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The Bone & Joint Journal
Vol. 105-B, Issue 5 | Pages 559 - 567
1 May 2023
Aoude A Nikomarov D Perera JR Ibe IK Griffin AM Tsoi KM Ferguson PC Wunder JS

Aims

Giant cell tumour of bone (GCTB) is a locally aggressive lesion that is difficult to treat as salvaging the joint can be associated with a high rate of local recurrence (LR). We evaluated the risk factors for tumour relapse after treatment of a GCTB of the limbs.

Methods

A total of 354 consecutive patients with a GCTB underwent joint salvage by curettage and reconstruction with bone graft and/or cement or en bloc resection. Patient, tumour, and treatment factors were analyzed for their impact on LR. Patients treated with denosumab were excluded.


Bone & Joint Open
Vol. 4, Issue 1 | Pages 38 - 46
17 Jan 2023
Takami H Takegami Y Tokutake K Kurokawa H Iwata M Terasawa S Oguchi T Imagama S

Aims

The objectives of this study were to investigate the patient characteristics and mortality of Vancouver type B periprosthetic femoral fractures (PFF) subgroups divided into two groups according to femoral component stability and to compare postoperative clinical outcomes according to treatment in Vancouver type B2 and B3 fractures.

Methods

A total of 126 Vancouver type B fractures were analyzed from 2010 to 2019 in 11 associated centres' database (named TRON). We divided the patients into two Vancouver type B subtypes according to implant stability. Patient demographics and functional scores were assessed in the Vancouver type B subtypes. We estimated the mortality according to various patient characteristics and clinical outcomes between the open reduction internal fixation (ORIF) and revision arthroplasty (revision) groups in patients with unstable subtype.


The Bone & Joint Journal
Vol. 103-B, Issue 8 | Pages 1414 - 1420
1 Aug 2021
Wellings EP Houdek MT Owen AR Bakri K Yaszemski MJ Sim FH Moran SL Rose PS

Aims. Orthopaedic and reconstructive surgeons are faced with large defects after the resection of malignant tumours of the sacrum. Spinopelvic reconstruction is advocated for resections above the level of the S1 neural foramina or involving the sacroiliac joint. Fixation may be augmented with either free vascularized fibular flaps (FVFs) or allograft fibular struts (AFSs) in a cathedral style. However, there are no studies comparing these reconstructive techniques. Methods. We reviewed 44 patients (23 female, 21 male) with a mean age of 40 years (SD 17), who underwent en bloc sacrectomy for a malignant tumour of the sacrum with a reconstruction using a total (n = 20), subtotal (n = 2), or hemicathedral (n = 25) technique. The reconstructions were supplemented with a FVF in 25 patients (57%) and an AFS in 19 patients (43%). The mean length of the strut graft was 13 cm (SD 4). The mean follow-up was seven years (SD 5). Results. There was no difference in the mean age, sex, length of graft, size of the tumour, or the proportion of patients with a history of treatment with radiotherapy in the two groups. Reconstruction using an AFS was associated with nonunion (odds ratio 7.464 (95% confidence interval (CI) 1.77 to 31.36); p = 0.007) and a significantly longer mean time to union (12 months (SD 3) vs eight (SD 3); p = 0.001) compared with a reconstruction using a FVF. Revision for a pseudoarthrosis was more likely to occur in the AFS group compared with the FVF group (hazard ratio 3.84 (95% CI 0.74 to 19.80); p = 0.109); however, this was not significant. Following the procedure, 32 patients (78%) were mobile with a mean Musculoskeletal Tumor Society Score 93 of 52% (SD 24%). There was a significantly higher mean score in patients reconstructed with a FVF compared with an AFS (62% vs 42%; p = 0.003). Conclusion. Supplementation of spinopelvic reconstruction with a FVF was associated with a shorter time to union and a trend towards a reduced risk of hardware failure secondary to nonunion compared with reconstruction using an AFS. Spinopelvic fixation supplemented with a FVF is our preferred technique for reconstruction following resection of a sacral tumour. Cite this article: Bone Joint J 2021;103-B(8):1414–1420


The Bone & Joint Journal
Vol. 101-B, Issue 6 | Pages 724 - 731
1 Jun 2019
Bernthal NM Upfill-Brown A Burke ZDC Ishmael CR Hsiue P Hori K Hornicek F Eckardt JJ

Aims

Aseptic loosening is a major cause of failure in cemented endoprosthetic reconstructions. This paper presents the long-term outcomes of a custom-designed cross-pin fixation construct designed to minimize rotational stress and subsequent aseptic loosening in selected patients. The paper will also examine the long-term survivorship and modes of failure when using this technique.

Patients and Methods

A review of 658 consecutive, prospectively collected cemented endoprosthetic reconstructions for oncological diagnoses at a single centre between 1980 and 2017 was performed. A total of 51 patients were identified with 56 endoprosthetic implants with cross-pin fixation, 21 of which were implanted following primary resection of tumour. Locations included distal femoral (n = 36), proximal femoral (n = 7), intercalary (n = 6), proximal humeral (n = 3), proximal tibial (n = 3), and distal humeral (n = 1).


The Bone & Joint Journal
Vol. 100-B, Issue 4 | Pages 646 - 651
1 Apr 2018
Attias N Thabet AM Prabhakar G Dollahite JA Gehlert RJ DeCoster TA

Aims

This study reviews the use of a titanium mesh cage (TMC) as an adjunct to intramedullary nail or plate reconstruction of an extra-articular segmental long bone defect.

Patients and Methods

A total of 17 patients (aged 17 to 61 years) treated for a segmental long bone defect by nail or plate fixation and an adjunctive TMC were included. The bone defects treated were in the tibia (nine), femur (six), radius (one), and humerus (one). The mean length of the segmental bone defect was 8.4 cm (2.2 to 13); the mean length of the titanium mesh cage was 8.3 cm (2.6 to 13). The clinical and radiological records of the patients were analyzed retrospectively.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_15 | Pages 23 - 23
1 Aug 2017
Lederman E
Full Access

Revision of the humeral component in shoulder arthroplasty is frequently necessary during revision surgery. Newer devices have been developed that allow for easy extraction or conversion at the time of revision preserving bone stock and simplifying the procedure. However, early generation anatomic and reverse humeral stems were frequently cemented into place. Monoblock or fixed collar stems make accessing the canal from above challenging. The cortex of the Humerus is far thinner than the femur and stress shielding has commonly led to osteopenia. Many stem designs have fins that project into the tuberosities putting them at risk for fracture on extraction. Extraction starts with an extended deltopectoral incision from the clavicle to the deltoid insertion. The proximal humerus needs to be freed from adhesions of the deltoid and conjoined tendon. The deltopectoral interval is fully developed. Complete subscapularis and anterior capsular release to the level of the latissimus tendon permits full exposure of the humeral head. After head removal the stem can be assessed for loosening and signs of periprosthetic joint infection. The proximal bone around the fin of the implant should be removed from the canal. If possible, the manufacturer's extractor should be utilised. If not, then a blunt impactor can be placed from below against the collar of the stem to assist in extraction. With luck the stem can be extracted from the cement mantle. If there is no concern for infection, the cement-in-cement technique can be used for revision. Otherwise, attempts should be made to extract all the cement and cement restrictor, if present. The small cement removal tools from the hip set can be used and specialised shoulder tools are available. An ultrasound cement removal device can be very helpful. The surgeon must be particularly careful to avoid perforation of the humeral cortex. This is especially important when near the radial nerve as injury can occur. When a well-fixed stem is encountered, an osteotomy of the proximal humerus is necessary. The surgeon can utilise a linear cut with an oscillating saw along the bicipital groove for the length of the implant. An osteotome is used to crack the cement mantle allowing stem extraction. Alternatively, a window can be created to offer additional access to the cement mantle. In the event the surgeon has required an osteotomy or window, cerclage wires, cables or suture will be needed and when the bone is potentially compromised, allograft bone graft struts (tibial shaft) are used for additional support. Care is needed when passing cerclage wires to avoid injury to the radial nerve which is adjacent to the deltoid insertion. If infection is suspected or confirmed an ALBC spacer is placed. When single stage revision is planned both cemented and uncemented stem options are available. Cement placed around the humeral stem has been suggested to decrease infection incidence. Revision of cemented humeral stems is a continued challenge in revision shoulder surgery. Newer systems and reverse total shoulder options have improved the surgeon's ability to achieve good outcomes when revising prior shoulder arthroplasty


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_22 | Pages 66 - 66
1 Dec 2016
Gehrke T
Full Access

Periprosthetic fractures involving the femoral meta/diaphysis can be treated in various fashions. The overall incidence of those fractures after primary total knee arthroplasties (TKA) ranges from 0.3 to 2.5%, however, can increase above 30% in revision TKA, especially in older patients with poorer bone quality. Various classifications suggest treatment algorithms. However, they are not followed consequently. Revision arthroplasty becomes always necessary if the implant becomes loose. Next, it should be considered in case of an unhappy TKA prior to the fracture rather than going for an osteosynthesis. Coverage of the associated segmental bone loss in combination with proximal fixation, can be achieved in either cemented or non-cemented techniques, with or without the combination of osteosynthetic fracture stabilization. Severe destruction of the metaphyseal bone, often does not allow adequate implant fixation for the revision implant and often does not allow proper anatomic alignment. In addition the destruction might include loss of integrity of the collaterals. Consequently standard or even revision implants might not be appropriate. Although first reports about partial distal femoral replacement are available since the 1960´s, larger case series or technical reports are rare within the literature and limited to some specialised centers. Most series are reported by oncologic centers, with necessary larger osseous resections of the distal femur. The implantation of any mega prosthesis system requires meticulous planning, especially to calculate the appropriate leg length of the implant and resulting leg length. After implant and maybe cement removal, non-structural bone might be resected. Trial insertion is important due to the variation of overall muscle tension and recreation of the former joint line. So far very few companies offer yet such a complete, modular system which might also be expanded to a total femur solution. Furthermore it should allow the implantation of either a cemented or uncemented diaphyseal fixation. In general, the fracture should be well bridged with a longer stem in place. At least 3 cm to 5 cm of intact diaphysis away to the fracture site is required for stable fixation for both cemented and cementless stems. Application of allograft struts and cables maximises the biomechanical integrity of the fracture zone to promote fracture repair and implant fixation. Modular bridging systems do allow centimeter wise adaption distally, to the knee joint. Consequently in modern systems fully hinged or rotational hinge knee systems can be coupled, and adjusted accordingly to the patellar tracking and joint line. Fixation of the tibial component can be achieved in uncemented and cemented techniques. We still prefer the latter. Although a reliable and relatively quick technique, frequent complications for all mega systems have been described. These usually include infections, rotational alignment and loosening of the femoral fixation or subsequent proximal femoral fractures. Infections usually can be related to large soft tissue compromise or extensive exposure or longer procedure times. Thus implantation of such reconstruction systems should be reserved to specialised centers, with adequate facilities experience, in order to minimise complications rates and optimise patients function postoperative


The Bone & Joint Journal
Vol. 97-B, Issue 4 | Pages 544 - 549
1 Apr 2015
Qu H Guo W Yang R Tang X Yan T Li D Yang Y Zang J

We determined the efficacy of a devitalised autograft (n = 13) and allograft (n = 16) cortical strut bone graft combined with long-stem endoprosthetic reconstruction in the treatment of massive tumours of the lower limb. A total of 29 patients (18 men:11 women, mean age 20.1 years (12 to 45) with a ratio of length of resection to that of the whole prosthesis of > 50% were treated between May 2003 and May 2012. The mean follow-up was 47 months (15 to 132). The stem of the prosthesis was introduced through bone graft struts filled with cement, then cemented into the residual bone. Bone healing was achieved in 23 patients (86%). The mean Musculoskeletal Tumour Society functional score was 85% (57 to 97). The five-year survival rate of the endoprostheses was 81% (95% confidence intervals 67.3 to 92.3). The mean length of devitalised autografts and allografts was 8.6 cm (5 to 15), which increased the ratio of the the length of the stem of the prosthesis to that of the whole length of the prosthesis from a theoretical 35% to an actual 55%.

Cortical strut bone grafting and long-stem endoprosthetic reconstruction is an option for treating massive segmental defects following resection of a tumour in the lower limb. Patients can regain good function with a low incidence of aseptic loosening. The strut graft and the residual bone together serve as a satisfactory bony environment for a revision prosthesis, if required, once union is achieved.

Cite this article: Bone Joint J 2015;97-B:544–9.


Bone & Joint Research
Vol. 4, Issue 2 | Pages 23 - 28
1 Feb 2015
Auston DA Werner FW Simpson RB

Objectives

This study tests the biomechanical properties of adjacent locked plate constructs in a femur model using Sawbones. Previous studies have described biomechanical behaviour related to inter-device distances. We hypothesise that a smaller lateral inter-plate distance will result in a biomechanically stronger construct, and that addition of an anterior plate will increase the overall strength of the construct.

Methods

Sawbones were plated laterally with two large-fragment locking compression plates with inter-plate distances of 10 mm or 1 mm. Small-fragment locking compression plates of 7-hole, 9-hole, and 11-hole sizes were placed anteriorly to span the inter-plate distance. Four-point bend loading was applied, and the moment required to displace the constructs by 10 mm was recorded.


The Bone & Joint Journal
Vol. 96-B, Issue 11_Supple_A | Pages 48 - 55
1 Nov 2014
Yasen AT Haddad FS

We are currently facing an epidemic of periprosthetic fractures around the hip. They may occur either during surgery or post-operatively. Although the acetabulum may be involved, the femur is most commonly affected. We are being presented with new, difficult fracture patterns around cemented and cementless implants, and we face the challenge of an elderly population who may have grossly deficient bone and may struggle to rehabilitate after such injuries. The correct surgical management of these fractures is challenging. This article will review the current choices of implants and techniques available to deal with periprosthetic fractures of the femur.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):48–55.


The Bone & Joint Journal
Vol. 96-B, Issue 11 | Pages 1449 - 1454
1 Nov 2014
Imbuldeniya AM Walter WL Zicat BA Walter WK

We describe the clinical and radiological results of cementless primary total hip replacement (THR) in 25 patients (18 women and seven men; 30 THRs) with severe developmental dysplasia of the hip (DDH). Their mean age at surgery was 47 years (23 to 89). In all, 21 hips had Crowe type III dysplasia and nine had Crowe type IV. Cementless acetabular components with standard polyethylene liners were introduced as close to the level of the true acetabulum as possible. The modular cementless S-ROM femoral component was used with a low resection of the femoral neck.

A total of 21 patients (25 THRs) were available for review at a mean follow-up of 18.7 years (15.8 to 21.8). The mean modified Harris hip score improved from 46 points pre-operatively to 90 at final follow up (p < 0.001).

A total of 15 patients (17 THRs; 57%) underwent revision of the acetabular component at a mean of 14.6 years (7 to 20.8), all for osteolysis. Two patients (two THRs) had symptomatic loosening. No patient underwent femoral revision. Survival with revision of either component for any indication was 81% at 15 years (95% CI 60.1 to 92.3), with 21 patients at risk.

This technique may reduce the need for femoral osteotomy in severe DDH, while providing a good long-term functional result.

Cite this article: Bone Joint J 2014;96-B:1449–54.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_12 | Pages 82 - 82
1 Jul 2014
Haidukewych G
Full Access

Peri-prosthetic fractures of the femur around a THA remain challenging injuries to treat. The Vancouver Classification helps to guide decision making, and is based on fracture location, implant fixation status, and remaining bone quality. It is critical to determine fixation status of the implant, even if surgical dislocation is necessary. Type A fractures involve the trochanters, and are usually due to osteolysis. Revision of the bearing surface and bone grafting of the lesions can be effective. Type B1 fractures occur around a well fixed stem, typically at the stem tip. Internal fixation with laterally based locked cable plates is effective. Optimising proximal fixation is important, typically with locked screws and cables. Allograft struts are probably unnecessary with modern angle stable plates. Type B2 and B3 fractures are treated with revision, either with a fully coated cylindrical or a modular fluted tapered titanium stem. Distal fixation should be optimised, while preserving vascularity to proximal bony fragments. The « internal scaffold » technique has been described with excellent results. Rarely, a proximal femoral replacement is necessary. Careful attention to detail and clear knowledge of stem fixation status is necessary for a good outcome


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_8 | Pages 97 - 97
1 May 2014
Haidukewych G
Full Access

Vancouver A: If minimal displacement and prosthesis stable can treat nonoperatively. If displacement is unacceptable and/or osteolysis is present consider surgery. AL: Rare, avulsions from osteopenia and lysis. If large, displaced and include large portion of calcar-can destabilise stem and prompt femoral revision. AG: More common. Often secondary to lysis. Does not usually affect implant stability. Minimal displacement. Treat closed × 3 months. Revise later is needed to remove the particle generator, debride defects and bone graft. Displaced with good host bone stock. Consider early ORIF and bone grafting. Vancouver B:. B1: Rarely non-operative. ORIF with femoral component retention. Need to carefully identify stem fixation. B2's classified as B1's are doomed to fail. B1's correctly identified treated with plate, allograft struts or both. High union rates with component retention. B2: Femoral revision +/− strut allograft. Best results seen with patients revised with uncemented, extensively porous coated femoral stems. May use modular, fluted taper stems. B3: Proximal femoral replacement - Tumor prosthesis, Allograft Prosthetic Composite (APC). Uncemented femoral stem - Extensively porous coated, Fluted, tapered stem, Allograft strut. Vancouver C: Treat with standard fracture techniques. These fractures are away from the femoral prosthesis. Rarely nonoperative. Fixation options – Cerclage, Strut Allograft, Plate fixation, Retrograde IM nail, or a Combination thereof. Avoid stress risers between implants. Bypass (overlap) fixation. Consider allowing 2.5 cortical diameters between devices


The Bone & Joint Journal
Vol. 96-B, Issue 1 | Pages 82 - 87
1 Jan 2014
Duquin TR Jacobson JA Schleck CD Larson DR Sanchez-Sotelo J Morrey BF

Treatment of an infected total elbow replacement (TER) is often successful in eradicating or suppressing the infection. However, the extensor mechanism may be compromised by both the infection and the surgery. The goal of this study was to assess triceps function in patients treated for deep infection complicating a TER. Between 1976 and 2007 a total of 217 TERs in 207 patients were treated for infection of a TER at our institution. Superficial infections and those that underwent resection arthroplasty were excluded, leaving 93 TERs. Triceps function was assessed by examination and a questionnaire. Outcome was measured using the Mayo Elbow Performance Score (MEPS).

Triceps weakness was identified in 51 TERs (49 patients, 55%). At a mean follow-up of five years (0.8 to 34), the extensor mechanism was intact in 13 patients, with the remaining 38 having bone or soft-tissue loss. The mean MEPS was 70 points (5 to 100), with a mean functional score of 18 (0 to 25) of a possible 25 points.

Infection following TER can often be eradicated; however, triceps weakness occurs in more than half of the patients and may represent a major functional problem.

Cite this article: Bone Joint J 2014;96-B:82–7.


The Bone & Joint Journal
Vol. 95-B, Issue 11_Supple_A | Pages 17 - 20
1 Nov 2013
Munro JT Masri BA Garbuz DS Duncan CP

Tapered, fluted, modular, titanium stems are increasingly popular in the operative management of Vancouver B2 and selected B3 peri-prosthetic femoral fractures. We have reviewed the results at our institution looking at stem survival and clinical outcomes and compared this with reported outcomes in the literature. Stem survival at a mean of 54 months was 96% in our series and 97% for combined published cases. Review of radiology showed maintenance or improvement of bone stock in 89% of cases with high rates of femoral union. Favourable clinical outcome scores have reported by several authors. No difference in survival or clinical scores was observed between B2 and B3 fractures. Tapered stems are a useful option in revision for femoral fracture across the spectrum of femoral bone deficiency.

Cite this article: Bone Joint J 2013;95-B, Supple A:17–20.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_29 | Pages 48 - 48
1 Aug 2013
Riemer B Dunn R
Full Access

Aim:. Historically, anterior decompression followed by posterior fusion has been the surgical management of choice in spinal tuberculosis. Due to theatre time being at a premium, we have evolved to performing anterior only debridement, allograft strut reconstruction and instrumentation for tuberculosis in the adult thoracic spine. The aim of this study is to review the safety and the efficacy of this treatment. Methods:. Twenty-eight adult thoracic tuberculosis patients were identified where anterior only surgery had been performed. These were all in the mid-thoracic spine as circumferential surgery is still favoured in thoracolumbar disease. The surgery was performed by a single surgeon at a tertiary hospital. Following transthoracic aggressive debridement, allograft humeral shafts were cut to size and inserted under compression and the spines instrumented with the use of screw-rod constructs into the body above and below. A retrospective review of clinical notes and radiological studies was performed. Results:. Twenty-seven of the patients presented with altered neurology; 2 had only sensory changes while 25 presented with paraparesis; 22 of these patients were unable to walk. The average surgical time was 2 hours 20 minutes with a median blood loss of 726 ml. The majority of patients had 2 vertebral bodies involved and required an average of a 4 body fusion. Surgical complications included inadvertent opening of the diaphragm in 1 patient and 1 patient deteriorated neurologically post operatively. 21 of 28 patients recovered to independent mobility at their latest follow-up appointment. 1 patient showed no recovery, 3 had some motor recovery that was not useful, 1 had some sensory but no motor recovery. 16 of 28 patients have documented bony fusion with no evidence of instrumentation failure in any patients. Conclusion:. Anterior only debridement, allograft strut reconstruction and instrumented fusion for the treatment of thoracic spinal tuberculosis is a safe and effective alternative to circumferential surgery in the adult patient


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_15 | Pages 14 - 14
1 Mar 2013
Benjamin-Laing H Konan S Rayan F Manktelow A Haddad FS
Full Access

Infected periprosthetic fractures around total hip arthroplasties are increasingly common and extremely challenging problem. The purpose of the study was to review the experience of two tertiary referral units managing infected periprosthetic femoral fractures using interlocking long-stem femoral prostheses either as temporary functional spacers or as definitive implants. Methods. A prospective review of 19 patients managed at two tertiary referral units between 2000 and 2011. Each patient was diagnosed and managed according to similar institutional protocols. Investigation through aspiration and biopsy of periprosthetic tissue supplemented haematological tests to confirm infection. The Cannulock uncoated stem was used in 14 cases, and the Kent hip prosthesis in 5 cases. Allograft struts were used in patients with deficient bone stock. Results. The mean follow-up for the series was a 53 months (range, 24–99 months). 13 patients underwent definitive revision within 7.9 months (range, 6–10 months; SD, 2.2 months). In 6 cases we implanted an extensively porous-coated stem, in 4 cases a tapered distally fixed cementless stem was used, and in 3 cases a proximal femoral replacement was used. There were no reinfections after the second stage revisions in these patients. 2 patients were offered further staged surgery due to persistently raised inflammatory markers but being mobile and relatively painfree declined. They are being managed in the community on oral antibiotics. Satisfactory outcome was noted in all cases, and in 13 cases, revision to a definitive stem was undertaken after successful control of infection and fracture union. The average postoperative Harris Hip score was 83 (range 79–89). All patients returned to their low to moderate premorbid functional state after discharge. Discussion. The use of interlocking stems offers a relatively appealing solution for a complex problem and avoids the complications associated with resection of the entire femur or the use of large quantities of bone cement


The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 11_Supple_A | Pages 58 - 60
1 Nov 2012
Munro JT Garbuz DS Masri BA Duncan CP

Tapered, fluted, modular, titanium stems have a long history in Europe and are increasing in popularity in North America. We have reviewed the results at our institution looking at stem survival and clinical outcomes. Radiological outcomes and quality of life assessments have been performed and compared to cylindrical non-modular cobalt chromium stems. Survival at five years was 94%. This fell to 85% at ten years due to stem breakage with older designs. Review of radiology showed maintenance or improvement of bone stock in 87% of cases. Outcome scores were superior in tapered stems despite worse pre-operative femoral deficiency. Tapered stems have proved to be a useful alternative in revision total hip arthroplasty across the spectrum of femoral bone deficiency.


The Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 1 | Pages 34 - 38
1 Jan 2011
Charity JAF Tsiridis E Sheeraz A Howell JR Hubble MJW Timperley AJ Gie GA

We evaluated all cases involving the combined use of a subtrochanteric derotational femoral shortening osteotomy with a cemented Exeter stem performed at our institution. With severe developmental dysplasia of the hip an osteotomy is often necessary to achieve shortening and derotation of the proximal femur. Reduction can be maintained with a 3.5 mm compression plate while the implant is cemented into place. Such a plate was used to stabilise the osteotomy in all cases. Intramedullary autograft helps to prevent cement interposition at the osteotomy site and promotes healing. There were 15 female patients (18 hips) with a mean age of 51 years (33 to 75) who had a Crowe IV dysplasia of the hip and were followed up for a mean of 114 months (52 to 168). None was lost to follow-up. All clinical scores were collected prospectively. The Charnley modification of the Merle D’Aubigné-Postel scores for pain, function and range of movement showed a statistically significant improvement from a mean of 2.4 (1 to 4), 2.3 (1 to 4), 3.4 (1 to 6) to 5.2 (3 to 6), 4.4 (3 to 6), 5.2 (4 to 6), respectively. Three acetabular revisions were required for aseptic loosening; one required femoral revision for access. One osteotomy failed to unite at 14 months and was revised successfully. No other case required a femoral revision. No postoperative sciatic nerve palsy was observed.

Cemented Exeter femoral components perform well in the treatment of Crowe IV dysplasia with this procedure.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 3 | Pages 349 - 355
1 Mar 2010
Babis GC Sakellariou VI O’Connor MI Hanssen AD Sim FH

We report the use of an allograft prosthetic composite for reconstruction of the skeletal defect in complex revision total hip replacement for severe proximal femoral bone loss. Between 1986 and 1999, 72 patients (20 men, 52 women) with a mean age of 59.9 years (38 to 78) underwent reconstruction using this technique.

At a mean follow-up of 12 years (8 to 20) 57 patients were alive, 14 had died and one was lost to follow-up. Further revision was performed in 19 hips at a mean of 44.5 months (11 to 153) post-operatively. Causes of failure were aseptic loosening in four, allograft resorption in three, allograft nonunion in two, allograft fracture in four, fracture of the stem in one, and deep infection in five. The survivorship of the allograft-prosthesis composite at ten years was 69.0% (95% confidence interval 67.7 to 70.3) with 26 patients remaining at risk. Survivorship was statistically significantly affected by the severity of the pre-operative bone loss (Paprosky type IV; p = 0.019), the number of previous hip revisions exceeding two (p = 0.047), and the length of the allograft used (p = 0.005).