Revision of total hip arthroplasty using an anterior cortical window, extensive strut allografts, and an impaction graft: follow-up study

PURPOSE: To report the outcome of revised total hip arthroplasty procedures involving an anterior cortical window, extensive strut allografts, and an Exeter impaction graft. METHOD: Eight patients (9 hips) with a mean age of 58 years underwent revision of total hip arthroplasty using the Exeter hip impaction graft system and strut allografts between 1995 and 1998. An extensile anterior approach was used, and an anterior cortical window was created in the femur, to remove the old implant. External strut allografts were attached by wires to provide cortical support. The mean follow-up duration was 74 months. Indications for surgery were aseptic loosening of previous implants in 8 hips and infection of one hip that had previously undergone total arthroplasty. RESULTS: 19 Dall Miles cables, 4 ordinary cerclage wires, and 8 cerclage wires tightened with the clincher knot technique were used to secure the allograft to the host bone. The strut grafts were found to be incorporated in all cases. No wires became loose. One patient developed 20 degrees of angulation at the allograft-host bone junction. Using the method of Fowler and Gie, we found that one femoral implant had subsided 2 mm within the cement mantle. Two other implants had 1 mm of subsidence at the cement bone interface, and one patient had a major subsidence of 15 mm that required revision. CONCLUSION: Using an anterior cortical window in the femur to remove the old implant does not predispose to failure of the allograft to incorporate into the host bone.     

Revision hip arthroplasty using strut allografts and fully porous-coated stems

At a minimum of 10 years after surgery, we prospectively evaluated the clinical and radiographic outcomes of revision total hip arthroplasties using cortical strut allografts and fully porous-coated cementless revision femoral components in patients with massive femoral bone deficiency. There were 21 men and 33 women (54 hips) in the series, with patients' mean age at the time of index revision being 54.6 years (range, 36 to 65 years). All femurs had 2 or 3 fresh-frozen femoral strut allografts. The Harris hip score improved from a mean of 21 points before revision surgery to a mean of 83 points at the latest case review. Two femoral stems (4%) had aseptic loosening and were revised. All allografts were predictably united to the host femur. On the basis of favorable results at a mean follow-up of 10.5 years, we recommend, as a salvage procedure, the use of fully porous-coated cementless femoral stems and strut allografts in revision surgery of the hip for massive femoral bone loss.     

Periprosthetic fracture of the femur after hip arthroplasty: The clinical outcome using cortical strut allografts

Between 1993 and 1998, 15 patients with periprosthetic fractures of the femur after hip arthroplasty were treated using deep-frozen cortical strut allografts as an adjunct support after internal fixation or revision arthroplasty. According to the Vancouver classification system, there were 7 type B1, 2 type B2, 4 type B3 and 2 type C fractures. Seven patients had severe osteopenia, 10 patients had bone defects between 2 to 7 cm and 2 were associated with infection. Nine patients had internal fixation of the fracture using a compression plate, and 6 had revision arthroplasty using a long-stemmed femoral prosthesis. The average length of the allograft was 13.9 cm. At an average follow-up of 31 months, all the patients had a satisfactory functional result except one who had a leg length discrepancy of 4 cm due to multiple operations. There were no non-unions, malunions or infections. The fractures healed between 10 to 24 weeks (average, 15.6 weeks). In conclusion, a cortical strut allograft associated with internal fixation can be an effective method of treating periprosthetic fractures of the femur after hip arthroplasty.     

Use of Locking Plate and Strut Onlay Allografts for Periprosthetic Fracture Around Well-Fixed Femoral Components

Background

The purpose of this study was to determine: validated clinical and radiographic outcomes of periprosthetic femoral fractures around stable hip implants treated with plate fixation and additional cortical strut onlay allografts without revision of the stem; radiographic signs of fracture healing; allograft-to-host bone union; resorption of cortical strut allograft; and frequency of complications.

Extended slide trochanteric osteotomy for revision total hip arthroplasty

BACKGROUND: The purpose of this study was to assess the rate of union, time to union, and complications associated with the extended slide trochanteric osteotomy. We also evaluated how outcomes were influenced by the preoperative cortical-bone thickness, the preoperative cancellous-bone quality of the greater trochanter, the number of cables used to reattach the trochanteric osteotomy fragment, and the use of cortical strut augmentation. METHODS: We reviewed the results for forty-six hips in forty-five patients who underwent a revision total hip arthroplasty with an extended slide trochanteric osteotomy between December 1991 and December 1996. Twenty-three patients were men, and twenty-two were women; the mean age at the time of the operation was 66.3 years. Two hips had an isolated acetabular revision, fifteen had an isolated femoral revision, and twenty-nine had acetabular and femoral revisions. One patient (one hip) was lost to follow-up. RESULTS: At a mean of forty-four months after the operation, the rate of union of the distal osteotomy site was 98 percent (forty-four of forty-five hips), with no change in the femoral component position. The time to union was not significantly correlated with the number of cables, the preoperative cortical-bone thickness, or the preoperative cancellous-bone quality of the greater trochanter. Interestingly, the time to bridging-callus union was significantly longer in the hips with a strut allograft than in the hips without a strut allograft (p = 0.04, t test for independent samples). Two fractures of the osteotomy fragment occurred, but neither necessitated another revision. CONCLUSIONS: The extended slide trochanteric osteotomy allows extensive acetabular and femoral exposure, facilitates removal of distal cement or a well fixed porous-coated stem, and allows reliable reattachment and healing of the trochanteric fragment.     

Fracture of the femur in revision hip arthroplasty with a fully porous-coated component

Fifty-four consecutive femoral component revisions with uncemented fully porous-coated stems were retrospectively reviewed for the prevalence of intraoperative fracture. Fracture of the femoral diaphysis occurred during insertion of a curved stem in 8 (15%) hips. One additional distal fracture of the femur occurred during exposure of the hip. All fractures occurred with a curved femoral stem. Treatment for intraoperative fractures included open reduction and internal fixation with cortical strut grafts and cables followed by protected weight bearing. This was successful in 6 hips. Even with the use of a curved stem, we report a high prevalence of intraoperative fracture of the femur in revision hip arthroplasty.     

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.     

全髋关节置换术后股骨假体周围Vancouver B型骨折治疗的随访研究

目的 探讨全髋关节置换术后股骨假体周围Vancouver B型骨折治疗方法的选择,总结同种异体皮质骨板移植重建股骨假体周围骨折的临床效果.方法 22例全髋关节置换术后股骨假体周围骨折患者,男7例,女15例;年龄平均65岁(53～75岁).Vancouver分类B1型5例,B2型4例,B3型13例.B1型骨折采用异体皮质骨板移植加钢丝环扎治疗;B2型骨折选择加长股骨柄翻修;B3型骨折选择骨水泥柄翻修,加同种异体皮质骨板移植和钢丝环扎同定.所有患者均获得随访,随访时间平均67个月(37～95个月).采用Harris髋关节功能评分、X线片、外周血T淋巴细胞亚群、抗体免疫复合物检测 和核素骨显像对治疗结果进行评价.结果 22例患者骨折全部愈合,21例患者能自由行走,1例需要助 行器帮助.末次随访Harris评分平均89分(79～93分).患者未发生免疫排斥反应;术后3个月,骨折愈合,术后12个月,移植骨板与宿主骨骨性愈合,股骨皮质厚度增加3～5mm;核素骨显像骨板移植区放射性核素分布较对侧浓集.3例患者移植骨板出现部分吸收现象.术后2年.骨板与宿主骨融合,移植骨板吸收停止.结论 针对股骨假体周围骨折不同类型分别采取不同方法治疗能够取得较好疗效,同种异体皮质骨板移植在维持骨折稳定性、促进骨折愈合、增加局部骨量和改善骨强度方面有较好疗效.     

Revision total hip replacement using a cementless interlocking distal femoral stem with allograft-cemented composite and the application of intramedullary and onlay cortical strut allografts: two case reports

It is often difficult to perform repeated revision total hip replacement (re-THR) after prosthesis loosening stemming from infection, mechanical loosening, and osteolysis. Reasons for this include the size of the bone defect and poor quality of the remaining bone. We have previously performed revision surgery using a cementless interlocking distal femoral stem with segmental cortical allograft-cemented composite for reconstruction in the presence of circumferential bone loss of the proximal femur according to Gustilo classification type IV [1]. However, in the case where the distal femur had a stovepipe canal due to osteoporosis, osteolysis, and infection, it was difficult to achieve stable fixation to the distal femoral cortical bone using a cementless interlocking distal femoral stem. Therefore, a cortical strut allograft is inserted into the femoral bone canal on the medial side, followed by the insertion of an interlocking stem. A further cortical strut allograft is inserted on the lateral side of the distal femur. In addition, the distal onlay allograft should pass over the allograft–host bone junction. The two allografts are finally secured with interlocking screws. The bone allografting to augment femoral bone deficiency was performed using mainly cadaveric bone allografts obtained from our bone bank [2, 3]. In this report, we describe two cases of re-THR involving the use of intramedullary and onlay cortical strut allografts with a cementless interlocking distal femoral long stem to achieve favorable fixation stability. The two patients were asked if the data from the case could be submitted for publication, and both gave their consent     

Major femoral bone loss in revision total hip arthroplasty treated with tapered, porous-coated stems

Clinical results of revision total hip arthroplasty using fully porous-coated tapered titanium stems to treat severe proximal femoral bone loss were evaluated in a retrospective review of 39 patients (45 hips). The bone was reinforced with cables in 39 hips, and in 14 hips strut allografts were added. Fixation was successful in 44 hips, and one hip required revision to treat undetected fracture and migration of the stem. All the others had radiographic evidence of bone attachment. Neither bone atrophy nor reconstitution was noted. Three patients (3 hips) had mild thigh pain, but the others had no pain related to the femoral component. Eight hips dislocated; one resolved and seven had recurrent dislocation that was treated with a constrained acetabular component, capsulorrhaphy, or liner reorientation. Ten patients (12 hips) used a walker and 10 patients (12 hips) used a cane at the last postoperative visit. Whereas fixation was successful with this surgical technique, complications related to deficiency of the soft tissue structures were common.     

Cementless revision of total hip arthroplasty using the anatomic porous replacement revision prosthesis

This study reports the results of revision total hip arthroplasty with the Anatomic Porous Replacement Revision Hip System (Intermedics Orthopedics, Austin, TX) to investigate the value of cementless fixation. Sixty-six hips in 65 patients were followed for a mean of 4.7 years in patients with a mean age of 56 years. Thirty-six patients were categorized as Charnley class A, 16 as class B, and 13 as class C. Forty (61%) of the femurs were classified before surgery as having loss of bone distal to the intertrochanteric line. Thirty-two (48%) of the femurs required augmentation with demineralized strut cortical allografts, 5 (8%) required bulk femoral allografts, and 12 hips (18%) required acetabular allografts. Overall, 4 stems (6%) and 2 acetabular components (4%) required further revision surgery. The reason for further revision in 1 stem and both acetabular components was allograft failure. Fifty-six (85%) hips had excellent or good Harris hip scores. Ninety percent of hips had no or slight pain, and 90% allowed patients to walk with no or slight limp. Those hips that had hydroxyapatite coating added to the porous coating had statistically improved Harris hip scores for both pain and limp. Stable fixation was present in 95% of stems. Demineralized strut grafts healed in 30 of 32 hips. Thirty-nine of 44 noncemented revision sockets had no radiolucent lines and there were no loose components. Cementless fixation was effective for these hips.     

全髋关节置换假体柄周围骨折的治疗

目的 :回顾性研究全髋关节置换假体柄周围骨折的治疗及预防。方法 :将本院近年收治的全髋置换假体柄周围骨折的 8例病例按Vancouver分类方法进行分类 ,其中A1型 3例 ,B1型 3例 ,B2型 1例 ,B3型 1例 ,分别用钢丝环扎固定 ,异体皮质骨板加钢丝环扎 ;骨水泥长柄假体翻修。结果 :术后随访 8～ 18个月 ,骨折愈合 ,假体固定可靠。结论 :全髋关节置换术后假体柄周围骨折用Vancouver分类方法分类 ,简单、适用。采用异体皮质骨板与钢丝环扎固定骨折 ,治疗假体柄周围骨折 ,不仅固定可靠而且能促进骨折愈合、恢复骨量。     

异体皮质骨支撑植骨在髋关节股骨翻修术中的应用

目的探讨异体皮质骨支撑植骨在髋关节股骨翻修术中应用的适应证及临床效果。方法从2001年10月至2007年12月，笔者对41例股骨严重骨缺损的患者在髋关节翻修术中应用了同种异体皮质骨支撑植骨。主要在以下三种情况下使用，一是采用延长股骨粗隆截骨（ETO）取股骨假体，而患者近端骨质疏松或原有严重的骨缺损，采用远端固定假体翻修，为增加股骨近端的强度或增加ETO后股骨近端的稳定性而采用，这类患者共20例；二是在采用打压植骨进行股骨重建时，因为股骨存在有节段性缺损，或因取股骨远端骨水泥而进行股骨开窗造成股骨节段性缺损时，为了封闭骨缺损，使其成为包容性缺损而采用，这类患者共6例；三是在有严重股骨骨质疏松的患者出现股骨骨折时采用，这类患者共15例。笔者进行了平均37个月（6～72个月）的随访。结果所有同种异体皮质骨在术后12个月可以看出有与宿主骨结合的征象，假体固定稳定。未发生感染、排异反应或假体松动征象，髋关节Harris评分从术前平均38分增加到术后的88．1分。结论异体皮质骨支撑植骨在某些股骨翻修情况下有其特殊的需要，能够作为生物接骨板提供机械稳定性和生物稳定性，目前有不可替代的作用。     

Impacted cancellous graft plus cement in hip revision

Revision of the femoral component is difficult in the presence of large cavitary defects of the femur. Impaction cancellous grafting used in conjunction with a cemented prosthesis has been recommended as a means of restoring bone stock while providing excellent and durable clinical results. Fifty-seven consecutive femoral revisions were done between 1993 and 1997 in 54 patients (24 men and 30 women) using the impaction grafting technique and a collarless, tapered, polished stem. Strut allografts were used for femoral reinforcement in 40 hips. No patient was lost to followup. One patient had an infection develop and had a resection arthroplasty. Three patients died of causes unrelated to the hip. After 6.3 years the clinical results were excellent. Radiographic evaluation showed no evidence of loosening in any of the 53 surviving hips. Subsidence of 1 to 3 mm was seen in 40 hips and subsidence of 4 to 6 mm was seen in two hips. Cancellous remodeling was observed in 42 hips. The most common complications were postoperative femoral fractures. All six fractures occurred at the distal end of the prosthesis, were not associated with prosthetic loosening, and were treated successfully with open reduction and internal fixation without prosthetic revision. These satisfactory results and the limited subsidence observed in our patients radiographs could be explained by the careful attention to the technical details of the procedure. However, even with the generous use of strut graft augmentation, postoperative femoral fractures remain our most serious complication.     

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.     

Cortical strut allografts in salvage revision arthroplasty: Surgical technique and clinical outcomes

BackgroundThe aim of this study was to present our clinical outcomes and surgical technique in strut allografts preparation using staggered holes to enhance osteointegration and demineralised bone matrix (DBM) as an adjunct to cortical strut allografts in salvage revision arthroplasty patients.MethodsRetrospective consecutive series of patients who required strut allograft femoral reconstructions with minimum 2 years follow up between 2012 and 2018. Frozen washed irradiated, cortical struts were used and prepared adding 2 mm staggered drill holes along the length of the strut and applying DBM paste on the graft-host interface. Outcome measures included radiographic strut union, graft resorption, infection and complications.Results15 patients included; 3 males and 12 females with median age 72 years (range 60–93). All had significant bony defects (Paprosky III/IV in 12 cases including 3 cases of periprosthetic hip fractures and further 3 cases of periprosthetic knee fractures around revision hinged implants). At final follow up, median 3.8 years (range 2.7–7.2), 14/15 (93.3%) struts had united at a median 6 months (range 5–8), complete incorporation with cortical round-off was seen at median 12 months (range 8–48) in 12/15 (80%) struts, 2/15 (13.3%) show radiographic evidence of proximal minimal graft resorptions although the remainder of the strut had integrated and were asymptomatic. There were no cases of infection.ConclusionsUse of strut allografts helps to reconstruct bone defects, restore bone stock, and provide stable fixation for complex patterns of periprosthetic fractures around hip/knee implants and salvage revision cases with 93.3% union rate at median 6 months.     

同种异体皮质骨板移植治疗股骨假体周围骨折

目的 评价同种异体皮质骨板移植治疗髋关节股骨假体周围骨折的临床治疗效果。方法 对7例髋关节置换术后股骨假体周围骨折患者应用深低温冷冻和环氧乙烷处理同种异体皮质骨板移植治疗股骨骨折。根据Harris评分,外周血T淋巴细胞亚群、抗体和免疫复合物检测、X线摄片以及核素骨显像评价其治疗效果。结果 患者未发生免疫排斥反应和感染,术后3、6、12、24个月Harris评分分别比术前平均增加21、32、40、40分。术后3个月骨折愈合,一部分移植骨板与宿主骨骨性连接,同位素骨显像骨板移植区放射性分布比对侧浓集。术后12个月,85％移植骨板与宿主骨融为一体,宿主股骨皮质厚度增加3～5mm,平均4．3mm,骨板放射性浓集进一步加深,15％移植骨板出现吸收现象。术后24个月,80％移植骨板重新塑形后恢复宿主股骨皮质骨密度,10％骨板表面吸收停止,股骨假体无松动。结论 深低温冷冻和环氧乙烷处理同种异体皮质骨板移植无菌、抗原性弱、生物相容性好,移植骨板能够维持骨折和假体稳定性,增加股骨局部骨量储备,避免再次手术取出金属内置物,是用来治疗股骨假体周围骨折较理想的方法之一。     

Supportive strut grafts for diaphyseal bone defects in revision hip arthroplasty

Large femoral cortical strut allografts were used to provide structural support of the femur in 20 patients in whom uncemented, extensively porous-coated, press-fit revision femoral stems were applied. The mean followup was 4.7 years. Radiographic analysis of the patients who had revision surgery revealed that in all 20 patients, the cortical femoral strut allografts showed incorporation. Small areas of graft resorption were observed in only two patients. Seventeen of the uncemented femoral revision stems radiographically showed bone ingrowth. Three of the revision femoral stems were interpreted as being fixed only by fibrous ingrowth after early subsidence after surgery. There were no reoperations. Before surgery, all patients were unable to walk and had severe pain. At followup, all patients were ambulatory and had considerable improvement in pain relief and in their ability to walk. The mean Harris hip score after surgery was 75 (range, 57.5-92). Complications consisted of one peroneal nerve palsy, which resolved; one deep venous thrombosis; one gastrointestinal ulcer; and one case of pneumonia. Supportive cortical strut allografts represent an alternative to the use of circumferential bulk allografts and total femoral replacements in patients with large combined proximal and diaphyseal bone defects.     

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.     

Impaction bone grafting for femoral revision hip arthroplasty with Exeter Universal stem in Japan

Objectives

The purpose of the present study was to analyze the retrospective clinical and radiographic results of femoral revision arthroplasties with impaction bone grafting performed by experienced Japanese surgeons.

Patients and methods

We investigated the radiographic and clinical records more than 2?years after the surgery in 99 hips of 93 patients. The average age was 66.3?years (36–84?years) and the average follow-up period was 5.2?years (2–13?years). The Merle d’Aubigné and Postel hip score was used for clinical assessment, and peri-operative fractures were recorded. The survival curve was estimated using Kaplan–Meier method.

Results

The mean Merle d’Aubigné and Postel hip score improved from 9.0 points to 15.2 points at the final follow-up. Augmentations for segmental defect of femoral cortices were undertaken in 55 hips. Metal or strut allograft plates were applied to 9 hips and 21 hips, respectively. Intra-operative fractures or perforations occurred in 20 hips. Re-operations of the femur were undertaken in nine hips including five post-operative femoral fractures. More than 5?mm of subsidence was observed in only 2 hips. The survival rates at 8?years after the operation were 94.8?% with femoral fractures as the end point, 93.1?% with any stem removal or exchange as the end point, and 99.0?% with aseptic stem loosening as the end point, respectively.

Conclusion

The present study showed encouraging mid-term results of impaction bone grafting for femoral revision arthroplasty by experienced surgeons in Japan. Aggressive augmentation of segmental defects and attenuated femoral shafts prevents massive stem subsidence and periprosthetic fracture.