanium sleeve should be combined with aPE or ceramic inlay, ametal head or inlay should never be used.

Treatment of Periprosthetic Femoral Fractures after Total Hip Arthroplasty Vancouver Type B.

The rate of periprosthetic femoral fractures following total hip replacement has been growing steadily in the last 20 years and ranges from 0.1% to 2.1%. These fractures are mostly related to older patients with the presence of chronic diseases and frequently poor bone quality. The treatment is surgically very complex and demanding, followed by a series of complications. The evaluation in this retrospective study included 23 patients who were medically treated from January 2004 to December 2015 with the mean follow-up of 14.5 (range, 9-25) months. There were 17 patients with cement total hip arthroplasty (THA) and 6 with cementless THA. During treatment of fractures, different techniques were implemented including the use of wire cerclage, dynamic compression plates (DCP), a locking compression plate (LCP) system, and long revision stem. For the purpose of distinguishing fractures, we used the Vancouver classification by Duncan and Masri. For clinical evaluation, we used the modified Merle d'Aubigne score system and monitored complications during treatment. The aim is to show treatment results of the type B periprosthetic femoral fractures by using different operative treatment techniques. According to the Vancouver classification within type B, 10 (43.47%) patients had type B1 fractures, another 10 (43.47%) patients had type B2 fractures, and three (13.04%) patients had type B3 fractures. According to gender distribution, there were eight (34.8%) male and 15 (65.2%) female patients, mean age 59.5 (range, 47-86) years. Twelve (52.2%) and 11 (47.8%) patients had left- and right-sided fractures, respectively. The mean length of hospital stay was 16 (range, 9-26) days. According to the Merle d'Aubigne score system, 10 patients with type B1 fractures had the mean score of 11.5 points, which is poor result. Poor result was also recorded in patients with type B2 fractures, with the mean score of 10.6 points. The three patients with type B3 fractures had the mean score of 12 points, which is considered fair score. In conclusion, Vancouver classification has been widely accepted and using the protocols makes decision making during treatment much easier. During treatment of this type of fracture, we used various implants, wire cerclage, DCP and LCP, as well as long stem revision. In certain cases, we applied surgical techniques, implants that are not recommended by the Vancouver protocol by which we treated periprosthetic femoral fractures; in these case, we recorded nonunion bone, malunion and breaking of implants, which resulted in poor treatment outcome.

The Synergy cementless femoral stem in primary total hip arthroplasty at a minimum follow-up of 15 years

We report on the outcome of the Synergy cementless femoral stem with a minimum follow-up of 15 years (15 to 17). A retrospective review was undertaken of a consecutive series of 112 routine primary cementless total hip arthroplasties (THAs) in 102 patients (112 hips). There were 60 female and 42 male patients with a mean age of 61 years (18 to 82) at the time of surgery. A total of 78 hips in the 69 patients remain in situ; nine hips in eight patients died before 15 years, and 16 hips in 16 patients were revised. Clinical outcome scores and radiographs were available for 94 hips in 85 patients. In all, four stems were revised. One stem was revised for aseptic loosening; two stems because of deep infection; and one because of periprosthetic femoral fracture. There was a significant improvement in all components of the Western Ontario and McMaster Universities Osteoarthritis Index score at the final follow-up (total: p < 0.001, pain: p < 0.001, stiffness: p < 0.001, function: p < 0.001). The mean Harris Hip Scores improved from 47 points (27 to 59) pre-operatively to 89 points (65 to 100) at the latest follow-up (p < 0.001). Kaplan-Meier survivorship, with stem revision for aseptic loosening as the endpoint, was 98.9% at 15 years (95% confidence interval (CI) 96.9 to 100, number at risk at 15 years: 90) and with stem revision for any reason was 95.7% (95% CI 91.7 to 99.8, number at risk at 15 years: 90). The Synergy cementless femoral stem demonstrates excellent survivorship and functional outcomes at 15 years. Cite this article: Bone Joint J 2017;99-B:29-36.