Revision Total Hip Arthroplasty for Large Medial Defects With Witch's Hat-Shaped Structural Allografts — Minimum 10-Year Follow-Up

A witch's hat-shaped structural allograft can restore bone stock over acetabular medial wall during revision total hip arthroplasty, which may be of importance for future re-revisions. However, long-term results are unclear. A retrospective review of 104 consecutive hips in 96 patients was performed to determine survivorship and functions. The minimum follow-up was 10 years. Nine patients required re-revision for cup aseptic loosening with a mean time to revision of 4.5 years. Kaplan–Meier survivorship was 89.4% at the endpoint. Radiographic evaluation revealed sixteen instances of minor medial wall graft absorption without significant cup migration. The mean modified Harris Hip Scores were 36 preoperatively and 86 at last follow-up. Revision acetabular surgery using a witch's hat-shaped allograft to restore acetabular medial wall provides an excellent alternative.     

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.     

Revision of Complex Acetabular Defects Using Cages with the Aid of Rapid Prototyping

This study details a method using rapid prototyping (RP) technique to assist in acetabular revision with complex bone defects. Hemi-pelvic RP models were built among 25 patients with complex acetabular bone defects. Each patient was scheduled to undergo revision using either commercially available or customized cages based on individualized RP models. Average follow-up was 4.4 years (range, 1 to 9 years). The average Harris hip score was 36.1 (range, 20 to 58) preoperatively and reached an average of 82.6 (range, 60–96) at the last follow-up. No mechanical failure or loosening was observed. One patient experienced hip dislocation 4 days postoperatively. The resultant findings of this study merit consideration of RP as a helpful clinical complement for dealing with some complex bone defect of acetabulum.     

Massive Bone Defect Compromises Postoperative Cup Survivorship of Acetabular Revision Hip Arthroplasty with Impaction Bone Grafting

We evaluated 66 acetabular revision arthroplasties using cemented cup with impaction bone grafting (IBG) to detect the extent that bone defect affects the outcome. We defined the maximum acetabular defect distance (MADD), which indicates the greatest depth of the grafted layer. Cup survival analysis with aseptic loosening as the endpoint revealed that the “MADD ≤ 20 mm” group showed higher survivorship than the “MADD > 20 mm” group (95% vs. 74%, P = 0.034), and that the simple-wall-defect group (none or one mesh used) showed higher survivorship than the complex-wall-defect group (two meshes used) (96% vs. 73%, P = 0.044). A favorable indication for acetabular IBG reconstruction is cases in which those cups can be placed at ≤ 20 mm MADD with a simple wall defect.     

Outcome of Porous Tantalum Acetabular Components for Paprosky Type 3 and 4 Acetabular Defects

Porous tantalum acetabular implants provide a potential solution for dealing with significant acetabular bone loss. This study reviews 24 acetabular revisions using tantalum implants for Paprosky type 3 and 4 defects. The mean Harris Hip Score improved from 35 ± 19 (range, 4–71) to 88 ± 14 (range, 41–100), p < 0.0001. Postoperative radiographs showed radiolucent lines in 14 hips with a mean width of 1.3 ± 1.0 mm (range, 0.27–4.37 mm). No gaps enlarged and 71% of them disappeared at a mean of 13 ± 10 months (range, 3–29 months). At a mean follow-up of 37 ± 14 months (range, 24–66 months), 22 reconstructions showed radiograpic evidence of osseointegration (92%). The two failures were secondary to septic loosening. When dealing with severe acetabular bone loss, porous tantalum acetabular components show promising short-term results.     

Minimum 20-Year Follow-Up Results of Revision Total Hip Arthroplasty With Improved Cementing Technique

A consecutive, non-selective cohort of 83 (77 patients) cemented total hip arthroplasty revisions using contemporary cementing techniques was analyzed at a minimum of 20 years following the index procedure. No patients were lost to follow-up. The average age at revision was 62.4 years (23 to 89). Twenty-two hips (26.5%) had had a reoperation, eighteen (21.7%) for aseptic loosening, 3 (3.6%) for femoral prosthesis fracture and 1 (1.2%) for dislocation. The incidence of re-revision for aseptic femoral loosening was 7.5% and for aseptic acetabular loosening was 21.7%. These results confirm that cemented femoral revision using improved cementing techniques is a durable option in revision hip surgery. In contrast to this, THA revisions using a cemented acetabular component have been less durable at this length of follow-up.     

Loosening After Acetabular Revision: Comparison of Trabecular Metal and Reinforcement Rings. A Systematic Review

The best method of revision acetabular arthroplasty remains unclear. Consequently, we reviewed the literature on the treatment of revision acetabular arthroplasty using revision rings (1541 cases; mean follow-up (FU) 5.7 years) and Trabecular Metal, or TM, implants (1959 cases; mean FU 3.7 years) to determine if a difference with regard to revision failure could be determined. Failure rates of the respective implants were compared statistically using a logistic regression model with adjustment for discrepancies in FU time. In our study, TM shows statistically significant decreased loosening rates relative to revision rings for all grades including severe acetabular defects and pelvic discontinuity. The severe defects appear to benefit the most from TM.     

One-Component Revision in Total Hip Arthroplasty: The Fate of the Retained Component

The purpose of the present study was to evaluate the long-term outcome of the unrevised part in one-component total hip arthroplasty revision (index operation). Forty-four patients (46 hips) with a mean age of 58 years at the time of the index operation were included. At the final follow-up, 4 of the 19 (21%) unrevised acetabular components and 6 of the 27 (22%) unrevised femoral components were subsequently revised at a mean time of 14 and 11 years from the index operation, and 22 and 24 years from the primary operation, respectively. We concluded that revision of a stable component is not justifiable on the basis of its long duration in use or non-ideal position or possible loosening on radiographs.     

Midterm Results of Hybrid Cement Technique in Revision Total Knee Arthroplasty

While the number of revision total knee arthoplasties (TKA) performed in the United States continues to rise annually, controversy exists whether intramedullary stems should be cemented or press-fit. Retrospective analysis of midterm survivorship rate of revision TKA using hybrid stem fixation in 119 patients was performed. Revision was performed predominantly for aseptic loosening (78) and infections (28). Average follow-up was 62 months (range, 46–80). Knee Society Pain and Function scores improved from 39 and 58 to 68 and 79 (P < .05). Fifty-eight tibial offsets and 28 femoral offsets were utilized. Three knees (2.5%) required revision without any cases of aseptic loosening. Radiographic complete or progressively advanced (> 2 mm) radiolucent lines were not observed in any patient. At mid-term follow-up, revision hybrid TKA provides excellent fixation with extremely low rates of aseptic loosening and avoids the inherent complications of extensive intramedullary cement.     

Total Hip Arthroplasty after Acetabular Fracture: Incidence of Complications,Reoperation Rates and Functional Outcomes: Evidence Today

The outcome of THA following acetabular fracture was analyzed on 654 patients with a systematic review approach. An uncemented acetabular and femoral component was used in 80.1% and 59.8% of the cases respectively. The median Harris hip score was 88 points. In the early THA group, Kaplan–Meier survivorship analysis with any loosening, osteolysis or revision as the end point revealed that the 10-year cup survival was 81% whereas in the late THA group was 76% (P = 0.287). The 10-year survival was 95% for the early stems and 85% for the late ones (P = 0.001). Due to their complexity these fractures should be managed in highly specializing units where the expertise of arthroplasty and trauma reconstruction is available.     

颗粒骨打压植骨结合多孔非骨水泥臼杯在AAOSⅢ型髋臼大面积骨缺损翻修中的应用

背景：颗粒骨打压植骨是修复髋臼骨缺损的重要方法,对大面积髋臼骨缺损采用打压植骨结合非骨水泥臼杯重建仍然存在争议。目的：探讨同种异体颗粒骨打压植骨结合多孔非骨水泥臼杯髋臼重建术修复AAOSⅢ型髋臼大面积骨缺损的方法及近期疗效。方法：随访2005年6月至2010年4月收治的28例（28髋）AA0SⅢ型髋臼大面积骨缺损患者。男18例,女10例,年龄34-74岁,平均53．8岁。髋关节置换术后感染醐翻修9例,骨溶解及髋臼假体松动翻修19例。本组AAOSⅢ型髋臼骨缺损面积大,术中见髋臼骨缺损超过髋臼关节面的50％。全部采用同种异体颗粒骨打压植骨结合多孔非骨水泥臼杯髋臼重建术。术后定期随访,观察臼杯有无松动、植入骨与宿主骨整合情况,髋关节功能评分采用Harris评分。结果：28例均获得随访,术后随访时间为13-70个月,平均43个月。Harris评分由术前32-48分,平均41分,提高至末次随访时86-95分,平均90分。28例髋臼假体均固定牢固无松动征象,植入骨逐渐与宿主骨整合,无感染及坐骨神经损伤。结论：在获得臼杯初始稳定固定的情况下,大面积颗粒骨打压植骨（臼杯与宿主骨接触面积〈50％）结合多孔非骨水泥臼杯髋臼重建术修复AAOSⅢ型髋臼大面积骨缺损近期疗效较好,远期疗效尚待进一步随访。     

Use of Jumbo Cups for Revision of Acetabulae With Large Bony Defects

Several methods of treatment are available for acetabular revision associated with bone loss. Jumbo cups (minimum diameter of 62 mm in women, 66 mm in men, or 10 mm larger than the normal contralateral acetabulum) are often useful for large defects. The purpose of this study is to report a large jumbo cup series with an average 10-year follow-up. A total of 196 jumbo cups in 186 patients with a minimum of 2-year follow-up were available for review. Harris hip score improved from 44 preoperatively to 72 postoperatively. Survivorship was 98% at 4 years and 96% at 16 years. Five revisions and two resection arthroplasties were performed for failure. In conclusion, porous jumbo cup acetabular revision with supplemental screw fixation provides good to excellent intermediate- and long-term outcomes.     

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.     

Tumor Endoprosthesis Revision Rates Increase With Peri-Operative Chemotherapy But Are Reduced With the Use of Cemented Implant Fixation

Chemotherapy may reduce osseointegration of tumor endoprosthesis, while delaying chemotherapy may reduce survival. We studied the effects of chemotherapy and cemented fixation on tumor endoprosthesis survivorship with a retrospective analysis of 50 consecutive patients receiving lower limb salvage surgery. We compared rates of radiographic loosening/revision and effect of cement fixation between chemotherapy/no chemotherapy cohorts. Chemotherapy increased the total revision rate (HR = 3.8 [1–14], P = 0.033), but did not affect aseptic loosening. Cement fixation reduced revision for loosening (HR = 0.09 (0.008–0.98),P = 0.012) and showed less radiographic loosening (HR = 0.09 (0.02–0.51),P = 0.00066). Cement fixation had lower rates of revision for loosening and radiographic loosening regardless of whether chemotherapy was given. We conclude that for these implants, cement fixation provides superior results to uncemented fixation.     

Long-Term Durability of the CLS Femoral Prosthesis in Patients with Osteonecrosis of the Femoral Head

Ninety-five hips with cementless wedge-shaped tapered CLS stem were evaluated with a mean duration of 12.7 years (range, 10.7–17.3 years). All patients were young and diagnosed with osteonecrosis of the femoral head. The Harris hip score was 92 at the latest follow-up. A subsidence greater than 3 mm was found in 3 hips (3.2%). Focal femoral osteolysis was found in 12 hips (12.6%). Endosteal bone formation and bony pedestal were observed in 94 hips (98.9%) and in 26 hips (27.4%), respectively. With revision for stem loosening as the end point, the survivorship showed 98.9% (95% CI, range 96.9%–100%) at 13 years. Stem alignment and proximal femur morphology did not influence loosening of the stem (p > 0.05).     

One-Component Revision of Failed Hip Resurfacing from Adverse Reaction to Metal Wear Debris

This study assessed the results of 90 one-component revisions for failed hip resurfacing due to adverse reaction to metal wear debris (76 acetabular, 14 femoral). Patients with a femoral head size 40–45 mm (n = 33) received a two-piece titanium meshed shell with a cross-linked polyethylene liner and patients with femoral head size 46–54 mm (n = 43) received metal-on-metal components. Patients with femoral head size > 45 mm who wished a metal-polyethylene bearing received a dual mobility femoral prosthesis. The mean follow-up was 61 months and the procedure was successful in 97% of the patients. Three failures required re-revision; there was one deep infection. There were no dislocations. One-component revision is a reasonable alternative to revision to total hip arthroplasty.     

Revision for Aseptic Loosening of Highly Porous Acetabular Components in Primary Total Hip Arthroplasty: An Analysis of 20,993 Total Hip Replacements

BackgroundHighly porous-coated titanium acetabular components have a high coefficient of friction and ultraporous surfaces to enhance bone ingrowth and osseointegration in total hip arthroplasty (THA). There have been concerns with the development of early radiolucent lines and aseptic loosening of highly porous acetabular components. It is unclear whether these concerns relate to a specific implant or the entire class. The aim of this study is to compare the revision rates for aseptic loosening of highly porous acetabular combinations in primary THA using data from a large joint replacement registry.MethodsData were retrieved from the Australian Orthopedic Association National Joint Replacement Registry for the study period September 1999 to December 2019. All primary THA procedures recorded and performed for osteoarthritis using the most common combinations for each highly porous acetabular component with highly cross-linked polyethylene and a 32-mm or 36-mm femoral head were included. The primary outcome measure was revision for aseptic loosening of the acetabular component. Results were adjusted for patient age and gender.ResultsThere were 20,993 primary THA procedures performed for osteoarthritis using a highly porous acetabular component across 6 combinations. Relative to the POLARSTEM/R3 (StikTite), the Exeter V40/Tritanium had a significantly higher risk of revision for aseptic loosening of the acetabular component (hazard ratio 0.21, 95% confidence interval 0.06-0.74, P = .014). There was no difference between any other highly porous acetabular component combination and no late revisions for aseptic loosening.ConclusionHighly porous-coated titanium acetabular components have low rates of aseptic loosening with long-term follow-up. A difference between components may exist.Level of EvidenceLevel III.     

Mortality Following Revision Total Knee Arthroplasty: A Matched Cohort Study of Septic versus Aseptic Revisions

We report the medium-term mortality after septic versus aseptic revision total knee arthroplasty (TKA) and factors that can contribute to mortality in revision TKA. Mortality rates of 88 patients undergoing septic revision (septic group) were compared with age- and year of surgery-matched 88 patients of aseptic revision (aseptic group). The overall mortality after revision TKA was 10.7% at a median of 4 years of follow-up (range, 2–7 years). However, the mortality after septic revision (18%, 16/88) was six times higher than that of aseptic revision (3%, 3/88) (P = 0.003). Infections with Staphylococcus aureus and/or methicillin resistance was not associated with higher mortality rates. Multivariate analysis indicated that increased age (P < 0.001), higher ASA class (P = 0.002), and septic revision (P < 0.001) were identified as independent predictors of increased mortality after revision TKA.     

Standard Versus Custom-Made Acetabular Implants in Revision Total Hip Arthroplasty

BackgroundToday, various options are used for the reconstruction of acetabular bone loss in revision total hip arthroplasty (RTHA). The aim of the study was to compare the outcomes of using standard acetabular implants (SAIs) and custom-made acetabular implants (CMAIs) in RTHA in cases with extensive acetabular bone loss.MethodsThis was a comparative analysis of the results of 106 operations of RTHA performed during the period from January 2013 to December 2019. In 61 cases (57.5%), CMAIs were used. In 45 cases (42.5%), SAIs were implanted.ResultsThe incidence of aseptic loosening of the acetabular component after RTHA in uncontained loss of bone stock of the acetabulum (type III-IV as per the Gross and Saleh classification) using the CMAI was less than that using the SAI (2.4% and 10.0%, respectively). The most significant differences in aseptic loosening rates were noted after implantation of the CMAI and SAI in pelvic discontinuity with uncontained bone defect (0% and 60.0%, respectively; P < .001).ConclusionThe ideal indications for the use of the CMAI are uncontained defects and pelvic discontinuity with uncontained loss of bone stock (types III-V Gross and Saleh classification). Treatment of these defects with the SAI leads to a higher incidence of aseptic loosening requiring re-revisions. Further observation is required to assess the effectiveness of using the CMAI and SAI in the long-term follow-up period.     

Revision arthroplasty with impaction bone grafting and Charnley-Kerboull cemented stem. Surgical technique and results

We report here the study of a personal series of 129 consecutive femoral impaction grafting during hip revision replacement performed between January 1991 and December 2005. The indication for the revision of the femoral component was aseptic loosening in 127 hips and septic loosening in two. The precise locations of the segmental defects and osteolytic areas were determined and classified, with use of the Endo-Klinik System, as follows: grade 2 in 75 hips, grade 3 in 43, and grade 4 in 11. Removal of the components, debris and cement was done with special care to achieve a complete resection of fibrous tissue in the medullary canal to ensure a direct contact between the graft and the host bone. Before impaction grafting, femoral segmental bone defects or windows were reconstructed and reinforced with strut allograft and cerclage wires. We used in all hips a special revision set of instruments specially designed for impaction grafting. All the acetabular cups were also revised. Clinical and radiologic evaluation was performed at six weeks, three months, six months and one year. Then, patients were reviewed every year for the first five postoperative years and every two years thereafter. A survivorship analysis was performed to determine the overall success of the procedure. Failure was defined as an implant that had been revised or that was radiologically loosened at the time of follow-up. The survival curve was derived from the cumulative survival rate over time, as calculated from the actuarial life table. At the last follow-up evaluation, seven patients (seven hips) had died and two (two hips) were lost to follow-up. The follow-up of these nine patients ranged from two to ten years. One hundred and twenty patients (120 hips) were reviewed with a mean follow-up of 8.2 years (range, two to 16 years). The average follow-up of the whole series was 8.4 years (range, two to 16 years). At the time of the final review 1 of the 129 hips had migration of the stem’s cement mantle relative to the bone (5 mm) with lucent lines at the graft-host interface in three Gruen zones. Another one had migration within the cement (8 mm) with lucent line at the distal graft-host interface and a distal fracture of the cement mantle. These two stems were considered as definitely loosed according to the criteria of Johnston et al. but none of them was revised. The remaining 127 hips showed no radiological changes at the latest examination concerning stem migration and radiolucent lines. One acetabular definite loosening occurred at ten years and was revised at 11 years postoperatively. In this respect, of the 129 hips, only one hip was revised at 11 years’ follow-up (0.7%). The survivorship analysis, with radiologic loosening as the endpoint, yielded a 98% cumulative survival rate for the femoral component and for the acetabular component, 99% at eleven years follow-up. The survival rate with revision for any reason as the endpoint was 99.4% at eleven years follow-up. The results observed in this series, regarding the need for a repeat revision for any reason, are in agreement with the excellent outcome reported by other authors using similar technique. Nevertheless two main differences must be emphasized when comparing the results of this study with the others. The first one is the low rate of subsidence and the second is the absence of postoperative femoral fracture. The quality of bone grafting and the use of a Kerboull stem, double tapered and polish, were associated with the very low rate of distal migration. The unconditional reconstruction of distal bone deficiency or weakness with bone graft strut appeared efficient to prevent the occurrence of femoral fracture, despite the unique use or standard stems.