Cancellous impaction grafting in femoral revision THA

Options in the management of the deficient femur during revision hip arthroplasty include cemented or cementless fixation. The results with cemented femoral revision have not been historically successful. While the use of extensively coated implants in revision total hip arthroplasty has been more uniformly excellent, issues, such as thigh pain, stress shielding, and lack of bone stock restoration, have been raised. Impaction grafting in revision hip arthroplasty is an attempt to reconstitute bone stock and avoid problems associated with excessively large or long uncemented stems. The original concept of impaction grafting was promoted by Slooff and applied to the femur by Gie and Ling. While originators' results were promising, issues, such as fracture and poor graft delivery, were noted. Modifications to the original technique were recently described by Howie, which used longer stems when necessary, as well as an improved graft delivery system. We report our results with 30 consecutive hips using this method. At follow-up, 3 patients were known to have died, leaving 27 for evaluation. Two of the 27 were failures: 1 recurrence of infection and 1 loose stem. The remaining 25 were clinical successes with bone stock restoration in all and no periprosthetic fractures. We believe that impaction grafting remains a viable option for the management of the severely deficient femur in whom cementless fixation methods are questionable.     

Revision total hip arthroplasty in juvenile chronic arthritis: 17 revisions in 11 patients followed for 4-12 years

BACKGROUND: Revision total hip arthroplasty (THA) in patients with juvenile chronic arthritis (JCA) is complicated by the young age of the patient, poor bone stock and small physical proportions. We report the complications and outcome of a prospective series of 17 revision THAs in Charnley class C JCA patients. METHODS: 15 acetabular components and 10 femoral components were revised. 13 cementless cups, 2 reconstruction/roof rings and cemented cups, and 4 cemented and 6 cementless femoral stems were implanted. 2 proximal femoral allografts and 1 strut allograft were used. Age at revision was 32 (21-53) years. Follow-up averaged 7 (4-12) years. RESULTS: 2 patients with cemented femoral stems developed loosening, osteolysis and fracture. Both were successfully revised to long-stem cementless implants with strut/proximal femoral allografts. 1 loose, worn cementless cup with osteolysis was revised. 1 patient with a peri-operative infection and late acetabular fracture had a loose, non-revised cementless cup. 1 case of sciatic nerve palsy occurred after revision using a reconstruction ring. 1 late infection necessitated resection arthroplasty. Harris hip scores improved from 53 (34-85) to 76 (47-96). INTERPRETATION: Revision THA in JCA has a substantial complication rate, even in experienced hands. The problem of obtaining long-term stable fixation, osteolysis, and replenishment of lost bone stock are major difficulties.     

Porous-coated femoral components in a canine model for revision arthroplasty

Six dogs had a total hip arthroplasty during which the femoral component was coated with methacrylate and inserted in the femoral canal, after the canal had been reamed to a larger diameter than that of the femoral stem (including the coating). Thus, the implant was loose and motion was present between it and the femur in each animal. Five dogs had a revision to a prosthesis with a porous polysulfone-coated stem. This prosthesis was not cemented in place. One dog was killed before the revision for the purpose of histological examination. Although bone was present in the porous surface of all five stems at the revision, the amount was scant in three. CLINICAL RELEVANCE: A model is described for the study of cemented hip-replacement prostheses that have failed. Although variable amounts of ingrowth of bone were observed after the revision to the porous-coated prostheses without bone cement, further study is needed to determine whether adequate ingrowth of bone occurs in this model.     

Cementless femoral revision arthroplasty of the hip: minimum 5 years followup.

Durable fixation of the femoral component to the bone in femoral revision arthroplasty of the hip is the main ingredient to a successful reconstruction. Because of poor durability of cemented fixation in revision, in 1984, one author began to use cementless fixation with extensively porous-coated chrome cobalt stems. The current authors report the durability of that fixation technique in 137 hips (134 patients) followed up 5 to 16 years. With a mean followup of 9.3 years, 10 (7%) of the stems have been removed. Five (4%) were removed for fixation problems and five (4%) were removed for infection. Using the radiographic criteria of Engh et al, 83% of the stems achieved bony ingrowth. No late failure of fixation was observed. Canal-filling prostheses were more likely to have bone ingrowth as were stems placed in femurs with lesser degrees of bone stock deficiency. Significant thigh pain was seen in 7% of bone ingrown stems, 16% of stable fibrous fixated stems, and 75% of unstable stems. Significant thigh pain in bone ingrown stems was observed more commonly in osteoporotic femurs and bone stock deficient femurs. Severe stress shielding correlated with preoperative osteoporosis and larger diameter stems but has not caused failure. Excellent durability of this fixation technique is evident.     

Extensively porous-coated stems for femoral revision: reliable choice for stem revision in Paprosky femoral type III defects

Between January 1999 and August 2008, ninety-six femoral revisions were performed with extensively porous-coated stems in Paprosky type III femoral defects (89 type IIIA and 7 type IIIB defects). Seven type IIIB defects with a mean canal of 16.5 mm were observed; 6 defects achieved stable bone ingrowth and 1 achieved stable fibrous condition. Average postoperative Harris Hip Score was 92.3±8 (range, 77-100), and all scores improved postoperatively. At a mean follow-up of 65.7 months, 92 stems achieved bone ingrowth, and 1 stem (type IIIB) achieved a stable fibrous condition. Three patients died from causes unrelated to the surgery during follow-up. The most frequent diagnosis for revision of the femoral component was loosening of the cementless stem (53 patients; 55.2%), followed by status after a Girdlestone procedure (21 patients; 21.8%), after total hip arthroplasty with acetabular wear (10 patients; 10.4%), loosening of the cemented stem (7 patients; 7.3%), and periprosthetic fracture (5 patients; 5.2%). The authors performed 65 total hip arthroplasty revisions, 23 femoral component revisions, and 8 revisions of femoral components with cemented liners in patients with well-fixed acetabular shells. Extensively porous-coated stems in femoral revision for Paprosky type III femoral defects provided good mid-term durability.     

Proximal femoral allografts in revision hip arthroplasty

We followed prospectively 69 patients with 78 proximal femoral allografts performed for revision of total hip arthroplasty for an average of 36 months (range 29 to 68). Large fragment proximal femoral allografts and cortical strut allografts were successful in 85%. Grafts smaller than 3 cm in length (calcar grafts) were clinically successful in 81%, but 50% underwent significant radiographic resorption. We conclude that large proximal femoral allografts and cortical strut allografts provide dependable reconstruction of bone stock deficiencies during revision total hip arthroplasty.     

Periprosthetic femoral fractures treated with a modular distally cemented stem

PURPOSE: To assess the treatment outcome of revision hip arthroplasty for Vancouver type B3 periprosthetic femoral fractures using a modular distally cemented stem. METHODS: 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. RESULTS: 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. CONCLUSION: Vancouver type B3 periprosthetic femoral fractures can be successfully treated with a distally cemented modular proximal femoral replacement prosthesis.     

骨形态发生蛋白在全髋关节置换翻修术中的应用研究进展

全髋关节置换翻修术中往往存在骨缺损及假体周围骨折等复杂情况,修复骨缺损、维持假体的稳定是翻修手术成功的关键之一,往往需要骨移植。目前临床使用的各种骨移植物都存在一定的缺陷。近年来,许多学者进行了重组人骨形态发生蛋白在全髋关节置换翻修术中的应用研究,包括假体周围骨形态发生蛋白的应用以修复骨缺损,骨形态发生蛋白结合异体骨的使用,改善异体骨骨折的愈合及重建等,结果显示骨形态发生蛋白较其他骨移植物在全髋关节置换翻修术的使用具有一定的优势,但还需要更进一步的研究。该文将对这些研究结果作一综述。     

Proximal femoral osteotomy as an adjunct in cementless revision total hip arthroplasty

Cementless total hip replacement techniques are increasingly used in revision arthroplasty. A major challenge is to achieve implant stability in a femur distorted by a failed arthroplasty. Five patients with aseptic loosening of cemented primary or revision total hip replacements complicated by significant proximal femoral disease, four with marked angular deformity of the femur and one with a subtrochanteric nonunion, were treated successfully with cementless revision arthroplasty combined with proximal femoral osteotomy. At follow-up examination, all femoral and trochanteric osteotomies had healed and D'Aubigne and Postel scores for pain, function, and range of motion had improved. All porous prostheses demonstrated radiographic features consistent with bone ingrowth fixation. No progressive stress shielding has been observed. Concomitant femoral osteotomy to correct anatomic deformity, in association with cementless total hip arthroplasty, results in union of the osteotomy and restoration of hip function.     

Femoral shaft fracture after hip arthroplasty

Femoral shaft fractures after hip arthroplasties were treated in 74 noncemented hemiarthroplasties and 65 cemented arthroplasties. In loose prostheses the best clinical results and the least number of operations were achieved with revision arthroplasty with a long-stem prosthesis, combined with simple internal fixation methods when applicable. In firmly fixed prostheses the results of revision arthroplasty and traction treatment were similar. Cemented revision arthroplasty did not interfere with fracture union. Internal fixation with the prosthesis in situ cannot be recommended because of a large number of secondary revision arthroplasties and nonunions. Removal of the femoral stem prosthesis and internal fixation nearly always require a secondary revision and cannot be recommended.     

The use of a hydroxyapatite-coated primary stem in revision total hip arthroplasty

Proximal ingrowth of femoral components in total hip arthroplasty (THA) is desirable because it minimizes proximal stress shielding associated with distal ingrowth stems and maximizes bone stock. This is a retrospective evaluation of initial results of revision THA using a proximally hydroxyapatite-coated femoral stem nominally designed for primary use. Patients requiring femoral stem revision were included if they had sufficient femoral bone stock to support a proximally fixed prosthesis (n = 33). This represents 53% of the femoral revisions performed during the period of the study. The average follow-up was 5 years (range 48-88 months). The mean Harris hip and Oxford hip scores were 86.5 and 25.2, respectively. Radiographically, 100% of the stems demonstrated bone ingrowth fixation. These results are superior to previous reports of primary cementless stems for revision THA. The use of a cementless nonmodular implant provides a viable option in some patients undergoing revision THA.     

Revision total hip arthroplasty in juvenile chronic arthritis: 17 revisions in 11 patients followed for 4–12 years

Background Revision total hip arthroplasty (THA) in patients with juvenile chronic arthritis (JCA) is complicated by the young age of the patient, poor bone stock and small physical proportions. We report the complications and outcome of a prospective series of 17 revision THAs in Charnley class C JCA patients.

Methods 15 acetabular components and 10 femoral components were revised. 13 cementless cups, 2 reconstruction/roof rings and cemented cups, and 4 cemented and 6 cementless femoral stems were implanted. 2 proximal femoral allografts and 1 strut allograft were used. Age at revision was 32 (21–53) years. Follow-up averaged 7 (4–12) years.

Results 2 patients with cemented femoral stems developed loosening, osteolysis and fracture. Both were successfully revised to long-stem cementless implants with strut/proximal femoral allografts. 1 loose, worn cementless cup with osteolysis was revised. 1 patient with a peri-operative infection and late acetabular fracture had a loose, non-revised cementless cup. 1 case of sciatic nerve palsy occurred after revision using a reconstruction ring. 1 late infection necessitated resection arthroplasty. Harris hip scores improved from 53 (34–85) to 76 (47–96).

Interpretation Revision THA in JCA has a substantial complication rate, even in experienced hands. The problem of obtaining long-term stable fixation, osteolysis, and replenishment of lost bone stock are major difficulties.     

Femoral revision total hip arthroplasty using a long-stem femoral component. Clinical and radiographic analysis

Proximal femoral bone stock deficiencies exist during many femoral revision arthroplasties, thus providing inadequate support and fixation for conventional-length cemented femoral components. The authors analyzed the long-term clinical and roentgenographic results of 165 hips requiring femoral revision arthroplasty with a long-stem femoral prosthesis. Intraoperative complications occurred in 23% of hips, with femoral perforations in 16% and femoral fractures in 5%. Of 110 hips with at least 5 years of follow-up study (average, 6.7 years), functional ratings were graded excellent in 34%, good in 36%, fair in 17%, and poor in 13%. Failures occurred in 17 hips (12%) and were attributed to aseptic loosening (11 hips), femoral component fracture (2), femoral shaft fracture (1), and sepsis (3). Symptomatic trochanteric separations occurred in 16% of hips. Rerevision or resection arthroplasty was required in 7 hips (5%) and recommended for another 10 hips (7%). Cemented long-stem femoral components (versus cemented conventional-length stems) decrease the extent and progression of femoral lucencies, thereby lowering the incidence of mechanical failures and improving long-term functional results in cemented femoral revision arthroplasty.     

Five-year postoperative results of cemented femoral arthroplasty in patients with systemic bone disease

To determine whether bone cellular abnormality affects the results of cemented femoral arthroplasty, 21 patients had biopsies of the iliac crest and femoral cortex at the time of surgery. Roentgenographic and histomorphometric studies were used to characterize fibrous membrane formation, cancellous bone, calcar resorption, and bone turnover. Patients with high bone turnover and decreased femoral thickness and density before surgery were at risk of developing calcar resorption and cancellous diaphyses, conditions that weaken proximal stem support and lead to early failure. These findings suggest that noncemented stems may be indicated in this group. Another group, osteoporotic patients, suffered from osteoblastic insufficiency, which may be the indication for the use of cemented stems rather than noncemented stems, which require bony ingrowth.     

Femoral shaft fracture after hip arthroplasty

Femoral shaft fractures after hip arthroplasties were treated in 74 noncemented hemiarthroplasties and 65 cemented arthroplasties.

In loose prostheses the best clinical results and the least number of operations were achieved with revision arthroplasty with a long-stem prosthesis, combined with simple internal fixation methods when applicable. In firmly fixed prostheses the results of revision arthroplasty and traction treatment were similar. Cemented revision arthroplasty did not interfere with fracture union. Internal fixation with the prosthesis in situ cannot be recommended because of a large number of secondary revision arthroplasties and nonunions. Removal of the femoral stem prosthesis and internal fixation nearly always require a secondary revision and cannot be recommended.     

The role of cemented stems in revision total hip arthroplasty

Cemented stems in revision total hip arthroplasty were reported to have unacceptably high rates of mechanical failure in early publications. This led to the development and current popularity of cementless revision stems, which have shown good results. However, there are still circumstances when cemented femoral revision can provide immediate, reliable fixation with comparatively good results, and this technique remains an important part of the arthroplasty surgeon's armamentarium. In this review, we will discuss the role of cemented stems in revision total hip arthroplasty, focusing on cement-in-cement revision, and impaction bone grafting of the femur.     

Favorable mid-to-long-term results of impaction bone grafting using a fresh frozen allograft bone with cemented stem for the treatment of Paprosky IV femoral bone defects

BackgroundFemoral revision surgery in patients with substantial bone loss is challenging. Impaction bone grafting using a cemented stem can be a good solution for reconstruction of the femur with poor bone stock and extensive bone loss. This study aimed to evaluate the mid-to-long-term clinical and radiographic results of impaction bone grafting using a cemented stem for Paprosky IV femoral bone defects.MethodsThirteen patients (13 hips) who underwent revision total hip arthroplasty with impaction bone grafting using a cemented stem and were followed up for at least 5 years were enrolled in this study. In all patients, a sufficient amount of fresh frozen bone of good quality was used. When cortical segmental defects were present, peripheral reinforcement with metal mesh and strut allograft was performed. The average follow-up duration was 11.1 (range, 5.3–15.1) years. The clinical and radiographic outcomes were reviewed at the final follow-up.ResultsThe average Harris hip score was 82.5 (range, 79–94), and the average University of California, Los Angeles activity score was 5.6 (range, 4–8) at the final follow-up. Radiographic assessment revealed an average femoral component subsidence level of 0.67 (range, 0.05–2.81) mm. There were no complications, except one case (7.6%) of periprosthetic fracture.ConclusionsImpaction bone grafting using a cemented stem yielded excellent mid-to-long-term outcomes. It is a reliable technique for Paprosky IV femoral bone defects, and even when severe femoral cortical bone defects are present, long-term stability can be obtained using a metal mesh and/or strut allograft.     

Hip revision arthroplasty. Approach to the femoral side

Total hip arthroplasty has proven to be a highly successful procedure but with its increased use in elderly patients and in young patients with high physical demands, there are an increasing number of joints requiring revision. Many factors, including loss of bone stock, joint instability, infection, fracture, trochanteric nonunion, and difficulty in implant or cement removal, make revision of the femoral component challenging to the surgeon. To address these factors and to achieve the goals of revision surgery, several key questions should be addressed. What exposure should be used? How can the implant be removed? What type of reconstruction should be used and which implant should be chosen? How can stable fixation be achieved? How can the bone defects be treated? The approach that the authors recommend to the femoral component in revision hip arthroplasty is outlined, taking into consideration each of the questions above. The classification system used by the authors for femoral bone defects present at the time of revision arthroplasty has four categories based on the integrity of the proximal cancellous bone and the cortical tube, which is used to select the technique of reconstruction. The literature on techniques for revision of a failed femoral component is reviewed.     

Morsellized allografts for fixation of the hip prosthesis femoral component: A mechanical and histological study in the goat

To simulate femoral intramedullary bone stock loss in revision surgery of failed total hip arthroplasties, a method was developed using impacted trabecular bone grafts. In 14 goats a cemented total hip arthroplasty was performed, fixating the stem within a circumferential construction of bone allografts. After 6 or 12 weeks, 4 goats were used for mechanical tests and 3 for histology.

The stability of the stems was determined in a loading experiment with roentgen-stereophotorammetric analysis; loads of up to 1.44 times body weight were used. One aseptic loosening was seen with gross movements. In the other cases the most important movements were axial rotations (max 0.24 degrees under 800 N) and axial translations (max. 0.16 mm under 800 N). After unloading some elastic recovery occurred. There were no differences between the 6 and 12-week groups. Histoogically, revascularization and remodeling of the grafts were evident. Bone apposition and bone resorption of the grafts resulted in a mixture of graft and new bone. There was more new bone formation in the 12-week group, but the process was not yet completed. The use of impacted trabecular bone grafts in cases of severe intramedullary bone stock loss seems to be a promising revision technique.     

Femoral reconstruction by massive allografts in revision of hip prostheses with major bone defects

Summary Major bone defects are commonly encountered in revision of total hip arthroplasties. We reconstruct both the acetabular and femoral component with bone allografts to allow successful implantation of a new prosthesis. Frozen femoral heads are used for all kinds of acetabular defects and for small femoral defects, and irradiated massive cortical allografts have been used since 1985 for major deficiencies of the femur. The femoral reconstruction technique differed according to the type of surgery: —After removal of a failed massive femoral prosthesis, a long-stem Charnley prosthesis was cemented in the proximal allograft and the distal host femoral shaft. —When revision of standard arthroplasties was performed, different surgical procedures were used according to the type of bone deficiency encountered, the goal being to preserve as much host bone as possible. We used either segmental allografts covered with the remaining host femoral cortex preserved with its soft tissue attachments, or segmental allografts impacted into an enlarged residual shaft. In other cases, a semi-circular allograft strut was used for replacing or reinforcing a deficient cortex. A cemented longstem Charnley prosthesis was generally used, but whenever possible a standard stem was implanted.From 1985 to the end of 1992, 102 upper femoral reconstructions for major revision arhtroplasties were performed in our department. Onlay struts had excellent results, always united, and complications were rare. Segmental allografts had a higher complication rate. The frequency of trochanteric complications (20%) implies firm initial fixation, apparently better ensured by plates, though screwing through the graft risks damaging it, as occurred once. Graft or prostheses failures were rare, and occurred mainly with large segmental allografts used in custommade massive prosthesis replacement, the conditions then being comparable with malignant tumor reconstruction surgery. When complications occurred, the benefit of initial bone stock repair was preserved in most cases, allowing easy further revision.Massive irradiated allografts appear to be an effective method in major femoral reconstructions. These results rely on safe bone banking procedures, which require predefined and strictly controlled methods. Good results also depend on suitable surgical techniques, particularly efficient graft stability, secure muscle reattachment, and reliable prostheses. The aim of the different surgical technics we used in revision arthroplasties was to obtain good anatomic situation, alignment and length, while preserving as much as possible of the residual host bone.