Isolated Acetabular Revision With Ceramic-on-Ceramic Bearings Using a Ceramic Head With a Metal Sleeve

The purpose of this study is to evaluate results of isolated acetabular revision with ceramic-on-ceramic bearings using a ceramic head with a metal sleeve. A retrospective review of fifty-three hips was performed. The mean patient age was 49.9 years and the mean follow-up period was 5.7 years. The mean modified Harris hip score improved from 47.5, pre-operatively, to 84.7 at the time of last follow-up (P < 0.001). Two patients reported squeaking of the hip. Three patients experienced loosening cup, necessitating re-revision surgery. There was a significant difference of acetabular bone defect between loose cup group and stable cup group (P = 0.018). There were no ceramic fractures and no osteolysis. The survival rate of the acetabular cup at the mid-term follow-up was 94.3%. In conclusion, ceramic head with a metal sleeve can be a reliable option for isolated acetabular revision.     

Palliation With Endoscopic Metal Stents May Be Preferable to Surgical Intervention for Patients With Obstructive Pancreatic Head Adenocarcinoma

The aim of this study was to evaluate the efficacy of endoscopically placed metal stents in comparison with operative procedures, in patients with obstructive pancreatic head cancer. Endoscopic stenting techniques and materials for gastrointestinal malignancies are constantly improving. Despite this evolution, many still consider operative procedures to be the gold standard for palliation in patients with unresectable obstructive pancreatic head cancer. This is a retrospective study of 52 patients who were diagnosed with obstructive (biliary, duodenal, or both) adenocarcinoma of the pancreatic head. Twenty-nine patients (endoscopy group) underwent endoscopic stenting. Eleven patients (bypass group) underwent biliodigestive bypass. Twelve patients (Whipple group) underwent Whipple operation with curative intent; however, histopathology revealed R1 resection (palliative Whipple). T₄ disease was identified in 13 (44.8%), 7 (63.6%), and 3 (25%) patients in the endoscopy, bypass, and Whipple groups, respectively. Metastatic disease was present only in the endoscopy group (n = 12; 41.3%). There was no intervention-related mortality. Median survival was 280 days [95% confidence interval (95% CI), 103, 456 days], 157 days (95% CI, 0, 411 days), and 647 days (95% CI, 300, 993 days) for the endoscopy, bypass, and Whipple groups, respectively (P = 0.111). In patients with obstructive pancreatic head cancer, endoscopic stenting may offer equally good palliation compared with surgical double bypass. The numerically (not statistically) better survival after palliative Whipple might be explained by the smaller tumor burden in this subgroup of patients and not by the superior efficacy of this operation.Key words: Palliation, Endoscopy, Metal stents, Biliodigestive bypass, Pancreaticoduodenectomy, Pancreatic adenocarcinomaAt presentation, patients given a diagnosis of pancreatic head adenocarcinoma will have approximately 10%, 35%, and 55% localized (upfront or potentially resectable), locally advanced, and metastatic disease, respectively.¹ Jaundice from mechanical obstruction of the common bile duct is the main presenting symptom in 80% of these patients. In addition, almost half of the patients will develop duodenal obstruction secondary to tumor overgrowth.² It is well documented that treatment of the malignant obstruction improves quality of life.³The most widely used palliative treatment of malignant biliary obstruction is the endoscopic placement of metal stents, especially if the patient''s estimated life expectancy exceeds 6 months.⁴ Metal stents yield biliary patencies of almost 2 years.⁵ On the other hand, when there is concomitant duodenal obstruction, literature favors surgical (biliodigestive bypass) over endoscopic palliation because of more durable intestinal patency rates,⁶ despite metal stent placement having better short-term outcomes and being more cost efficient.⁷ In addition, literature supports biliodigestive bypass at exploration even in asymptomatic patients, because approximately 20% of them will develop obstruction at a later point.^8,9Endoscopically placed biliary and duodenal metal stents exhibit a geometric progress of evolution because of substantial improvements in manufacturing technology and materials.¹⁰ The fourth-generation metal stents used now in everyday practice are made of nitinol alloy and may be covered (partially or fully) with materials that improve patency rates.¹¹ In addition, biliary and duodenal stents may be used easily in combination for palliation of the same patient, without significant technical problems.¹² Furthermore, recent studies show that stent efficacy increases with synchronous use of chemotherapy or radiotherapy.¹³ Moreover, metal stents that release chemotherapeutic agents have started being used in clinical practice.¹⁴The aim of this study was to evaluate, in patients with unresectable obstructive pancreatic head adenocarcinoma, the efficacy of the newer endoscopic metal stents compared with the standard operative procedures.     

Early Results of 827 Trabecular Metal Revision Shells in Acetabular Revision

We evaluated the survival of 827 acetabular revisions with Trabecular Metal Revision Shell using data from a nationwide arthroplasty register. The mean age of the patients was 69.1 years. The 3-year overall survivorship was 92% (95% confidence interval, 88-95), which coincides with earlier reports. Revision rate for aseptic loosening was only 2%. The most common reason for revision was dislocation of the prosthesis with or without malposition of the socket (60%). Age was found to have significant effect on cup survivorship: each additional year in age decreased the risk of revision by 2.4% (95 % confidence interval, 0.1-4.7; P = .044). We found no differences in survival rates between aseptic and septic revisions. Furthermore, sex, diagnosis, and hospital volume did not affect the survival.     

Primary Total Hip Arthroplasty With a Spongy Metal Surface Acetabular Component for Hip Dysplasia

We evaluated the clinical and radiographic results of primary total hip arthroplasty for 81 dysplastic hips (71 patients) using cementless Spongiosa Metal II cups (ESKA Implants, Lübeck, Germany). The mean follow-up period was 6.4 years (minimum 5 years), and the preoperative mean Japanese Orthopaedic Association hip score had improved from 45.2 to 87.4 points at the latest follow-up. The radiographic outcome was no aseptic loosening in all 81 hips. The hip center was located significantly more superior than in the contralateral normal hip in 45 patients, but the difference was less than 10 mm; however, there was no significant difference in the lateral position of the hip center. The use of a Spongiosa Metal II cup for dysplastic hips provided satisfactory 5- to 10-year clinical and radiographic results.     

Long-Term Results of Acetabular Reconstruction Using Ganz Acetabular Rings

Background

Our study examines the long-term results of acetabular reconstruction using the Ganz acetabular reinforcement ring (GRR) in total hip arthroplasty.

Editorial Commentary: Rotator Cuff Tendon Healing May Be Enhanced With a Blanket

After rotator cuff repair, the regeneration of the anatomic enthesis may be beneficial. Although many cell and growth factor studies have been performed, none have shown a consistent regeneration of this structure. The use of bone marrow vents in the greater tuberosity has been associated with improved healing. The resultant clot has been dubbed a “crimson duvet” or blanket. The use of this readily available—and inexpensive—modality should be maximized in patients undergoing rotator cuff repair. In the end, a goal could be to enhance tendon-to-bone healing via a scaffold, cells, and growth factors. Pending inevitable reliable advances in biological augmentation, mesenchymal stem cells and growth factors from the greater tuberosity are just a marrow-stimulating pick away.     

Late Transection of the Sciatic Nerve in Association With an Acetabular Reconstruction Cage

We report a case of a late-onset sciatic nerve palsy that occurred in association with an acetabular reconstruction cage. On surgical exploration, the nerve was found to be completely transected secondary to abrasion over the posterior flange of the reconstruction cage.     

The Survival and Fate of Acetabular Reconstruction With Impaction Grafting for Large Defects

Background  

Impaction bone grafting has been used for acetabular reconstruction in revision surgery. However, most series do not establish differences in survival in revisions with differing severity of bone loss.     

MRI Findings Following Metal on Metal Hip Arthroplasty and Their Relationship With Metal Ion Levels and Acetabular Inclination Angles

Following the global recall of all ASR metal on metal hip products, our aim was to correlate MRI findings with acetabular inclination angles and metal ion levels in patients with these implants. Both cobalt and chromium levels were significantly higher in the presence of a periprosthetic fluid collection. There was no association between the presence of a periprosthetic mass, bone marrow oedema, trochanteric bursitis or greater levels of abductor muscle destruction for cobalt or chromium. There was no association between the level of periprosthetic tissue reaction and the acetabular inclination angle with any of the pathologies identified on MRI. The relationship between MRI pathology, metal ion levels and acetabular inclination angles in patients with ASR implants remains unclear adding to the complexity of managing patients.     

Reconstruction of Acetabular Posterior Wall Fractures

Background

The results after acetabular fracture are primarily related to the quality of the articular reduction. We evaluated the results of internal fixation of posterior wall fractures with using three-step reconstruction.

Methods

Thirty-three patients (mean age at the time of injury, 47.9 years; 28 males and 5 females) were followed for a minimum of 2 years after surgery. The three-step reconstruction included 1) preservation of soft tissues and reduction of the marginally impacted osteochondral (articular) fragments using screws, 2) filling the impacted cancellous void with a bone graft, and 3) reinforcement with buttress-plating. Clinical evaluation was done according to the criteria of D''aubigne and Postel, while the radiological criteria were those of Matta. The associated injuries and complications were evaluated.

Results

The clinical results were excellent in 15 (45.5%) patients and they were good in 5 (15.2%), (i.e., satisfactory in 60.7%), while the radiologic results were excellent in 10 (30.3%) and good in 14 (42.4%) (satisfactory in 72.7%). Heterotopic ossification was common, but this did not require excision, even without prophylactic treatment with indomethacin. Deep infection was the worst complication and this was accompanied by a poor outcome.

Conclusions

This study confirms that three-step reconstruction facilitates accurate and firm reduction of displaced posterior wall fractures of the acetabulum. Therefore, we anticipate less long-term arthrosis in the patients treated this way.     

The Utilization of Metal Augments Allows Better Biomechanical Reconstruction of the Hip in Revision Total Hip Arthroplasty With Severe Acetabular Defects: A Comparative Study

Background

Reconstructing the normal hip biomechanics is important for a successful revision total hip arthroplasty (THA). Little is known about whether using metal augments in revision THA is biomechanically superior to traditional techniques.

Mid-term Follow-up of the Direct Anterior Approach in Acetabular Revision Hip Arthroplasty Using a Reconstruction Cage With Impaction Grafting

BackgroundSevere acetabular bone loss is often treated with reconstruction cages and impaction grafting using allograft bone. Accurate implant positioning is crucial for successful clinical and radiological outcomes. The direct anterior approach (DAA) is a standard approach for primary total hip arthroplasty (THA) that is being used more frequently for revision THA. The aim of this study was to report midterm clinical and radiological outcomes of acetabular revision arthroplasty using the DAA to address large acetabular defects by using a reconstruction cage and impaction grafting.MethodsAcetabular cup revisions were performed in 64 patients (64 hips) with severe acetabular bone loss. All patients received reconstruction cages with impaction grafting via the DAA. The stem was also revised in 22 patients. Complications, radiological, and functional outcomes were assessed.ResultsSix of the 64 patients were revised at a mean follow-up of 27.6 months (range, 11-84 months), two each for implant failure, infection, and recurrent dislocation. One hip showed the radiological failure of the implant, but the patient was asymptomatic and was not revised. The median Western Ontario McMasters Osteoarthritis Score (WOMAC) for the cohort overall improved significantly (P < .01) by the latest follow-up compared with preoperative scores.ConclusionGood midterm outcomes can be obtained with the DAA for acetabular cup revisions done to address severe acetabular bone loss by using reconstruction cages and impaction grafting. The number of complications was within the expected range for this type of revision procedure at midterm follow-up, and dislocation rates were low.     

Extended Ischiopubic Fixation Using Porous Metal Augments in Cementless Acetabular Reconstruction during Revision Total Hip Arthroplasty

ObjectivesThe aims of this study were to introduce the definition, indication, and surgical technique of extended ischiopubic fixation (EIF) and to investigate the early clinical, radiographic results and complications of hips revised with EIF.MethodsPatients who underwent revision THA utilizing the technique of EIF which was defined as securing the porous metal augment >5 mm deep into the ischium and/or pubic ramus to gain adequate mechanical support and fresh host bone for bony ingrowth in a single institution from February 2015 to February 2020 were retrospectively reviewed. After applying the inclusion and exclusion criteria, a total of 30 hips (28 patients) were eligible for the study and were enrolled. Four patients were lost to follow‐up postoperatively. The data of the remaining 24 patients (26 hips) were analyzed. The patients'' clinical results were assessed using of the Harris Hip Score and any complications including postoperative periprosthetic joint infection, intraoperative fracture, postoperative periprosthetic fracture, dislocation, nerve palsy, hematoma or wound complication were documented. The radiographic results were assessed with the construct stability, the position of the center of rotation, and cup orientation.ResultsThe median age of these 25 patients was 62.00 (interquartile: 54.25–68.25) years, with a median body mass index (BMI) of 22.60 kg/m² (interquartile: 21.49–25.12 kg/m²). A total of 12 (48%) patients were female. At a median duration of follow‐up of 49.16 months, 20 (80%) patients rated their satisfaction level as “very satisfied,” five (20%) were “satisfied.” The median HHS improved from 36.00 (interquartile range: 31.25–49.75) preoperatively to 81.00 (interquartile range: 74.75–88.25) at the most recent follow‐up (p < 0.001). No complications such as periprosthetic joint infection, intraoperative fracture, periprosthetic fracture, dislocation, nerve palsy, hematoma, or wound complication were identified. All constructs were considered to have obtained stable fixation. The median vertical and horizontal distance between the latest postoperative centers of rotation to the anatomic center of rotation improved from 13.62 and 8.68 mm preoperatively to 4.42 and 4.19 mm at final follow‐up (p < 0.001).ConclusionsEarly follow‐up of patients reconstructed with porous metal augments using the EIF technique demonstrated satisfactory clinical results with no particular complications, stable fixation, and restoration of the center of rotation.