In this retrospective study, we investigated the results of revision total hip replacement (THR) using a cemented long-stemmed Exeter femoral component, with a minimum length of 205 mm in patients with extensive femoral bone defects. The study included 37 consecutive patients with a mean age of 76 years (39 to 93) and a mean follow-up of nine years (5 to 16). A total of 26 patients (70%) had a pre-operative Endo-Klinik score of 3 or 4. Impaction bone grafting was used in 24 patients (65%). At the time of evaluation, 22 patients (59%) were still alive and were evaluated clinically and radiologically. A total of 14 patients died during follow-up and their data were included until the time of their death. One reconstruction failed after five years and five months owing to recurrent dislocation: the hip was converted to an excision arthroplasty. Intra-operative fractures or fissures were encountered in nine patients (24%), but none occurred during impaction of the bone graft. Post-operative peri-prosthetic fractures occurred in two patients (5%); both were treated with plate fixation. At nine years, survival with the endpoint of all-cause re-revision was 96.3% (95% CI 76.4 to 99.5); including re-operations for any reason, it was 80.7% (95% CI 56.3 to 92.3%). There were no re-revisions for aseptic loosening.

The survival of long stem cemented femoral components following revision THR is satisfactory in a fragile population with extensive femoral defects.

Cite this article: Bone Joint J 2014; 96-B:1207–13.

Aims

Periprosthetic femoral fracture (PPF) is a major complication following total hip arthroplasty (THA). Uncemented femoral components are widely preferred in primary THA, but are associated with higher PPF risk than cemented components. Collared components have reduced PPF rates following uncemented primary THA compared to collarless components, while maintaining similar prosthetic designs. The purpose of this study was to analyze PPF rate between collarless and collared component designs in a consecutive cohort of posterior approach THAs performed by two high-volume surgeons.

Aims

The aim of this retrospective study was to assess the incidence of early periprosthetic femoral fracture (PFF) associated with Charnley-Kerboull (CK) femoral components cemented according to the ‘French paradox’ principles through the Hueter anterior approach (HAA) in patients older than 70 years.

Aims

“Get It Right First Time” (GIRFT) and NHS England’s Best Practice Tariff (BPT) have published directives advising that patients over the ages of 65 (GIRFT) and 69 years (BPT) receiving total hip arthroplasty (THA) should receive cemented implants and have brought in financial penalties if this policy is not observed. Despite this, worldwide, uncemented component use has increased, a situation described as a ‘paradox’. GIRFT and BPT do, however, acknowledge more data are required to support this edict with current policies based on the National Joint Registry survivorship and implant costs.

Aims

We aimed to compare the implant survival, complications, readmissions, and mortality of Vancouver B2 periprosthetic femoral fractures (PFFs) treated with internal fixation with that of B1 PFFs treated with internal fixation and B2 fractures treated with revision arthroplasty.

Aims

Periprosthetic fractures (PPFs) around cemented taper-slip femoral prostheses often result in a femoral component that is loose at the prosthesis-cement interface, but where the cement-bone interface remains well-fixed and bone stock is good. We aim to understand how best to classify and manage these fractures by using a modification of the Vancouver classification.

We aimed to assess whether using long stem femoral components, with cemented distal fixation and proximal impaction grafting allows early patient mobilisation, reconstitution of the proximal femur and long term stability of fixation in patients with aseptic loosening and proximal femoral analysis. Over the past ten years 239 patients have been treated with an Elite Plus cemented long stem femoral implant, 33% with concomitant proximal impaction bone grafting. Many of the patients had co-morbidities. The average age at revision was 72 years (range 48 to 91). There was a slight female predominance. Fourteen percent of hips had been previously revised. Forty-eight patients were deceased and 22 were not available for follow-up; this left a cohort of 169 patients who were available for radiological and questionnaire review at an average of 4.5 years. According to the Paprosky grading for pre-operative bone loss 40% had moderate to severe bone loss (grade IIIb or IV). The Barrack grading was used to assess the cement mantle post-operatively with 65% showing good cementation. The Harris and O'Neill grades were used at final review to assess probability of loosening with only 8% being probably or definitely loose. The average Oxford Hip Score was 29. Mesh ± cables were required in a third of cases to allow adequate containment and pressurisation. It was generally felt that the long stem needed to be at least one third longer than the initial component. The re-revision rate was 1.2 with a 10 year survivorship analysis of 94%. The complication rate of almost 6% included periprosthetic fractures, dislocations, infection and mesh breakage. A long stem cemented femoral implant can be useful in bypassing proximal femoral deficiency in the appropriate patient

Revision arthroplasty for infected hip arthroplasty creates a challenging scenario to surgeons. Either a single stage or more traditionally a two-stage revision is performed. Most surgeons utilise an antibiotic loaded cement spacer, but the implant is often rotationally unstable predisposing to dislocation, acetabular bone loss and fracture of the spacer. Pain and discomfort on mobilisation also often occur. We would like to introduce an alternative approach to this challenging scenario with the use of a two-stage revision with an extended trochanteric osteotomy and loosely cemented hip arthroplasty as the first stage spacer. Surgical Technique: The first stage involves removal of metal ware with all infected tissue and cement performed through an extended trochanteric osteotomy. Circlage wires reduce the osteotomy and a long stem femoral component is inserted with antibiotic infused cement limited to the calcar region. The acetabulum is similarly removed and replaced with a loosely cemented polyethylene liner. The second stage is delayed until the infection is settled and the osteotomy is healed. Removal of the metalware is performed with relative ease, without need for an osteotomy. Reinsertion of an uncemented femoral and acetabular component is then performed. However a second stage is not always required in some patients. We report a single surgeon series comprising 10 patients from December 2003 to June 2007. The most common organism isolated was Staphylococci species. All operations were performed via a posterior approach. 9 patients were clinically assessed and the Harris hip score calculated. All patients were radiologically assessed. Osteotomies healed in all patients. Only 6 patients underwent a second stage and radiographs show good osseous integration of both components. Two patients are awaiting a second stage revision, while the other two are asymptomatic and not interested in undertaking the second stage. No dislocations, bony erosions or reinfection was noted in our series. We recommend this alternative approach to the conventional one or two staged revision arthroplasty. The extended trochanteric ostoetomy ensures rapid and complete removal of all foreign and infected material. The loosely cemented spacer effectively delivers local antibiotic and provides a stable, asymptomatic hip whilst awaiting the second stage, which may not be required

Aims

Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF.

Aims: The purpose of this study is to evaluate the experience of the Prague tumour centre with total hip replacements after tumour resections. Methods: 180 THR were implanted between 1971 and 2001 in the Prague tumour centre after resections of primary and secondary bone tumours. 158 had special long and 22 standard stems. The patients were followed in a minimum one-year interval both clinically and radiologically until their death or for at least þve years. Clinical and radiological data are evaluated. Results: Among the 158 long stem femoral components there were 63 primary bone tumours (10 Ewing sarcoma, 10 myeloma 9 chondrosarcoma, 7 osteosarcoma, 7 malignant þbrous histiocytoma, 4 malignant lymphoma, 4 giant cell tumours and 15 other benign tumours). Most of the 95 metastatic cases originated in the breast, kidney and lungs. The range of motion was surprisingly good when muscles were reattached around the stem. Luxations occurred until the antiluxating cup was developed. Even if these patients showed a higher risk of infection, reoperation was not a severe problem. Conclusions: THR with a long stem is a good salvage method after primary tumour resection around the hip. It is a method of choice in meta-static patients with or without pathologic fractures especially in solitary bone metastasis. Luxation can be a problem when not using an antiluxa-ting cup as well as replacement in children with unþnished skeletal development. Reattachment of the Ç muscle ring È improves the outcome

Aims

The early mortality in patients with hip fractures from bony metastases is unknown. The objectives of this study were to quantify 30- and 90-day mortality in patients with proximal femoral metastases, and to create a mortality prediction tool based on biomarkers associated with early death.

Aims

We investigated patient characteristics and outcomes of Vancouver type B periprosthetic fractures treated with femoral component revision and/or osteosynthesis.

Aim: The objective of this study was to compare the initial stability of an uncemented curved long stem femoral component (ABR, Zimmer, Warsaw Indiana) implanted using conventional broaching to an uncemented ABR implanted as a revision using morselized compacted allograft to fill a circumferential proximal bone defect. Materials and Methods: Primary: Eight fresh frozen human femurs were implanted with correctly sized ABR stems without cement using standard surgical instruments and 1mm distal overreaming. The implant was loaded cyclically at 3 hz on a MTS servohdraulic materials test frame in a direction representing the peak force of the stance phase of the gait (2.5 X body weight). A 3-dimensional motion measurement device with six linear variable transformers measure the relative motion between the bone and the prosthesis with an accuracy of 0.5μm. The contruct was loaded in ten cycle increments until the component was seated and then recoverable motion was recorded over a further ten loading cycles. Revision: In the revision case bone loss was modelled by removing all the cancellous bone from the proximal femur with 1mm distal overreaming. Morselized bone graft was impacted into the defect using specially prepared smooth tamps shaped to the geometry of the ABR stem. The original prosthesis was then reimplanted without the use of cement. The seating and testing cycles were repeated. Primary and revision vectors were compared using a paired students t – test. Results: There was no statistically significant difference in the magnitude of the resultant vector of the 3 translational components of the micro motion between the two methods of implantation (p=0.19). Conclusions: Initial stability of a cementless femoral implant is a requirement for bone ingrowth. The use of compacted morsellized allograft in a revision Total Hip Arthroplasty with a proximal circumferential defect can provide a stable bed for the implantation of an uncemented femoral component. The revised implant using the compacted allograft method was initially as stable as the primary implantation. This technique would be particularly applicable when the surgeon would like to avoid the use of cement in a revision setting. The use of this method for uncemented revision Total Hip Arthroplasty should be studied further in a clinical setting before it is advocated for widespread use

Aims

This study describes and compares the operative management and outcomes in a consecutive case series of patients with dislocated hemiarthroplasties of the hip, and compares outcomes with those of patients not sustaining a dislocation.

Aims

The aim of this study was to compare early functional and health related quality of life outcomes (HRQoL) in patients who have undergone total hip arthroplasty (THA) using a bone conserving short stem femoral component and those in whom a conventional length uncemented component was used. Outcome was assessed using a validated performance based outcome instrument as well as patient reported outcome measures (PROMs).

The purpose of this paper is to discuss the risk factors, prevention strategies, classification, and treatment of intra-operative femur fractures sustained during primary and revision total hip arthroplasty.

The October 2013 Hip & Pelvis Roundup³⁶⁰ looks at: Young and impinging; Clothes, weather and femoral heads?; Go long, go cemented; Surgical repair of the abductors?; Aspirin for DVT prophylaxis?; Ceramic-on-polyethylene: a low-wear solution?; ALVAL and ASR™: the story continues….; Salvaging Legg-Calve-Perthes’ disease

We describe 129 consecutive revision total hip replacements using a Charnley-Kerboull femoral component of standard length with impaction allografting. The mean follow-up was 8.2 years (2 to 16). Additionally, extramedullary reinforcement was performed using struts of cortical allograft in 49 hips and cerclage wires in 30.

There was one intra-operative fracture of the femur but none later. Two femoral components subsided by 5 mm and 8 mm respectively, and were considered to be radiological failures. No further revision of a femoral component was required. The rate of survival of the femoral component at nine years, using radiological failure as the endpoint, was 98%. Our study showed that impaction grafting in association with a Charnley-Kerboull femoral component has a low rate of subsidence. Reconstruction of deficiencies of distal bone with struts of cortical allograft appeared to be an efficient way of preventing postoperative femoral fracture for up to 16 years.

We investigated 219 revisions of total hip replacement (THR) in 211 patients using a collarless double-taper cemented femoral component. The mean age of the patients was 72 years (30 to 90). The 137 long and 82 standard length stems were analysed separately. The mean follow-up was six years (2 to 18), and no patient was lost to follow-up.

Survival of the long stems to re-revision for aseptic loosening at nine years was 98% (95% confidence interval (CI) 94 to 100), and for the standard stems was 93% (95% CI 85 to 100). At five years, one long stem was definitely loose radiologically and one standard stem was probably loose. Pre-operative femoral bone deficiency did not influence the results for the long stems, and corrective femoral osteotomy was avoided, as were significant subsidence, major stress shielding and persistent thigh pain.

Because of these reliable results, cemented long collarless double-taper femoral components are recommended for routine revision THR in older patients.

It is unclear whether there is a limit to the amount of distal bone required to support fixation of supracondylar periprosthetic femoral fractures. This retrospective multicentre study evaluated lateral locked plating of periprosthetic supracondylar femoral fractures and compared the results according to extension of the fracture distal with the proximal border of the femoral prosthetic component.

Between 1999 and 2008, 89 patients underwent lateral locked plating of a supracondylar periprosthetic femoral fracture, of whom 61 patients with a mean age of 72 years (42 to 96) comprising 53 women, were available after a minimum follow-up of six months or until fracture healing. Patients were grouped into those with fractures located proximally (28) and those with fractures that extended distal to the proximal border of the femoral component (33).

Delayed healing and nonunion occurred respectively in five (18%) and three (11%) of more proximal fractures, and in two (6%) and five (15%) of the fractures with distal extension (p = 0.23 for delayed healing; p = 0.72 for nonunion, Fisher’s exact test). Four construct failures (14%) occurred in more proximal fractures, and three (9%) in fractures with distal extension (p = 0.51). Of the two deep infections that occurred in each group, one resolved after surgical debridement and antibiotics, and one progressed to a nonunion.

Extreme distal periprosthetic supracondylar fractures of the femur are not a contra-indication to lateral locked plating. These fractures can be managed with internal fixation, with predictable results, similar to those seen in more proximal fractures.