Radiographic and Clinical Outcomes of Modular Tapered Fluted Stems for Femoral Revision for Paprosky III and IV Femoral Defects or Vancouver B2 and B3 Femoral Fractures

BackgroundExtensive femoral bone loss poses a challenge in revision total hip arthroplasty (rTHA). Many techniques have been developed to address this problem including fully porous cylindrical stems, impaction bone grafting, and cementation of long stems, which have had varied success. Modular tapered fluted femoral stems (MTFS) show favorable results. We sought to determine the minimum 2-year radiographic and clinical performance of MTFS in rTHA in a population with extensive proximal femoral bone loss.MethodsOur clinical database was queried retrospectively for all patients who underwent rTHA with an MTFS. We included patients with Paprosky 3 and 4 femoral bone loss and patients with Vancouver B2 and B3 periprosthetic femur fractures. Patients without 2-year follow-up were invited to return to clinic for X-ray evaluation and to complete clinical questionnaires. We assessed distance of stem subsidence and presence of stem fixation on final X-ray. We recorded all-cause revision and survival of the stem at final follow-up.ResultsOne hundred twenty-nine patients were available for follow-up. Average follow-up time was 3.75 years. One hundred twenty-two stems (95%) remained in place at final follow-up. Median subsidence was 1.4 mm (range 0-21). All-cause revision rate was 16.3% (21 patients). Of the hips revised, 10 were for instability, 6 for infection, 1 for aseptic loosening, and 1 for periprosthetic femur fracture. Three were revised for other reasons. The stem was revised in 7 patients (5.4%), and the most common reason for stem revision was infection (5 patients). The other 2 stems were revised for aseptic loosening in a Paprosky 4 femur and periprosthetic femur fracture. Survival of tapered modular fluted stems with aseptic failure as an endpoint was 98.4%. The mean Hip disability and Osteoarthritis Outcome Score, Joint Replacement score at final follow-up was 73, and mean Veterans Rand 12 item health survey physical and mental scores were 32.8 and 52.2, respectively.ConclusionIn patients with Paprosky 3, 4 femoral defects or Vancouver type B2, B3 fractures, modular tapered fluted stems for femoral revision show excellent outcomes at minimum 2-year follow-up.     

High Survivorship With Cementless Stems and Cortical Strut Allografts for Large Femoral Bone Defects in Revision THA

Background

Numerous studies have investigated the clinical and radiographic results of revision THAs with use of cementless stems and cortical strut allografts. However, to our knowledge, no long-term followup studies have evaluated patients undergoing revision THA with use of cortical strut allografts where the allografts provided the primary stability for extensively coated femoral stems in the presence of extensive femoral diaphyseal bone defects.

Question/purposes

We performed this study to determine (1) validated outcomes scores; (2) radiographic signs of fixation and allograft healing; (3) frequency of complications; and (4) survivorship of the components after use of cortical strut onlay allografts in Types IIIB and IV femoral diaphyseal bone defects.

Methods

Between 1994 and 2003, we performed 140 revision THAs in 130 patients with Paprosky Types IIIB and IV femoral diaphyseal defects. The patients were treated using extensively coated femoral stems and cortical strut allografts because primary axial or rotational stability could not be achieved without grafting. Ten of the patients (10 hips; 7.7%) were lost to followup or died before 10 years; the remaining 120 patients (130 hips) represent the study group in this retrospective study. There were 66 men and 54 women. Their mean age at the time of index surgery was 59 ± 18 years (range, 36–67 years). The primary diagnosis was predominantly osteonecrosis of the femoral head (53%). The most common reason for revision was aseptic loosening (97%), followed by periprosthetic fracture (3%). The mean time from primary to revision THA was 12 years (range, 8–27 years). The mean duration of followup was 16.1 years (range, 12–20 years).

Results

The mean Harris hip score was 39 ± 10 points before revision and improved to 86 ± 14 points at 16 years followup (p = 0.02). The mean preoperative WOMAC score was 62 ± 29 (41–91) points and improved to 22 ± 19 (11–51) points at 16 years followup (p = 0.003). Of the 130 stems, 113 (87%) had bone ingrowth, five (4%) had stable fibrous ingrowth, and 12 (9%) were unstable. All allografts were incorporated. Four hips (3%) had a displaced femoral shaft fracture at the stem tip; four (3%) had a postoperative dislocation; and six (5%) had early postoperative infection. Kaplan-Meier survivorship analysis, with revision or radiographic failure as the endpoint, revealed that the 16-year rate of survival of the components was 91% (95% CI, 0.88%–0.96%).

Conclusion

Supportive cortical strut onlay allografts provided high survivorship beyond 12 years of followup in revision THAs. Future studies might compare this approach with allograft-prosthesis composites, proximal femoral replacement, or modular fluted, tapered stems.

Level of Evidence

Level IV, therapeutic study.     

Results of Revision Total Hip Arthroplasty with Modular,Titanium-Tapered Femoral Stems in Severe Proximal Metaphyseal and Diaphyseal Bone Loss

Evidence supporting modular, tapered stems for severe proximal metaphyseal and diaphyseal bone loss is limited. We report our clinical experience with its use for severely deficient femurs. Of 211 revision total hip arthroplasties (THAs), 18 tapered, modular titanium stems were implanted in Paprosky type III and IV femurs. Clinical data were reviewed for function, stability, structural failure and revision surgery at a mean follow-up of 4.5 years. The overall survival rate was 94%. One required revision due to infection and subsidence. The mean subsidence was 3.5 mm and the mean pre- and post-operative Harris Hip score was 56 and 79, respectively. In surviving cases, patients achieved satisfactory function and there were no mechanical failures. Modular, tapered stems demonstrated acceptable outcomes for management of severe proximal metaphyseal and diaphyseal defects.     

Second-generation Modular Acetabular Components Provide Fixation at 10 to 16 Years

Background  

First-generation modular titanium fiber-metal-coated acetabular components had high rates of wear, pelvic osteolysis, and liner dissociation. Second-generation components were designed to reduce the incidence of these problems but it is unclear whether the changes achieved these goals.     

Comparative Biomechanical In Vitro Study of Different Modular Total Knee Arthroplasty Revision Stems With Bone Defects

BackgroundThe aim of this study is to investigate the effects of different stem lengths and types including cones on primary stability in revision total knee arthroplasty with different femoral bone defects and fixation methods in order to maximize bone preservation. It is hypothesized that longer stems provide little additional mechanical stability.MethodsThirty-five human femurs were investigated. A distal bone defect, Anderson Orthopedic Research Institute classification (s. 33) type-F2a, was created in group 1-3 and type-F3 in group 4-6. A cemented, rotating hinge femoral component was combined with different stems (100 and 160 mm total or hybrid cemented cones, or a 100-mm custom-made anatomical cone stem). The femora were loaded according to in vivo loading during gait. Relative movements were measured to investigate primary stability. Pull-out testing was used to obtain a parameter for the primary stability of the construct.ResultsRelative movements were small and similar in all groups (<40 μm). For small defect, the pull-out forces of cemented long (4583 N) and short stems (4650 N) were similar and about twice as high as those of uncemented stems (2221 N). For large defects, short cemented stems with cones showed the highest pull-out forces (5500 N). Long uncemented stems (3324 N) and anatomical cone stems (3990 N) showed similar pull-out forces.ConclusionAll tested stems showed small relative movements. Long cemented stems show no advantages to short cemented stems in small bone defects. The use of cones or an anatomical cone stem with hybrid cementation seems to offer good stability even for larger bone defects. The use of a short cemented stem (with or without cone) may be a suitable choice with a high potential for bone preservation in total knee arthroplasty revision with respective bone defects.     

Treatment of Failed Allograft Prosthesis Composites Used for Hip Arthroplasty in the Setting of Severe Proximal Femoral Bone Defects

This study assessed failures of allograft prosthesis composites (APC) and revisions with a new APC. Twenty-one patients with failed APC’s after revision hip arthroplasty with severe proximal femoral bone loss underwent revision with a new APC. Causes of failure were aseptic loosening (18 patients), infection (3 patients). Of these 21 APC revisions, two patients failed (after 60, 156 months). The 5 and 10 year survival rates were 83.5% (95% CI, 79–100%, number at risk 12 and 6 accordingly). In addition, two patients had non-union at the host-allograft bone junction and were augmented with bone autograft and plate. These results suggest that failed APCs may be revised to a new APC with a predictable outcome.     

Cemented Polished Tapered Stems in Patients Less Than 50 Years of Age: A Minimum 10-year Follow-Up

We report the outcome of 58 consecutive polished tapered stems in 47 patients younger than 50 years, with a minimum of 10 years of follow-up. No stems were revised for aseptic loosening or osteolysis. The Harris hip scores were good or excellent in 76% of the patients. There was excellent preservation of proximal bone.     

Survival,Local Recurrence,and Function After Pelvic Limb Salvage at 23 to 38 Years of Followup

Background  

Malignant pelvic tumors frequently pose challenges to surgeons owing to complex pelvic anatomy and local extension. External hemipelvectomy frequently allows adequate margins but is associated with substantial morbidity and reduced function. Limb salvage is an alternative approach when adequate margins can be achieved, but long-term function and survival are unclear.     

High Survivorship of Short-Cemented Femoral Stems in Condylar Revision Total Knee Arthroplasty Without Significant Metaphyseal Bone Loss: Minimum 5-Year Follow-Up

BackgroundWe aimed to evaluate the outcomes of hybrid fixation technique in condylar revision total knee arthroplasty (rTKA) using cementless metaphyseal tibial sleeves and short-cemented femoral stems with a rotating platform articulation.MethodsRetrospective consecutive study of all condylar rTKAs with a cemented femoral stem between 2009 and 2016 was conducted. Patients were identified using a local prospective database and linkable data obtained from the National Joint Registry for rTKA. Demographic, clinical, and surgical data were collected from patients’ electronic health records. The primary outcome measure was mechanical failure and implant survivorship using a nationally collected data, complications, re-operations, and “any-cause revision” were also recorded.ResultsThere were 72 consecutive patients (72 knees) with minimum 5-year follow-up: 33 (45.8%) females and 39 (54.2%) males with a median age of 70 years (range 47-88). The indication for revision surgery was aseptic loosening (n = 34, 47.2%), instability (n = 17, 23.6%), infection (n = 14, 19.5%) with 10 patients having 2-stage approach and 4 patients with single-stage approach, stiffness (n = 4, 5.6%), and malalignment (n = 3, 4.1%). At mean follow-up of 6.87 years (median 6.7; range 5-11.8), only 2 patients required revision for infection. Using “any-cause implant revision” as an end point, implant survivorship for this construct was 97.2% at median 6.7 years. To date, none of the femoral stems have been revised for mechanical failure.ConclusionIn rTKA with good femoral condylar bone stock, we have shown excellent survivorship with a short-cemented femoral stem, in conjunction with a mobile-bearing and a tibial sleeve. This has the advantage of reducing the length of the revision construct of this complex surgery.Level of EvidenceLevel IV.     

Mid‐ to Long‐Term Outcomes of Cementless Modular,Fluted, Tapered Stem for Massive Femoral Bone Loss in Revision Total Hip Arthroplasty

ObjectiveTo evaluate mid‐ to long‐term results of revision total hip arthroplasty for massive femoral bone loss using a cementless modular, fluted, tapered stem.MethodsThis is a retrospective study performed at a single hospital. During the period of January 2007 to January 2015, 33 patients (34 hips) underwent primary revision surgery with cementless modular, fluted, tapered stems due to femoral bone loss. Sixteen men and 17 women were included in the study, with an average age of 63.9 ± 11.7 years (range, 27 to 88 years). Operative data including operative duration, length of incision, drainage volume and duration, blood loss and transfusion, cases of bone graft and extended trochanteric osteotomy were recorded. Clinical evaluation was performed using Harris hip score (HHS), visual analogue scale (VAS), and patients'' satisfaction. Radiographic data including femoral stem fixation, subsidence, integrin of allograft bone, and leg length discrepancy were assessed. Complications and survivorship were evaluated using Kaplan–Meier survival rate.ResultsThe mean follow‐up was 9.1 ± 2.5 years (range, 5–13 years). The Harris hip score was 43.6 ± 11.5 preoperatively and maintained at 86.5 ± 6.6 at the time of latest follow‐up (P < 0. 05). The X‐ray showed bone ingrowth fixation in 30 hips (88%), fibrous stable fixation in three hips (9%), and instability in one hip (3%). The average stem subsidence was 3.9 ± 2.2 mm (range, 1 to 10 mm). The mean difference in leg length in our study was 3.3 ± 2.7 mm (range, 0 to 10 mm), and the leg length discrepancy in 28 (82%) patients was within 5 mm. No case of junction fracture was observed. Seven (21%) intraoperative fractures occurred in our study. Three (9%) cases with infection were observed after revision. Six (18%) patients had lower limb vein thrombosis. The survivorship of prostheses with re‐revision for any reason was 95% (95% CI, 12.0 to 13.0) at the 10‐year follow‐up. Three (9%) re‐revisions were needed, including one for aseptic loosening, one for dislocation, and one for infection.ConclusionThe mid‐ to long‐term results of revision total hip arthroplasty with the cementless modular, fluted, tapered stems are encouraging for massive femoral bone loss.     

High Failure at a Minimum 5-Year Follow-Up in Primary Total Hip Arthroplasty Using a Modular Femoral Trunnion

BackgroundModular femoral trunnions enable the surgeon to independently adjust offset, leg length, and anteversion in total hip arthroplasty (THA). However, modularity may result in an increased risk of fretting and corrosion along with a higher risk of implant dissociation or fracture. The purpose of this study is to evaluate mid-term survivorship of THAs using a cementless modular system.MethodsA consecutive series of 221 patients who underwent a primary THA using the ALFA II modular stem by a single surgeon between 2002 and 2004 were reviewed. Survivorship of the ALFA II modular hip system was evaluated at a minimum of 5 years postoperatively.ResultsOf the 221 patients, 28 (12.7%) died from causes unrelated to the surgery before adequate follow-up, and 64 (29.0%) patients were lost to follow-up. The remaining 129 patients had a mean 6.5-year (range: 5-8 years) follow-up. All-cause survivorship of the modular stem system was 81% (95% confidence interval = 69-90) at a mean 6.5-year follow-up. Of the 25 (19.4%) cases requiring revision surgery, 52.0% was for dissociation of the modular components, 32.0% was for fracture of the prosthesis, 12.0% was for instability/multiple dislocations, and 4.0% was for chronic septic THA. Body mass index (odds ratio = 1.080) and offset (odds ratio = 1.254) were independent risk factors for mechanical failures of the modular stem system.ConclusionThe modular stem hip system of interest in this study demonstrates a high failure rate at mid-term follow-up, and we caution against the use of similar designs in primary THAs.     

Influence of Geometry and Extent of Coating on Survival of Cementless Distal-Locking Revision Stems at 7 to 18 Years

BackgroundWe aimed to compare the long-term clinical outcomes, complications, and survival of 2 revision stems with different geometries, extents of coating, and distal-locking mechanisms.MethodsWe retrospectively compared outcomes at a minimum of 7 years following revision THA using 2 proximally coated distal-locking stems: 98 Ultime first-generation (G1) and 116 Linea second-generation (G2) stems. Ten-year Kaplan-Meier survival was assessed considering stem re-revision for any reason and for aseptic reasons. At final follow-up, Harris Hip Score and Oxford Hip Score were collected, and any thigh pain or complications were noted.ResultsConsidering re-revision for any reason, survival was 69% for G1 stems and 91% for G2 stems. Considering re-revision for aseptic reasons, survival was 77% for G1 stems and 92% for G2 stems. Re-revisions were due to fracture of 6 G1 stems but no G2 stems. Complications that required reoperation without stem or cup removal occurred in 3 of the G1 stems and 1 of the G2 stems. Compared to the G1 stems, the G2 stems resulted in better Harris Hip Score (83 vs 71, P = .001), Oxford Hip Score (22 vs 27, P = .019), less thigh pain (4% vs 39%, P < .001), and fewer nonoperated complications (9% vs 15%).ConclusionThe second-generation stem had significantly better survival and clinical outcomes than the first-generation stem. The differences in survival and clinical outcomes could be attributed to the larger coated surface of the G2 stem and to the fact that the G1 stem was originally intended as a temporary implant to be followed by de-escalation.     

High Survivorship and Few Complications With Cementless Total Wrist Arthroplasty at a Mean Followup of 9 Years

Clinical Orthopaedics and Related Research® - Total wrist arthroplasty (TWA) has been described as traditionally being performed with fixation in the radius and carpus with cement. The TWA...