Femoral impaction bone grafting (IBG) may be used to restore bone stock in revision total hip arthroplasty (THA) and allow use of a shorter, than otherwise, length prosthesis. This is most beneficial in young patients who are more likely to require further revision surgery. This study aimed to assess the results of femoral IBG for staged revision THA for infection. A prospective cohort of 29 patients who underwent staged revision THA for infection with femoral IBG and a cemented polished double-tapered (CPDT) stem at the final reconstruction was investigated.

The minimum follow-up was two years (2 – 10 years, median 6 years). Stem subsidence was measured with radiostereometric analysis. Clinical outcomes were assessed with the Harris Hip, Harris Pain, and and Société Internationale de Chirurgie Orthopédique et de Traumatologie Activity (SICOT) Scores. The original infection was eradicated in 28 patients. One patient required a repeat staged revision due to re-infection with the same organism. At two-year follow-up, the median subsidence at the stem-bone interface was −1.70 mm (−0.31 to −4.98mm). The median Harris Hip Score improved from 51 pre-operatively to 80 at two years (p=0.000), the Harris Pain Score from 20 to 44 (p=0.000) and the SICOT Score from 2.5 to 3 (p=0.003).

As successful eradication of infection was achieved in the majority of patients and the stem migration was similar to that of a primary CPDT stem, this study supports the use of femoral IBG during the final reconstruction of the femur after staged revision THA for infection.

Introduction

To evaluate the clinical success and hip pain and function of patients with infected hip replacement treated by two-stage exchange using a temporary implant with high dose vancomycin added to the antibiotic cement at the first stage revision.

The purpose of this paper is to review the early results of Prostalac system under licence from Therapeutic Goods Administration for Professor Howie in the management of two stage exchange hip arthroplasty for infection (restricted to Royal Adelaide Hospital) and the addition of vancomycin and teicoplanin powder to tobramycin cement without additional tobramycin.

Thirteen patients were treated for an infected THR with the Prostalac system. Preoperative and intra-operative cultures were taken to identify the infective organisms. Vancomycin 3 gm was added to the Prostalac cement mantle per 40 gm packet of antibiotic bone cement containing tobramycin 1 gm. Teicoplanin 2.4 gm was used in one case where the patient had a known vancomycin allergy. Postoperatively patients underwent six weeks of IV antibiotics followed by four to six weeks of oral.

A short term successful clinical outcome was determined by implantation of a total hip prosthesis at the time of second stage operation and no reoperations resulting from recurrent infection and off antibiotics for â□¥ 6 months with normal clinical and CRP lab values.

Thirteen patients received the Prostalac system. No patient was lost to follow-up. Nine have progressed to second stage revision, eight of which had femoral impaction grafting. Two deaths occurred not attributed to the Prostalac system. Three superficial wound infections and two required washout and debridement. One Prostalac stem subsidence. There has been no recurrence of deep joint infection. Retention of the second stage prosthesis has been 100% at 17 months.

The PROSTALAC system with the addition of vancomycin or teicoplanin to the tobramycin antibiotic cement has encouraging short-term results for treatment of deep joint infection. Complication rate has been well within the range reported in literature. Successful early outcomes are encouraging with all patients in the Prostalac study having retained their permanent hip prosthesis following second stage surgery.

This study aimed to compare the early clinical results and stem subsidence between three consecutive series of revision hip replacement cases with femoral impaction bone grafting to evaluate the effects of developments in technique. In the original series 1 (n=23), bone graft was irradiated at 25kG. I n series 2 (n=12) non-irradiated double washed graft and long stems were used as required.

In series 3 (n=21) modular tamps were used. Sensitive radiographic analysis techniques, EBRA and RSA, were used to measure stem subsidence. Major stem re-revision was required in five hips in series one, one hip in series two and no hips in series three. Two periprosthetic fractures occurred in series one. There was a statistically significant reduction in stem subsidence at the cement-bone interface at 12 months between series one and series two and three (p<0.05). In series three there was negligible stem subsidence at the cement-bone interface.

Technique developments in femoral impaction grafting, including the use of modular tamps designed to simply the procedure, yields excellent early clinical and radiographic results. Using RSA, we have shown that the fixation of the stems in bone is comparable to that achieved in primary hip replacement.

Introduction: In the past, surgeons have found impaction bone grafting technically difficult leading to its limited use. This paper reviews the long term results and developments in instrumentation and techniques aimed at simplifying femoral impaction grafting at revision hip replacement. The expanded indications for this procedure are reviewed and recent results of stem fixation using radiostereometric analysis (RSA) are reported.

Methods: The impaction bone grafting procedure, using a cemented collarless polished double taper stem, has been used in 66 hips (median patient age 63yrs) since 1993. The technique has undergone numerous developments. Modular tamps have been used in the last 29 hips and in the last seven hips, a pneumatic mechanical vibration device has been used in place of manual impaction. Stem subsidence at both the prosthesis-cement and cement-graft/bone interfaces was measured, more recently using radiostereometric analysis.

Results: There was a high early incidence of failure in the initial cases but there have been no further revisions for mechanical failure at up to 15 years. Technique developments have resulted in dramatic improvements in stem fixation achieved. In the modular tamp cases, the mean stem subsidence at the cement-bone interface at 12 months was 0.07mm (0 to 0.7mm) at 12 months. The stem subsidence in the hips where the mechanical vibration device was used was 0.05mm (0 to 0.06mm). Femoral impaction grafting offers special advantages in younger patients include standard femoral stem revision and at the second stage of two stage revision for infection.

Discussion and Conclusion: A stable cement-bone interface is achieved using advanced techniques of femoral impaction grafting that includes the use of modular impaction instruments. Early results of mechanical vibration impaction are encouraging. Femoral impaction grafting restores bone and new techniques simplify the femoral revision procedure.

Introduction: Periacetabular osteotomy is a complex procedure which is associated with significant complications during the learning period and difficult to maintain such expertise when it is undertaken infrequently. Results were reviewed to determine if this difficult PAO procedure can be safely learnt by a process of mentoring and review.

Methods: A structured mentoring program was adopted by the senior author. A double approach was used in the first 11 cases to enhance exposure and minimise the risk of complications. Fifteen osteotomies have subsequently been undertaken using a single approach. The median patient age was 28 years (13–41 years). The median follow-up was 5 years (2–14 years). The clinical and radiographic results were examined.

Results: Two cases in the double approach series progressed to total hip replacement and there were two other major reoperations. Two cases in the single approach series had an ischial non-union not requiring reoperation. The median Harris hip score at latest review was 82 (35–100) and 80 (26–100) for the double and single approach series respectively. All radiographic indices indicated correction of the acetabulum for both series.

Discussion and Conclusion: A structured program of mentoring and review has allowed a complex surgical procedure to be learnt and surgical expertise maintained at a distant centre while avoiding the complications previously associated with the learning curve and achieving the acetabular correction similar to the originator of the procedure.

Introduction Peri-acetabular osteolysis is a serious complication of total hip arthroplasty (THA). The aim of this study was to determine, using quantitative computed tomography (CT), the location, volume and rate of progression of peri-acetabular osteolytic lesions, and to determine the validity of this CT technique with intra-operative measurements.

Methods High-resolution spiral multislice CT scan (Somatom Volume Zoom, Siemens, Munich, Germany), with metal-artefact suppression protocol, was used to measure the volume of osteolytic lesions around 47 cementless THAs in 36 patients (median age 73 years, duration 14 years, range five to 24 years). In vitro validation was undertaken. CT scans were taken from the top of sacroiliac joint down to two centimetres below the end of the prosthesis. Reconstruction images were analysed by two different observers and progression of osteolysis with time was determined. In some patients, subsequently revised, in-vivo CT measurements were compared to intra-operative measurements. The rate of progression of osteolytic lesions was calculated. The technique was optimised and validated by extensive in-vitro studies, using bovine and human pelves.

Results The incidence of lesions located in each site was: the ilium, 65%; around fixation screws, 20%; in the anterior column, nine percent; and in the medial wall, six percent. Some lesions were shown to be relatively quiescent, while others were aggressively osteolytic. Intra and inter-observer error for the CT measurement technique was four percent and 2.8%, respectively. In vitro volumetric measurements of simulated bone defects adjacent to the acetabular component and fixation screw were accurate to within 96% and precise to 98%. In addition, preliminary data obtained intra-operatively indicate the accuracy of CT in identifying the sites of osteolysis.

Conclusions CT is thus a valid and reliable technique for investigating the natural history of osteolysis and the factors that may influence its progression. It will also enable assessment of non-surgical treatments of osteolysis.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.