Introduction: To evaluate the medium-term outcome of patients undergoing revision knee arthroplasty with structural allograft for uncontained defects.

Methods: We followed prospectively 50 patients undergoing 52 revision knee replacements with 66 structural grafts in three institutions. An independent investigator reviewed twenty-nine knees in 27 patients after a mean of 96.9 months.

Results: Twelve knees were re-revised at a mean of 70.7 months. Two of these patients retained their allografts. Eleven patients died with their structural allograft and implants intact and were not awaiting revision at a mean of 93 months.

Failure was defined as an increase of less than 20 points in the modified HSS knee score at the time of the review or the need for an additional operation related to the allograft. Thirteen knees were deemed to be failures giving a 75% success rate. Graft resorption occurred in five patients resulting in implant loosening. Four failed due to infection and non-union between the host bone and allograft was present in two. One patient with both knees grafted failed to gain a 20-point improvement. Survival analysis showed a 72% survival at 10 years. Clinically, the modified HSS score improved from a mean of 32.5 pre-operatively to 75.6 at the time of the review. Radiographic analysis of the surviving grafts showed no severe resorption, one moderate and two mild cases of resorption. Evaluation for loosening revealed one patient with a loose tibial component, while three patients had non-progressive tibial radiolucent lines. All four patients were asymptomatic.

Conclusions: Our results demonstrated encouraging medium-term survival of allografts utilised for revision knee replacement in a group of difficult patients with massive bone loss.

Introduction: Diffuse pigmented villo-nodular synovitis (DPVNS) of the knee remains a difficult tumor to eradicate. We report our experience with a combined posterior and open synovectomy technique.

Method: A single surgeon operated on 40 patients averaging 35 years old (14 to 68 years). The patients were placed into one of three groups: group I received surgery alone (five patients), group II had surgery and intra-articular radiation synovectomy using Dysprosium-165 (165Dy) (30 patients), and group III had surgery and external beam radiation (5 patients). The adjuvant radiation was performed three months postoperatively. MRI evaluation was used preoperatively and post-operatively.

Results: The average combined Knee Society Scores and range of motion improved. Thirty-seven patients (92.5%) had a good or excellent results; two (5%) had a fair result; and one (2.5%) had a poor result. There were seven recurrences (17.5%). None occurred in group I; five occurred in group II (12.5%); and two occurred in group III (5%).

Discussion & Conclusions: This technique allowed excellent visualisation and removal of intra- and extra-articular DPVNS tissue with excellent functional results and few recurrences documented by MRI. Adjuvant intra-articular radiotherapy may be beneficial for small foci of residual disease but complete resection of all DPVNS tissue was the key to prevent recurrence. External beam radiation did not prevent recurrence and possibly predisposed patients to pain and less improvement in knee flexion. Extensive pre-operative degenerative joint disease predisposes patients to continued pain.

Introduction: The reconstruction of the severely deficient proximal femur is more commonly achieved with a large composite proximal femoral allograft and a prosthesis.

Aim: To review our experience with this technique in 19 revision total hip arthroplasties (18 patients) treated between December 1988 and January 1997.

Cases: There were 15 females and three males. The average age was 56 years (32 to 78 years). The primary diagnoses included osteoarthritis (seven), rheumatoid arthritis (six), congenital dislocation (two), avascular necrosis (one), septic arthritis (one), and ankylosing spondylitis (one). Each underwent an average of three (range: one to 9) previous hip operations. The average time from the previous operation was 10.65 years (0.25 to 25). All hips had significant periprosthetic osteopenia and bone loss on preoperative radiographs. Five had previous infections with two subsequent Girdlestone arthroplasties. Six presented with periprosthetic fractures and loose components.

The hips were approached posteriorly. A step cut was used to secure the host to allograft junction. The femoral component was cemented within the allograft and with a press-fit in the host bone. All but three cases had iliac crest bone graft and/or residual host bone chips added to the host-allograft site. The acetabulum was revised concurrently in 13 (two whole acetabular allografts).

Results: The average period of follow-up was 57.6 months(range: 25 to 127 months). The time taken to heal was estimated radiographically as less than 8.5 months (range: three to 18 months). The average Harris Hip Scores improved from 25.6 to 75.53. One patient complained of persistent pain post-operatively. The complications included proximal migration of the greater trochanter in five, one infection that was converted to a Girdlestone excisional arthroplasty 27 months later, and seven patients with dislocations.

Conclusions: Allograft prosthetic reconstruction of the proximal femur is a durable construct with up to ten years follow-up. This technique preserved host bone while providing additional bone for future reconstruction. There was substantial improvement in function with low complication rates.

Aim: The S-ROM femoral component is a versatile modular prosthesis that can be adapted to the majority of complex hip revision situations. The purpose of this study is to review the results of this prosthesis with a minimum follow-up of two years.

Method: Fifty-six consecutive revision hip arthroplasties using the S-ROM femoral component were performed in 49 patients by the senior author. The patients with segmental femoral allografts were excluded. A retrospective chart review and radiographic analysis was performed and the pre-operative and post-operative modified Harris hip scores compared.

Results: Forty-nine patients with 56 hips were evaluated between two and seven years after revision surgery. There were 25 females and 24 males. The average age was 66.6 years (range: 44.8 to 94.6). Revision arthroplasties were performed for loose components in 36 hips, infected components in 10 hips, recurrent dislocation in three hips and for miscellaneous diagnoses in seven. The average number of previous surgical procedures on the affected hip was 2.4 (range: one to seven). The modified Harris hip score improved from a pre-operative average of 42 to a post-operative average of 73 at the most recent follow-up examination. Three patients had failed revisions at seven years (5%). One patient underwent a resection arthroplasty for infection, one patient underwent re-revision for recurrent dislocation and one patient dislocated, became infected and is on suppressive antibiotic therapy. Other complications included nine dislocations (16%), seven intra-operative fractures (13%), trochanteric irritation in five patients (9%), residual thigh pain in three patients (5%), heterotopic ossification in two patients (4%), one post-operative sciatic nerve palsy (2%) and early osteolysis in one patient (2%).

Conclusion: Short to intermediate term follow-up of the S-ROM femoral component in this group of revision patients has yielded excellent results. In terms of loosening and osteolysis these results are comparable to primary hip arthroplasty using the S-ROM prosthesis.

Aim: The current trend in fixation of acetabular components is towards press-fit, no-hole components to reduce the wear debris production and its access to the bone prosthesis interface. The purpose of this study is to review the outcome of no holes or holes with or without adjuvant screw fixation in a porous expanded rim modular acetabular component of the same design with a minimum of two year follow up.

Method: This was a retrospective review of the charts and radiographs of 204 consecutive Osteonics PSL acetabular components inserted by the same surgeon. Radiographic analysis included assessments of radiolucencies in the three zones of Charnley & DeLee, as well as assessments of migration and wear using the technique of Livermore. Osteolytic cysts were recorded and any progression noted.

Results: The underlying diagnosis was similar in all groups with osteoarthritis comprising 57%. In the screw group one component has been revised for loosening secondary to impingement. Three had significant osteolysis, all of which have been revised. There was no significant difference for the 28 mm heads between the groups for radiolucencies or migration. The 22 mm heads had a higher rate of linear wear. Complications included seven dislocations, two with grade three heterotopic ossification and one late haematogenous infection.

Conclusion: Comparing acetabular components with and without screws and no-hole components there was no significant difference in radiolucencies, wear and migration. Osteolytic cysts occurred only in cups with holes and screws. Because of these findings the surgeon continues to use the no-hole cup wherever possible in primary and revision arthroplasty. Longer follow up will be required to confirm that this decreased osteolysis persists over time in the no-hole group.