Introduction. Especially in young patients, total hip implants with proven long-term follow-up data should be used. Despite this, almost all patients under 30 years old will face a revision of their hip prosthesis during their life time because of their life expectancy. Therefore, all the used implants should be revisable with reliable outcome. Although, several studies have evaluated the outcome of different THA implants in patients under 30, only few report the long term follow-up of 10 years or more. None of them present the outcome of the revised total hips. Methods. We retrospectively reviewed prospectively collected data of 48 consecutive patients (69 hips), all received a cemented implant and in case of acetabular bone stock deficiency (29 hips), a reconstruction with bone impaction grafting (BIG) was performed. Mean age at surgery was 24.6 years (range, 16.0–29.0 years). Two patients were lost to follow-up. As far as we know, no revisions are performed in these two patients and their data are included in the study up to their last radiographic control. All failed hips were revised with again cemented implants and, if needed, bone impaction grafting. For the primary THA Kaplan-Meier survival curves at 10- and 15-year endpoint revision for any reason and revision for aseptic loosening were calculated. Separate survival rates at 10- and 15- year were calculated for the BIG group versus the non-BIG group. The outcome of the revised hips was studied and reported with re-revision as the endpoint. Results. Mean follow-up of all 69 hips was 11.5 years (range 2–23.4 years). During follow-up 13 revisions were performed. No stem revisions occurred, except in 3 septic failures. The 10- and 15-year survival rates with endpoint revision for any reason were 86% (95%-CI: 74–92%) and 75% (95%-CI:59-86%), the same endpoints revision for aseptic loosening were 90% (95%-CI: 79–96%) and 82% (95%-CI: 65–92%), respectively. The 10- and 15-year survival rates with endpoint revision for any reason in the BIG group were 93% (95%-CI: 74–98%) and 83% (95%-CI:49-95%), whereas for the non-BIG group the rates were 81% (95%-CI: 69–91%) and 71% (95%-CI:50-84%). None of the 13 revisions needed a re-revision within 10 years after re-implantation, although one cup failed after 13 years. Conclusion. This study shows that cemented primary total hip implants in patients under 30 years have acceptable outcomes at 10 and 15 years after surgery. Remarkably, the outcomes of the bone impaction grafting technique are superior to non BIG hips, the BIG-group shows a higher survival percentage as the non-BIG group. However, the most interesting part of the study is that the revised hips, all again re-cemented and, if needed, reconstructed with bone impaction grafting were performing well with no re-revisions within 10 years after surgery

Background. These days, total hip arthroplasties (THA) are more implanted in young patients. Due to the expected lifespan of a THA and the life expectancy of young patients, a future revision is inevitable. Indirectly increasing the number of revisions in these patients. Therefore we evaluated the results of revision THA in patients under the age of 60 years. However, we used a unique protocol in which we used in all cases of acetabular and/or femoral bone deficiencies reconstruction with bone impaction grafting. Methods. To determine the mid- to longterm results of cemented revision total hip arthroplasties in patients under the age of 60, all clinical data and radiographs were analyzed of patients operated between 1992 and 2005. Patients with multiple previous revisions were also included. Only cemented components were used. During this period 146 consecutive revision total hip arthroplasties were implanted in 129 patients. This included 124 cup and 106 stem revisions. The average age at index surgery was 47 years. No case was lost. Mean follow-up was 7.6 (range, 2.0–16.7) years. Results. Outcome of clinical questionnaires improved significantly after revision THA. During follow-up 19% (28 hips) needed a repeat revision (aseptic loosening 13, septic loosening 10, recurrent dislocations 2, traumatic loosening 2, and abductor contracture 1). Seven of 146 cases (4.8%) ended finally in a permanent Girdlestone. Seventeen (14%) of the 124 cups were radiographically loose, 11 were revised. Four (4%) of the 106 stems were radiographically loose, 2 were revised. The 10-years survival was 78% with endpoint revision for any reason and 87% with endpoint revision for aseptic loosening. 28 hips needed repeat revision after the index revision. No significant differences in survival were found looking at the different indications for revision. Conclusions. The survival of cemented revision THA in patients under the age of 60 is satisfying. Reconstruction of acetabular and femoral bone deficiencies with bone impaction grafting is a promising and biological attractive technique in this young and high demanding population and enhances the revisability of a THA

Background. Because of the long life expectancy of young total hip arthroplasty (THA) patients and the limited durability of prosthetic implants in young patients, surgeon's always must take into account that the primary THA will be revised in the future. Therefore, not only the survival of the primary total hip in young patients is important, but we would also like to accentuate the revisability of a primary THA in this specific and high demanding patient population. Methods. Based on our philosophy, we always use cemented hip in young patients, if needed with acetabular bone impaction grafting. 343 consecutive cemented THA in 270 patients under the age of 50 years were evaluated, all implanted between 1988 and 2006. We also assessed the results of the revised THA (n=53) within the same population. Clinical, radiographical and survival of primary and revision THA were evaluated. Outcome. Survival analysis of all 343 hips with endpoint revision for any reason of either component showed a survival of 86% after 10 years. Survival of the stem and cup with endpoint aseptic loosening 93% after 10 years. Remarkably, the THA in which the cemented cup was combined with acetabular bone impaction grafting had a survival of 90% (SE 2.8) in contrast to a survival of 82% (SE 3.4) of the cups without an acetabular revision with endpoint revision for any reason of the whole prostheses(log-rank test, p=0.156) at 10 years. With no patient lost during follow-up, 53 primary hips were revised after a mean follow-up of 8.9 (range 2.0–19.3) years. The average follow-up of the revision THA was 4.2 (range 0.1–14.8) years. Three hips of this revision cohort needed a repeat revision, two had a reinfection after a septic revision and one revised cup failed 12 years after revision. The survival of the revised cohort with endpoint revision for any reason was 91% after 5 years, with endpoint aseptic loosening the survival at 5 years was 100 %. As well after primary as revision THA good clinical outcome scores were measured. Interpretation. Cemented implants in young patients showed satisfying results in primary as well as after revision THA with very acceptable survival and clinical outcomes. Keeping in mind that the young patient will outlive their primary THA, the primary hip has to be revisable and the results of the revision THA must be as good as the primary THA. Bone defects both in primary and revision THA can be successful managed with impacted bone grafts, without the need for augments, cages or larger implants

Managing severe acetabular bone defects during primary and revision total hip arthroplasty is a challenging problem. Standard treatment options for this cases is using of acetabular reconstruction type-Burch-Schneider rings. Unfortunately, the possibility of osseointegration of these implants with surrounding bone has always remained a contentious issue. The emergence in recent years of new designs of trabecular titanium, representing a symbiosis of acetabular reconstructive plates and modular cup helped to solve this problem on a completely new level. The aim of this prospective study is to evaluate the short and mid-term clinical and radiographic outcomes of different types of acetabular revision cups - old and new design. From 2006 to 2015, we performed 48 acetabular reconstruction with reconstruction rings CONTUR Smith and Nephew(group 1) and 34 operations with Delta TT Lima Revision system (group 2). The mean age of patients was 59.2 years (range 30–79). Indications for operations included fractures in acetabular region (10 pat – 12,2 %), acetabular nonunions with bone defects (14 pat – 17,1%), aseptic loosening with multiple dislocation of the primary implants in 38 cases (46,3%) and second stage of infection treatment in 20 cases (24.4%). Clinical and functional outcomes were evaluated by Harris Hip Score (HHS). Bone density in Charnley's zones was measured by dual-energy x-ray absorptiometry. With CONTUR reconstruction rings were used 3 different types of bearing surface articulation (22 metal/polyethylene, 10 ceramic/polyethylene, and 16 oxinium/polyethylenel). With Delta TT Revision system were used metal/poly couples in 22 cases, ceramic/poly in 6 cases, and ceramic/ceramic couple in 4 cases. In two patients with high risk of dislocations were used double mobility system. In all operations with CONTUR rings was used bone impaction grafting to fill cavitary defects (Paprosky 2B-3A), with Delta TT Revision system in 14 cases (41,2%) additionally TT augments were used. In group 1 were 3 dislocations (6,3 %), 2 deep infections (4,2 %) and 4 aceptic loosenings with secondary instability of implants (8,3 %). In group 2 Trabecular Titanium showed a high capacity of osseointegration, providing good results in short-term follow-up. We registered only 2 dislocations (5,8 %) and 1 aceptic loosening (2,9 %). The mean HHS increased from 39.7 (range 23–62) preoperatively to 86.5 (range 68–98) at the last follow-up examination. The implanted cups were radiographically stable at the last follow-up visit (1 and 2 years) without radiolucent lines or periprosthetic osteolysis. Conclusions. Delta Revision TT is a good solution for acetabular reconstruction even when there are cavitary and segmental bone defects. Modularity of this system make it possible to correct inlay position, center of hip rotation and minimising the risk of dislocation

Introduction. Total hip arthroplasties in younger patients often requires revision because these patients frequently have acetabular deficiencies, which hamper proper implantation of the cup essential for good long-term prosthesis survival. For 30 years, we have used a biological acetabular-reconstruction technique with bone-impaction grafting in all patients <50 years with an acetabular deficiency at surgery, always in combination with a cemented total hip implant. Methods. We evaluated all 150 consecutive patients (177 hips) < 50 years with an acetabular reconstruction by bone-impaction grafting surgically-treated from 1978–2004 at our clinic. Mean follow-up was 10.3 (range, 2.0–28.3) years with no patient lost to follow-up. Mean index surgery age was 38.1 (range, 16–49) years. Clinical, radiological, and statistical analysis of all patients was performed. Results. Twenty-eight of 177 hips were revised at a mean of 10.5 years (range, 5 days to 23.2 years). Reasons for revision were: aseptic loosening (n=17), septic loosening (n=3), recurrent dislocations (n=3), traumatic loosening (n=2), neuropathy (n=1), wear (n=1), and fracture (n=1). Ten-year and 15-year survival with endpoint revision of any component for any reason was 91% and 78%. Ten-year survival with endpoint aseptic loosening was 96% for the cup and 97% for the stem. Conclusion. Performing a total hip implant in combination with acetabular bone impaction grafting in younger patients with acetabular bone stock loss seems to be an attractive approach as the long-term results are acceptable and fulfill the NICE-criteria, showing a ten -year survival of more than 90% with endpoint revisions for any reason

INTRODUCTION. Managing severe periacetabular bone loss during revision total hip arthroplasty (THA) is a challenging task. Multiple treatment options have been described. Delta Revision Trabecular Titanium™ (TT) cup is manufactured by Electron Beam Melting (EBM) technology that allows modulating cellular solid structures with an highly porous structure were conceived to rich the goals of high bone ingrowth and physiological load transfer. The caudal hook and fins ensure additional stability and the modular system allows the surgeon to treat bone defects in the most complex revisions. Entirely modular, the system can meet all intra-operative needs thanks to a customized implant construction. The aim of this prospective study is to evaluate the short to mid-term clinical and radiographic outcomes of this acetabular revision cups. MATERIALS AND METHODS. We prospectively assessed clinical and radiographic results of 31 cases of acetabular revisions that were performed from June 2007 and March 2012 by Delta TT Lima Revision system. The mean age of patients was 69.5 years (range 29–90). The causes of revision were aseptic loosening in 22 cases (71.0%), periprosthetic acetabular fractures in 4 cases (13.0%), multiple dislocation of the primary implant in 3 cases (9.6%) and outcome of infection in 2 cases (6.4%). Stem revision was performed in 11 cases (35,4%). In 24 cases bone impaction grafting was used to fill cavitary defects (Paprosky 2B-3A); in 7 cases TT augments were used with the same aim. The average follow-up was 32 months (range 12–69). RESULTS AND CONCLUSIONS. No major complications were observed. The mean HHS significantly increased from 39.9 (range 17–60) preoperatively to 86.5 (range 65–100) at the last follow-up examination. The implanted cups were radiographically stable at the last follow-up visit without radiolucent lines or periprosthetic osteolysis. Trabecular Titanium showed a high capacity of osseointegration, providing excellent results in short to mid-term follow-up. The impaction grafting has demonstrated effective restoration of bone stock and no radiographic evidence bone resorption (Fig. 1). DISCUSSION. Delta Revision TT is a good solution for acetabular revision surgery even when there are cavitary and segmental bone defects. It is possible to restore muscle tension and correct anatomical impairments, while enhancing implant stability and minimising the risk of dislocation

A cleaning process reduces the contamination risk in bone impaction grafting but also modifies the grain size distribution. The cleaned allograft shows a higher mechanical stability than the untreated group. In revision total hip replacement, bone loss can be managed by impacting porous bone chips. The bone chips have to be compacted to guarantee sufficient mechanical strength. To improve the safety of bone grafts and to reduce the risk of bacterial and viral contamination, cleaning processes are used to remove the organic portion of the tissue while maintaining its mechanical characteristics. A cleaning procedure described by Coraca-Huber et al. was compared to untreated allografts by performing a sieve analysis, followed by an uniaxial compression test. Differences in grain size distribution and weight loss during the cleaning procedure were compared to data from literature. Yield stress limits, flowability coefficients as well as initial density and density at the yield limit of the two groups were determined for each group over 30 measurements. The measurements were taken before and after compression with an impaction apparatus (dropped weight). The cleaning process reduced the initial weight by 56%, which is comparable to the results of McKenna et. al. Cleaned allograft showed a 25% lower weight of bone chips sized > 4 mm compared to data from a previous study. The cleaned bone chips showed a statistically significant (p > 0.01) higher yield limit to a compression force (0.165 ± 0.069 MPa) compared to untreated allograft after compaction (0.117 ± 0.062 MPa). The flowability coefficient was 0.024 for the cleaned allograft and 0.034 for the untreated allograft. Initial density as well as the density at the yield limit was higher for the untreated allografts, as the sample weight was twice as high as in the cleaned group, to compensate for the washout of the organic portion. The cleaned bone grafts showed a higher compaction rate, which was 31%, compared the the untreated group with a compaction rate of 22%. The cleaned allograft showed a higher compaction rate, which means that the gaps between the single grains are filled out with smaller particles, resulting in better interlocking. In the untreated allograft the interlocking mechanism is hindered by the organic elements. This observation is confirmed by a reduced flowabillity and a higher yield stress limit. The loss of weight as well as a higher compaction rate implies that more cleaned graft material is needed to fill bone defects in hip surgery. Sonication may damage the bone structure of the allograft and reduce the size of the particles

In Total Hip Arthroplasty (THA) bone loss is recovered by using compacted porous bone chips. The technique requires the morsellised allograft to be adequately compacted to provide initial stability for the prosthesis in order to prevent early massive subsidence and to induce bone remodeling. Therefore the bone grafts provide initial stability and an environment in which revascularization and incorporation of the graft into the host skeleton may occur. Acetabular reconstruction with impacted morsellised cancellous grafts and cement leads to satisfactory long-term results. In the acetabular impact-grafting procedure, a hammer and an impaction stick is used for manual compaction. Another technique uses a hammer driven by compressed air, which could lead to higher density and improved stability of bone chips in the acetabulum. The aim of this study was to compare two different compaction modes for bone impaction grafting for the acetabulum. The hypothesis was that a pneumatic impaction method would produce less variable results than the manual impaction mode and lead to better compaction results of the bone chips in less time. Bone mass characteristics were measured by force and distance variation of a penetrating punch, which was lowered into a plastic cup filled with bone chips. For each compaction method and for each time interval (0, 3, 6, 9, 12, 15 and 30 [s] of compaction time) 30 measurements of force and distance variations were taken. From the measurements of force and distance variations bulk density, contact stiffness, impaction hardness and penetration resistance were calculated before and after the established time intervals of compaction. Since not all data was normally distributed the non-parametric U-Test was used for comparison of the two impaction methods. Particle size distribution was determined using sieve analysis according to Din 18123 standard after the compaction experiments. Results have shown that the pneumatic method leads to higher values in impaction hardness, contact stiffness and bulk density and is more suitable to increase the primary stability of the implant. The differences in bulk density, impaction hardness and contact stiffness where statistically significant (p<0.01). No significant differences were found between the two different methods concerning the penetration resistance. The coefficient of uniformity C. u. , calculated from the particle size distribution determined by the sieve analysis, has a value of 3.8. The particle size distribution is comparable to the results published in literature. Pneumatic impaction achieves higher density values in less time with less force applied and results in more reproducible outcomes when used. It reduces therefore the risk of bone fracture, as smaller peak forces are used for less time. However for optimal osteointegration it is not recommended to achieve maximum density. Further clinical studies should determine a reference value for optimal growth-in of osteocytes. Manual impaction shows more variable results and depends much on the experience of the surgeon. The pneumatic hammer is therefore a suitable tool to standardize the impaction process for acetabular bone defects

Purpose:. Tuberosity healing in hemiarthroplasty for proximal humerus fractures remains problematic. Improved implant design and better techniques for tuberosity fixation have not been met with improved clinical results. The etiology for tuberosity failure is multifactorial; however thermal injury to host bone is a known effect of using polymethylmethacrylate for implant fixation. We hypothesized that the effect of thermal injury at the tuberosity shaft junction could be diminished by utilizing an impaction grafting technique for hemiarthroplasty stems. Methods:. Five matched pairs of cadaveric humeri were skeletonized and hemiarthroplasty stems were implanted in the proximal humeri in two groups. The first group had full cementation utilized from the surgical neck to 2 cm distal to the stem (cement group) and the second group had distal cementation with autologous cancellous bone graft impacted in the proximal 2.5 cm of the stem (impaction grafting group). Thermocouples were used to measure the inner cortical temperature at the tip of the stem, surgical neck, and at the level of the cement-graft interface for both treatment groups (see Fig. 1). Experiments were initiated with the humeri fully submerged in 0.9% sodium chloride and all three thermocouples registering a temperature of 37 ± 1°C. Statistical analyses were performed with a one-sided, paired t-test. Results:. The maximum recorded cortical bone temperature at the surgical neck was significantly decreased by 23% from 52.4 ± 8.1°C in the cement group to 40.4 ± 4.8°C in the impaction grafting group (p = 0.037). We identified no significant differences in maximum recorded temperature at the cement-graft interface between the impaction grafting group (44.3 ± 6.3°C) and the cement group (47.4 ± 6.4°C) (p = 0.254). A similar finding was observed between groups at the tip of the hemiarthroplasty stem (impaction grafting group 54.2 ± 5.7°C; cemented group 52.3 ± 7.3°C, p = 0.303). Conclusion:. Given the known threshold of 47°C as the onset of permanent thermal injury to bone,. 1. impaction grafting maintains the temperature at the surgical neck during cementation below this critical value. Impaction grafting may serve as a beneficial surgical technique to mitigate the effects of thermal injury on tuberosity healing in proximal humeral hemiarthroplasty for fracture