One-stage revision hip arthroplasty for infection using primary cementless stems as first-line implants: About 35 cases

Outcomes of Primary Cementless Femoral Stems Used in Revision Hip Arthroplasty

INTRODUCTION

An abundance of literature exists assessing outcomes of revision THA using diaphyseal engaging stems; however, there is little research into the use of primary-style femoral stems in revision THA. Primary stems may have benefits including cost reduction, maintenance of proximal bone stock, and ease of potential future reconstructions. The purpose of this study was to evaluate the aseptic survival rate of revision THAs using primary femoral stems.

METHODS

A review of our registry was performed to identify patients from 2010 to 2020 who underwent all-cause revision THA utilizing a primary metaphyseal-engaging stem for femoral reconstruction. Patients who had a history of previous revision THA or those treated with cement or bone graft augmentation were excluded. There were seven patients excluded due to a lack of two-year follow-up. Implant survival, complications requiring revision surgery, and ambulatory status at final follow-up were documented. There were 78 patients who met the final inclusion criteria. The mean follow-up was 5.2 years (range, 2.0 to 10.0).

RESULTS

The most common indications for index revision were aseptic loosening (44%) or infection (34%). Pre-revision Paprosky classification of the femur was Type I in 41 patients (52%), Type II in 37 patients (47%), and Type 3A in one patient (1%). Overall, 13 patients (16.5%) required re-revision, five for periprosthetic fracture, six for instability, and two for recurrent infection. Of those, seven of 13 required femoral component revision. When excluding recurrent infections, the aseptic femoral-component survivorship for the cohort was 94%. There were three patients who sustained a fracture requiring stem re-revision. A Vancouver B1 fracture was sustained > two years postoperatively, and two Vancouver B2 fractures were sustained within six months postoperatively. There were no femoral re-revisions for aseptic loosening.

CONCLUSION

Primary metaphyseal-engaging femoral stems provide reliable fixation during revision THA in patients who have preserved proximal metaphyseal bone with similar complication rates to those previously reported in the literature for revision THA.

One-Stage Revision Using Cementless Reconstruction for Chronically Infected Total Hip Arthroplasty: An Average of 11 Years of Follow-Up

BACKGROUND

Although interest in one-stage revision has increased in recent years, long-term follow-up reports remain notably scarce. This study aimed to present the 11-year outcomes of cementless one-stage revision for chronically infected total hip arthroplasty (THA), including infection-free survivorship, radiographic and clinical outcomes, and complications.

METHODS

A retrospective analysis conducted between 2010 and 2016 included 126 patients who had chronically infected THA and underwent one-stage revision using cementless reconstruction. Kaplan-Meier survival analysis was used to assess postoperative survival, while Cox regression analysis identified risk factors for reinfection. Updated postoperative imaging, Harris Hip Scores, and complications were recorded. Successful infection treatment was defined as the absence of clinical symptoms of infection during follow-up.

RESULTS

During a mean follow-up period of 11 years (range, eight to 14), 16 patients experienced infection recurrence, resulting in a 10-year infection-free survival rate of 85.4%. Cox regression analysis identified age ≥ 65 years (HR [hazard ratio] 3.0, 95% CI [confidence interval] 1.2 to 8.6; P = 0.02) and American Society of Anesthesiologists grade III (HR 3.1, 95% CI 1.1 to 8.1; P = 0.03) as significant risk factors for reinfection. The presence of a sinus tract, prolonged operative time, culture-negative periprosthetic joint infection, methicillin-resistant pathogen infection, and prior surgery for infection were not associated with recurrence. Among the patients, two experienced recurrent dislocations and one had aseptic loosening, leading to a 10-year aseptic rerevision-free survival rate of 97.0%. The mean postoperative Harris Hip Scores at the latest follow-up was 77.9 points (range, 68.5 to 86.7; P < 0.001). Complications occurred in 26 patients (23.4%), and the 10-year reoperation-free survival rate was 78.7%.

CONCLUSIONS

A one-stage revision using cementless reconstruction for infected THA demonstrated a favorable infection control rate and sustained satisfactory clinical outcomes. However, further studies with higher-level evidence are needed to validate these findings.

Hip-resection arthroplasty: A valuable treatment for complex hip prosthetic joint infection?

INTRODUCTION

Management of recurrent hip prosthetic joint infection (PJI) is challenging. Hip-resection arthroplasty is a last-choice rescue strategy for complex PJI. The main objective was to assess prospectively the mid-term infectious and functional PJI outcomes of patients managed with hip-resection arthroplasty.

HYPOTHESIS

In complex multi-operated PJI, hip-resection arthroplasty may cure the infection without any major impact on hip function, which is often already very limited.

MATERIAL AND METHODS

This prospective cohort study conducted in a French Referral Center for bone-and-joint infections included all hip PJIs treated with hip-resection arthroplasty from 2004 to 2019. Patients were followed for at least 2 years, with recording of the following events: reinfection, including relapse or new infection, and PJI-related death. Hip functional status was assessed with the modified Merle d'Aubigné-Postel (mMAP) score. The primary outcome was 2-year event-free survival (EFS). The secondary outcomes were the 4- and 6-year EFS rates and hip functional status at 2 years.

RESULTS

We included 30 patients: median age, 65 years; 39% women. Median [IQR] PJI duration was 15 [4-39] months and patients underwent a median of 5 surgical procedures before resection arthroplasty. The 2-year reinfection free-survival was 89.2% (95% CI: 70.2-96.4). After a median follow-up of 70 [32-103] months, we observed: 1 relapse, 4 new infections, 7 revisions for mechanical reasons and 1 PJI-related death. Median mMAP score 2 years postsurgery was 12, versus 7 before; pain reduction was the main benefit of resection arthroplasty.

DISCUSSION

Hip-resection arthroplasty achieves sepsis and pain control, and can be a valuable last-line rescue strategy for patients with complex or recurrent hip PJIs.

LEVEL OF EVIDENCE

II; monocentric prospective cohort.

Is there a cardiovascular risk associated with the use of fluoroquinolones for the treatment of osteoarticular infections? Analysis of a retrospective cohort of 817 patients from a surgical and infectious disease referral center (CRIOAC)

INTRODUCTION

Bone joint infection is a rare but serious complication, the treatment of which most often requires intervention combined with prolonged high-dose antibiotic therapy. Fluoroquinolones are among the standard antibiotics for the treatment of these infections, particularly in combination with rifampicin for staphylococcal infections and as monotherapy for Gram-negative bacilli infections. However, recent studies, confirmed by several meta-analyses, have highlighted an increased cardiovascular risk such as aortic aneurysm and mitro-aortic regurgitation occurring early following fluoroquinolone use, leading to recommendations for caution from health agencies. These meta-analyses are often based on limited series with numerous indication biases (variable treatment durations) and low doses. We therefore conducted a single-center, single-prescriber, real-life study of a continuous series of osteo-articular infections. The objectives were to determine the rate of cardiovascular events (aortic aneurysm, mitro-aortic regurgitation) at 60 days, the mortality rate at 60 days, and at the final follow-up.

HYPOTHESIS

Our hypothesis was that despite long-term, high-dose treatments, there was no increased cardiovascular risk in patients treated for osteo-articular infections with fluoroquinolones.

MATERIALS AND METHODS

Between 2017 and 2019, 817 patients were treated at the CRIOAC (Referral Center for Complex Osteo-Articular Infections) Lille-Tourcoing (332/817 patients received treatment with fluoroquinolones). This retrospective cohort study assessed the onset or worsening of cardiovascular events (such as aortic aneurysms and mitro-aortic regurgitation) and death at 2 months using a propensity score.

RESULTS

After propensity score weighting, there was no significant difference in the risk of aortic aneurysm and mitro-aortic regurgitation at 60 days (Odds ratio (OR) 0.921 [0.317; 2.673], p = 0.879) or in the risk of death at 60 days (OR 1.252 [0.502; 3.118]; p = 0.630). There was also no significant difference in the risk of death at last follow-up after propensity score weighting (OR 1.011 [0.646; 1.582], p = 0.962).

DISCUSSION

The results of this study suggest that the use of fluoroquinolones in patients treated for osteoarticular infections does not pose a significant increased risk of aortic aneurysm, mitro-aortic regurgitation, or death within two months. We believe it is reasonable to continue prescribing fluoroquinolones for osteoarticular infections while maintaining surveillance for these events.

LEVEL OF EVIDENCE

III; case-control study with propensity score.

What Is the Role of Local Antimicrobial Protection for One-Stage Revision for Peri-Prosthetic Hip Infection?

The aim of this review is to investigate the effective role of local antimicrobial protection for one-stage cemented and cementless hip revision surgery. Twelve studies reporting the results of cemented single-stage procedures with a minimum two-year follow-up were reviewed. When pooling together the data, no infection recurrence was observed on average in 83.3% of the patients (a range of 75.0% to 100%). Only two papers included patients treated without the use of antibiotic-loaded bone cement, with an average infection control of 95.9% in a total of 195 patients. This figure appears to be better than the 80.7% infection control obtained by pooling together all the remaining studies. Concerning cementless one-stage revision, a total of 17 studies, reporting on 521 patients, showed an average of 90.0% (range 56.8% to 100%) no infection recurrence at a minimum two-year follow-up. No comparative study investigated cementless revision with or without local antibacterial protection. The pooled data showed an average infection control of 86.7%, without the application of local antibacterials, compared to 90.1% to 100% with local antimicrobial protection, depending on the technology used. No statistical difference could be found, either considering local antibacterial strategies alone or pooled together. No side effects had been reported by any local antibacterial technique. Local antibacterial protection for one-stage hip revision surgery, although safe and largely performed in the clinical setting, appears to still rely mainly on experts' opinions with no prospective or comparative trial, hence no definitive conclusion can be drawn concerning its effective role in one-stage hip revision surgery.

Impact of fixation method on femoral bone loss: a retrospective evaluation of stem loosening in first-time revision total hip arthroplasty among two hundred and fifty five patients

PURPOSE

Implant loosening represent the most common indication for stem revision in hip revision arthroplasty. This study compares femoral bone loss and the risk of initial revisions between cemented and uncemented loosened primary stems, investigating the impact of fixation method at primary implantation on femoral bone defects.

METHODS

This retrospective study reviewed 255 patients who underwent their first revision for stem loosening from 2010 to 2022, receiving either cemented or uncemented stem implants. Femoral bone loss was preoperatively measured using the Paprosky classification through radiographic evaluations. Kaplan-Meier analysis estimated the survival probability of the original stem, and the hazard ratio assessed the relative risk of revision for uncemented versus cemented stems in the first postoperative year and the following two to ten years.

RESULTS

Cemented stems showed a higher prevalence of significant bone loss (type 3b and 4 defects: 32.39% vs. 2.72%, p < .001) compared to uncemented stems, which more commonly had type 1 and 2 defects (82.07% vs. 47.89%, p < .001). In our analysis of revision cases, primary uncemented stems demonstrated a 20% lower incidence of stem loosening in the first year post-implantation compared to cemented stems (HR 0.8; 95%-CI 0.3-2.0). However, the incidence in uncemented stems increased by 20% during the subsequent years two to ten (HR 1.2; 95%-CI 0.7-1.8). Septic loosening was more common in cemented stems (28.17% vs. 10.87% in uncemented stems, p = .001). Kaplan-Meier analysis indicated a modestly longer revision-free period for cemented stems within the first ten years post-implantation (p < .022).

CONCLUSION

During first-time revision, cemented stems show significantly larger femoral bone defects than uncemented stems. Septic stem loosening occurred 17.30% more in cemented stems.

Cementless Primary Stems in Revision Hip Arthroplasty: A Narrative Review

Cementless primary stems in revision hip arthroplasties may be conservative options to preserve bone stock and provide adequate reconstruction of the hip biomechanics. However, there is still little evidence about indications, limitations, and outcomes. This narrative review showed that conventional standard stems were adopted in different revision settings, up to Paprosky IIIA grade bone defects. In cases of acceptable metaphyseal bone stock, when a scratch fit of at least 4 cm can be achieved, a conventional cementless stem may be an adequate solution. Mid-term clinical and radiographic outcomes and survival rates were similar to long revision stems, whereas complications, surgical time, and costs were lower among conventional stems. However, unsuitable contexts for conventional stems included canal diameters larger than 18 mm and failed revision stems with cortical weakening. Even short stems can be considered in revisions, in order to preserve bone stock and stay proximal to femoral remodeling zones and bone/cement plugs. Short stems were successfully adopted up to Paprosky IIIA bone defects, achieving mid-term survival rates not inferior to long revision stems. Ageing, osteoporosis, and intraoperative femoral fractures were the main negative prognostic factors. In very select cases, a downsizing technique (from longer to shorter stems) may be adopted to simplify the procedure and reduce complications.