Clinical evaluation of 104 hip resection arthroplasties after removal of a total hip prosthesis

Girdlestone resection arthroplasty of the hip (GRA): a case series-outdated procedure or acceptable outcome?

Despite considerable legacy issues, Girdlestone's resection arthroplasty (GRA) remains a valuable tool in the armoury of the arthroplasty surgeon. When reserved for massive lysis in the context of extensive medical co-morbidities which preclude staged or significant surgical interventions, and/or the presence of pelvic discontinuity, GRA as a salvage procedure can have satisfactory outcomes. These outcomes include infection control, pain control and post-op function. We describe a case series of 13 cases of GRA and comment of the indications, peri, and post-operative outcomes.

Comparing Articulating Spacers for Periprosthetic Joint Infection After Primary Total Hip Arthroplasty: All-Cement Versus Real-Component Articulating Spacers

BACKGROUND

There are a variety of methods available to treat periprosthetic joint infection (PJI), including 2-stage revision with the use of an antibiotic spacer. This study compares the outcomes of real-component (RC) and all-cement (AC) articulating spacers for total hip arthroplasty (THA) PJI treatment.

METHODS

This multicenter retrospective study assessed all articulating spacers placed for THA PJI between April 2011 and August 2020. Patients were dichotomized based on spacer type (RC vs AC).

RESULTS

One hundred four patients received articulating spacer constructs (RC group = 75, AC group = 29). Leg-length discrepancy was significantly greater in the AC group after the second stage (3.58 vs 12.00 mm, P = .023). There were no significant differences in reoperation rates following first-stage spacer placement (P = .752) and time to reimplantation (P = .127) between the groups. There were no significant differences in reinfection rates (RC group = 10.0%, AC group = 7.1%, P = 1.000) and reoperation rates following second-stage revision THA (RC group = 11.7%, AC group = 10.7%, P = 1.000). Hospital length of stay (in days) had a trend toward being shorter following the first (7.35 vs 11.96, P = .166) and second stage (3.95 vs 5.43, P = .107) for patients in the RC group. Patients in the RC group were more likely to be discharged home following the first (P = .020) and second (P = .039) stages.

CONCLUSION

Given that there were no differences in reinfection and reoperation rates between the 2 spacer constructs, RC articulating spacers may provide a significant benefit for patient comfort during 2-stage exchange treatment of PJI while adding no increase in risk profile.

Elevated NSD3 histone methylation activity drives squamous cell lung cancer

Amplification of chromosomal region 8p11-12 is a common genetic alteration that has been implicated in the aetiology of lung squamous cell carcinoma (LUSC)^1-3. The FGFR1 gene is the main candidate driver of tumorigenesis within this region⁴. However, clinical trials evaluating FGFR1 inhibition as a targeted therapy have been unsuccessful⁵. Here we identify the histone H3 lysine 36 (H3K36) methyltransferase NSD3, the gene for which is located in the 8p11-12 amplicon, as a key regulator of LUSC tumorigenesis. In contrast to other 8p11-12 candidate LUSC drivers, increased expression of NSD3 correlated strongly with its gene amplification. Ablation of NSD3, but not of FGFR1, attenuated tumour growth and extended survival in a mouse model of LUSC. We identify an LUSC-associated variant NSD3(T1232A) that shows increased catalytic activity for dimethylation of H3K36 (H3K36me2) in vitro and in vivo. Structural dynamic analyses revealed that the T1232A substitution elicited localized mobility changes throughout the catalytic domain of NSD3 to relieve auto-inhibition and to increase accessibility of the H3 substrate. Expression of NSD3(T1232A) in vivo accelerated tumorigenesis and decreased overall survival in mouse models of LUSC. Pathological generation of H3K36me2 by NSD3(T1232A) reprograms the chromatin landscape to promote oncogenic gene expression signatures. Furthermore, NSD3, in a manner dependent on its catalytic activity, promoted transformation in human tracheobronchial cells and growth of xenografted human LUSC cell lines with amplification of 8p11-12. Depletion of NSD3 in patient-derived xenografts from primary LUSCs containing NSD3 amplification or the NSD3(T1232A)-encoding variant attenuated neoplastic growth in mice. Finally, NSD3-regulated LUSC-derived xenografts were hypersensitive to bromodomain inhibition. Thus, our work identifies NSD3 as a principal 8p11-12 amplicon-associated oncogenic driver in LUSC, and suggests that NSD3-dependency renders LUSC therapeutically vulnerable to bromodomain inhibition.

Girdlestones excision arthroplasty: current update

Girdlestones procedure has become a salvage operation reserved for patients with significant co-morbidities. Recent literature addresses this infrequently used intervention inadequately. This observational study aims to update current literature and review the modern role of this intervention in orthopaedic practice. Twenty-four records were obtained from which patient demographics, indications and co-morbidities were investigated. Seventeen patients completed an abridged Harris Hip Scoring questionnaire and commented on satisfaction. The average age was 78 years and patients had multiple co-morbidities. Dementia was the most frequent condition but several patients suffered from cardiovascular and respiratory disease. The most common operative indication was persistent prosthetic infection with Staphylococcus aureus, the most common pathogen. Overall mortality was 41% but all surviving patients had complete resolution of infection and 65% had adequate pain control. No patients mobilised without aids although 29% of patients were able to manage stairs and 29% were able to mobilise outdoors. Only 29% were unsatisfied with the outcome. This study demonstrates that Girdlestones candidates are an ageing high-risk group and shows that the Girdlestones procedure can, in select cases, provide good functional outcomes. However such intervention comes at the expense of high mortality and should therefore only be used as a last resort.

Managing femoral head osteonecrosis in patients with sickle cell disease

With an increasing number of people immigrating between different countries, sickle cell disease (SCD) is spreading all over the world. Due to improved health care, the life span of SCD patients has increased and many of them live to adulthood and middle-age. Osteonecrosis of the femoral head is one of the most common musculo-skeletal problems in SCD patients. Once osteonecrosis starts in the femoral head, it can progress from early to late stages in just a few years. Managing osteonecrosis of the femoral head in young-adults is a challenging problem and, in many situations, it requires major surgical procedures. In the early stages of the disease it is advisable to treat it by femoral head preserving procedures. In advanced stages, hip replacement arthroplasty (HPA) is indicated. In SCD patients, the incidence of operative complications and failure rates are higher than that for osteonecrosis due to other causes. Understanding the problems of SCD patients; appropriate diagnosis, prognosis, implications of the procedure performed and taking the necessary precautions, can reduce the complications and delay the failure of surgical procedures.

Total hip arthroplasty for primary septic arthritis of the hip in adults

Two-stage total hip arthroplasties (THA) performed after primary septic arthritis of hip were studied to evaluate the surgical outcomes and complications. Of 28 cases, the reinfection rate was 14% and complication rate was 36%. At an average follow-up period of 77 months, the outcome in 22 patients (79%) was rated as good or excellent, 4 as fair, and 2 as poor. Leg length discrepancy improved from a preoperative mean of 2.89 cm to a postoperative mean of 0.61 cm. Despite a higher complication rate, two-stage THA was still deemed a worthy procedure because hip function was significantly improved in patients with primary septic arthritis of the hip.

Investigations on the wear behaviour of the temporary PMMA-based hip Spacer-G

Total hip replacement has become one of the most successful orthopaedic procedures. However, complications due to infections may give serious problems and have devastating consequences for the hip implant. The use of a temporary three-dimensional polymethylmethacrylate (PMMA) cement spacer may be an alternative to solve infections in hip implants, improving the lives of patients awaiting reimplantation. In order to evaluate their wear behaviour, five PMMA Spacer-G femoral heads were tested against five post-mortem pelves in a hip joint simulator with bovine calf serum as lubricant. The surface of the worn spacers was characterized by scanning electron microscopy (SEM) analysis; all the samples revealed a similar morphology, showing areas characterized by different degrees of wear. Particle debris was isolated from the lubricant and PMMA particles and bone fractions were quantified. The amount of debris was found to be higher than where no-temporary prostheses were used. However, this result is acceptable since wear debris is removed by lavage irrigation when the Spacer-G is explanted. On the basis of these data, it is considered that the use of the cement Spacer-G could be a promising approach to the treatment of complicated infections of the hip joint. Therefore, Spacer-G is worthy of further research.

Complications associated with reimplantation after girdlestone arthroplasty

Complications associated with reimplantation of a total hip arthroplasty after resection or Girdlestone arthroplasty for treatment of an infected hip are not well-documented. Forty-four hips in 44 patients with a minimum 2-year followup (range, 2-9 years) from the time of reimplantation total hip arthroplasty were evaluated retrospectively. The average Harris hip score changed from 40 preoperatively to 78 at the latest followup. One patient had persistent infection requiring rerevision surgery, and another patient had rerevision surgery for recurrent dislocation. Complications related to the prosthesis consisted of dislocations in five patients (11.4%), recurrent infection in one patient (2.3%), trochanteric nonunion in four patients (9.1%), hematoma in one patient, heterotopic ossification in one patient, and postoperative wound drainage in one patient. Resection arthroplasty of the hip is highly effective in eradicating infection. In the current series, 97.7% of patients were free of infection at the latest followup. However, with an 11.4% dislocation rate and 39% of patients having a persistent limp, alternative approaches need to be evaluated which might reduce these complications.

Resection arthroplasty of the hip

Forty-four patients with 46 resection arthroplasties performed for various indications were followed an average of 8.0 years. Pain relief was good or excellent in 77% and eradication of infection was achieved in all but one. Completeness of cement removal at the time of resection arthroplasty did not affect the results or control of infection. Patients with a history of prior septic total hip arthroplasty had results similar to those for patients with other indications for resection arthroplasty. A comprehensive review of the literature supports these results.

Unsatisfactory results after repeated revision of hip arthroplasty. 61 cases followed for 5 (1-10) years

61 cemented second revision total hip arthroplasties and 18 cemented third revision total hip arthroplasties were studied with emphasis on causes of failure, complications, risk of further revision, and clinical and radiographic results of surviving, not further revised patients. Aseptic loosening was the major reason for both second and third revisions followed by recurrent dislocations. Of 61 second revisions, 21 failed again. Postoperative dislocation was the major complication, encountered in 10/61 after second revisions and in 4/18 third revisions. 10 second revisions were reoperated on without exchange of components, but for causes related to the implant. The clinical and radiographic outcome of surviving, not further revised patients was favorable, but must be seen in the light of the high rate of further revisions. In 33 of 53 second revisions and in 5 of 13 third revisions left for evaluation, the outcome was considered unsatisfactory. We conclude that reoperations for failed arthroplasties should be the prerogative of highly experienced centers.

Girdlestone's modified resection arthroplasty

Thirty-three patients were operated for septic (n = 20) and aseptic (n = 13) loosening of their hip prostheses using Girdlestone's operation over 10 years. An average of 46.6 months later, 22 of these patients were given a follow-up examination. Clinical evaluation according to Harris showed an improvement in mean values from 25 to 53 points, which can be attributed mainly to a marked reduction in pain, as function remained poor and the patients still depended on walking aids. The infection ceased in 92% of the patients with septic prosthesis loosening.