Underwent Revision Hip Arthroplasty Research Articles

The Effect of Bolus Administration of Tranexamic Acid in Revision Hip Arthroplasty

We assessed the efficacy of tranexamic acid in reducing transfusion requirements in patients undergoing revision hip arthroplasty. A prospective cohort study was designed comparing Tranexamic acid administration in 30 patients compared to 30 patients in a control group. Blood loss was measured in theatre, pre- and postoperative haemoglobin measurements were recorded and postoperative haemodynamic parameters were evaluated. The mean postoperative haemoglobin was 9.5 g/dl in the tranexamic acid group and 8.2 g/dl in the control group (p<0.01). The mean haemoglobin reduction was 2.7 g/dl in the tranexamic acid group and 3.4 g/dl in the control group (p = 0.47). Mean transfusion requirements were 2.76 units in the study group and 4.0 units in the control group (p = 0.49) and the frequency of transfusion was reduced (p = 0.032). Infected revisions showed no reduction in transfusion requirements with tranexamic acid administration (p = 0.25). There was a reduced frequency of transfusion in patients when revision was performed for aseptic loosening (p = 0.027). This group of patients may benefit from tranexamic acid administration.

Preoperative comorbidity and modes of failure in revision hip arthroplasty: a single-surgeon series in a tertiary referral centre

Revision hip arthroplasty is associated with higher morbidity post-operatively than primary surgery. We reviewed data on 102 consecutive patients (124 procedures) undergoing revision hip arthroplasty by a single surgeon from January 2005 to June 2009 in 2 institutions. Indications of failure: 62% aseptic loosening, 15% infection, 11.5% fracture, 10.6% dislocation or instability and 0.9% implant failure. Preoperative comorbidities: 28.4% cardiac, 4% respiratory and 6.8% diabetic. Morbidity: 3.9% complication rate (5 of 124 procedures). 73.5 median age and 46% over 75years old. Modes of failure in our population leading to revision hip arthroplasty are similar to other studies. We showed a low morbidity following revision hip arthroplasty despite significant preoperative comorbidities and a high proportion of elderly patients. In conclusion, gender, age (>75) and preoperative comorbidities should not deter from revision surgery.

Early Results of Revision Hip Arthroplasty Using a Ceramic Revision Ball Head

In the case of a ceramic fracture or cup revision with exchange of the ceramic ball head on a used stem, there is always the danger of another ceramic fracture when using a standard ceramic ball head owing to a possibly damaged stem taper. The purpose of this study was to analyze the results of revision hip arthroplasty using a new ceramic revision ball head. Ninety-one patients, who underwent revision hip arthroplasty using a ceramic revision ball head, were analyzed clinically. The Harris hip score and visual analog scale score increased significantly. There were no further ceramic fractures or noises. Especially, in cases with a damaged taper or ceramic fracture, surgeons should consider using a ceramic revision ball head in combination with a ceramic or a polyethylene insert.

Reconstruction of rotation center in revision hip arthroplasty

Objective To discuss the feasibility of positioning the acetabular center,fixing acetabular implant correctly and reconstructing hip rotation center according to Harris fossa and the remaining anatomical markers of acetabular notch in revision hip arthroplasty.Methods Twenty-eight patients underwent revision hip arthroplasty from April 2007 to June 2009.Based on Paprosky type,3 cases with type Ⅰ were treated with biological fixed acetabular component;8 cases with ⅡA and ⅡB were reconstructed with using of morselized bone grafting and large diameter cemented acetabular prosthesis;17 cases with type ⅡC,ⅢA and ⅢB were treated with using of morselized bone grafting and fixation of acetabular reinforcement ring.Among them,5 patients with massive bone loss in acetabular wall were reconstructed with the use of the structural and morselized bone grafting.The center of the original acetabulum was believed to be in the lunate cartilage surface which was closed to Harris fossa.During the operation,the center was located in the site which was 25-28 mm above in line with perpendicular bisector of acetabular notch connecting line.The acetabular center was the point of positioning acetabular prosthesis (Ⅰ type) or making new acetabulum by impaction bone grafting.Acetabular reinforcement ring (Ⅱ,Ⅲ type) was fixed in accordance with proper transverse angle and anteversion angle.The vertical distance from hip rotation center to teardrop connection and the horizontal distance from hip rotation center to teardrop were measured on preoperative and postoperative radiograph.And the outcomes of reconstruction of rotation center were evaluated.Results The vertical distance was changed from (14.22±3.39) mm preoperatively to (32.64±4.51) mm postoperatively.The difference was statistically significant (t=3.65,P＜ 0.05).The horizontal distance was changed from (25.13±3.46)mm preoperatively to (32.87±4.73) mm postoperatively.The difference was statistically significant (t=2.72,P＜0.05).Conclusion Using residual Harris fossa and acetabular notch as the anatomical markers in revision hip arthroplasty,the restoration of the anatomical hip center has shown to be favorable. Key words: Arthroplasty,replacement,hip; Reoperation; Hip prosthesis

Trabecular Metal Used for Major Bone Loss in Acetabular Hip Revision

The purpose of this study was to evaluate the outcome of trabecular metal (TM) acetabular components used in revision hip arthroplasty with major bone deficiency. We retrospectively reviewed the records of 46 patients undergoing revision hip arthroplasty with severe acetabular bone loss. Clinical outcomes were assessed using Harris Hip Score, Western Ontario and McMaster Universities, and Short-Form 12. Mean follow-up was 50 months. All patients had Paprosky type IIc or III acetabular bone deficiency. Major complications included 1 infection, 2 dislocations, and 1 arterial bleeding. Average Harris Hip Score was 78.2. Short-Form 12 scores were within population-based age-matched averages. Western Ontario and McMaster Universities scores were mainly in the 2 lowest disability categories. Porous tantalum shows promising results in revision arthroplasty with severe acetabular bone loss.

Impaction morselized allografting combined with cementless long stem for femoral defects in femoral component revision

To retrospectively analyze the clinical and radiological results of the impaction morselized allografting combined with cementless long stem for femoral component revision in patients with significant bone loss. From July 2003 to June 2009, 27 patients (27 hips) underwent revision hip arthroplasty in femurs with bone defect using impaction allografting and cementless components. There were 15 male and 12 female with mean age of 67 years. According to the Paprosky classification system, the bone defects in femur were classified into type II in 3 cases, type III in 21 cases and type IV 3 cases. The patients were followed up postoperatively to observe the clinical and radiological results, and if there had the stem subsidence, periprosthetic fracture, infection and other complications. Twenty-three patients were followed up. The mean follow-up time was 26 months. Harris score improved from 43 points pre-revision to 83 points at the final follow-up. No femoral stem loosening and failure occurred. There were 4 stem with a mean 3.3 mm subsidence. One case had an acute infection after revision and treated successfully by debridement and drainage, antibiotics. No stem need further revision. Radiographic analysis showed all the revised stem was stable, and graft incorporation was seen in at least 1 zone in 100% of the femurs. The results of this study demonstrates that femoral support and vigorous impaction grafting combined with cementless long stem results in an good intermediated-term clinical effects.

Tranexamic Acid Reduces Allogenic Transfusion in Revision Hip Arthroplasty

Revision THA is associated with high blood loss and a high probability of blood transfusion in the perioperative period. In November 2003, government legislation established the Blood Utilization Program at our center to reduce the rate and risks associated with allogenic transfusion. The purposes of this study were to (1) determine whether the allogenic transfusion rate in patients undergoing revision THA decreased in those who were reviewed preoperatively by the Blood Utilization Program versus those who were not; (2) determine whether tranexamic acid reduced the rate of transfusion; and (3) identify potential perioperative clinical parameters that are associated with an increased risk of blood transfusion. We included all 159 patients who underwent revision THA from January 2006 to October 2008 having either a socket and/or femoral stem revision except those having only a liner exchange. One hundred and one patients attended the Blood Utilization Program preoperatively and 58 patients did not (ie, they required urgent/emergency surgery). The Blood Utilization Program referral made no difference in transfusion rate or transfusion amount; however, the transfusion rates and amount were decreased by 8% and one unit, respectively. In patients referred to the Blood Utilization Program, the intraoperative use of tranexamic acid (an antifibrinolytic) was associated with reduced transfusions, regardless of dosage; preoperative erythropoietin tended to reduce transfusions while preoperative oral iron supplements did not. To further increase the relevance of the blood utilization program, the guidelines for patients undergoing revision hip arthroplasty need to be redefined. Level III, therapeutic study. See the guidelines online for a complete description of level of evidence.

Decreased Dislocation After Revision Total Hip Arthroplasty Using Larger Femoral Head Size and Posterior Capsular Repair

The purpose of this study was to determine if the use of both a larger femoral head size and a posterior capsular repair would lead to a decreased incidence of dislocation following revision total hip arthroplasty (THA). Two hundred forty-two consecutive revision THAs with posterolateral approach were performed between 2000 and 2005. Group 1 had 132 revision THAs with posterolateral approach and 28-mm head size without posterior capsule repair. Group 2 had 100 revision THAs with a 32-mm head size and repair of the remaining hip capsule. There were no statistically significant differences in the two groups. Group 1 had 14 dislocations (10.6%). Group 2 had 3 dislocations (2.7%) ( P < .05). Based on the results of this retrospective review, the authors recommend the use of both larger femoral head sizes and repair of any posterior capsular tissue available in patients undergoing revision hip arthroplasty.

Impaction bone grafting of the acetabulum at hip revision using a mix of bone chips and a biphasic porous ceramic bone graft substitute

Background and purpose One of the greatest problems of revision hip arthroplasty is dealing with lost bone stock. Good results have been obtained with impaction grafting of allograft bone. However, there have been problems of infection, reproducibility, antigenicity, stability, availability of bone, and cost. Thus, alternatives to allograft have been sought. BoneSave is a biphasic porous ceramic specifically designed for use in impaction grafting. BoneSave is 80% tricalcium phosphate and 20% hydroxyapatite. Previous in vitro and in vivo studies have yielded good results using mixtures of allograft and BoneSave, when compared with allograft alone. This study is the first reported human clinical trial of BoneSave in impaction grafting.Methods We performed a single-institution, multi-surgeon, prospective cohort study. 43 consecutive patients underwent revision hip arthroplasty using BoneSave and allograft to restore missing bone in the acetabulum. 9 patients had cemented acetabular components implanted and 34 uncemented. 10 patients had cemented femoral components implanted and 1 had an uncemented femoral component. 32 patients did not have their femoral component revised.Results No patients were lost to follow-up. At a mean follow-up of 24 (11–48) months, there were no re-revisions and there was no implant migration. 1 acetabular component had confluent lucent lines at the implant-graft interface. Complications were rare (1 fracture, 2 dislocations). Patient satisfaction with the procedure was high.Interpretation Short-term results indicate that impaction grafting of BoneSave and allograft is an effective method of dealing with loss of bone stock at revision hip surgery.

Effects of synovial fluid from aseptic prosthesis loosening on collagen production in osteoblasts

Synovial fluid from a loose prosthesis may act as a vehicle for factors that regulate bone turnover. The effect of such synovial fluid on osteoblasts has been studied. Synovial fluid obtained from patients who underwent revision hip arthroplasty because of aseptic prosthesis loosening was studied regarding the effect on protein synthesis, procollagen I mRNA expression, the secretion of procollagen I carboxyterminal propeptide (PICP) and osteocalcin in MG63 osteoblasts. Protein synthesis was increased and procollagen I mRNA expression was decreased by synovial fluid from patients with prosthesis loosening. Synovial fluid stimulated the total PICP in cell medium, but there was no change after correction for cell protein content in the cells. Synovial fluid in patients with prosthesis loosening has a general stimulatory effect on collagen formation and osteoblast proliferation because of a stimulatory effect on cell growth. Aseptic prosthesis loosening may be associated with an increase in bone formation.

Posterior Approach With Posterior Soft Tissue Repair in Revision Total Hip Arthroplasty

We investigated the influence of the posterior approach with soft tissue repair in revision hip arthroplasty by evaluating the rate of early posterior dislocation. Ninety-one patients (96 hips) who had undergone revision hip arthroplasty through the posterior approach were observed for 1 year or until dislocation occurred. Fifty-six revision hip arthroplasties were performed using the posterior approach with soft tissue repair technique. The results of these procedures were compared with those of 40 revision hip arthroplasties that had been performed using the posterior approach without soft tissue repair. The dislocation rate of 10.0% in 40 hips using the posterior approach without soft tissue repair was reduced to 1.9% in 56 hips using the posterior approach with soft tissue repair.

Periprosthetic Femoral Fractures Treated with a Modular Distally Cemented Stem

To assess the treatment outcome of revision hip arthroplasty for Vancouver type B3 periprosthetic femoral fractures using a modular distally cemented stem. 22 men and 14 women (37 hips) aged 66 to 79 (mean, 70) years underwent revision hip arthroplasty for Vancouver type B3 periprosthetic femoral fractures. The indication for surgery was periprosthetic fracture with stem loosening and loss of proximal bone stock. The patients were referred from other hospitals after previous surgeries had failed: 8 with 3 previous surgeries, 19 with 2, and 9 with one. Using a transtrochanteric approach, the existing prosthesis was removed and a modular proximal femoral replacement stem was inserted, bypassing the area of proximal femoral fracture and bone loss. The stem was distally cemented. Patients were immobilised within 48 hours of surgery. Patients were followed up for a mean of 14 (range, 8-18) years. The mean Harris hip score improved from 29 (range, 5-40) to 78 (range, 56-88); 24 patients attained excellent or good scores (>80), 10 attained fair, and 2 attained poor scores. The mean healing time was 7 (range, 6-14) months; there was no non-union. Improvement in proximal bone stock was noted on serial radiographs. None of the stems had cement fracture or migration, requiring revision. Two (5%) of the patients had dislocations. Vancouver type B3 periprosthetic femoral fractures can be successfully treated with a distally cemented modular proximal femoral replacement prosthesis.

Intraoperative Red Blood-Cell Salvage in Revision Hip Surgery

Revision hip arthroplasty is commonly associated with substantial blood loss and the subsequent need for transfusion. This leads to an increased risk of blood-borne infection and hemolytic reactions. The purpose of this study was to demonstrate whether the use of intraoperative red blood-cell salvage in revision hip arthroplasty reduces the overall rate of allogeneic transfusion. Forty-seven patients who had undergone revision hip arthroplasty with the use of intraoperative cell salvage were identified. A computer database was used to individually match these patients, for age, sex, and eleven operative variables, to control patients who had undergone revision hip arthroplasty in the same unit without intraoperative cell salvage. Data gathered included the total allogeneic transfusion requirement for each patient, preoperative and postoperative hemoglobin levels, and operative time. The total allogeneic transfusion requirement was significantly lower in the group that had intraoperative cell salvage than in the control group (median, 2 compared with 6 U of packed red blood cells, p = 0.0006), with a median reduction in allogeneic transfusion of 4 U. There was no significant difference in preoperative or postoperative hemoglobin levels between the groups. The use of intraoperative cell salvage significantly lowered the allogeneic transfusion requirement, which can lead to substantial cost savings. To our knowledge, this is the first study in which the use of intraoperative red blood-cell salvage in revision hip arthroplasty was evaluated by matching patients on the basis of age, sex, and operative variables.

The role of hereditary hemochromatosis in aseptic loosening following primary total hip arthroplasty

Hereditary hemochromatosis (HH) results in increased iron absorption and subsequent deposition in tissue. This condition occurs predominantly in individuals of Northern European and Celtic origin with Ireland having one of the highest allele frequencies in the world. This study examines the hypothesis that homozygosity for either the C282Y or H63D mutations in the HFE gene may be associated with aseptic loosening following total hip arthroplasty (THA). Two groups of individuals were screened for the C282Y and H63D mutations associated with HH. Group 1 were individuals who had undergone primary hip arthroplasty and group 2 were individuals who had undergone revision hip arthroplasty for aseptic loosening. Exclusion criteria included rheumatoid or other inflammatory arthropathies and revision due to causes other than aseptic loosening. Significantly more patients in the revision THA group were homozygous for the C282Y genotype ( P = 0.014). Aseptic loosening occurred earlier in these patients ( P = 0.009), in particular in the patients who had clinical signs of hemochromatosis. No association was seen with the H63D mutation and revision THA. The incidence of HH in the group of primary THA patients was no higher than the background incidence. Patients who require primary THA and who are homozygous for the C282Y mutation have an increased risk of developing aseptic loosening, leading to revision THA. Moreover C282Y homozygosity appears to be associated with earlier aseptic loosening than in individuals without the C282Y mutation.

Impaction allografting and the Kerboull acetabular reinforcement device

Background The incidence of acetabular loosening with segmental and cavitatory bone loss increases as the number of total hips implanted increases. Revisionhip arthroplasty using impacted bone graft and an acetabular reinforcement device is one solution to this problem.Patients and methodsClinically and radiographically, we assessed 35 hips in 33 patients who had undergone revision hip arthroplasty using impaction grafting and the Kerboull acetabular reinforcement device. Mean follow-up was 5 (3–7) years.Results The mean Mayo score preoperatively was 30, which improved to a mean score of 85. Good to excellent clinical results were seen in 25 patients. The 8 individuals scoring below 80 had significantly more comorbid conditions than the others. No acetabular reconstruction required re-revision. Aseptic loosening occurred in 6 patients. Graft resorption occurred in 5 cases, resulting in inferior hook fracture of the Kerboull device. This was noted at a mean of 13 months after surgery. Further follow-up showed this to be non-progressive, with incorporation of the remaining graft to the host bone. These patients all had good to excellent Mayo hip scores.Interpretation Early results of revision acetabular surgery using impaction grafting and the Kerboull shell in patients with severe osteolysis have shown good functional outcome. However, 6 of 35 patients had radio-graphic evidence of aseptic loosening without progression for 4 years. Long-term follow-up is required to ensure that this loosening does not result in failure.

Bone viability determination in human cancellous bone from patients undergoing revision hip arthroplasty

In December 2000, Sulzer Orthopedics Inc. announced the recall of specific lots of Inter-Op acetabular components as a result of an adverse tissue response to a contaminant on the porous surface of the component. This study was initiated to assess bone viability surrounding the primary and revision components. Twelve patients were placed on a double-tetracycline labeling protocol before revision surgery. Initial and final acetabular reamings were frozen-sectioned using cryostat technology. A mineral apposition rate, preoperative and postoperative radiographs, and Harris Hip Scores were evaluated. The tetracycline data showed that bone viability was not compromised at initial or final reaming levels in this series of patients. Significant improvement was observed in postoperative Harris Hip Scores when compared with preoperative Harris Hip Scores.

Intraoperative fracture of the femur in revision total hip arthroplasty with a diaphyseal fitting stem.

In revision total hip arthroplasty, intraoperative split fractures and cortical perforation fractures are becoming a more common concern with the increasing use of diaphyseal fitting cementless stems. The purpose of this study was to evaluate the risk factors and frequency of intraoperative fractures with the use of these stems and their effect on radiographic and functional outcomes. We performed a retrospective case-control study of 211 consecutive patients who had undergone revision hip arthroplasty with a diaphyseal fitting cementless stem between December 1998 and March 2002. Sixty-four patients sustained an intraoperative fracture of the femur. One hundred and fifteen patients were followed for a minimum of two years; function was analyzed with self-administered outcome questionnaires, and radiographs were evaluated for evidence of bone ingrowth into the femoral stem. Risk factors associated with an intraoperative fracture were a substantial degree of preoperative bone loss, a low femoral cortex-to-canal ratio, underreaming of the cortex, and the use of a large-diameter stem. The majority of the diaphyseal undisplaced linear fractures occurred at the distal end of an extended trochanteric osteotomy during stem insertion. Fracture due to cortical perforation occurred most often during cement removal. These intraoperative fractures had no significant effect on the functional outcome or radiographic evidence of bone ingrowth. There was a surprisingly high rate of intraoperative femoral fractures associated with the use of a diaphyseal fitting stem in revision total hip arthroplasty. Identification of risk factors such as preoperative bone loss and a low cortex-to-canal ratio may permit planning to avoid such fractures. However, the final functional and radiographic outcomes appear to have been unaffected by the fracture when it had been managed appropriately. Prognostic study, Level II-1 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Efficacy of intraoperative blood collection and reinfusion in revision total hip arthroplasty.

Patients undergoing revision total hip arthroplasty frequently require perioperative blood transfusion, increasing the risk for blood-borne disease and anaphylactic and hemolytic reactions. The purpose of this retrospective study was to evaluate the effect of intraoperative blood collection and reinfusion on net blood loss in patients undergoing revision hip arthroplasty. The medical records of 126 patients who had had a revision total hip arthroplasty with intraoperative blood salvage, with use of a collection and reinfusion device, during a twenty-eight-month period were reviewed. For comparison, the medical records of ninety-six patients who had undergone revision hip arthroplasty without intraoperative blood salvage were reviewed. Each of the 222 patients was categorized into a group on the basis of the type of revision. Patients who had a revision of the femoral and acetabular components (Group C) had significantly higher mean intraoperative and total blood loss than did those who had a revision of the femoral component only (Group A [p = 0.009 and p = 0.02, respectively]) or a revision of the acetabular component only (Group B [p = 0.0001 for both]). Total blood loss was not significantly different between Groups A and B. The mean amount of blood reinfused intraoperatively was 356 mL for the patients in Group A, 374 mL for the patients in Group B, and 519 mL for the patients in Group C. Regression analysis showed a significant decrease in net blood loss with intraoperative collection and reinfusion in Groups B (p = 0.002) and C (p = 0.0001) but not in Group A. Intraoperative collection and reinfusion substantially decreased net perioperative blood loss in patients who had a revision of both components (Group C) and in those who had a revision of the acetabular component (Group B). The use of intraoperative blood collection and reinfusion appears to be a valuable method of preserving blood volume in the perioperative period.

Apoptosis of Cells of Interfacial Tissue of Aseptic Loosening and Osteolysis after Hip rthroplasty

Purpose : To evaluate the relationships between the apoptosis induced by nitric oxide (NO), aseptic loosening and osteolysis, which are the most serious causes of failure after total hip arthroplasty. Materials and Methods : Apoptosis of the inflammatory cells of interface tissues from 18 patients who underwent revision hip arthroplasty was identified by Terminal Deoxyribonucleotidyl Transferase-Mediated dUTP Nick End Labeling (TUNEL). The reaction to immunostaining of inducible nitric oxide synthase (iNOS), p53, Bax, Bcl2, and Ki-67 were evaluated. Six joint capsules obtained from six patients of femoral neck fracture were studied as controls. Results : Sixteen (89%) of 18 interface tissues were positive for iNOS, p53, and Bax monoclonal antibody and twelve (40%) for Bcl2 and Ki-67 monoclonal antibody. All tissues were positive for TUNEL. In the control group of six joint capsules, only one (17%) was positive for iNOS and Bax, and three (50%) were positive for TUNEL. The incidences of apoptotic signals at the interfacial tissue of aseptic loosening and osteolysis were significantly greater than those of the control. Conclusion : The current study suggested that the apoptosis of inflammatory cells, due to oxidative stress by NO, might be involved in the development of implant loosening and osteolysis after total hip arthroplasty. This information might be crucial for the treatment and prevention of periprosthetic osteolysis and subsequent loosening.

An audit on the blood transfusion requirements for revision hip arthroplasty.

The hospital transfusion committee of Swindon and Marlborough NHS Trust had formulated a maximum surgical blood ordering schedule (MSBOS) which included the standard practice of 6 units of blood for revision hip arthroplasty. A retrospective audit of 73 patients who underwent revision hip arthroplasty over a year was undertaken to identify current practice and to ensure that the standard was adequate for patient safety. Information regarding the number of units requested, number of units transfused, pre-operative haemoglobin (Hb), lowest postoperative Hb and number of additional units of blood requested within 3 days postoperatively, was collected from patients' case-notes. Of the 73 patients, 80.3% received less than 6 units, 12.2% received 6 units and 7.5% received more than 6 units. Based on pre-operative Hb, blood usage was analysed. Of cross-matched units, 92.3% were used when pre-operative Hb was < 12 g/dl, 64.4% were used when Hb was between 12.1-13.0 g/dl, 54.3% were used when the Hb was between 13.1-14.0 g/dl, 38.9% were used when Hb was between 14.1-15.0 g/dl and 39.7% used with pre-operative Hb of > 15.0 g/dl. Of the total, 14 patients had a postoperative Hb of < 9 g/dl for whom additional units of blood were ordered and given to achieve a Hb of between 10.1-14.2 g/dl prior to discharge. This audit suggests that in patients with pre-operative Hb of 13 g/dl or more, the cross-match could be 4 units instead of 6 units for revisions.