大转子延长截骨在全髋关节翻修术中应用的临床评价

目的 回顾性研究采用大转子延长截骨(extended troehanteric osteotomy,ETO)行全髋关节翻修术后股骨柄的位置变化,评价ETO在股骨假体稳定件髋关节翻修术中的作用.方法 1998年1月至2007年6月,采用ETO对股骨柄或骨水泥壳固定稳定性全髋关节33例33髋进行翻修.翻修术后采用Harris评分和MOMAC评分评估髋关节功能,摄动态X线片观察截骨块愈合、假体位置改变及股骨柄与股骨髓腔匹配等情况.结果 25例随访12～103个月,平均63个月.Harris评分由术前平均38.4分,提高到末次随访时88.7分;WOMAC评分由术前平均56.2分,降至末次随访时42.8分.大转子截骨块均在术后4～10个月骨性愈合.3例发生股骨柄下沉.平均3.4mm.股骨柄假体出现外翻、内翻各1例.无术中或术后骨折、钢丝断裂、感染、假体周围骨溶解以及异位骨化发生.术后关节脱位1例.结论 对假体固定稳定性股骨柄进行翻修,采用ETO有利于假体的安全取出,术后截骨块愈合率高,延长截骨不影响假体稳定性.股骨柄下沉、位置改变、截骨块骨折等并发症发生率低.     

Survivorship and Radiological Analysis of a Monoblock,Hydroxyapatite-Coated Titanium Stem in Revision Hip Arthroplasty

BackgroundWe evaluated the survivorship, incidence of complications, radiological subsidence, proximal stress shielding, and patient-reported outcomes of a conservative, monoblock, hydroxyapatite-coated femoral stem.MethodsThis retrospective cohort study reports on 254 revision hip arthroplasties between January 2006 and June 2016. The mean age of patients was 71 years. The mean length of follow-up was 62 months (range 12-152).ResultsThere were 13 stem re-revisions: infection (4), periprosthetic fracture (4), aseptic stem loosening (3), stem fracture (1), and extended trochanteric osteotomy nonunion (1). Kaplan-Meier aseptic stem survivorship was 97.33% (confidence interval 94-100) at 6 years. There were 29 intraoperative fractures. There were 6 cases of subsidence greater than 10 mm; however, none required revision. Ninety-six percent of cases showed no proximal stress shielding. Thigh pain was reported in 3% of cases.ConclusionThis study confirms that this stem provides good survivorship at 6 years, acceptable complication rates, adequate proximal bone loading, low incidences of thigh pain, and reliable clinical performance in revision hip arthroplasty.Key MessageA monoblock, fully hydroxyapatite-coated titanium stem is reliable in revision arthroplasty with mild-moderate femur deficiencies.     

Is extended trochanteric osteotomy safe for use in 2-stage revision of periprosthetic hip infection?

To evaluate the safety of using extended trochanteric osteotomy (ETO) in a 2-stage revision of periprosthetic hip infection, we performed a retrospective review of 23 patients using ETO in the revision of infected hip arthroplasty and compared them to 46 patients using ETO in the revision of noninfected hip arthroplasty. Harris Hip Score improved from 36 points preoperatively to 82 points postoperatively. Infection was eradicated in 22 patients (96%). ETO healed in all at a mean of 10.6 weeks. No stem was revised for aseptic loosening. Complications included 2 periprosthetic fractures, 1 peroneal nerve palsy, and 1 dislocation. Postoperative Harris Hip Score, ETO union rate, time to healing of ETO, stem stability, and complication rate did not differ between the 2 groups. Our data suggest that ETO can be safely used in treating periprosthetic hip infection.     

The removal of extensively porous-coated femoral stems

Cementless total hip arthroplasty (THA) is the favored fixation for primary THA in the United States. While cylindrical extensively porous-coated femoral stems have demonstrated long-term survivability, the distal ingrowth can create challenges in cases where these stems need to be extracted. This technique article outlines the current methods for extracting extensively porous-coated stems. Traditionally, the extended trochanteric osteotomy (ETO) has been used; however, we present a technique that eliminates the need for osteotomy fixation hardware, eliminates the risk of fragment migration, and nonunion while not compromising the surgeons ability to convert to an ETO if necessary.     

Revision total hip arthroplasty using a fluted and tapered modular distal fixation stem with and without extended trochanteric osteotomy

We reviewed 62 revision total hip arthroplasties performed using a fluted and tapered modular distal fixation stem after a mean follow-up of 4.2 years. An extended trochanteric osteotomy (ETO) was used in 32 of the 62 hips (52%), whereas no osteotomy was used in the remaining 30 hips. The mean postoperative Harris hip score among the patients was 87.3 points. The mean stem subsidence was 1.1 mm. With the exception of one reoperation for a deep infection, no femoral revision was performed because of mechanical failure. Complications included intraoperative diaphyseal split fractures (6%), cortical perforations (6%), and dislocations (5%). Postoperative Harris hip scores, femoral component stability, and overall complication rates did not differ between the group treated with an ETO and that treated without it. However, the rates of cortical perforation and marked stem subsidence (>5 mm) were significantly higher in the group treated without an ETO than those in the group treated with an ETO, but these were not significantly different when stratified by femoral bone defect. The potential advantages of this implant design could be highlighted in a clinical setting when inserted using an ETO.     

股骨大转子延长截骨在假体稳定股骨柄翻修中的应用

目的 评估大转子延长截骨在股骨假体固定稳定型全髋关节翻修术中应用的中期临床效果.方法 1998年1月至2005年6月对27例患者(27髋)采用大转子延长截骨对股骨柄和(或)骨水泥壳固定稳定的全髋关节翻修.临床随访评估包括Harris评分和WOMAC评分,术前Harris评分平均42.7分,WOMAC评分平均55.6分;影像学评估包括术后拍摄X线片,对比观察截骨块愈合时间、是否存在截骨延迟愈合或不愈合,截骨块是否发生移位以及假体是否下沉等.结果 共19例患者(19髋)获得随访,平均随访时间5.3年.无一例发生术中或术后骨折.术后Harris评分平均87.3分,WOMAC评分平均46.3分.所有患者大转子截骨块均于术后6个月内愈合.无股骨大转子截骨块向近端移位,3例发生股骨柄下沉,平均下沉3.4 mm,无钢丝断裂.结论 对于假体固定稳定型股骨柄翻修,采用股骨大转子延长截骨有利于手术操作和翻修假体的植入和固定,有利于截骨块的愈合,降低术中、术后并发症发生率,中期疗效显著.     

Locking compression plate versus revision-prosthesis for Vancouver type B2 periprosthetic femoral fractures after total hip arthroplasty

IntroductionRevision arthroplasty is currently the recommended treatment for periprosthetic femoral fractures after primary total hip arthroplasty (THA) and stem loosening (Vancouver B2). However, open reduction and internal fixation (ORIF) utilizing locking compression plate (LCP) might be an effective treatment with a reduced surgical time and less complex procedure in a typically elderly patient collective with multiple comorbidities. The purpose of this study was to compare the functional and radiographic outcomes in two cohorts with Vancouver B2 periprosthetic femoral fractures after primary THA, treated either by ORIF with LCP fixation, or by revision arthroplasty utilizing a non-cemented long femoral stem.Materials and Methods36 patients with Vancouver B2 periprosthetic femoral fractures following THA, who had been treated between 2000 and 2014, were reviewed. Eight fractures were treated with LCP fixation, fourteen fractures with the first-generation revision prosthesis (Helios^®), and fourteen fractures with the second-generation revision prosthesis (Hyperion™). The patients were assessed clinically with the Parker mobility score and radiographically.ResultsA total of ten males and 26 females formed the basis of this report with an average age of 81years (range, 64 to 96 years). All fractures treated with LCP fixation alone healed uneventfully and there were no signs of secondary stem migration, malalignement or plate breakage. The average surgical time was shorter in the ORIF cohort; however, the results were not statistically significant. The postoperative Parker mobility score at latest follow-up showed no difference between the groups.ConclusionsAccording to the results of the current study, we conclude that the use of LCP fixation can be a sufficient option for the treatment of Vancouver B2 periprosthetic femoral fractures correspondingly with femoral stem loosening.     

A Distal Fluted,Proximal Modular Femoral Prosthesis in Revision Hip Arthroplasty

Most reports on the use of modular femoral stems during revision surgery have involved short follow-up periods. The authors evaluated the clinical and radiographic performance of 59 patients fitted with a distal fix modular stem. The average follow-up period was 8.2 years. Average Harris hip score was improved from 47 to 87.6. Of 19 patients with trochanteric osteotomy, 4 had a displaced greater trochanter. Re-revision was performed in 5 patients, and 3 of these were for subsidence (of these 3, subsidence was associated with dissociation of the coupling part in 1 and with osteotomy nonunion in other 2 [proximal component only]). Modular distally fixed femoral stems were found to offer intraoperative flexibility, but to suffer from subsidence and intraoperative greater trochanter and metaphyseal femoral fractures.     

Extended trochanteric osteotomy (ETO) fixation for femoral stem revision in periprosthetic fractures: Dall–Miles plate versus cables

Background

Extended trochanteric osteotomy (ETO) is a well-established surgical technique used for femoral stem retrieval in revision hip arthroplasty procedures. Fixation of ETO is commonly achieved through wire, cable or cable–plate fixation. No evidence exists to date to suggest which method is superior when used in an acute traumatic setting.

Methods

Thirty cases of acute periprosthetic fracture requiring femoral stem revision with an ETO were identified over a 10-year period. Each case had a loose femoral prosthesis which was revised using an ETO approach. Nineteen of these were fixed using cables only, and 11 were fixed using a cable–plate construct. Radiographic outcomes measured included greater trochanter migration, osteolysis, union, time to union and overall success using the Beals and Tower classification. Clinical outcomes were assessed using the modified Harris Hip Score.

Results

Twenty-three Vancouver B/C-type fractures were identified. The remaining seven consisted of other fracture types with a loose femoral stem requiring revision through ETO. Mean follow-up was 32 months in the cable group and 12 months in the cable–plate group. The cable–plate construct performed better than cables alone. Mean migration rates were 1.7 mm lower in the cable–plate group (p < 0.05). Beals and Tower classification of radiographic outcomes was significantly better in the cable–plate group (p < 0.01). Modified Harris Hip Scores were better in this group also (p < 0.05).

Conclusion

When utilising an ETO approach for femoral stem revision in acute periprosthetic fractures, superior clinical and radiographic outcomes can be achieved if fixation involves a cable–plate system instead of cables only.

     

Extended trochanteric osteotomy for the treatment of vancouver B2/B3 periprosthetic fractures of the femur

Periprosthetic femur fractures after total hip arthroplasty are a growing concern as their prevalence is expected to rise. A retrospective review was performed of all patients undergoing revision total hip arthroplasty with an extended trochanteric osteotomy (ETO) for treatment of a Vancouver B2/B3 fracture at our institution. Fourteen patients were identified having a minimum of 2-year follow-up. Clinical and radiographic evaluation was performed for all patients. At a mean 44.5 months of follow-up, mean modified D'Aubigne and Postel scores were 8.6. In all cases the ETO and fracture healed with radiographic evidence of osseointegration of the femoral component. Use of an ETO for the treatment of periprosthetic femur fractures provides excellent exposure, facilitates component implantation, and is compatible with fracture healing and good short-term clinical results.     

Extended Trochanteric Osteotomy Followed by Cemented Impaction Allografting in Revision Hip Arthroplasty

The aim of this study is to present the medium- to long-term results of all cases of femoral impaction allografting revision at our institution that required an extended trochanteric osteotomy (ETO) at the time of surgery. Eighteen patients with a mean age of 60 years were evaluated. Indication for revision was aseptic loosening in all cases. The mean follow-up was 123 months (51-170). Charnley-D'Aubigné-Postel scores, stem length, ETO length, ETO healing, and complications were recorded. No patient was lost to follow-up. Signs of clinical healing were noted within the first 6 postoperative months. The difference between the preoperative and postoperative clinical scores was statistically significant. No nonunion of the ETO was observed in any case. These results give support to the combined use of these techniques.     

Revision Total Hip Arthroplasty Using an Extensively Porous Coated Femoral Stem

Background

To determine the benefit of an extensively porous coated femoral stem in patients receiving revision total hip arthroplasty.

Methods

This study reviewed the results of 35 patients who received a revision total hip arthroplasty with extensively porous coated femoral stem between August, 1996, and December, 2002. The mean follow-up period was 77.5 months. The clinical and radiological results were evaluated by the Harris hip score and serial roentgenographic findings.

Results

The preoperative and postoperative Harris hip score was 68.3 and 92.5, respectively. Radiographically, none of the acetabular components showed any evidence of migration, tilt, rotation, or shedding of metal particles. In addition, none of the femoral components showed evidence of subsidence, pedestal, or shedding of metal particles. Twenty-two hips had a mild stress shield and 2 hips had a moderate stress shield. The perioperative complications encountered were deep vein thrombosis (1 case), mild heterotopic ossification (4 cases), intraoperative periprosthetic fractures (1 case), and nonunion of the trochanteric osteotomy site (2 cases).

Conclusions

Extensively porous coated femoral stems and acetabular components produce excellent clinical and radiological results in revision total hip arthroplasty.     

Revision total hip replacement without trochanteric osteotomy

Revision total hip replacement has traditionally required a trochanteric osteotomy for successful cement removal and component reinsertion. In this study the authors have concluded that in most instances the revision total hip replacement procedure can be successfully performed without trochanteric osteotomy. The advantages are underscored by the high percentage of trochanteric complications with trochanteric osteotomy for revision total hip replacement and the ease of rehabilitation without trochanteric osteotomy. Also, improved functional results without trochanteric osteotomy were noted. The specific indications for the procedure included revision total hip replacement with ununited prior trochanteric osteotomy, revision total hip replacement with femoral shaft fractures, and revision total hip replacement with stem fractures requiring only acetabular revision. The contraindications to the procedure are fibrous union or ununited trochanteric osteotomy from prior total hip replacement, severe acetabular protrusion of the acetabular component, advanced myositis ossificans, ankylosis of the hip, and advanced proximal femoral osteoporosis. The operating room records, x-rays, and outpatient records of 63 total hip revisions in 52 patients were reviewed. There was a minimum 2-year follow up with a range from two years to seven years. The patients were divided into two groups, comparing 21 trochanteric osteotomized revisions to 44 with trochanteric sparing techniques. Both groups were analyzed for age, type of implant, intraoperative perforation of femur, intraoperative femoral shaft fractures, intraoperative cortical window, component malpositioning extraneous cement, intraoperative blood loss, operating time, postoperative leg length inequality, persistent abductor weakness, average first day of ambulation, wound infection, dislocation, nonunion of the trochanter, and postoperative pain. In the nonosteotomized group, there was a 21% decreased blood loss, a 14% decrease in persistent abductor weakness, a 14% decrease in subluxation and dislocation, a 30% decrease operating time and a 50% reduction in intraoperative femoral perforation. In the osteotomized group there were six cases of fibrous union of the greater trochanter, two cases requiring removal of broken wires for trochanteric bursitis. A detailed surgical technique and representative cases are presented. In carefully selected cases, revision total hip replacement is optimally performed without trochanteric osteotomy. Postoperative trochanteric problems of nonunion, broken wires, bursitis, and abductor weakness can effectively be eliminated by avoiding trochanteric osteotomy.(ABSTRACT TRUNCATED AT 400 WORDS)     

Cement-in-cement stem revision for Vancouver type B periprosthetic femoral fractures after total hip arthroplasty: A 3-year follow-up of 23 cases

Background and purpose Revision surgery for periprosthetic femoral fractures around an unstable cemented femoral stem traditionally requires removal of existing cement. We propose a new technique whereby a well-fixed cement mantle can be retained in cases with simple fractures that can be reduced anatomically when a cemented revision is planned. This technique is well established in femoral stem revision, but not in association with a fracture.Patients and methods We treated 23 Vancouver type B periprosthetic femoral fractures by reducing the fracture and cementing a revision stem into the pre-existing cement mantle, with or without supplementary fixation.Results 3 patients died in the first 6 months for reasons unrelated to surgery. In addition, 1 was too frail to attend follow-up and was therefore excluded from the study, and 1 patient underwent revision surgery for a nonunion. The remaining 18 cases all healed with radiographic union after an average time of 4.4 (2–11) months. There was no sign of loosening or subsidence of the revision stems within the old cement mantle in any of these cases at the most recent follow-up after an average of 3 (0.3–9) years.Interpretation Our results support the use of the cement-in-cement revision in anatomically reducible periprosthetic fractures with a well-preserved pre-existing cement mantle. This technique is particularly useful for the elderly patient and for those who are not fit for prolonged surgical procedures.     

Claw plate fixation of the greater trochanter in revision total hip arthroplasty

The purpose of this retrospective study was to evaluate a new trochanteric claw plate for trochanteric fixation. From 1998 to 2004, 31 procedures were performed by one surgeon. Mean follow-up was 2.2 years. Indications for the procedure included 16 nonunion, 7 trochanteric osteotomy, 5 periprosthetic fractures, and 3 intraoperative fractures. Median Harris hip scores improved from 47 to 92 points (P < .0001). No patient had an abductor lurch postoperatively (P < .0001). No patient had moderate or severe pain postoperatively (P < .0001). Median active abduction increased from 0 degrees to 25 degrees (P < .0001). Osseous union occurred in 28 of 31 hips. Plate-related complications occurred in 6 of 31 hips. No significant difference was identified for outcomes based on indication. In conclusion, the claw plate in this study can sufficiently treat the complex situation of trochanteric nonunion, fracture, or osteotomy.     

The Use of Extended Trochanteric Osteotomy in 2-Stage Reconstruction of the Hip for Infection

BackgroundThe effect of extended trochanteric osteotomy (ETO) with immediate cerclage wire fixation on the scene of chronic periprosthetic joint infection on infection eradication and the osteotomy healing remains unclear.MethodsOne hundred seventeen patients who underwent two-stage revision total hip arthroplasty for chronic periprosthetic joint infection were enrolled in the study. The minimum follow-up was 2 years. Of these, 48 patients had underwent ETO and immediate cerclage wire fixation during the first-stage surgery, while 69 did not undergo ETO or any other osteotomy. In addition, 18 patients had underwent ETO in the second-stage reimplantation surgery. Repeated debridement, curative rate of infection, and complications were compared between the 2 groups. Meanwhile, osteotomy healing between the first and second osteotomy were also compared.ResultsThe repeated debridement rate and curative rate of infection were 2.1% and 95.8% in the ETO group, compared with 13.0% and 82.6% in the non-ETO group; there were significant difference between the 2 groups in these parameters (P = .037 and .030, respectively). Meanwhile, osteotomy healing rate was 93.8% in first-stage surgery with infection scene and 100% in second-stage surgery without infection; no significant difference was detected in osteotomy healing rate and time to healing (P = .278 and .803, respectively). The rate of complication was similar in both groups.ConclusionsETO combined with immediate cerclage wire fixation does not appear to reduce the rate of infection eradication. There was no harmful effect on complication rate and osteotomy healing.     

Long-Term Results of Revision Total Hip Arthroplasty Using a Modern Extensively Porous-Coated Femoral Stem

BackgroundThe use of an extensively porous-coated uncemented cobalt-chrome monoblock femoral stem for revision total hip arthroplasty (THA) is well established with excellent mid-term results. The aim of this study is to report the long-term survivorship of these implants in femoral stem revisions.MethodsThis is a long-term retrospective review of prospectively collected data of 55 femoral stem revisions in 55 patients using a contemporary, cementless extensively porous-coated cobalt-chrome monoblock stem. All patients between 2001 and 2006 who underwent first time femoral stem revision with a contemporary, cementless extensively porous-coated cobalt-chrome monoblock stem were included. Harris Hip Score, Western Ontario and McMaster Universities Index, and University of California Los Angeles activity scores were recorded preoperatively and at latest follow-up. Radiographs were analyzed for evidence of loosening, subsidence, osteolysis, and bony union. This study included 55 patients, comprising of 36 females (66%) and 19 males (34%) with a mean age of 66.4 ± 9.3 years at the time of surgery. The mean time interval from index procedure was 9.8 ± 2.9 years. Mean time from revision THA to final follow-up was 13.2 ± 2.17 years with a minimum of 10 years of follow-up.ResultsIndications for revision included aseptic loosening (33), prosthetic joint infection (13), and periprosthetic fracture (10). Significant improvement in Harris Hip Score (85.1 ± 1.77 vs 51.8 ± 2.3, P < .001), Western Ontario and McMaster Universities Index (17.6 ± 0.77 vs 33.3 ± 0.8, P < .001), and University of California Los Angeles (5.25 ± 0.2 vs 2.7 ± 0.36, P < .001) scores were found at latest follow-up compared to preoperative. Fifty-four patients (98%) achieved stable bony ingrowth on radiographic analysis. All 10 patients treated for periprosthetic fractures achieved bony union of their fractures. Two patients suffered intraoperative periprosthetic fractures and were treated with a cable-plating system. There were no mechanical failures and no femoral stem re-revisions. One patient was diagnosed with a deep infection and was treated with chronic suppressive antibiotic therapy due to significant medical comorbidities.ConclusionRevision of the femoral component with a contemporary extensively porous-coated cobalt-chrome femoral stem has excellent functional outcomes, radiographic outcomes, and long-term survivorship with minimal complications.     

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

Background

Femoral 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.

Use of a long distally fixed intramedullary stem to treat a periprosthetic femoral fracture following total hip arthroplasty using a thrust plate hip prosthesis: A case report

IntroductionThe thrust plate hip prosthesis (TPP; Zimmer, Winterthur, Switzerland) is a hip prosthesis that is no longer in production. Few reports have focused on periprosthetic fractures following total hip arthroplasty (THA) with the use of a TPP.Presentation of caseWe report a 57-year-old woman with a periprosthetic femoral fracture 13 years after THA with the use of a TPP. A plain radiograph showed a displaced subtrochanteric fracture of the right femur just below the distal tip of the lateral plate without implant loosening. She underwent revision surgery with a long distally fixed intramedullary stem in conjunction with a plate and cable system. Three months after surgery, bone union was confirmed using radiography and the patient was clinically asymptomatic.DiscussionWe encountered three major problems while planning surgical treatment, these being, discontinuation of the TPP system, loss of proximal femoral cancellous bone, and difficulties with the type of subtrochanteric fracture. After considering these problems, we planned revision surgery using a long distally fixed intramedullary stem in conjunction with a plate and cable system.ConclusionThis case shows that sufficient implant preparation based on precise preoperative planning is necessary to obtain good clinical results for the surgical treatment of periprosthetic femoral fractures following THA with the use of a TPP.     

Trochanteric slide osteotomy in revision total hip arthroplasty for loosening

We used a trochanteric slide osteotomy (TSO) in 94 consecutive revision total hip arthroplasties (90 with replacement of both the cup and stem). This technique proved to be adequate for removing the components, with few complications (two minor fractures), and for implanting acetabular allografts (18%) and reinforcement devices (23%). Trochanteric union was obtained in most patients (96%), even in those with septic loosening (18/19), major femoral osteolysis (32/32), or previous trochanteric osteotomy (17/18). TSO is versatile, since it can be extended by a femoral flap (four cases) or a distal femoral window (eight cases). Despite significant bone loss, in 24% of the femora and 57% of the acetabula, favourable midterm results were achieved and only six reoperations were required, Including two for trochanteric nonunion and two for loosening. It leaves the lateral femoral cortex intact so that a stem longer than 200 mm was needed in only 25% of patients. This is a considerable advantage compared with the extended trochanteric osteotomy in which the long lateral flap (12 to 14 cm) requires an average length of stem of 220 mm beyond the calcar. TSO provides an approach similar in size to the standard trochanteric osteotomy but with a rate of nonunion of 4% versus 15%. It reduces the risk of difficulties with removal of the stem, and removes the need for routine distal anchoring of long revision stems. The limited distal femoral compromise is very important in patients with a long life expectancy.