Impaction grafting in association with the Charnley-Kerboull cemented femoral component

Is cemented revision total hip arthroplasty a reasonable treatment option in an elderly population?

Revision THA is increasingly performed especially in the elderly population. The surgeon’s challenge is to provide a solution that supports immediate full weight-bearing, despite poor bone quality. Shape-closed revision stems facilitate that by combining cement fixation with additional press-fit anchoring. The design tolerates varying cement mantle thickness and inconsistent cancellous bone lining of the femoral canal. Following that philosophy, we present our mid-term results using a long version of a cemented Charnley- Kerboull type stem. From 2010 to 2017, 38 long Charnley-Kerboull revision stems (Centris^®, Mathys European Orthopaedics, Bettlach, Switzerland) were implanted and followed prospectively. Surgery was performed via a Hardinge approach in supine position with a third generation cementing technique. Patients were mobilized using full-weight bearing as early as possible. Survival was determined for stem revision for aseptic loosening and stem and/or cup revision for any reason. 20 stems had a minimum follow-up (f/u) of 2 years and were included for further radiological analysis. Detailed subsidence analysis as an early predictor for later aseptic loosening was performed using EBRA-FCA software. Further, the presence of osteolysis and cement debonding was evaluated. Mean follow- up was 4 years. No patient was lost to f/u.18 died of causes unrelated to THA. Stem survival was 100%. Survival for any re-operation was 82.2% (two early infections, one soft-tissue debridement, one cup exchange for recurrent dislocations). None of the cases revised for septic loosening showed signs of persistent infection at final f/u. EBRA-FCA revealed two oligosymptomatic cases of subsidence of 5mm and 6mm over a course of 2 and 12 months, respectively, with stable implants thereafter. Neither required revision. There was no development of osteolysis or debonding. The stem provides a reliable early fullweight bearing solution for revision THA with excellent mid-term survival in an elderly population. Even in two cases where subsidence was present, mobility was not impaired and re-revision could be avoided.

Composition dependent mechanical behaviour of S53P4 bioactive glass putty for bone defect grafting

To improve the handling properties of S53P4 bioactive glass granules for clinical applications, bioactive glass putty formulations were developed. These formulations contain both granules and a synthetic binder to form an injectable material that is easy to shape. To explore its applicability in load-bearing bone defect grafting, the relation between the putty composition and its mechanical behaviour was assessed in this study. Five putty formulations with variations in synthetic binder and granule content were mechanically tested in confined compression. The results showed that the impaction strains significantly decreased and the residual strains significantly increased with an increasing binder content. The stiffness of all tested formulations was found to be in the same range as the reported stiffness of cancellous bone. The measured creep strains were low and no significant differences between formulations were observed. The stiffness significantly increased when the samples were subjected to a second loading stage. The residual strains calculated from this second loading stage were also significantly different from the first loading stage, showing an increasing difference with an increasing binder content. Since residual strains are detrimental for graft layer stability in load-bearing defects, putty compositions with a low binder content would be most beneficial for confined, load-bearing bone defect grafting.

Selecting the surgical approach for revision total hip arthroplasty

Selecting the approach for revision total hip arthroplasty is a crucial step in pre-operative planning. Whether the surgical objectives can be reached via a conventional approach or require a specific approach must be determined. The best approach depends on multiple factors including the reason for revision, patient's characteristics, implants requiring removal, previous approach, soft tissue and bone lesions, and surgeon's level of experience. These factors are discussed herein, as well as the potential and limitations of conventional approaches and the indications for specific approaches.

A technique for decision-making in cementless femoral revision hip arthroplasty

Classification systems for femoral revision of a failed THA fail to address several of the more critical determinants. The aim of the present study was to assess the reliability of a simplified algorithm for decision making during cementless reconstruction for femoral loosening with respect to stem length, stem design and the need for an extended trochanteric osteotomy. Four observers with different levels of clinical experience blindly assessed 40 X-rays of hips scheduled for a femoral revision. Intra-observer and inter-observer reliability of 4 radiographic criteria were assessed: 1) diaphyseal bone loss extension to the isthmus; 2) proximal femoral remodelling; 3) presence of cement; and 4) cortical thickness. Inter-observer agreement relating to the four criteria was good (κ = 0.66) for the extension to isthmus, moderate (κ = 0.57) for proximal femoral remodelling and very good for presence of cement (κ = 1) and cortical thickness (κ = 0.88). Intra-observer agreement was good for extension to isthmus and proximal femoral remodelling and very good for presence of cement and cortical thickness. Based on these criteria, an algorithm has been developed to describe 4 reconstruction options. The algorithm seems reliable for decision making during femoral cementless revision, but research into comparison with intraoperative findings is still required.

LEVEL OF EVIDENCE

Level II, Development of diagnostic criteria on consecutive patients.

Age-dependent fracture risk in hip revisions with radial impaction grafting technique: a 5-10 year medium-term follow-up study

Radial impaction grafting (RIG) potentially improves the durability and reliability of cementing the femoral components in revision total hip arthroplasty (THA). In this multicenter, prospective study, 88 revision THAs (87 patients) with RIG technique were performed. The average follow-up time was 7.0 years (range, 5.0-10.2). There were 14 femur fractures: 2 intraoperative, 5 within 3 months after surgery, and 7 later in the postoperative stage (range, 5-84 months). Sixteen patients were lost to follow-up and 20 died without stem re-revision. None of the patients have been re-revised for any reason during follow-up. Age was observed to be a significant factor for determining fracture risk. In conclusion, RIG can be considered a reliable surgical technique, especially for younger patients.

Experience of structural onlay allografts for the treatment of bone deficiency in revision total hip arthroplasty

Background and Aims:

Loss of femoral bone stock in elective revision total hip arthroplasty poses unique and substantial challenges. Structural onlay allografts may provide mechanical stability for the cementless revision prosthesis and increase bone stock.

Material and methods:

At least one cortical onlay allograft was used in 40 elective total hip arthroplasty revisions (40 patients) to reconstruct femoral bone defects. The operations were performed between January 1999 and August 2010 in the Turku University Hospital, Finland. The mean follow-up time was 52 months (range: 12–125 months).

Results:

The allografts were incorporated into the bone tissue in 37 of 40 (92.5%) patients. Cementless revision stems healed in 36 of 40 (90.0%) patients, but these patients were not exactly the same patients whose allografts were successfully incorporated. One or more surgical complications were experienced by 14 of 40 (35.0%) patients during follow-up. In all, 4 of 40 (10.0%) patients (all women) had hip infections during follow-up. Of the 7 patients with rheumatoid arthritis, 4 (57.1%) had at least one complication.

Conclusions:

The use of the cortical onlay allografts provides a feasible option for restoring the integrity of the proximal femur in revision total hip arthroplasty, but the complication rate is high, particularly in female patients with rheumatoid arthritis.

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.

Medium-term outcome of titanium uncemented stems in revision total hip arthroplasty

PURPOSE

To assess the medium-term outcome of titanium uncemented modular tapered stems in revision total hip arthroplasty (THA).

METHODS

A questionnaire was mailed to 421 patients who underwent revision THA using a titanium uncemented modular tapered stem. 66 of whom underwent re-revision THA. The questionnaire was composed to reveal the Charnley classification, the modified 12-item Oxford hip score, and the Devane patient activity level.

RESULTS

323 (77%) of the patients responded. The mean follow-up time was 6.6 years. 12 patients underwent bilateral revision THA. The mean Oxford hip score was 35.7, compared to 35.8 for all-component revision at postoperative month 6 in the New Zealand Joint Registry. The median Oxford hip scores for the subgroups of the stem-only revision (n=92), all-component revision (n=215), and re-revision (n=16) were 38, 39.9, and 30, respectively. The difference was significant between all-component revision and re-revision (adjusted p=0.003), and between stem-only revision and re-revision (adjusted p=0.037). Regarding patient distribution according to the Charnley class and the Devane patient activity level, the difference was significant between the mean Oxford hip scores of Charnley classes B and C (adjusted p=0.017), and between the Devane patient activity levels of Charnley classes A and C (adjusted p=0.043).

CONCLUSION

The medium-term outcome of revision THA using a titanium uncemented modular tapered stem was comparable to that reported for other stems.

First-time revision using impacted morsellised allograft bone with a cemented Exeter stem

Previously, radiostereometric analysis following hip revision performed using impacted morsellised allograft bone and a cemented Exeter stem has shown continuous subsidence of the stem for up to five years. It is not known whether the subsidence continues thereafter. In our study, 17 of 25 consecutive osteo-arthritic patients with aseptically loose stems who underwent first-time revision using impacted morsellised allograft bone and a cemented Exeter stem were followed by yearly radiostereometric examinations for nine years. The mean subsidence at six weeks was 1.1 mm (0.1 to 2.3), from six weeks to one year 1.3 mm (0 to 2.6), from one to five years 0.7 mm (0 to 2.0), and from five to nine years 0.7 mm (0.1 to 3.1). That from six weeks to nine years was 2.7 mm (0 to 6.4) (95% confidence interval 2.0 to 3.5). The Charnley pain score significantly improved after revision, and was maintained at nine years, but walking ability deteriorated slightly as follow-up extended. Of the eight patients who were not followed for nine years, two had early subsidence exceeding 11 mm.

Our findings show that in osteo-arthritic patients who undergo revision for aseptic loosening of the stem using impacted morsellised allograft bone and a cemented Exeter stem, migration of the stem continues over nine years at a slower rate after the first year, but without clinical deterioration or radiological loosening.

Revision total hip arthroplasty with femoral impaction bone grafting

PURPOSE

To report the radiological and clinical results of revision total hip arthroplasty (THA) with femoral impaction bone grafting (IBG).

METHODS

4 men and 9 women (15 hips) aged 38 to 84 years underwent revision THA with femoral IBG using Elite plus stems for aseptic loosening or infection.

RESULTS

The mean follow-up duration was 7.7 years. The Harris hip score improved from 61.7 to 83.7. There was no pain in 11 hips and slight pain in 4. The mean subsidence was 5.7 mm. The mean change of alignment was 1.2 degrees. There was no radiological evidence of stem loosening. One stem was revised due to a peri-prosthetic fracture. Cortical healing was noted in 11 hips, and trabecular incorporation in 10.

CONCLUSION

Although intra- and post-operative complications were not uncommon, femoral IBG is a safe procedure in carefully selected patients and offers good medium-term results.