Early complications after one hundred and forty-four consecutive hip revisions with impacted morselized allograft bone and cement

BACKGROUND: The use of impacted morselized allograft bone and cement in hip revision arthroplasty has been popular, but studies that specifically address intraoperative and postoperative complications have been scarce. METHODS: All complications that occurred during, and within the first year after, 144 consecutive hip revision arthroplasties (108 stems and 130 sockets) performed with impacted morselized allograft bone and cement were recorded. Clinical and radiographic follow-up evaluation was performed at three months and at one year after surgery for all patients except eight (seven who had died of causes unrelated to the hip surgery and one who had sustained a stroke). Of these eight patients, seven had a six-week and/or three-month follow-up evaluation. RESULTS: Thirty-nine femoral fractures occurred in thirty-seven hips; twenty-nine of the fractures occurred during surgery and ten, within five months after surgery. Of the intraoperative femoral fractures, twelve were proximal, nine were diaphyseal, and eight involved the greater trochanter. Of the postoperative femoral fractures, one was proximal and nine were diaphyseal. Other intraoperative complications were the creation of a femoral cortical window in seven hips and incidental perforation of the femoral cortex in fourteen. Multivariate analysis showed the risk factors for femoral fracture during or after revision to be concomitant disease, greater deficiency of the femoral bone stock, and an intraoperative femoral window or perforation. Other complications included dislocation of the femoral head in nine hips, deep infection in one hip, persistence of preoperative deep infection in one hip, and superficial wound infection requiring wound débridement in two hips. CONCLUSIONS: We found the complication rate to be high after hip revision arthroplasty performed with impacted morselized allograft bone and cement. The most serious complication was postoperative diaphyseal femoral fracture.     

髋关节置换术中股骨假体周围骨折危险因素的分析

目的分析髋关节置换术中股骨假体周围骨折的发生情况和危险因素。方法选择本组自2002年1月至2008年12月所有行初次和翻修髋关节置换术患者共3021髋(初次置换术2718髋,翻修术294髋),分析术中股骨假体周围骨折的发生情况,并用Logistic回归分析骨折发生的相关因素,包括性别、年龄、术前诊断、假体类型、固定方式。用2检验进行初次置换和翻修术中发生骨折的差异性检验。结果总的术中股骨假体周围骨折发生率为5.7%(173/3021),其中初次置换发生率为4.0%(110/2718),翻修术发生率为21.4%(63/294)。初次置换应用骨水泥股骨假体术中骨折发生率为1.9%(8/429),非骨水泥股骨假体术中骨折发生率为4.5%(102/2289),初次置换术中骨折82.7%(91/110)发生于干骺端;翻修术应用骨水泥股骨假体术中骨折发生率为18.8%(21/112),非骨水泥股骨假体术中骨折发生率为23.1%(42/182),翻修术术中骨折62%(39/63)发生于骨干部。Logistic回归分析显示:初次髋关节置换术中骨折的危险因素包括性别、术前诊断、固定方式、假体类型;翻修术性别、年龄、假体固定方式不是引起术中骨折的危险因素。应用2检验,翻修术中股骨假体骨折的风险与初次置换相比差异有统计学意义(P0.000),OR值为6.5,95%CI(4.6,9.1)。结论初次髋关节置换术中股骨假体周围骨折的发生率为4.0%,主要发生于干骺端(83.6%),女性、髋关节发育不良、髋部骨折、高位脱位、非骨水泥固定是术中骨折的危险因素;髋关节翻修术中股骨假体周围骨折的发生率(21.4%),远高于初次髋关节置换术,主要发生于骨干部(61.9%),骨折的发生与否可能主要取决于翻修时的骨质情况,性别、年龄、假体固定方式并不是主要的影响因素。     

人工髋关节置换术并发股骨骨折临床分析

目的探讨人工髋关节置换术并发股骨骨折的病因、治疗及预防。方法总结本院１９７２年４月～１９９６年６月行人工髋关节置换术９４５例，其中人工髋关节翻修术１４２例，初次人工髋关节置换术４９３例，人工股骨头置换３１０例。结果术中共发生股骨骨折２５例，总发生率为２．６％，其中人工髋关节翻修术８例，初次人工髋关节置换术１２例，人工股骨头置换５例。结论骨质疏松、医源性、先天性的股骨解剖结构改变以及软组织松解不彻底是发生术中骨折的主要原因。以下措施可有效地预防术中骨折的发生：（１）术前测量髓腔的大小，选择合适的假体；（２）彻底松解髋周软组织，脱位或复位时避免暴力；（３）用长假体应充分扩大髓腔；（４）假体置入时如遇有阻力，应避免强力打入，如突然有突破感，应考虑可能有骨折，应术中透视或照像。     

Fractures at the tip of long-stem prostheses used for revision hip arthroplasty

We report a retrospective analysis of the incidence of intraoperative femur fractures at the tip of the prosthesis in 45 consecutive, uncemented, long (205-mm), straight hydroxyapatite, fully coated stems used for revision arthroplasty of the hip. Five patients were lost to follow-up. Intraoperative fractures of the distal femur occurred in 7 cases (17.5%). In the remaining 33 cases in which no fracture occurred, the tip of the implanted stem was found to be potentially at risk for causing a fracture in 18 (55%) cases. We concluded that uncemented, 205-mm, straight femoral stems should be used with caution in the setting of revision hip surgery. A bowed stem of that length may be a safer alternative. Otherwise, a shorter, straight stem may reduce the risk of complications at the stem tip.     

Revision of failed total hip arthroplasty with a proximal femoral modular cemented stem

We have designed a modular cemented femoral component for revision of failed total hip arthroplasty in which deficiency of the proximal femur is such as to require a variable extrafemoral portion of the stem. We present the results of the first 74 operations in 72 patients; 56 of the patients had grade-3 or grade-4 femoral deficiency as defined by Gustilo and Pasternak and 24 had fractures of the proximal femur, of which 22 were periprosthetic. There was or had been infection in 19 hips. At a mean follow-up of 5 years 9 months (1 to 12 years) nine stems were radiologically loose of which three had been revised. There were no failures in 45 cases in which there was fixation of the distal stem of 10 cm or more. Dislocation occurred in nine patients and there were four cases of infection in the 19 which were, or had been, infected previously. There were no neurovascular complications and no intraoperative femoral fractures. The femoral bone stock improved radiologically in 45 hips of which 29 showed considerable reformation of the proximal femur; 27 remained unchanged and two showed increasing osteoporosis.     

Early Post-operative Periprosthetic Femur Fracture in the Presence of a Non-cemented Tapered Wedge Femoral Stem

Non-cemented femoral fixation in hip arthroplasty has become the standard of practice in the USA. However, recent literature has brought attention to an increasing incidence of periprosthetic femur fractures with certain stem designs. This study examines reasons for early periprosthetic femur fractures in patients with a hip arthroplasty performed using a non-cemented tapered wedge stem design. A multivariate analysis using a matched-cohort design was performed to assess any potential risk factors that may predispose to such fractures. Six of 2,220 hips (0.3%) suffered a periprosthetic femur fracture within the first year after surgery; five of six were Vancouver Type B2. The average time to fracture was 9 weeks. This group of patients had a significantly higher canal–flare index and lower canal–calcar ratio. This complication may be preventable by having a better appreciation of the fit between the implant and the bone during pre-operative planning, with the goal of avoiding a proximal–distal mismatch.     

Femoral fractures in conjunction with total hip replacement.

We reviewed thirty-eight cases, in thirty-six patients, of fracture of the femur distal to the base of the neck incurred in conjunction with total hip replacement. There were thirteen preoperative, eighteen intraoperative, and seven postoperative fractures. The cases were contributed by thirteen surgeons. We found that the preoperative fractures with pre-existing disease in the hip joint were effectively treated by primary total hip replacement using custom-made femoral components with long necks or long stems, or both. The intraoperative femoral fractures usually occurred while the surgeon was reaming the canal, seating the femoral component, or manipulating the femur in patients who were predisposed to fracture. Theoretically these lesions can be treated like preoperative fractures, but this demands immediate access to custom-made femoral components with long necks or long stems, or both, along with an appreciation of the extent and significance of the fracture. Inadequate fixation was found to lead to painful non-union or late loosening of the femoral component in four of eighteen patients. Postoperative fractures occurred too rarely for us to draw any definite conclusions about management, except to say that surgical treatment can be hazardous and traction has been successful in this series and in other reports. Prophylactic measures, however, may help to prevent postoperative femoral fractures. Most of these fractures occur through a cortical defect near the tip of the femoral component. A long-stem femoral component may help to prevent postoperative fractures whenever a proximal cortical defect of the femur is present preoperatively or is created at surgery.     

Three- to 7-year results with the uncemented SL femoral revision prosthesis

Between 1988 and 1991, 40 Wagner SL femoral revision stems were irnplanted at the Orthopaedic Departments of the University of Basel and of the Kantonsspital Liestal, Switzerland. The indications were: 27 cases of extensive bone resorption and destruction of the proximal prosthetic bed, seven periprosthetic fractures, two Girdlestone situations after removal of infected total hip arthroplastiy (THA), 1 case each of primary arthroplasty for congenital dysplasia of the hip, failed osteosynthesis of a pertrochanteric fracture, subtrochanteric femoral fracture and femoral fracture with subsequent osteomyelitis. The average follow-up time was 47 months. The average age of the patients was 70 years (range 37–85 years). The average preoperative hip score was 32 points, postoperative 78 points. We noted to severe complications such as thrombosis, pulmonary embolism or nerve injury. No case of early infection has occurred to date. Four hips required further revision, one after a haematogenous infection of the prosthesis 2 years after implantation, one 4 weeks after surgery because of a stem which was significantly undersized compared with the medullary canal of the femur. Two hips were revised after 3 and 4 years, respectively, for continuous subsidence and loosening in the medullary canal. Both revisions were successfully achieved using a femoral component of larger diameter. We recommend the Wagner SL femoral revision stem, not as a routine procedure to treat loosening, but for patients with severe femoral bone resorption after THA or periprosthetic fractures, those in the Girdlestone situation and geriatric patients with pertrochanteric or subtrochanteric fractures.     

Simultaneous bilateral total hip arthroplasty in sickle cell disease

Simultaneous bilateral uncemented total hip arthroplasty for avascular necrosis of the femoral head resulting from sickle cell disease was performed in 18 consecutive patients (36 hips). The patients were followed 2 to 10 years (mean, 5.7 years). All patients showed improvement in postoperative hip scores compared with preoperative scores for pain, range of motion, and function. There were 2 immediate postoperative complications related to sickling of red blood cells. One intraoperative fracture of the proximal femur occurred. There was 1 superficial and 1 deep infection. There was no femoral stem loosening, but 1 protrusio acetabuli occurred. One acetabular cup was revised for instability. Heterotopic ossification developed in 2 patients. Simultaneous bilateral total hip arthroplasty in sickle cell disease is a good option in a select group of patients with adequate hydration and ventilation in the perioperative and postoperative periods.     

Proximal femoral allograft treatment of Vancouver type-B3 periprosthetic femoral fractures after total hip arthroplasty

BACKGROUND: Periprosthetic femoral fractures following total hip arthroplasty are becoming more prevalent. When a fracture occurs in a femur with substantial proximal bone deficiency, the surgical options for revision are limited. One option includes the use of a proximal femoral allograft. METHODS: We retrospectively assessed the results and complications of the use of a proximal femoral allograft to treat twenty-five Vancouver type-B3 periprosthetic fractures in twenty-four patients. The mean duration of follow-up was 5.1 years. Clinical results were graded with use of the Harris hip score. Radiographs were assessed for evidence of trochanteric union, host-allograft union, allograft resorption, and component loosening or fracture. Failure of the procedure was defined as the need for revision surgery requiring graft removal. RESULTS: The mean postoperative Harris hip score was 70.8. At the time of the final follow-up, twenty-one of the twenty-four patients reported no or mild pain and twenty-three patients were able to walk; fifteen required a walking aid. The greater trochanter united in seventeen of the twenty-five hips, and osseous union of the allograft to the host femur occurred in twenty hips. There was mild graft resorption in four hips and moderate graft resorption in two. Four (16%) of the twenty-five hips required repeat revision. CONCLUSIONS: The use of a proximal femoral allograft for the treatment of a Vancouver type-B3 periprosthetic femoral fracture can provide a satisfactory result in terms of pain relief and function at five years.     

Intraoperative fractures during uncemented Furlong bipolar hemiarthroplasty

Uncemented bipolar hemi-arthroplasty is one of the methods used to treat elderly patients with displaced intracapsular fractures of the femoral neck. In an effort to achieve a tight fit during uncemented hip hemiarthroplasty there are instances where intraoperative fractures have occurred. We retrospectively reviewed 165 consecutive uncemented Furlong Hydroxyapatite ceramic coated bipolar hemiarthroplasty performed for displaced intracapsular fracture neck of femur, and found 7.4% (12) intraoperative fractures of the proximal femur. Nine fractures involved the calcar, one each occurred in the anterior wall, posterior wall and greater trochanter. All fractures were linear and minimally displaced. Of the five fractures that occurred during reaming two were fixed with circlage wires. The remaining seven fractures occurred during prosthesis implantation of which three were fixed with circlage wires or cables. All patients had standard postoperative management and were allowed full weight bearing except in two patients (both fixed fractures) who were kept partial weight bearing for 6 weeks post operation. At 1 year follow up, all patients were mobilising full weight bearing and were pain free. We conclude, fractures of the proximal femur that occur while performing uncemented (Furlong) hemi-arthroplasty for the fractures of the femoral neck may not require any further intervention if the fracture involves the medial column, and is minimally displaced with a stable implant, regardless of whether they occur during reaming or implantation.     

Recognizing anterior metaphyseal femoral bone loss during uncemented total hip arthroplasty: the skylight sign

During preparation for uncemented femoral arthroplasty, a phenomenon has been observed that indicates thinning of anterior metaphyseal bone to a critical level. Light can be seen from within the canal passing through the anterior cortex. This skylight sign alerts the surgeon that a cortical defect or fracture can occur on reaming, broaching, or component insertion. In 420 consecutive arthroplasties, a skylight sign was noted in 97 (23%) hips. In 5 of those hips an oval cortical defect was created and in 3 hips a fracture occurred during broaching or insertion. Loosening developed in 1 hip with fracture. No fractures or defects occurred in hips without a skylight sign. If a skylight sign is present, the femur is at risk and preventive measures should be taken.     

Conversion of failed hip hemiarthroplasties after femoral neck fractures

Hemiarthroplasty has been the preferred treatment for fractures of the femoral neck in elderly patients. The objective of the current study was to assess the outcome of revision of failed hemiarthroplasty to total hip arthroplasty in patients with a primary diagnosis of a femoral neck fracture. One hundred thirty-two conversions were done in 108 women and 24 men. One hundred two cemented and 30 uncemented hemiprostheses were revised to 88 cemented, 17 uncemented, and 27 hybrid total hip arthroplasties and the patients were followed up an average of 7.1 years (range, 5.1-15.3 years). Nine hips (6.8%) were revised for loosening and four additional hips (3%) were loose at the last followup. Survivorship free of revision was 96.5% (95% confidence interval, 93%-100%) at 5 years and 92% (95% confidence interval, 86%-98%) at 10 years. Major perioperative complications occurred frequently (45%), including 12 intraoperative femoral fractures (9%) and 13 dislocations (9.8%) Three of 12 (25%) of the intraoperative femoral fractures developed later femoral component loosening and all occurred during conversion of an uncemented Austin-Moore type hemiprosthesis. Conversion of endoprostheses to total hip arthroplasties after femoral neck fractures is fraught with high complication and loosening rates. Careful patient selection for each type of arthroplasty (hemiarthroplasty versus total hip arthroplasty) may help ameliorate the outcome of arthroplasty for patients with femoral neck fractures.     

Total Hip Arthroplasty in Patients With Osteopetrosis

BackgroundOsteopetrosis is an inherited bone disease associated with high risk of osteoarthritis and fracture non-union, which can lead to total hip arthroplasty (THA). Bone quality and morphology are altered in these patients, and there are limited data on results of THA in these patients. The goals of this study were to describe implant survivorship, clinical outcomes, radiographic results, and complications in patients with osteopetrosis undergoing primary THA.MethodsWe identified 7 patients (9 hips) with osteopetrosis who underwent primary THA between 1970 and 2017 utilizing our total joint registry. The mean age at index THA was 48 years and included two males and five females. The mean follow-up was 8 years.ResultsThe 10-year survivorship free from any revision or implant removal was 89%, with 1 revision and 1 resection arthroplasty secondary to periprosthetic femoral fractures. The 10-year survivorship free from any reoperation was 42%, with 4 additional reoperations (2 ORIFs for periprosthetic femoral fractures, 1 sciatic nerve palsy lysis of adhesions, 1 hematoma evacuation). Harris hip scores significantly increased at 5 years (P = .04). Five hips had an intraoperative acetabular fracture, and 1 had an intraoperative femur fracture. All postoperative femoral fractures occurred in patients with intramedullary diameter less than 5 mm at a level 10 cm distal to the lesser trochanter.ConclusionPrimary THA in patients with osteopetrosis is associated with good 10-year implant survivorship (89%), but a very high reoperation (58%) and periprosthetic femoral fracture rate (44%). Femoral fractures appear associated with smaller intramedullary diameters.     

A biomechanical comparison of periprosthetic femoral fracture fixation in normal and osteoporotic cadaveric bone

Several techniques are described for fixation of Vancouver B1 femoral shaft fractures after total hip arthroplasty. Twenty-four femurs were scanned by dual x-ray absorptiometry scanned and matched for bone mineral density. Femurs were implanted with a cemented simulated total hip prosthesis with a simulated periprosthetic femur fracture distal to the stem. Fractures were fixed with Synthes (Paoli, Pa) 12-hole curved plates and 4 different constructs proximally. Each construct was loaded to failure in axial compression. Constructs with locking and nonlocking screws demonstrated equivalent loads at failure and were superior in load at failure compared with cables. Cable constructs failed proximally. No proximal failures occurred in specimens fixed with screws and cables. A combination of locked or nonlocked screws and supplemental cable fixation is recommended for the treatment of Vancouver B1 periprosthetic femur fractures.     

Impaction allograft with cement for the revision of the femoral component. A minimum 39-month follow-up study with the use of the Exeter stem in Asian hips

We report the results of impaction bone grafting of the femoral side in revision total hip arthroplasty in Asian hips (South Korean patients) in which the surgery was performed with the use of the Exeter stem. The minimum follow-up was 39 months (mean, 48.4; range, 39-66). There was subsidence of the cement-graft interface (<1 mm) in three hips (5%), of the stem-cement interface (<1 mm) in 12 hips (21%) and of the stem-cement interface (1-2 mm) in 14 hips (25%). Five hips (9%) developed intraoperative femoral fracture and two hips (4%) femoral perforation in revision. The complications of femoral fracture and subsidence did not have an adverse effect on the final clinical outcomes. The impaction of fresh-frozen allograft and use of a cemented, polished, tapered stem (Exeter stem) were also successful with good clinical and radiographic outcomes in our study of Asian hips (South Korean patients). However, we used smaller stems than the usual ones used for Western patients because of the smaller femur sizes.     

Total hip arthroplasty for acute femoral neck fractures using a cementless tapered femoral stem

The purpose of this study was to evaluate the osseointegration potential and implant-related complications of cementless total hip arthroplasty with a titanium alloy collarless, tapered, wedge-shaped femoral stem with a proximal circumferential plasma-spray coating in patients with acute hip fractures. The cohort consists of 85 patients with a mean age of 78.1 years. The mean duration of follow-up was 3.8 years. Total hip arthroplasty conferred significant improvement in function for all patients. All femoral components were stable with evidence of bone ingrowth (84 hips) or fibrous fixation (1 hip). Mild thigh pain was present in 3 patients. The complications included dislocation (3 cases), intraoperative femoral fracture (2 cases), and periprosthetic femoral fracture in the postoperative period (1 case). There was one reoperation for revision of the femoral component in the patient with a periprosthetic fracture. There were 25 (29%) deaths. Cementless total hip arthroplasty using a tapered proximally coated femoral stem is a viable option for the treatment of a displaced hip fracture and preexistent arthritis.     

The use of femoral struts and impacted cancellous bone allograft in patients with severe femoral bone loss who undergo revision total hip replacement: a three- to nine-year follow-up

We determined the midterm survival, incidence of peri-prosthetic fracture and the enhancement of the width of the femur when combining struts and impacted bone allografts in 24 patients (25 hips) with severe femoral bone loss who underwent revision hip surgery. The pre-operative diagnosis was aseptic loosening in 16 hips, second-stage reconstruction in seven, peri-prosthetic fracture in one and stem fracture in one hip. A total of 14 hips presented with an Endoklinik grade 4 defect and 11 hips a grade 3 defect. The mean pre-operative Merle D'Aubigné and Postel score was 5.5 points (1 to 8). The survivorship was 96% (95% confidence interval 72 to 98) at a mean of 54.5 months (36?to 109). The mean functional score was 17.3 points (16 to 18). One patient in which the strut did not completely bypass the femoral defect was further revised using a long cemented stem due to peri-prosthetic fracture at six months post-operatively. The mean subsidence of the stem was 1.6 mm (1 to 3). There was no evidence of osteolysis, resorption or radiolucencies during follow-up in any hip. Femoral width was enhanced by a mean of 41% (19% to 82%). A total of 24 hips had partial or complete bridging of the strut allografts. This combined biological method was associated with a favourable survivorship, a low incidence of peri-prosthetic fracture and enhancement of the width of the femur in revision total hip replacement in patients with severe proximal femoral bone loss.