The effect of preoperative planning and impaction grafting surgical technique on intraoperative and postoperative complication rate for femoral revision patients with moderate to severe bone loss mean 4.7-year results

Impaction bone grafting for femoral revision hip arthroplasty with Exeter stem in Japan: An extended 10- to 15-year stem survival analysis of the previously reported series

BACKGROUND

Femoral impaction bone grafting (IBG) was introduced in the late 1990s in Japan and has gradually become recognized as a useful option for femoral revision. The aim of the present study was to retrospectively analyze 10 to 15 years of clinical results of femoral revision arthroplasties of IBG using Exeter stem performed by experienced Japanese surgeons.

METHODS

We investigated radiographic and clinical records more than 2 years after surgery in 99 hips of 93 patients. The average age was 66.3 years (36-84 years) and the average follow-up period was 11 years (2-23 years and 8 months). Merle d'Aubigné and Postel hip score was used for clinical assessment, and re-operations for any reason 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 14.5 points at the final follow-up. Re-operations were undertaken in 15 hips of 14 patients for aseptic acetabular component loosening (n = 1 hip), recurrent dislocation (n = 2 hips), infection (n = 4 hips), and periprosthetic femoral fracture (n = 8 hips). The survival rates at 10 and 15 years after operation were 87.1% and 81.1% with any type of re-operation as the endpoint, 92.2% and 92.2% with stem removal or exchange as the endpoint, 94.9% and 88.1% with re-operation for periprosthetic femoral fracture as the endpoint, and 99.0% and 99.0% with re-operation for aseptic stem loosening as the endpoint, respectively.

CONCLUSIONS

The present study showed encouraging results of femoral IBG over 10 years by experienced surgeons in Japan. Although femoral IBG is recognized as a technically complex procedure, survivorship of the stem is excellent, with a 15-year stem survival rate of 99.0% at the end point of aseptic loosening.

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

BACKGROUND

Femoral 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.

METHODS

Thirteen 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.

RESULTS

The 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.

CONCLUSIONS

Impaction 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.

Effects of femoral bone defect morphology on initial polished tapered stem stability in massive defect model: a biomechanical study

Background

Good outcomes have been reported in revision total hip replacement with massive segmental defects using impaction bone grafting with circumferential metal meshes. However, the morphology of defects that require a mesh is poorly defined. The purpose of this study was to evaluate the effects of a variety of segmental defects on load transmission to the proximal femur under both axial and rotational loads.

Methods

Initial stability of the Exeter stem was investigated in a composite bone model using three medial bone defect morphologies: Long (length 5 cm × width 2 cm), Short (2.5 cm × 2 cm), Square (3.2 cm × 3.2 cm), Square with mesh (3.2 cm × 3.2 cm defect covered with metal mesh), and with no defect as control. Specimens (5 per group) were axially loaded and internally rotated up to 20° or to failure. Strain distributions of the femora were measured using a strain gauge.

Results

All Square group specimens failed while rotation was increasing. In the other four groups, failure was not observed in any specimens. Mean torsional stiffness in the Long (4.4 ± 0.3 Nm/deg.) and Square groups (4.3 ± 0.3 Nm/deg.) was significantly smaller than in the Control group (4.8 ± 0.3 Nm/deg.). In the medio-cranial region, the magnitude of the maximum principal strain in the Square group (1176.4 ± 100.9) was significantly the largest (Control, 373.2 ± 129.5, p < 0.001; Long, 883.7 ± 153.3, p = 0.027; Short, 434.5 ± 196.8, p < 0.001; Square with mesh, 256.9 ± 100.8, p < 0.001). Torsional stiffness, and both maximum and minimum principal strains in the Short group showed no difference compared to the Control group in any region.

Conclusions

Bone defect morphology greatly affected initial stem stability and load transmission. If defect morphology is not wide and the distal end is above the lower end of the lesser trochanter, it may be acceptable to fill the bone defect region with bone cement. However, this procedure is not acceptable for defects extending distally below the lower end of the lesser trochanter or defects 3 cm or more in width.

Clinical observation of biomimetic mineralized collagen artificial bone putty for bone reconstruction of calcaneus fracture

This study investigated clinical outcomes of biomimetic mineralized collagen artificial bone putty for bone reconstruction in the treatment of calcaneus fracture. Sixty cases of calcaneal fractures surgically treated with open reduction and internal fixation in our hospital from June 2014–2015 were chosen and randomly divided into two groups, including 30 cases treated with biomimetic mineralized collagen artificial bone putty as treatment group, and 30 cases treated with autogenous ilia as control group. The average follow-up time was 17.2 ± 3.0 months. The results showed that the surgery duration and postoperative drainage volume of treatment group were significantly lower than control group; there were no statistically significant differences in the fracture healing time, American Orthopaedic Foot and Ankle Society scores at 3 and 12 months after surgery, Böhler’s angle, Gissane’s angle and height of calcaneus between the two groups. There were no significant differences in wound complication and reject reaction between the two groups, while significant difference in donor site complication. As a conclusion, the implantation of biomimetic mineralized collagen artificial bone putty in the open reduction of calcaneal fracture resulted in reliable effect and less complications, which is suitable for clinical applications in the treatment of bone defect in calcaneal fractures.

Fracture of the C-Stem cemented femoral component in revision hip surgery using bone impaction grafting technique: report of 9 cases

We present a series of 9 fractures of a C-Stem femoral component (6 long stems and 3 conventional stems) that had been implanted with the use of impaction bone grafting (IBG). The length of the long fractured stems was 240 mm in 4 cases and 200 mm in 2. The patients presented had an average BMI of 26.5 and an average of 2.7 previous hip surgeries (range 2-5 surgeries) before the stem fracture. A total of 5 cases presented with a metal mesh fracture in addition to the fractured stem. Bending of the stems or stem defects was not observed in any case. Typical fracture waves consistent with fatigue failure were clearly visible on all the cut surfaces, starting anterolaterally and propagating to the medial side. Although fatigue fracture of a modern cemented tapered polished femoral stem is a rare event, stress due to the absence of proximal femoral bone support could be sufficient to put this stem at a higher risk for fatigue fracture in non-obese patients.

Proximal femoral reconstruction with impaction bone grafting and circumferential metal mesh

INTRODUCTION

Impaction bone grafting (IBG) using a circumferential metal mesh is one of the options that allow restoration of the femoral bone stock and stability of the implant in revision hip arthroplasty. Here we examine the clinical and radiographic outcome of this procedure using a cemented stem, including experimental analysis of the initial stability of mesh-grafted bone-cemented stem complexes.

METHODS

We retrospectively reviewed six hips (six patients) that had undergone femoral revisions with a circumferential metal mesh, impacted bone allografts, and a cemented stem. The mean follow-up period was 3.9 years (range 2.4-4.8 years). Hip joint function was evaluated using the Japanese Orthopaedic Association hip score, and radiographic changes were determined from radiographs. The initial resistance of mesh-grafted bone-cemented stem complexes to axial and rotational force was measured in a composite bone model with various segmental losses of the proximal femur.

RESULTS

The hip score improved from 50 (range 10-84) preoperatively to a mean of 74 (range 67-88) at the final follow-up. The overall implant survival rate was 100 % at five years when radiological loosening or revision for any reason was used as the endpoint. No stem subsided more than 3 mm vertically within one year after implantation. Computed tomography showed reconstitution of the femoral canal in a metal mesh. In mechanical analyses, there was no relationship between IBG reconstruction rates under axial compression and stem subsidence or failure load. In contrast, under rotational load, the rotation angles of the stem to the stainless steel mesh were strongly affected by the IBG reconstruction rate.

CONCLUSIONS

The short-term results show good outcomes for reconstruction of proximal bone loss with IBG and a circumferential mesh. The procedure should be applied in cases where the circumferential proximal bone loss is less than half the length of the implanted stem.

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.

Midterm results of femoral impaction bone grafting with an allograft combined with hydroxyapatite in revision total hip arthroplasty

The purpose of this study was to evaluate the outcome of femoral impaction bone grafting with an allograft combined with hydroxyapatite (HA). Fifty-four consecutive femoral reconstructions that were performed with the use of frozen morselized allografts and HA were followed up retrospectively. The average follow-up period was 92 months. A femoral head and HA were mixed and used as allograft. The average Merle d'Aubigné clinical score improved from 8.9 preoperatively to 13.1 points postoperatively. Stem subsidence was seen in 26 hips; however, it was not progressive after 1 year postoperatively. Cortical repair was detected at an average of 7 months postoperatively. Impaction bone grafting with an allograft combined with HA provided favorable results, with bone remodeling and less subsidence.

The extent of the bone defect affects the outcome of femoral reconstruction in revision surgery with impacted bone grafting: a five- to 17-year follow-up study

We report the results of 79 patients (81 hips) who underwent impaction grafting at revision hip replacement using the Exeter femoral stem. Their mean age was 64 years (31 to 83). According to the Endoklinik classification, 20 hips had a type 2 bone defect, 40 had type 3, and 21 had type 4. The mean follow-up for unrevised stems was 10.4 years (5 to 17). There were 12 re-operations due to intra- and post-operative fractures, infection (one hip) and aseptic loosening (one hip). All re-operations affected type 3 (6 hips) and 4 (6 hips) bone defects. The survival rate for re-operation for any cause was 100% for type 2, 81.2% (95% confidence interval (CI) 67.1 to 95.3) for type 3, and 70.8% (95% CI 51.1 to 90.5) for type 4 defects at 14 years. The survival rate with further revision for aseptic loosening as the end point was 98.6% (95% CI 95.8 to 100). The final clinical score was higher for patients with type 2 bone defects than type 4 regarding pain, function and range of movement. Limp was most frequent in the type 4 group (p < 0.001). The mean subsidence of the stem was 2.3 mm (SD 3.7) for hips with a type 2 defect, 4.3 mm (SD 7.2) for type 3 and 9.6 mm (SD 10.8) for type 4 (p = 0.022). The impacted bone grafting technique has good clinical results in femoral revision. However, major bone defects affect clinical outcome and also result in more operative complications.

Femoral impaction grafting in revision total hip arthroplasty: a follow-up of 540 hips

Between 1987 and 1999, 540 revision total hip arthroplasties in 487 patients were performed at our institution using the femoral impaction grafting technique with a cemented femoral stem. All patients were prospectively followed up for 2 to 15 years postoperatively with no loss to follow-up. A total of 494 hips remained successfully in situ at an average of 6.7 years. The 10-year survival rate was 98.0% (95% confidence interval, 96.2-99.8) with aseptic loosening as the end point and 84.2% (95% confidence interval, 78.5-89.9) for reoperation for any reason. Indication for surgery and the use of any kind of reinforcement significantly influenced outcome (P < .001). This is the largest known series of revision THA with femoral impaction grafting, and the results support continued use of this technique.

Proximal femoral reconstructions with bone impaction grafting and metal mesh

Extensive circumferential proximal cortical bone loss is considered by some a contraindication for impaction bone grafting in the femur. We asked whether reconstruction with a circumferential metal mesh, impacted bone allografts, and a cemented stem would lead to acceptable survival in these patients. We retrospectively reviewed 14 patients (15 hips) with severe proximal femoral bone defects (average, 12 cm long; 14 type IV and one type IIIB using the classification of Della Valle and Paprosky) reconstructed with this method. The minimum followup was 20 months (average, 43.2 months; range, 20-72 months). Preoperative Merle D'Aubigné and Postel score averaged 4.8 points. With revision of the stem as the end point, the survivorship of the implant was 100% at one year and 86.6% at 72 months. The mean functional score at last followup was 14.4 points. We observed two fractures of the metal mesh at 31 and 48 months in cases reconstructed with a stem that did not bypass the mesh. Dislocation (3 cases) and acute deep infection (3 cases) were the most frequent complications. Patients with complete absence of the proximal femur may be candidates for biological proximal femoral reconstructions using this salvage procedure. Bone impaction grafting must be a routine technique if this method is selected.